Copyright Undertaking - PolyU Electronic Theses

Copyright Undertaking

This thesis is protected by copyright, with all rights reserved.

By reading and using the thesis, the reader understands and agrees to the following terms:

1. The reader will abide by the rules and legal ordinances governing copyright regarding the use of the thesis.

2. The reader will use the thesis for the purpose of research or private study only and not for distribution or further reproduction or any other purpose.

3. The reader agrees to indemnify and hold the University harmless from and against any loss, damage, cost, liability or expenses arising from copyright infringement or unauthorized usage.

IMPORTANT

If you have reasons to believe that any materials in this thesis are deemed not suitable to be distributed in this form, or a copyright owner having difficulty with the material being included in our database, please contact [email protected] providing details. The Library will look into your claim and consider taking remedial action upon receipt of the written requests.

Pao Yue-kong Library, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong

http://www.lib.polyu.edu.hk

The Hong Kong Polytechnic University

School of Nursing

The Effects of a TTM-based Exercise Stage-Matched Intervention on

Patients with Coronary Heart Disease

Zhu Lixia

A thesis submitted in partial fulfillment of the requirements for the

degree of Doctor of Philosophy

December 2011

lbsys

Text Box

This thesis in electronic version is provided to the Library by the author. In the case where its contents is different from the printed version, the printed version shall prevail.

iii

ABSTRACT

Title: The effects of a TTM-based Exercise Stage-Matched Intervention (ESMI)

on patients with coronary heart disease

Background: Coronary heart disease (CHD) is a leading cause of death and disability

among adults worldwide. Regular exercise or exercise-based cardiac rehabilitation has

been shown to be beneficial to cardiac patients; however, participation and adherence

to exercise programmes is poor. The Transtheoretical Model (TTM) has been

demonstrated to be a successful model for changing exercise behaviour in various

populations from adolescents to the elderly. However, there have been few studies on

the use of the TTM for changing exercise behaviour among CHD patients.

Aim: To examine the effects of a TTM-based Exercise Stage-Matched Intervention

(ESMI) on sedentary patients with CHD. The primary outcome indicator is change in

exercise behaviour. The secondary outcome indicators are anginal attacks and quality

of life.

Methods: This study involved a randomized controlled trial using consecutive

sampling. A total of 196 subjects were recruited and randomly assigned to one of the

following three groups: the Conventional (C) Group (n = 67), the Patient Education

(PE) Group (n = 64), and the ESMI Group (n = 65). Outcome measures included

exercise stages of change, exercise self-efficacy, exercise decisional balance, exercise

duration per week, conditions of angina, and quality of life. Data collection was

carried out at baseline (T0), post-intervention (T1), at the 3-month follow-up period

iv

(T2), and at the 6-month follow-up period (T3). Data analysis was conducted based on

the intention-to-treat principle. Last observation carried forward (LOCF) was

employed to handle the missing data. One-way ANOVA, the Kruskal-Wallis test, and

Chi-square test were applied to analyze data among the three groups at each time

point. One-way repeated ANOVA, the Friedman test, and Cochran‘s Q test were used

to analyze data within groups over time.

Results: A total of 150 subjects completed the whole study. The findings showed that

significantly positive effects on changes in exercise behaviour were found in the

ESMI group, in terms of a more positive shift in the exercise stages of change (p <

0.001), higher exercise self-efficacy (p < 0.001), greater exercise benefits (p < 0.001),

fewer exercise barriers (p < 0.001), longer total exercise duration (minutes/week) (p <

0.001), and longer moderate exercise duration (minutes/week) (p < 0.001), after the

completion of the 8-week ESMI when compared with the C and PE groups. With

regard to anginal attacks, no significant differences in frequency, severity, and

duration of anginal attacks were found among the three groups at each time point. The

ESMI group demonstrated significantly better quality of life, in terms of

improvements in physical limitation (p < 0.01), treatment satisfaction (p < 0.001), and

disease perception (p < 0.001) of Seattle Angina Questionnaire (SAQ), and in physical

component summary (p < 0.01), mental component summary (p < 0.001), and

reported health transition (p < 0.05) of SF-36 after the completion of the 8-week

ESMI when compared with the C and PE groups. These significantly positive effects

were maintained at the 3- and 6-month follow-up periods, with the exception of those

for total exercise duration (minutes/week) and reported health transition, which had

disappeared at the 6-month follow-up period.

v

Conclusion: The TTM-based ESMI has significantly positive effects on changes in

exercise behaviour and quality of life in sedentary CHD patients. The findings

highlight the feasibility and importance of providing CHD patients with a structured

or formal patient education programme guided by the TTM.

vi

Publications arising from the thesis

1. Zhu, L.X., Ho, S.C., Ruan, G.Q., Xie, Q. & Sit, J.W.H. (2012). The effects of an

exercise stage-matched intervention on exercise behavior change in patients with

coronary heart disease - A randomized controlled trial. European Heart Journal,

14(suppl. A): A16.

2. Zhu, L.X., Ho, S.C. & Sit, J.W.H. (2012). The effects of an exercise stage-

matched intervention on quality of life in patients with coronary heart disease.

International Journal of Nursing Practice, 18(Suppl. 1): 30.

3. Zhu, L.X., Ho, S.C. & Sit, J.W.H. (2012). The experiences of Chinese patients

with coronary heart disease. Journal of Clinical Nursing, 21(3-4), 476-484.

4. Zhu, L.X., Ho, S.C. & Sit, J.W.H. (2011). The effects of exercise stage-matched

interventions on exercise behavior change among patients with coronary heart

disease - A pilot study. International Journal of Cardiology, 147(Suppl. 1): s11.

5. Zhu, L.X., Ho, S.C., Ruan, G.Q. & Sit, J.W.H. (under review). Can

TTM motivate CHD patients to do exercise? A report from a small-scaled

feasibility study in China. Applied Nursing Research.

6. Zhu, L.X., Ho, S.C. & Wong, T.K.S. (under review). Systematic review of the

effectiveness of health education programme on exercise behaviour change in

patients with heart disease. Patient Education and Counselling.

7. Zhu, L.X., Ho, S.C., Ruan, G.Q., Xie, Q., Zhu, H.H. & Sit, J.W.H. (under review).

Comparison of the demographic and clinical profile and outcome of dropouts and

completers in a randomized exercise trial among patients with coronary heart

disease. Journal of Clinical Rehabilitation.

vii

Conference presentations

1. Zhu, L.X., Ho, S.C., Ruan, G.Q., Xie, Q. & Sit, J.W.H. (2012). The effects of an

exercise stage-matched interventions on exercise behavior change in patients with

coronary heart disease - A randomized controlled trial. ICC 2012 International

Congress of Cardiology, Hong Kong, 24-26 February 2012, A16.

2. Zhu, L.X., Ho, S.C. & Sit, J.W.H. (2012). The effects of an exercise stage-

matched interventions on quality of life in patients with coronary heart disease.

The 15th

East Asian Forum of Nursing Scholars (EAFONS), Singapore, 22-23

February 2012, 30.


interventions on exercise behavior change among patients with coronary heart

disease – A pilot study. CUHK-Mayo Clinic-Asia Cardiovascular Summit, Hong

Kong, 26-27 March 2011, s11.


interventions on patients with coronary heart disease: A pilot study. Wuhan

International Conference 2010, Community Engagement Paving the Way to

Optimal Health, Wuhan, 3-4 April 2010, 80.

5. Zhu, L.X., Ho, S.C. & Sit, J.W.H. (2009). The experiences of Chinese patients

with coronary heart disease. The 12th East Asian Forum of Nursing Scholars

(EAFONS), Tokyo, Japan, 13-14 March 2009, 50.

viii

ACKNOWLEDGEMENTS

As a PhD student in the School of Nursing (SN), The Hong Kong Polytechnic

University, studying was a magnificent as well as a challenging experience for me. I

encountered difficulties and hardships. Nonetheless, these four years are also among

the happiest times of my life, and have provided me with some of my most precious

memories. Many people have directly or indirectly helped me to overcome my fear

and difficulties, enabling me to successfully complete my studies. I would like to

express my deepest gratitude to them here.

First of all, I sincerely thank my chief supervisor, Dr Jacqueline Ho, and my co-

supervisor, Dr Janet Sit, for their guidance and supervision throughout the whole

course of my doctoral studies. It would have been impossible for me to complete my

doctoral project without their kind support, encouragement, and help during these four

years. I would also like to take this opportunity to thank my two other co-supervisors,

Dr Guoqiang Ruan and Dr Qiang Xie, for their kind support and help during the data

collection process.

I also thank Miss Haihua ZHU for allowing me to collect data in the Xiamen Heart

Centre and giving me substantial support during the collecting of data. Many thanks

go to Dr Shuilong Chen, who offered me valuable assistance in screening patients and

prescribing exercises during the process of data collection. Special thanks go to Miss

Si Shi, who helped me to collect data for this study. Without their kind help and

support, it would have been impossible to complete the data collection process so

smoothly. I also wish to thank all of the nursing sisters in the cardiovascular ward of

ix

the Xiamen Heart Centre and The First Affiliated Hospital of Xiamen University for

their valuable assistance in many areas. In addition, I wish to thank all of the

participants in this study. Without their participation and full support, it would have

been impossible for me to conduct my research.

I would like to express my deepest appreciation to my family. I could have achieved

nothing without the support, love, and understanding of my husband, Haidong Yang,

throughout the whole study. I wish to express my special appreciation to my son,

Jingchen Yang. I would not have had the peace of mind to study without my son‘s

support. I also wish to express my deepest gratitude to my parents, Qingfu Zhu and

Jinyan Lin, who brought me up. I am especially grateful to my parents-in-law, Jinrui

Yang and Meipi Yang. I would not have been able to complete my studies without

their kind support and help in taking care of my son during the past four years. My

appreciation also is extended to other family members, Wenjin Yang, Guobao Zhu,

Liying Zhu, Yuanbao Zhu, and others, for their encouragement and support in the past

four years.

x

TABLE OF CONTENTS

Contents Page

Certificate of originality ……………………………………………………… ii

Abstract ……………………………………………………………………….. iii

Publications arising from the thesis …………………………………………. vi

Conference presentation ……………………………………………………... vii

Acknowledgement …………………………………………………………….. viii

Table of contents ……………………………………………………………… x

List of tables …………………………………………………………………... xiv

List of figures …………………………………………………………………. xvii

Chapter 1: Introduction ……………………………………………………… 1

1.1 Introduction …………………………………………………………….., 1

1.2 Background ……………………………………………………………… 1

1.3 Aim and Objectives ……………………………………………………... 7

1.4 Research questions ……………………………………………………… 7

1.5 Theoretical framework ………………………………………………….. 8

1.6 Significance of the study ……………………………………………….. 12

1.7 Thesis outline …………………………………………………………… 14

1.8 Summary ………………………………………………………………... 15

Chapter 2: Literature Review ……………………………………………….. 16

2.1 Introduction ……………………………………………………………... 16

2.2 Coronary heart disease (CHD) ………………………………………….. 16

2.2.1 Definition of coronary heart disease ………………………………. 16

2.2.2 Prevalence of coronary heart disease …………………………….... 17

2.2.3 Impact of coronary heart disease on patients …………………….... 21

2.3 Exercise and coronary heart disease …………………………………….. 34

2.3.1 Benefits of exercise for CHD patients …………………………….. 35

2.3.2 Hospital-based versus home-based exercise programmes ……….... 49

2.3.3 Cardiac rehabilitation programmes in China …………………….... 52

2.3.4 Safety of exercise for CHD patients ………………………………. 53

2.3.5 Poor attendance of exercise-based cardiac rehabilitation …………. 54

2.4 Patient education and exercise behaviour ……………………………….. 57

xi

2.4.1 Information needs of CHD patients ……………………………….. 57

2.4.2 Patient education on health promotion ……………………………. 61

2.4.3 Patient education and exercise behaviour …………………………. 66

2.4.4 Factors affecting the effectiveness of patient education …………... 95

2.4.5 Theoretical basis for patient education ……………………………. 98

2.5 The Transtheoretical Model (TTM) ……………………………………... 102

2.5.1 Overview of the TTM ……………………………………………... 103

2.5.2 The TTM and exercise behaviour………………………………….. 113

2.5.3 The TTM for changing exercise behaviour among patients with

heart disease ………………………………………………………...

131

2.6 Summary ……………………………………………………………….... 135

Chapter 3: Research Methodology ………………………………………….. 137

3.1 Introduction ……………………………………………………………... 137

3.2 Study design …………………………………………………………….. 137

3.3 Settings ………………………………………………………………….. 139

3.4 Sampling ………………………………………………………………… 139

3.5 Procedures ……………………………………………………………..... 142

3.6 Intervention ……………………………………………………………… 144

3.7 Instruments ……………………………………………………………… 153

3.8 Data collection …………………………………………………………... 170

3.9 Ethical considerations …………………………………………………… 171

3.10 Data analysis ………………………………………………………….... 172

3.11 Summary ……………………………………………………………….. 176

Chapter 4: The Pilot Study …………………………………………………... 177

4.1 Introduction ……………………………………………………………... 177

4.2 Aims …………………………………………………………………….. 177

4.3 Description of the setting………………………………………………… 177

4.4 Procedures ………………………………………………………………. 178

4.5 Results …………………………………………………………………... 180

4.5.1 Demographic and clinical characteristics …………………………. 183

4.5.2 Exercise stages of change …………………………………………. 186

4.5.3 Exercise self-efficacy ……………………………………………... 187

4.5.4 Exercise decisional balance ……………………………………….. 187

xii

4.5.5 Exercise …………………………………………………………… 189

4.5.6 Angina …………………………………………………………….. 190

4.5.7 Quality of life ……………………………………………………... 191

4.6 Implications for the main study …………………………………………. 195

4.7 Summary ……………………………………………………………….... 198

Chapter 5: Results ………………………………………………………......... 199

5.1 Introduction ……………………………………………………………... 199

5.2 Recruitment of patients ………………………………………………….. 199

5.3 Demographic and clinical characteristics of dropouts versus completers.. 202

5.4 Demographic and clinical characteristics of the patients ……………….. 205

5.5 Effects of the exercise stage-matched intervention (ESMI) …………….. 210

5.5.1 Exercise stages of change …………………………………………. 210

5.5.2 Exercise self-efficacy ……………………………………………... 218

5.5.3 Exercise decisional balance ……………………………………….. 222

5.5.4 Exercise …………………………………………………………… 228

5.5.5 Angina …………………………………………………………….. 234

5.5.6 Quality of life ……………………………………………………... 245

5.6 Summary ……………………………………………………………….... 273

Chapter 6: Discussion ………………………………………………………… 274

6.1 Introduction ……………………………………………………………... 274

6.2 High participation/completion rate ……………….................................... 274

6.3 The effects of the ESMI on CHD patients ………………………………. 276

6.3.1 Exercise behaviour …………………………………………........... 277

6.3.2 Health outcomes ……………………………………………........... 290

6.4 Tracking of the TTM-based ESMI on exercise behaviour …………….... 298

6.5 Limitations and controversies of the TTM ……………………………… 300

6.6 Nursing role of cardiac rehabilitation in mainland China ………………. 306

6.7 Summary ………………………………………………………………... 308

Chapter 7: Conclusions and Implications …………………………………... 310

7.1 Introduction ……………………………………………………………... 310

7.2 Conclusions from the findings …………………………………………... 310

7.3 Limitations of this study and recommendations for future research ……. 312

7.4 Implications ……………………………………………………………... 314

xiii

7.5 Summary ………………………………………………………………... 318

References ……………………………………………………………………... 319

Appendices ……………………………………………………………………. 365

Appendix I Contraindications for Exercise Training ……………………… 366

Appendix II Ethics Approval Letters ……………………………………… 368

Appendix III Access Approval Letters from the Hospitals …………........... 369

Appendix IV Screening Guidelines ………………………………………... 372

Appendix V Information Sheet ……………………………………………. 386

Appendix VI Consent Form ……………………………………………….. 388

Appendix VII Protocol of Weekly Patient Education Session …………….. 389

Appendix VIII Guidelines for Exercise Prescription ……………………… 390

Appendix IX Exercise Stage-Matched Pamphlets ……………..................... 397

Appendix X An Example of the TTM-based ESMI……………................... 444

Appendix XI Screening Form ……………………………………………… 446

Appendix XII Questionnaires ……………………………………………… 452

Appendix XIII Scoring Instructions ……………………………………….. 471

Appendix XIV Training Package ………………………………………….. 488

Appendix XV Status of Normal Distribution and Homogeneity of Variance

of Each Variable .......................................................................... 515

Appendix XVI The Results of the Baseline Outcome Comparisons ............. 516

Appendix III Access Approval Letters from the Hospitals - Chinese

Version ...................................................................................... ... 521

Appendix IV Screening Guidelines – Chinese Version……………………. 524

Appendix V Information Sheet – Chinese Version……………………….... 532

Appendix VI Consent Form – Chinese Version……………………………. 533

Appendix VII Protocol of Weekly Patient Education Session – Chinese

Version…...................................................................................... 534

Appendix VIII Guidelines for Exercise Prescription – Chinese Version ….. 535

Appendix IX Exercise Stage-Matched Pamphlets – Chinese Version…....... 541

Appendix XI Screening Form – Chinese Version .…………........................ 590

Appendix XII Questionnaires – Chinese Version …………......................... 596

Appendix XIII Scoring Instructions – Chinese Version …………................ 613

Appendix XIV Training Package – Chinese Version …………………….... 629

xiv

LIST OF TABLES

Table Page

Table 2.1 Studies on the effect of patient education on exercise behaviour …. 68

Table 2.2 Definitions of the processes of change for physical activity ……… 112

Table 2.3 The emphasis of different change processes according to stages of

change …………………………………………………………......

113

Table 3.1 Protocol of weekly exercise stage-matched intervention session ..... 148

Table 3.2 Guidelines of goal, processes, and strategies for changing exercise

behaviour in each stage ……………………………………............

149

Table 3.3 Outcome measurements …………………………………………… 157

Table 4.1 Demographic characteristics of the subjects ………………………. 184

Table 4.2 Clinical characteristics of the subjects …………………………….. 185

Table 4.3 Distribution of the exercise stages of change in the three groups …. 186

Table 4.4 Changes in the exercise stages of change in the three groups at T1 .. 186

Table 4.5 Changes in the mean scores of the exercise self-efficacy (ESE) in

the three groups ……………………………………………………

187

Table 4.6 Changes in the mean scores of the exercise benefits scale (EBS)

and exercise barriers scale (EBBS) in the three groups …………...

188

Table 4.7 Changes in the mean minutes of the total exercise duration and

moderate exercise duration per week in the three groups …………

189

Table 4.8 Changes in angina frequency, angina severity and angina duration

in the three groups ………………………………………................

190

Table 4.9 Changes in the mean scores of the five subscales of SAQ in the

three groups ………………………………………………………..

192

Table 4.10 Changes in the mean scores of the eight domains of SF-36 in the

three groups ………………………………………………………..

194

Table 5.1 Demographic characteristics of dropouts versus completers ……… 202

Table 5.2 Clinical characteristics of dropouts versus completers ……………. 204

Table 5.3 Demographic characteristics of the subjects ………………………. 206

Table 5.4 Clinical characteristics of the subjects …………………………….. 209

Table 5.5 Exercise stages of change at each time point ……………………… 212

Table 5.6 Comparisons of movement of exercise stages of change among

xv

groups at each time point …………………………………………. 215

Table 5.7 Comparisons of the mean change scores of the exercise stages of

change among groups at each time point ……………………….....

217

Table 5.8 Comparisons of exercise stages of change within each group across

time ………………………………………………………………...

218

Table 5.9 Mean and standard deviation of the exercise self-efficacy (ESE)

scale scores at each time point …………………………………….

219

Table 5.10 Comparisons of the mean change scores of the exercise self-

efficacy (ESE) scale among groups at each time point ……………

221

Table 5.11 Comparisons of exercise self-efficacy (ESE) within each group

across time …………………………………………………………

222

Table 5.12 Mean and standard deviation of the exercise benefits (EBS) scale

scores and exercise barriers scale (EBBS) scores at each time

point ………….................................................................................

224

Table 5.13 Comparisons of the mean change scores of the exercise benefits

scale (EBS) scores and exercise barriers scale (EBBS) scores

among groups at each time point ………………………………….

227

Table 5.14 Comparisons of the exercise benefits scale (EBS) scores and

exercise barriers scale (EBBS) scores within each group across

time ………………..........................................................................

228

Table 5.15 Mean and standard deviation of exercise duration (minutes/week)

at each time point ………………………………………………….

230

Table 5.16 Comparisons of the mean change minutes of exercise duration

(minutes/week) between groups at each time point ……………….

233

Table 5.17 Comparisons of exercise duration (minutes/week) within each

group across time ………………………………………………….

234

Table 5.18 Mean and standard deviation of angina frequency, angina severity

and angina duration at each time point ……………………………

237

Table 5.19 Comparisons of angina frequency, angina severity and angina

duration among groups at each time point ………………………...

240

Table 5.20 Comparisons of angina frequency, angina severity and angina

duration within each group across time ……………………………

242

Table 5.21 Comparisons of items on angina attack and anti-anginal drugs

xvi

taken in the past one week at each time point …………………….. 243

Table 5.22 Comparisons of anginal attack and anti-anginal drugs taken

within each group across time …………………………………......

245

Table 5.23 Mean and standard deviation of subscales of SAQ at each time

point ………………………………………………………………..

248

Table 5.24 Comparisons of mean change scores of subscales of SAQ among

groups at each time point ……………………………….................

253

Table 5.25 Comparisons of subscale scores of SAQ within each group across

time ………………………………………………………………...

255

Table 5.26 Mean and standard deviation of eight domains of SF-36 at each

time point …………………………………………………………..

258

Table 5.27 Comparisons of mean change scores of eight domains of SF-36

among groups at each time point ………………………………...

268

Table 5.28 Comparisons of eight domains of SF-36 within each group across

time ………………………………………………………………..

271

Table 6.1 The change in exercise stages of change in the ESMI group during

the intervention period .....................................................................

299

xvii

LIST OF FIGURES

Figure Page

Figure 1.1 Theoretical framework of the study …............................................. 11

Figure 2.1 The transtheoretical model of behaviour change …………………. 104

Figure 2.2 Relationship among stages of change, processes of change,

decisional balance and self-efficacy ……………………………….

105

Figure 3.1 Flowchart of the study design …………………………………….. 138

Figure 4.1 Flowchart of the pilot study ………………………………………. 182

Figure 5.1 Flowchart of the recruitment process....…………………………... 201

Figure 5.2 The number of patients in the action and maintenance stages at

each time point …………………………………………………….

213

Figure 5.3 The change in the exercise self-efficacy (ESE) scores throughout

the study …………………………………………………………...

220

Figure 5.4 The change in the exercise benefits scale (EBS) scores throughout

the study …………………………………………………………...

225

Figure 5.5 The change in the exercise barriers scale (EBBS) scores

throughout the study ……………………………………………….

225

Figure 5.6 The change in the total exercise duration (minute/week)


231

Figure 5.7 The change in the moderate exercise duration (minute/week)


231

Figure 5.8 The change in the angina frequency (episode/week) throughout

the study …………………………………………………………...

238

Figure 5.9 The change in the angina severity (0-10) throughout the study ….. 238

Figure 5.10 The change in the angina duration (minute/week) throughout the

study ……………………………………………………………….

239

Figure 5.11 The change in the physical limitation scores of SAQ throughout

the study …………………………………………………………...

249

Figure 5.12 The change in the angina stability scores of SAQ throughout the

study ……………………………………………………………….

249

Figure 5.13 The change in the angina frequency scores of SAQ throughout

the study …………………………………………………………...

250

xviii

Figure 5.14 The change in the treatment satisfaction scores of SAQ


250

Figure 5.15 The change in the disease perception scores of SAQ throughout

the study …………………………………………………………...

251

Figure 5.16 The change in the physical functioning scores of SF-36

throughout the study ………………………………………………

260

Figure 5.17 The change in the role-physical scores of SF-36 throughout the

study ……………………………………………………………….

260

Figure 5.18 The change in the bodily pain scores of SF-36 throughout the

study ……………………………………………………………….

261

Figure 5.19 The change of the general health scores of SF-36 throughout the

study ……………………………………………………………….

261

Figure 5.20 The change in the vitality scores of SF-36 throughout the study 262

Figure 5.21 The change in the social functioning scores of SF-36 throughout

the study …………………………………………………………...

262

Figure 5.22 The change in the role-emotional scores of SF-36 throughout the

study ……………………………………………………………….

263

Figure 5.23 The change in the mental health scores of SF-36 throughout the

study ……………………………………………………………….

263

Figure 5.24 The change in the physical component summary of SF-36


264

Figure 5.25 The change in the mental component summary of SF-36


264

Figure 5.26 The change in the reported health transition scores of SF-36


265

1

Chapter 1 Introduction

1.1 Introduction

This chapter presents an overview of this study and the reasons for conducting it. It

includes the background to the research problem, and the aims and objectives,

research questions, theoretical framework, and significance of the study.

1.2 Background

Although the World Health Organization (WHO) emphasizes primary and secondary

preventions of coronary heart disease (CHD), CHD is still a leading cause of death

and disability among adults worldwide (Lloyd-Jones, Adams, Brown et al., 2010).

The prevalence of CHD has increased rapidly over the past few decades in China

(Zhang, Lu & Liu, 2008). Around 652,000 people were diagnosed with CHD and

400,000 died of the disease in 2004, accounting for 22.0% of deaths from

cardiovascular disease and 9.0% of total deaths among the country‘s urban population

(Zhang, Lu & Liu, 2008). CHD has become the third leading cause of death among

Chinese adults (Health Statistics Information Centre of Ministry of Health, 2010). The

burden of caring for those with CHD has been growing in China and will become the

leading health care issue if methods of both primary and secondary prevention are not

addressed (Teo, Liu, Chow et al., 2009).

Exercise training alone or exercise-based cardiac rehabilitation has been shown to be

beneficial to CHD patients (Senuzun, Fadiloglu, Burke & Payzin, 2006; Taylor,

2

Brown, Ebrahim et al., 2004; Valkeinen, Analtonen & Kujala, 2010). The benefits

include a decrease in the frequency of anginal attacks and the number of sublingual

glyceryl trinitrate (GTN) tablets that need to be taken (Burke, Williams & Lockyer,

2002; Lewin, Furze, Robinson et al., 2002), a reduction in mortality rates, fatal

reinfarctions, and cardiac risk factors (e.g., lipid profiles and BMI) (Chair, Thompson,

Tang & Leung, 2007; Jolliffe, Rees, Taylor et al., 2001; Kelley, Kelley & Franklin,

2006; Taylor, Brown, Ebrahim et al., 2004), and improvements in physical

functioning (Brubaker, Witta & Angelopoulos, 2003; Franklin, Bonzheim, Warren et

al., 2002; Senuzun, Fadiloglu, Burke & Payzin, 2006), psychological well-being

(Arnold, Sewell & Singh, 2007; Burke, Williams & Lockyer, 2002; Lewin, Furze,

Robinson et al., 2002), and quality of life (Davies, Moxham, Rees et al., 2002; Hwang

& Marwick, 2009; Jeger, Jörg, Rickenbacher et al., 2007).

However, the participation rate in exercise training or exercise-based cardiac

rehabilitation programmes is low around the world despite convincing evidence of the

benefits of such programmes. In the United States, two large cohort reports on

Medicare patients showed that only 12.2% (N = 601,099) to 18.7% (N = 267,427) of

CHD patients attended at least one session of an outpatient cardiac rehabilitation

programme after being discharged from the hospital (Suaya, Shepard, Normand et al.,

2007; Suaya, Stason, Ades et al., 2009). In England, nationally, 29.0% of eligible

CHD patients attended cardiac rehabilitation programmes, with the proportion ranging

from 14.0% to 37.0% within regions (Bethell, Lewin, Evans et al., 2008). In Japan,

the national participation rate in outpatient cardiac rehabilitation programmes

following acute myocardial infarction was found to be only 3.8-7.6% (Goto, Saito,

Iwasaka et al., 2007). In Hong Kong, a study exploring the utilization of a 7-week

3

phase II outpatient cardiac rehabilitation programme showed that only 25.0% (37/145)

of the participants attended at least one session during the 6-month period following

their discharge from hospital and only 7.5% (11/145) completed the programme

(Chan, Chau & Chang, 2005). Although exercise-based cardiac rehabilitation has

been well developed in many countries, it is still underdeveloped in mainland China

(Thompson & Yu, 2007; Wang, Chair, Thompson & Twinn, 2009).

Of those who participated in cardiac rehabilitation programmes, the dropout rate is

high. In a randomized exercise trial, around 20.0% of patients following myocardial

infarction who participated in the exercise programme withdrew from it after two

months, and the dropout rate reached 45.0% during the first six months of the

programme (Dorn, Naughton, Imamura & Trevisan, 2001). Another study showed

that around 50.0% of women with CHD (107/228) failed to complete the prescribed

sessions (Sanderson & Bittner, 2005). Similar observations were made by Moore et al.

(2003), Sanderson et al. (2003), Sarrafzadegan et al. (2007), and Worcester et al.

(2004). Women, elderly persons or those with a low level of education, and those

suffering from depression or severe diseases were particularly prone to dropping out

of the programmes (Dorn, Naughton, Imamura & Trevisan, 2001; Suaya, Shepard,

Normand et al., 2007; Witt, Jacobsen, Weston et al., 2004). Given such discouraging

figures, interventions are needed to improve the uptake of exercise-based cardiac

rehabilitation programmes and adherence to them.

The possible reasons for the low attendance rates and poor adherence to exercise-

based cardiac rehabilitation programmes may be that CHD patients lack the interest or

motivation to attend the programmes (Evenson, Johnson & Aytur, 2006), or that they

4

lack the confidence to perform exercises, worry about the occurrence of angina, or

hold the misconception that physical activity may provoke an anginal attack

(Kristofferzon, Löfmark & Carlsson, 2007; Thompson & Lewin, 2000; Zhu, Ho & Sit,

2012). Our previous interview (Zhu, Ho & Sit, 2012) with 11 Chinese CHD patients

in mainland China shows that patients perceived CHD as a life-threatening illness

mostly related to chest pain and worries about the recurrence of heart attacks. Patients

often hold misconception that heart attacks are unpreventable and that physical

activity provokes chest pain. The result of these misconceptions is fewer changes in

behaviour and disengagement from physical activity. The use of action-oriented

interventions in cardiac rehabilitation programmes may also contribute to the low

attendance rates. This is because such interventions are typically designed for people

who are highly motivated and ready to change their behaviour. They are not effective

enough to motivate changes in behaviour among those who have no intention to

change or no interest in changing their behaviour (Marcus, Emmons, Simkin-

Slverman et al., 1998).

Health education is the most common intervention for increasing physical activity

among ageing adults (Conn, Valentine & Cooper, 2002). Having a theory/model to

guide health education is thought to be more effective in producing changes in

behaviour than having no theory/model (Painter, Borba, Hynes et al., 2008).

Numerous models and theories, such as the Transtheoretical Model (TTM), the Social

Cognitive Theory (SCT), the Health Belief Model (HBM), the Theory of Reasoned

Action (TRA), and the Theory of Planned Behaviour (TPB), have been used for

patient education to promote behavioural changes. Among these models/theories, the

TTM has been found to be effective on motivating changes in behaviour (Faghri,

5

Omokaro, Parker et al., 2008; Kim, 2007 & 2008; Lippke, Schwarzer, Ziegelmann et

al., 2010; Prochaska & DiClemente, 1983). The strength of the TTM is that it treats

behavioural change as a dynamic rather than an ―all or nothing‖ phenomenon

(Marshall & Biddle, 2001). The SCT, TPB, and HBM all focus on explaining a purely

behavioural criterion, namely, engaging in behaviour or not, whereas the TTM

explains a complex, mixed criterion that includes five stages of readiness for

behavioural change based on the cognitive, motivational, and behavioural aspects of

an individual (Courneya, 1995). The TTM allows practitioners to develop a stage-

matched intervention with reference to the stages of readiness for behavioural change.

For example, for an individual at the stages of precontemplation and contemplation,

no action-oriented intervention will be implemented because of the individual‘s lack

of intention or preparation to change his/her behaviour at these stages. Thus, the

employment of the TTM for changing exercise behaviour may be more appropriate

than mismatched or action-oriented interventions (Marcus, Emmons, Simkin-

Silverman et al., 1998).

A number of studies have illustrated that the TTM is an effective model for changing

exercise behaviour among various populations, from adolescents (Nigg & Courneya,

1998) to the elderly (Burbank, Reibe, Padula & Nigg, 2002; Findorff, Stock, Gross &

Wyman, 2007; Greaney, Riebe, Garber et al., 2008; Resnick & Nigg, 2003). Several

cross-sectional and longitudinal studies (Hellman, 1997; Jue & Cunningham, 1998)

showed that the application of the TTM for changing exercise behaviour could be

adopted for older adults with heart disease. Unfortunately, there have been few studies

examining the effects of the TTM-based intervention on changes in exercise

behaviour among heart disease patients. In our previous systematic review (Zhu, Ho

6

& Wong, unpublished), we found only three studies that used the TTM to motivate

heart disease patients to exercise. However, these three studies came to different

conclusions about adherence to exercise (Hughes, Gillies, Kirk et al., 2002; Hughes,

Mutrie & Maclntyre, 2007; Naser, Jafar, Kumar et al., 2008).

Despite these inconsistent results, all of these three studies recruited participants

immediately after the completion of the formal cardiac rehabilitation programme.

Clearly, all of the participants were in the preparation, action, or maintenance stages

at the time that they entered the study, which means that they were ready to change

their behaviour or already active at baseline. Based on the TTM, the strategies and

techniques (processes of change) used to motivate individuals in the precontemplation

or contemplation stages to change their behaviour are different from those in the

preparation, action, or maintenance stages because those in the precontemplation

stage usually have no intention or interest in changing their behaviour (Prochaska &

DiClemente, 1983). Individuals in the precontemplation stage tend to be defensive

and avoid changing their thinking and behaviour and to use fewer processes of change

than those in any other stage (Prochaska & DiClemente, 1983). Thus, whether the

TTM-based Exercise Stage-Matched Intervention (ESMI) is effective at motivating

sedentary patients with heart disease, who are in the precontemplation, contemplation,

and preparation stages, to engage in exercise is not clear.

In summary, regular exercise is beneficial for CHD patients. However, rates of

participation and adherence to exercise-based cardiac rehabilitation programmes are

unsatisfactory. The TTM is well known for motivating changes in behaviour; however,

it is seldom used to bring about changes in exercise behaviour among CHD patients.

7

Therefore, whether or not it can motivate sedentary CHD patients to engage in

exercise is unclear.

1.3 Aim and Objectives

The aim of this study is to evaluate the effects of a TTM-based Exercise Stage-

Matched Intervention (ESMI) on sedentary patients with CHD. The primary outcome

indicator is change in exercise behaviour in terms of exercise stages of change,

exercise self-efficacy, exercise decisional balance, and exercise duration per week.

The secondary outcome indicators are anginal attacks and quality of life. The

following objectives were set accordingly:

(1) To evaluate the effects of the TTM-based ESMI on changes in exercise

behaviour in CHD patients;

(2) To evaluate the effects of the TTM-based ESMI on anginal attacks in CHD

patients;

(3) To evaluate the effects of the TTM-based ESMI on the quality of life of CHD

patients.

1.4 Research questions

In accordance with the objectives of this study, the following research questions were

generated:

8

Will the CHD patients participating in the Exercise Stage-Matched Intervention

(ESMI) group:

（1） demonstrate a more positive shift in exercise stages of change than the

patients in the Patient Education (PE) group and the Conventional (C)

group?

（2） demonstrate higher exercise self-efficacy than the patients in the PE group

and the C group?

（3） demonstrate better exercise decisional balance in terms of greater exercise

benefits and fewer exercise barriers than the patients in the PE group and

the C group?

（4） demonstrate longer exercise duration (minutes/week) than the patients in

the PE group and the C group?

（5） demonstrate greater improvement in anginal attacks in terms of a reduction

in the frequency (episode/week), severity, and duration (minutes/week) of

angina and the number of anti-anginal drugs taken than the patients in the

PE group and the C group?

（6） demonstrate greater improvement in quality of life than the patients in the

PE group and the C group?

1.5 Theoretical Framework

In this study, the Exercise Stage-Matched Intervention (ESMI) was guided by the

TTM. The TTM consists of four constructs, including stages of change, processes of

change, self-efficacy for behavioural change, and decisional balance (Prochaska &

DiClemente, 1983). Based on the stages of change, individuals are divided into one of

9

the following five stages: precontemplation (no intention to start exercise in the next

six months), contemplation (being aware the problem exists and thinking about

starting exercise), preparation (currently engaging in some exercise, but not regularly),

action (successfully exercising regularly for less than six months), and maintenance

(exercising regularly for more than six months) (Marcus, Eaton, Rossi & Harlow,

1994; Prochaska & DiClemente, 1983). In this study, regular exercise is defined as

accumulating at least 30 minutes of moderate intensity physical activity throughout

the day for more than five days of the week (American College of Sports Medicine,

2006; Marcus, Forsyth & Blair, 2003).

The processes of change are covert and overt strategies and techniques that

individuals engage in when they attempt to modify their behaviours (Prochaska,

DiClemente & Norcross, 1992). There are ten processes, including consciousness

raising, dramatic relief, self-reevaluation, social liberation, environmental

reevaluation, helping relationships, counterconditioning, reinforcement management,

self-liberation, and stimulus control. Self-efficacy for behavioural change is an

important predictor of progress, with a linear increase from the precontemplation to

the maintenance stage. Higher self-efficacy means that individuals have a higher level

of confidence in their ability to engage in exercise. Decisional balance includes the

benefits and costs of performing a behavioural change, which vary across stages of

change. In the precontemplation stage, the benefits are meagre, with the costs

outweighing the benefits. By the contemplation or preparation stage, the benefits

increase to the same level as the costs, with the benefits eventually outweighing the

costs in the action and maintenance stages (Plotnikoff, Hotz, Birkett & Courneya,

2001).

10

The stages of change represent a temporal or developmental dimension that allows us

to understand when particular changes in attitudes, intentions, and behaviours occur,

while the processes of change enable us to understand how these changes occur

(Prochaska, DiClemente & Norcross, 1992). The TTM offers a promising approach to

integrating the stages and processes of change. Based on the stages of change,

researchers can develop stage-matched interventions. Individuals in different stages

use different processes of change to help them move on to a more advanced stage.

The processes of change are strategies and techniques used to motivate CHD patients

to change their exercise behaviour. For patients in different exercise stages of change,

different goals are set and different processes of change are used to enable them to

progress in stage. Subsequently, the ESMI improves individuals‘ exercise stages of

change, exercise self-efficacy, and exercise decisional balance (Kim, 2008; Marcus,

Emmons, Simkin-Silverman et al., 1998). Individuals with higher exercise self-

efficacy have more confidence about changing their exercise behaviour, which results

in a more positive shift in exercise stages of change. When the level of benefits of

changing one‘s exercise behaviour increase to the same level as the barriers,

individuals start to take action to change their exercise behaviour. When the benefits

outweigh the barriers, individuals are more likely to successfully adhere to exercise

behaviour, namely in the action and maintenance stages. The result is motivation to

engage in exercise.

After being motivated to exercise, individuals will tend to increase the duration of

their exercise, which is beneficial for CHD patients in terms of reducing anginal

11

attacks (Hambrecht, Walther, Möbius-Winkler et al., 2004) and improving their

quality of life (QoL) (Hwang & Marwick, 2009). A theoretical framework for the

ESMI is shown in Figure 1.1.

Processes of change

ESMI

Stages of

change

Decisional

balance

Self-efficacy

Exercise Motivation

Figure 1.1 Theoretical Framework of the Study

Reduce

Angina

Improve

Quality of Life

Increase

Exercise

Duration

12

1.6 Significance of the Study

The benefits of exercise-based cardiac rehabilitation programmes for cardiac patients

have been well documented. It is a worldwide problem that the participation and

adherence rates to the programmes are poor. The extent to which cardiac

rehabilitation services are effective depends on the patients‘ willingness and/or ability

to participate in and adhere to the recommended strategies necessary to achieve the

desired benefits (Sanderson & Bittner, 2005). Thus, how to motivate CHD patients to

exercise and/or how to improve the participation rate in exercise-based cardiac

rehabilitation programmes are global concerns. The TTM is an effective model for

bringing about changes in various behaviours, including exercise. Investigating the

effects of the TTM-based Exercise Stage-Matched Intervention (ESMI) on motivating

sedentary CHD patients to engage in exercise is timely, necessary, and important.

Although many studies regarding cardiac rehabilitation have been conducted in recent

years on patients with CHD, most of these were conducted in Western countries. Few

such studies have been conducted in China. Chen and Whitlock (2009) have pointed

out that more than 80.0% of deaths from cardiovascular disease are occurring in low-

and middle-income countries such as China, but most of the studies on this disease

have been conducted among populations in high-income countries. As a result, many

of the related clinical and public health policies being applied in lower-income

countries stem from studies carried out in high-income ones, and may therefore be

inappropriate given the substantially different physical, social, and economic

environments between the two types of countries. Thus, the findings from this study

13

should provide evidence for clinical practice and a foundation for further studies and

for the development of cardiac rehabilitation programmes in China.

Cardiac rehabilitation programmes have been well developed in many Western

countries. However, they are new to mainland China and are underdeveloped

(Thompson & Yu, 2007; Wang, Chair, Thompson & Twinn, 2009). Few hospitals in

China provide structured patient education programmes or formal cardiac

rehabilitation programmes for cardiac patients. Our previous qualitative study shows

that CHD patients eagerly sought information about cardiac rehabilitation and how to

prevent the recurrence of another heart attack, especially information about diet and

physical activity (Zhu, Ho & Sit, 2012). The findings from the qualitative study

highlight the need for health education to support CHD patients in mainland China.

There are no formal or structured patient education programmes in Xiamen City,

China, where the actual study was carried out. The introduction of a structured or

formal patient education programme supplemented with a booklet would be a great

improvement in the care of CHD patients. In addition, due to the increased prevalence

of chronic diseases, the Chinese government has been emphasizing primary and

secondary prevention of chronic diseases. Thus, together with the limited health care

resources, the paucity of rehabilitation facilities, and an underdeveloped

reimbursement system, the TTM-based ESMI may be a trend in the development of

cardiac rehabilitation programme in China. Home-based rehabilitation, one of the

characteristics of the TTM, should be a more practical and feasible approach to

helping Chinese CHD patients.

14

Regular exercise has been shown to be beneficial to patients with heart disease. It is

envisaged that the proposed health education programme based on the TTM will

motivate sedentary patients with coronary heart disease to engage in exercise and

consequently improve their angina and quality of life.

1.7 Thesis outline

This study consists of seven principal chapters, namely, the introduction, literature

review, research methodology, findings of the pilot study, results of the main study,

discussion, and conclusion and implications.

Chapter 1 starts with some relevant background information on the prevalence of

CHD and the benefits of exercise-based cardiac rehabilitation. Subsequently, the

problems and gaps in research, as well as the justification and significance of the

study are presented. The related aim, objectives, and research questions are then listed.

The theoretical framework of this study is provided. Lastly, this chapter provides an

outline summarizing the main contents of this thesis.

Chapter 2 contains a comprehensive review of the existing literature regarding the

research context and the main constructs under investigation, namely, coronary heart

disease, exercise, patient education, and the transtheoretical model of behaviour

change (TTM). Chapter 3 addresses the methodological issues of this study, namely,

the research design, sampling design, research procedures, detailed intervention,

outcome measurements, data collection, and data analysis.

15

Chapter 4 describes the findings from the pilot study and discusses the implications

for the main study. Chapter 5 presents the results of the main study. Chapter 6 fully

discusses the results of the main study by focusing on the research questions and

compares the findings with previous studies and the literature. Finally, Chapter 7

draws the conclusions of this study and discusses the implications for nursing practice,

as well as the limitations of the study and recommendations for future research.

1.8 Summary

Coronary heart disease is a leading cause of death and disability among adults

worldwide. Exercise-based cardiac rehabilitation programmes have been shown to

benefit patients with heart disease. However, rates of attendance in and adherence to

such programmes are poor. The TTM is a successful model for changing exercise

behaviour among various populations. Few studies have been conducted on the use of

the TTM for changing exercise behaviour in CHD patients. Therefore, whether or not

such a programme can motivate sedentary CHD patients to engage in exercise is

unclear. It is thus necessary to conduct a study to evaluate the effects of the TTM-

based Exercise Stage-Matched Intervention (ESMI) on changing the exercise

behaviour of sedentary CHD patients in China.

16

Chapter 2 Literature Review

2.1 Introduction

This chapter begins with a review of the literature on coronary heart disease (CHD),

including the prevalence of CHD and the impact of CHD on patients, followed by the

benefits and safety of exercise for CHD patients. Patient education and the

Transtheoretical Model (TTM) to promote exercise are presented as possible

approaches to address the low attendance rate in exercise-based cardiac rehabilitation

programmes. It is concluded that it is necessary to develop a patient education

programme based on the TTM to motivate sedentary CHD patients to engage in

exercise.

2.2 Coronary Heart Disease (CHD)

This section presents the definition and prevalence of CHD, and the impact of CHD

on patients, including physical, psychological, and social domains, and quality of life.

2.2.1 Definition of Coronary Heart Disease (CHD)

Coronary heart disease (CHD), also called ischemic heart disease, refers to coronary

circulation failure arising from a reduction or arrest of the blood supply to the

myocardium resulting from atherosclerosis of the coronary arteries and related

phenomena such as atheromatous plaque rupture and thrombosis (Khaw, 2005). CHD

manifests clinically as angina pectoris, myocardial infarction, cardiac failure,

17

arrhythmias and/or sudden death, usually related to acute arrhythmias. This study

focuses on patients with angina pectoris and/or myocardial infarction and those who

had undergone percutaneous coronary intervention (PCI).

2.2.2 Prevalence of Coronary Heart Disease (CHD)

This subsection presents the prevalence of CHD in foreign countries and China,

illustrating that the prevalence of CHD is high around the world.

Although the primary and secondary prevention of CHD is well developed, CHD is

still a leading cause of death and disability among adults worldwide. According to the

World Health Organization (WHO) (2008), an estimated 17.5 million people died of

cardiovascular disease (CVD) in 2005, representing 30.0% of all global deaths. Of

those deaths, 7.6 million were due to heart attacks and 5.7 million were due to strokes.

Around 82.0% of CVD deaths occurred in low and middle income countries (LMIC),

such as China. It was reported that, if appropriate action is not taken, an estimated

23.6 million people will die of CVD every year by 2030, mainly from coronary heart

disease and stroke (WHO, 2011).

According to the National Service Framework (2008), annually around 1.4 million

people suffer from angina and nearly 300,000 people suffer from myocardial

infarction (MI). In the United States, the prevalence of CHD was estimated to be 13

million (6.9% of the population) in 2002 (Bittner & Sanderson, 2006). Statistics from

the American Heart Association (2001) show that around 450,000 people die of CHD

each year. A recent report from the American Heart Association (Rosamond, Flegal,

18

Furie et al., 2008) shows that an estimated 600,000 new heart attacks and 320,000

recurrent attacks occur annually, and that CHD causes 20.0% of all deaths in the

United States. Rosamond et al. (2008) stated that 770,000 new heart attack cases

would be reported in America in 2008, and that nearly 430,000 would be potentially

recurrent attack cases. The prevalence of CHD was found to increase with age but to

decrease with rising educational levels (Rosamond, Flegal, Furie et al., 2008). It has

been reported that an estimated 30 million Americans will be diagnosed with CHD by

2050 (Foot, Lewis, Pearson & Beller, 2000).

In the United Kingdom, approximately two million people are suffering from angina

(Deaton & Namasivayam, 2004). The prevalence of angina was 5.0-10.0% in men

aged 40 to 60, with the incidence increasing with age (Bono, 1999). A recent cohort

study (Lampe, Morris & Walker, 2005), which followed up 7,735 men aged 40 to 59

from 1978 to 2000, showed that the rate of major coronary events fell substantially by

an average of 3.6% per year over the 20-year period, while the rate at which angina

pectoris was first diagnosed increased by an average of 2.6% per year. The findings

suggest that the number of survivors of CHD has increased.

In Finland, CHD causes approximately 14,000 deaths (7,500 men and 6,500 women)

every year in a population of about five million (Lukkarinen & Hentinen, 1997).

Approximately 50,000 people are diagnosed with coronary artery disease annually.

Cardiovascular disease is also the leading cause of morbidity and mortality in Ireland,

accounting for 39.0% of all deaths (Condon & McCarthy, 2006). In Sweden, it was

estimated that 90,000 people are being hospitalized annually due to MI.

19

Cardiovascular disease accounts for about 30.0% of all deaths in Sweden and 13.0%

of deaths are caused by MI (Bergman & Bertero, 2003).

In Hong Kong, heart disease has been the second leading cause of death since the

1960s (Department of Health, 2011), and more than 68.0% of all deaths from heart

disease are due to CHD (Hospital Authority, 2011). On average, CHD kills one Hong

Kong citizen every hour (Census and Statistics Department, 2011). Deaths from CHD

have increased in the period between 1981 and 2009, rising from 2,103 deaths in 1981

to 4,003 in 2005 and 4,360 in 2009 (Hospital Authority, 2011). Age standardized

CHD mortality rates in Hong Kong for those aged 35-64 were 44.3 (95% confidence

intervals (CI) 40.2-48.2) per 100,000 males and 14.1 (95% CI 11.6-16.6) per 100,000

females (Dwyer, Emmanuel, Janus, Wu, Hynes & Zhang, 2003). These figures

suggest that the mortality rate from CHD is high in Hong Kong. In short, the situation

regarding the prevalence of CHD in Hong Kong is also not promising.

The prevalence of CHD in China does not present an optimistic picture. It has

increased rapidly over the past few decades in China (Wu, 2003; Zhang, Lu & Liu,

2008) and has now become the third leading cause of death among Chinese adults

(Health Statistics Information Centre of Ministry of Health, 2010). The mortality rate

of CHD increased by 50.0% in men and by 27.0% in women aged 35 to 74 years in

Beijing between 1984 and 1999 (Critchley, Liu, Zhao, Wei & Capewell, 2004). From

1990 to 2000, the mortality rate of CHD has increased by 4.5% in urban areas and

4.1% in rural areas (Wu, 2003). Recent reports have shown that the morbidity rate of

CHD in China among those aged 35-74 years ranges from 2.0% to 6.0% (Chen, Meng

& Wei et al., 2007; Chen, Wei & Meng et al., 2005; Huang, Wang, Xu & Yin, 2002;

20

Li, Sun, Zheng et al., 2007; Yan, Zhang, Yang et al., 2004). Annually, there are 0.5

million new cases of MI and 3.0 million new cases of CHD (Yang, Yang & Liu,

2007). Around 652,000 people were diagnosed with CHD and 400,000 died of the

disease in 2004, accounting for 22.0% of deaths from cardiovascular disease and

9.0% of total deaths among the urban population (Zhang, Lu & Liu, 2008). According

to statistics from the WHO, in China, cardiovascular disease accounted for 33.0% of

all deaths in 2005 (WHO, 2005) and the estimated mortality of CHD was 7.3% of all

deaths in 2004 (WHO, 2004). The average mortality rate of CHD was 51.1 per

100,000 in China, ranging from 33.7 per 100,000 in rural areas to 74.1 per 100,000 in

urban areas in 2006 (Health Statistics Information Centre of Ministry of Health, 2007).

The report also illustrated that the mortality rate of CHD rises with age (2.1 per

100,000 in those aged 30-34 and 2454.8 per 100,000 in those aged 85 or above). The

latest report indicated that the mortality rate of heart disease was 128.8 per 100,000 in

cities in 2009, accounting for 20.8% of all deaths, and 112.9 per 100,000 in counties,

accounting for 17.2% of all deaths, with a rate of 118.3-133.2 per 100,000 males and

109.2-124.4 per 100,000 females in both the city and county (Health Statistics

Information Centre of Ministry of Health, 2010). The burden of caring for those with

CHD has been growing in China and will become the leading health care issue if

methods of both primary and secondary prevention are not addressed (Teo, Liu, Chow

et al., 2009).

The above review illustrates the globally high prevalence of CHD. CHD is a leading

cause of death and disability among adults globally. The prevalence of CHD has

grown quickly in recent decades in China to currently become the third leading cause

of death among adults in China.

21

2.2.3 Impact of Coronary Heart Disease on Patients

In view of the fact that CHD is one of the leading causes of death, it is important to

know about the impact of CHD on patients with respect to the physical, psychological,

emotional, and social aspects of their life, and their quality of life.

2.2.3.1 Physical Impact

The physical impact of CHD on patients can be illustrated in terms of symptoms

suffered by the patients, the limitations placed on their physical activities, or physical

disabilities.

2.2.3.1.1 Symptoms

Patients with CHD often experience a series of symptoms. Many qualitative studies

have demonstrated that the most common symptoms reported by CHD patients are

chest pain, breathlessness, and fatigue (Albarran, Clarke & Crawford, 2007;

Fitzsimons, Parahoo & Stringer, 2000; Jerlock, Gaston-Johansson & Danielson, 2005;

Johansson, Dahlberg & Ekebergh, 2003; McCormick, Naimark & Tate, 2002;

Roebuck, Furze & Thompson, 2001). Chest pain has been found to be the most severe

symptom and the most frequent reason cited by patients for why they were worried

about an impending heart attack (Roebuck, Furze & Thompson, 2001). Fitzsimons

and co-workers (2000) interviewed 70 patients waiting to undergo coronary artery

22

bypass graft (CABG) surgery. They found that the patients reported chest pain as an

experience that caused them to panic and that it was a major difficulty in their lives.

A number of quantitative studies also have indicated that CHD patients often

complain of chest pain, shortness of breath, and fatigue. A recent study in Pittsburgh

that recruited 116 black and 1,080 white CHD patients revealed that 73.8% of the

patients complained about shortness of breath, 71.8% reported experiencing chest

pain, and 5.9% reported fatigue (Hravnak, Whittle, Kellwy et al., 2007). Lindgren,

Fukuoka, Rankin and others (2008) questioned 247 elderly (age > 65 years) patients

with CHD about the symptoms they had experienced in the week before being

hospitalized. They found that fatigue was the most frequently reported symptom

(76.0%), followed by shortness of breath (62.0%) and chest pain (56.0%). These

studies have illustrated that CHD patients commonly suffer from chest pain,

breathlessness, and fatigue.

The influence of fatigue, usually raised as a complaint at the early stage of a post-MI

attack (Wiklund, Sanne, Elmfeldt et al., 1984), declines after the acute phase of MI

has passed (Hravnak, Whittle, Kellwy et al., 2007). Unlike fatigue, complaints of

chest pain and shortness of breath may last for a long time in the post-MI period. In

several large-scale cross-sectional studies, around 27.0% of patients complained of

angina one month after MI according to the Seattle Angina Questionnaire (SAQ),

24.0% six months after MI, and 20.0% 12 months after MI (Maddox, Reid, Spertus et

al., 2008; Plomondon, Magid, Masoudi et al., 2007; Spertus, Dawson, Masoudi et al.,

2006). Beinart et al. (2003) observed 1975 patients seven months after the onset of

acute coronary syndromes and found that appropriate 31.0% of the patients had

23

angina monthly, 25.0% had it weekly, and 8.7% experienced it daily. Around 50.0%

of CHD patients reported dyspnea one month after MI (Arnold, Spertus, Jones et al.,

2009). Near 40.0% of MI survivors reported chest pain and around 60.0% reported

dyspnea within five years following MI (Brown, Melville, Gray et al., 1999; Norekvål,

Wahl, Fridlund et al., 2007).) The dyspnea was strongly related to the severity of the

chest pain (Bengtson, Herlitz, Karlsson & Hjalmarson, 1996). These findings suggest

that angina and dyspnea are two common symptoms among patients with CHD, and

that these symptoms will persist for a long period of time.

Previous studies have indicated that symptoms of angina and/or dyspnea among

patients are strongly related to higher mortality (Arnold, Spertus, Jones et al., 2009;

Berecki-Gisolf, Humphreyes-Reid, Wilson & Dobson, 2009; Mozaffarian, Bryson,

Spertus et al., 2003), lower functional capacity (Scirica, 2009), a poorer quality of life

(Arnold, Spertus, Jones et al., 2009; Scirica, 2009), more frequent episodes of

rehospitalization (Arnold, Spertus, Jones et al., 2009), and lower treatment

satisfaction (Plomondon, Magid, Masoudi et al., 2007). The symptoms subsequently

influence the prognosis of CHD patients.

In a word, chest pain, shortness of breath, and fatigue were the most common

symptoms in CHD patients. Fatigue improved with time, while chest pain and

shortness of breath could have a prolonged impact on patients and were negatively

associated with survival rates, quality of life, rehospitalization, and treatment

satisfaction. Thus, interventions to improve anginal pain and shortness of breath are

critically important.

24

2.2.3.1.2 Physical Activity Limitations or Physical Disabilities

CHD patients have a lower exercise capacity than age-matched individuals without

CHD (Mital, Shrey, Govindaraju et al., 2000). As reported, heart disease has been

ranked as the third leading cause of activity limitations among those suffering from

chronic diseases (Pinsky, Jette, Branch et al., 1990). A cross-sectional study involving

4,286 women aged 60 - 79 years from 23 towns in England has shown that 37.2% of

the women experience limitations in locomotor activity and that CHD is the disease

with the second-strongest association with this limitation in activity (OR = 2.3)

(Adamson, Lawlor & Ebrahim, 2004). Following a heart attack, patients often

perceive some degree of disability or handicap. Near 90.0% of female MI survivors

(N = 145) reported that heart disease limited their daily activities during the first five

years of the post-MI period (Norekvål, Wahl, Fridlund et al., 2007). The Framingham

disability study (Pinsky, Jette, Branch et al., 1990) (N = 2576) found that disability is

is more prevalent in subjects with CHD than in those without CHD. Both

uncomplicated and complicated angina pectoris are strongly related to the degree of

disability in both men and women of all age groups. Similarly, MI patients are more

likely than those without MI to show a decline in physical functioning and social

functioning (Mendes de Leon, Krumholz, Vaccarino et al., 1998). Clearly, CHD

commonly has an impact on the daily activities of patients or results in physical

disability.

Limitations in physical activity are associated with symptoms, especially chest pain.

Kiessling and Henriksson (2007) assessed the prevalence and severity of chest pain

symptoms using the Canadian Cardiovascular Society Angina Classification in 253

25

Swedish patients with CHD. They found that 59.0% of the patients had slight to

severe chest pain limiting ordinary activities at baseline, 48.0% at the 1-year follow-

up period, and 49.0% at the 2-year follow-up period. Another study (Bengtson,

Herlitz, Karlsson & Hjalmarson, 1996), which involved 831 patients awaiting

revascularization, demonstrated that 88.0% of the patients reported chest pain that

limited their daily activities to some extent. Restricted physical activities were also

reported by CHD patients in several qualitative studies (Fitzsimons, Parahoo &

Stringer, 2000; Roebuck, Furze & Thompson, 2001). Thompson and Lewin (2000)

stated that CHD patients may lack the confidence to engage in exercise, worry about

the occurrence of angina, or hold the misconception that physical activity may

provoke an anginal attack, all of which will result in further physical deterioration.

Our preliminary qualitative study has also shown that CHD patients often stop

engaging in physical activity due to worries about provoking anginal pain (Zhu, Ho &

Sit, 2012).

Physical activity limitations or physical disability can have a further impact on the

rehabilitation of patients with CHD because physical activity or exercise is a core

component of cardiac rehabilitation programmes. Due to such limitations or

disabilities, CHD patients may stop participating in exercise-based cardiac

rehabilitation programmes. Previous studies have indicated that regular exercise or

involvement in an exercise-based cardiac rehabilitation programme significantly

increases the exercise capacity, physical fitness, and quality of life of CHD patients

(Ades, Pashkow, Fletcher et al., 2000; Bize, Johnson & Plotnikoff, 2007; Davies,

Moxham, Rees et al., 2010; Hwang & Marwick, 2009; Jeger, Jörg, Rickenbacher et al.,

2007) and reduced mortality, fatal reinfarction, and cardiac risk factors (e.g., lipid

26

profiles and BMI) (Jolliffe, Rees, Taylor et al., 2001; Kelley, Kelley & Franklin, 2006;

Taylor, Brown, Ebrahim et al., 2004). Consequently, physical limitations will delay a

patient‘s recovery.

To conclude, the most common symptoms experienced by CHD patients are chest

pain, shortness of breath, and fatigue. Patients with CHD often suffer from limitations

to their physical activities or physical disabilities to some degree. It is has been

reported that symptoms, especially chest pain, restrict their physical activities.

2.2.3.2 Psychological and Emotional Impact

The major forms of psychological and emotional distress that CHD patients complain

about are anxiety and depression, which may influence the prognosis of their disease.

This subsection presents a review of the above mentioned issues, so that the

psychological and emotional impact of CHD on patients can be addressed clearly.

2.2.3.2.1 Psychological and Emotional Distress

Owing to the high recurrence of heart attack and the high mortality rates of CHD,

patients often suffer from some kinds of psychological distress. The most common

forms of psychological distress in CHD patients are depression and anxiety. A

number of studies using various measuring instruments to examine the status of the

psychological health of CHD patients have indicated that the rate of depression

among such patients ranges from 28.4% to 78.6%, and the rate of anxiety ranges from

20.8% to 97.0% (Aben, Verhey, Strik et al., 2003; Chen, Gu, Lu & Yang, 1997; Cruz,

27

Fleck & Polanczyk, 2010; Du, Jiang, Yang et al., 2003; Hou, 2005; Jia & Shao, 2005;

Josephson, Casey, Waechter, Rosneck & Hughes, 2006; Long, Wang, Wang & Song,

2005; Todaro, Shen, Raffa et al., 2007; Wiklund, Sanne, Elmfeldt, Vedin &

Wilhelmsson, 1984; Zhang, Tang & Yu, 2005; Zhou & You, 2003). These findings

suggest that CHD patients have high morbidity rates from depression and anxiety.

When the Symptom Checklist 90 (SCL-90) was used to measure the psychological

health of CHD patients, the findings illustrated that the scores in all subscales of SCL-

90, especially in somatization, phobia, anxiety, and depression, were much higher for

CHD patients than for non-CHD patients (p < 0.05) (Aben, Verhey, Strik et al., 2003;

Huang & Zhang, 2004, Meng, Guo & Guo, 2004; Xu, 2004; Yue, 2004; Zhang,

Huang, Han & Li, 2004; Zhang, Wang & Zeng, 2004; Zhu, Lin, Huang et al., 2007).

These findings suggest that CHD patients have poor psychological health and are

prone to depression and anxiety.

When the relationship between emotional distress and cardiovascular symptoms (e.g.,

chest pain, fatigue, palpitations, presyncope, and dyspnea) was investigated, a strong

negative association was identified (Ketterer, Knysz, Keteyian et al., 2008). A

phenomenographic study (Johansson, Swahn & Strömberg, 2007) has revealed that a

patient‘s anxiety is mostly related to the nature of his/her physical symptoms. The

more severe the symptoms, the more likely anxiety is to emerge. A qualitative study

(White, Hunter & Holttum, 2007) with five newly diagnosed MI women has shown

that fear and anxiety are the most frequent emotional reactions to cardiac events.

Concerns about the future are one of main reasons for fear and anxiety. The patients

reported that they felt angry and frustrated by over-protectiveness, being told what to

28

do, and their restricted abilities. The perceived loss of their independence and the

existence of physical disabilities also made them feel sad.

Psychological and emotional distress in patients could last for a long period of time. A

study involving 201 MI patients has shown that 65.0% of the patients felt anxious and

depressed two months after MI (Wiklund, Sanne, Elmfeldt, Vedin & Wilhelmsson,

1984). More than half of the patients with acute coronary syndromes (N = 160)

reported anxiety and loss of confidence 3-12 months after hospitalization (Yuval,

Halon & Lewis, 2007). Almost one-fifth of the CHD patients failed to deal with their

emotional distress 3-5 years following the disease (Boersma, Maes & Joekes, 2005).

Younger patients are more likely than older ones to be suffering from psychological

distress. A study (Beckie, Fletcher, Beckstead et al., 2008) comparing the

psychological health of 92 younger (≤ 64 years) and 90 older (> 64 years) women

with CHD found that younger women had significantly worse psychosocial profiles

than older ones. Sixty-four per cent of younger women had depressive symptoms,

while the figure was 37.0% in older ones. Younger women also reported feeling

significantly more anxious than older ones (p < 0.001).

To conclude, anxiety and depression are common in CHD patients, especially

younger ones. Such feelings can persist for a long period of time.

29

2.2.3.2.2 Prognosis of CHD Patients with Psychological and Emotional

Symptoms

Previous studies (Albert, Chae, Rexrode et al., 2005; Ariyo, Haan, Tangen et al., 2000;

Gump, Matthews, Eberly & Chang, 2004) have demonstrated that levels of anxiety

and depression can predict the severity of CHD. The presence of depression and

anxiety is related to cardiac events, such as the recurrence of angina pectoris and

myocardial infarction, and sudden death (Frasure-Smith, Lesperance & Talajic, 1995;

Hemingway & Marmot, 1999; Lauzon, Beck, Huynh et al., 2003; Shen, Avivi, Todaro

et al., 2008). In a prospective cohort study (Rothenbacher, Hahmann, Wusten et al.,

2007), 1,052 patients with CHD aged 30-70 years were recruited. The results suggest

that anxiety might be a much stronger predictor than depression for subsequent

adverse cardiovascular events in patients with CHD. In another prospective study with

536 MI patients (Moser, Riegel, McKinley et al., 2007), the results indicated that

patients with a higher level of anxiety have significantly more episodes of

complications, such as ventricular tachycardia, ventricular fibrillation, reinfarction,

and ischemia in the acute stage, which influence a patient‘s prognosis. In addition,

CHD patients with anxiety or depression are less likely to adhere to medical advice

(Lauzon, Beck, Huynh et al., 2003; Thompson & Lewin, 2000; Ziegelstein, Fauerbach,

Stevens et al., 2000), less likely to return to work (So.dermana, Lisspersa & Sundinb,

2003; Thompson & Lewin, 2000), more likely to withdraw from cardiac rehabilitation

programmes (Josephson, Casey, Waechter, Rosneck & Hughes, 2006; Yohannes,

Yalfani, Doherty & Bundy, 2007), and more likely to have a poorer prognosis (Barth,

Schumacher & Herrmann-Lingen, 2004) as compared with CHD patients without

psychological distress.

30

The presence of anxiety and depression can also increase the mortality rate of CHD

patients. A recent meta-analysis (Barth, Schumacher & Herrmann-Lingen, 2004) has

shown that depressive symptoms increase the risk of mortality in CHD patients. The

death rate of patients with depression is double that of those without depression (OR =

2.2) within two years after the initial assessment. Even in the long term, the mortality

rate is still higher in CHD patients with depressive symptoms (OR = 1.8). The results

suggest that depression has to be considered as a relevant risk factor in patients with

CHD. Barefoot, Helms, Mark, and others (1996) examined the relationship between

depression and long-term mortality risk in patients with CHD for up to 19.4 years.

The results demonstrated that patients with moderate to severe depression have a

69.0% greater risk of cardiac death and a 78.0% greater risk of all-cause mortality

than non-depressed patients. The findings also showed that patients with moderate to

severe depression have an 84.0% greater risk of cardiac death 5-10 years later and a

72.0% greater risk after 10 years when compared with non-depressed patients. It is

concluded that depression may be persistent or frequently recurrent in CHD patients

and is associated with CHD progression, the triggering of acute events, or both.

Szekely, Balog, Benko, and others (2007) explored the long-term (four years) impact

of anxiety on mortality in 180 patients after cardiac surgery. They found that patients

with anxiety had a significantly higher mortality rate than those who did not suffer

from anxiety. A cohort study (Shibeshi, Yong-Xu & Blatt, 2007) with 516 CHD

patients over an average of 3.4 years illustrated that the risk of nonfatal MI or total

mortality rises with each unit of increase in the cumulative mean anxiety score.

31

Several studies have also shown that depression and/or anxiety are independent

factors associated with a worse quality of life, when the Medical Outcomes Study 36-

Item Short-Form (SF-36) was used to measure the quality of life of patients (Cruz,

Fleck & Polanczyk, 2010; Dickens, McGowan, Percival et al., 2006; Herry N,

Suryadipradja, Shatri & Prodjosudjadi, 2005; Lam, Chin, Lee et al., 2009). These

findings suggest that depression and/or anxiety predict the quality of life of patients.

In addition, patients with psychological problems have a higher consultation rate

(Lam, Chin, Lee et al., 2009), which implies that such patients add to the medical

burden.

To conclude, anxiety and depression are common in CHD patients. CHD patients with

such forms of psychological distresses as anxiety and depression have a poorer

prognosis than those who do not suffer from such distress. Depression and/or anxiety

also impair the quality of life of CHD patients. It is therefore important to identify

methods to improve the psychological health of CHD patients.

2.2.3.3 Social Impact

This subsection presents the impact of CHD on the social life of patients and the

burden on society of caring for CHD patients.

The physical activity of patients is strongly associated with social participation

(Adamson, Lawlor & Ebrahim, 2004). Previous studies have shown that the

proportion of adults returning to work after acute MI varies from 35.0% to 90.0%

(Cay, Vetter, Philip & Dugard, 1973; Earle, Ayanian & Heymann, 2006). Patients

32

with a higher socioeconomic status, a higher level of education, and who were

younger were more likely to resume work after acute MI. Patients with MI were

significantly less likely to return to work than patients with angina (56.0% versus

94.0%) (Earle, Ayanian & Heymann, 2006). Patients with a history of heart attack

tended to retire early, stop working, or look for a less demanding job. Those returning

to work experienced a considerable decrease in working efficiency. Symptoms such

as angina and breathlessness, together with emotional upset, and the attitude of

patients towards their physical disabilities were considered to be contributing factors.

Returning to work is a hallmark of recovery from CHD. Patients with limited physical

activities will reduce their social activities.

Apart from the social impact on individuals, the cost of CHD treatments is also a

burden. Bittner and Sanderson (2006) reported that over $100 billion is spent annually

on CHD in the United States in direct medical costs, disability payments, and lost

productivity. The estimated direct and indirect cost of CHD was $156.4 billion in

2008 in the United States (Rosamond, Flegal, Furie et al., 2008). The physical

limitations induced by CHD not only affect the social activity of patients, such as

their ability to return to work, but also increase the financial burden on society.

In a word, after MI patients are less likely to return to work and impose a heavy

burden on society. Thus, providing cardiac rehabilitation programmes to improve the

health of CHD patients, which consequently helps them return to work early and

reduces the social and financial burden of their illness, is meaningful.

33

2.2.3.4 Impact on Quality of Life (QoL)

Since CHD impairs the physical, psychological, and social health of patients, the

result is that they have a poor quality of life. Findings from a qualitative study showed

that MI leads to a variety of health-related problems that affect the quality of life of

patients (Roebuck, Furze & Thompson, 2001). Other studies have indicated that CHD

patients have a rather poor quality of life with respect to SF-36, with little

improvement found between admission and one month post discharge (Spiraki,

Kaitelidou, Papakonstantinou et al., 2008). Indeed, declines were observed in three of

the eight domains of SF-36 three months post discharge (Failde & Soto, 2006).

Around 25.0% of CHD patients had a poor quality of life (Zboralski, Galecki,

Wysokiński et al., 2009). Although many studies have shown that the quality of life of

CHD patients improves over time (Brink, Grankvist, Karlson et al., 2005;

Kristofferzon, Löfmark & Carlsson, 2005), patients following MI still had a clinically

poor health-related quality of life two years after acute MI (Bengtsson, Hagman,

Währborg & Wedel, 2004). When compared with an age- and sex-matched healthy

population, MI patients scored lower in most domains of SF-36 within a period of 2.5

years following MI (Alsén, Brink, Persson et al., 2010; Pettersen, Reikvam, Rollag &

Stavem, 2008; Sacker, Head & Bartley, 2008; Worcester, Murphy, Elliott et al., 2007;

Zboralski, Galecki, Wysokiński et al., 2009). These findings suggest that CHD

impairs the quality of life of patients. Patients with a poor quality of life suffered

significantly higher mortality in the 10 years following MI (Parakh, Bhat, Thombs et

al., 2010). Clearly, interventions to improve the quality of life of CHD patients are

necessary.

34

To sum up, CHD patients often experience a series of physical, psychological, and

emotional symptoms. The most common physical symptoms are chest pain,

breathlessness, and fatigue; the most common psychological and emotional symptoms

are anxiety and depression. These symptoms restrict patients‘ physical and social

activities. As a result, both the quality of life of the patients and society will be

affected.

2.3 Exercise and Coronary Heart Disease (CHD)

Physical activity refers to any bodily movement that is produced by the contraction of

skeletal muscles and that increases energy expenditure above the resting level.

Exercise is a subclass of physical activity and is defined as planned, structured, and

repetitive bodily movements performed specifically to improve or maintain physical

fitness (Fletcher & Braun, 2008).

Physical exercise is a core component of cardiac rehabilitation (Taylor, Brown,

Ebrahim et al., 2004), which has been shown to benefit the health of CHD patients

(Warburton, Katzmarzyk, Rhodes & Shephard, 2007). This section presents the

benefits of exercise for CHD patients, followed by similar effects contributed by

hospital/centre-based and home-based exercise programmes. The situation of cardiac

rehabilitation in China is then described and the safety of exercise for patients with

CHD is discussed. Finally, the poor attendance of exercise-based cardiac

rehabilitation programme is presented.

35

2.3.1 Benefits of Exercise for CHD Patients

This subsection reviewed the benefits of exercise for CHD patients in terms of lipid

indicators, heart rate (HR), blood pressure (BP), psychological well-being, angina,

coronary events, and quality of life.

2.3.1.1 Benefits of Exercise on Lipid Indicators

Lipid indicators, such as total cholesterol (TC), low-density lipoprotein cholesterol

(LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride (TG), are

related to the prognosis of CHD patients. The elevated levels of TC, LDL-C, or TG,

or lowered HDL-C increase the risks of reinfarction and mortality from CHD. A

number of studies have shown that regular exercise or exercise-based cardiac

rehabilitation leads to a significant reduction in body mass index (BMI), TC, LDL-C,

and TG levels, and significant increase in HDL-C levels (Asbury, Slattery, Grant et al.,

2008; Chair, Thompson, Tang & Leung, 2007; de Geus, van Hoof, Aerts & Meeusen,

2008; Franklin, Bonzheim, Warren et al., 2002; Jiang, Sit & Wong, 2007; Milani,

Lavie & Cassidy, 1996; Senuzun, Fadiloglu, Burke & Payzin, 2006). A decrease in

BMI would result in greater improvements in TC, LDL-C, and HDL-C in CHD

patients (Kelley, Kelley & Franklin, 2006).

Several meta-analyses have indicated that aerobic exercise or exercise-based cardiac

rehabilitation significantly increases HDL-C levels and decreases TC, LDL-C, and

TG levels in adults (Conn, Hafdahl, Cooper et al., 2009; Kelley, Kelley & Tran, 2005;

Kodama, Tanaka, Saito et al., 2007) and in CHD patients (Jolliffe, Rees, Taylor et al.,

36

2001; Kelley, Kelley & Franklin, 2006; Taylor, Brown, Ebrahim et al., 2004).

Kodama and others (2007) showed that every 10-minute prolongation of exercise per

session is associated with an approximately 1.4 mg/dl increase in HDL-C levels. This

finding suggests that exercise duration is very important because an increase in the

level of HDL-C is beneficial for CHD patients. These studies confirmed that regular

exercise or exercise-based cardiac rehabilitation benefits CHD patients in terms of

improving their lipid levels, consequently reducing their cardiac risk factors.

2.3.1.2 Benefits of Exercise on Heart Rate (HR) and Blood Pressure (BP)

Elevated HR is related to an increase in demand for oxygen, even when the heart

performed at a constant external work (Rosano, Vitale & Volterrrani, 2010).

Myocardial ischemia occurs from a mismatch between myocardial oxygen supply and

demand, both of which are influenced by HR. Elevated resting HR has long been

regarded as an independent predictor of cardiovascular and all-cause mortality in all

populations because high HR has direct detrimental effects not only on myocardial

ischemia but also on the progression of atherosclerosis, ventricular arrhythmias, and

left ventricular function (Batty, Shipley, Kivimaki et al., 2010; Rosano, Vitale &

Volterrrani, 2010). The risk increases when HR ≥ 70 bpm. A cohort study involving

9,580 subjects indicated that every 10 bpm increase in the resting HR was associated

with an 8.0% increase in major cardiovascular events in patients with stable CHD,

and a resting HR of ≥ 70 bpm was associated with a 40.0% increase in the risk of all-

cause mortality and more than double the risk of hospitalization due to heart failure

(Ho, Bittner, DeMicco et al., 2010).

37

A large-scale survey with 5,017 men and 5,607 women aged 30-69 years has

demonstrated an inverse dose-response relationship between self-reported leisure

physical activity and resting HR for both men and women (Emaus, Degerstrøm,

Wilsgaard et al., 2010). Aerobic exercise has been shown to lead to a significant

reduction in resting HR (Shiotani, Umegaki, Tanaka et al., 2009). Results from

several randomized controlled trials have also shown that exercise training or

exercise-based cardiac rehabilitation significantly increases maximal oxygen uptake

(Dressendorfer, Franklin, Cameron et al., 1995; Hambrecht, Walther, Mobius-Winkler,

et al., 2004; Hung, Daub, Black et al., 2004), and significantly reduces resting HR for

patients with CHD (Dressendorfer, Franklin, Cameron et al., 1995; Franklin,

Bonzheim, Warren et al., 2002). A meta-analysis has indicated that exercise training

significantly decreases resting HR in patients with heart disease (van Tol, Huijsmans,

Kroon et al., 2006). These findings suggest that exercise has the benefit of reducing

resting HR in patients with CHD.

Similar to HR, elevated BP increases risks for patients with CHD. Patients with CHD

have significantly higher systolic and diastolic BP as compared with those without

CHD (Kannel, Schwartz & McNamara, 1969). In a population-based prospective

study (Dorjgochoo, Shu, Zhang et al., 2009), the results showed that hypertension and

higher levels of individual BP parameters including systolic and diastolic BP, pulse

pressure, and mean arterial pressure were positively associated with mortality from all

causes, strokes, and CHD. Each five mmHg increment in systolic BP or mean arterial

pressure was associated with an increased risk of stroke mortality. In this study,

hypertension (all grades) accounted for 9.3% of all-cause, 25.5% of stroke-cause, and

21.7% of CHD-cause mortality.

38

Several studies have demonstrated an inverse relationship between physical activity

and BP (Fagard & Cornelissen, 2007; So, Sung, Li et al., 2010). One study on

Japanese male workers showed that subjects who walked > 8,000 steps/day or

exercised > 3 times/week had a significantly lower risk of developing hypertension as

compared with those who walked < 4,000 steps/day or exercised < 3 times/week

(Ishikawa-Takata, Tanaka, Nanbu & Ohta, 2010). Exercise training has a significant

effect on reducing BP (Cornelissen, Verheyden, Aubert & Fagard, 2010; Reboredo,

Henrique, Faria et al., 2010). Previous studies have shown that exercise training or

exercise-based cardiac rehabilitation has a significantly positive effect on reducing

systolic or diastolic BP among patients with CHD (Asbury, Slattery, Grant et al., 2008;

Franklin, Bonzheim, Warren et al., 2002; Jiang, Sit & Wong, 2007). Similar results

were found in two meta-analyses in patients with heart disease (Taylor, Brown,

Ebrahim et al., 2004; van Tol, Huijsmans, Kroon et al., 2006). These findings suggest

that exercise can decrease BP, which is beneficial for the prognosis of CHD patients.

2.3.1.3 Benefits of Exercise on Psychological Well-Being

CHD patients often experience some kinds of psychological distress, such as anxiety

and depression. Such distress can independently predict the poor prognosis of patients

with CHD, including the recurrence of angina pectoris and myocardial infarction, and

sudden death (Lauzon, Beck, Huynh et al., 2003; Rothenbacher, Hahmann, Wusten et

al., 2007; Shen, Avivi, Todaro et al., 2008).

39

Previous randomized controlled trials or quasi-experimental studies have shown that

exercise training or exercise-based cardiac rehabilitation led to significant

improvements in anxiety, depression, and other psychological symptoms (Arnold,

Sewell & Singh, 2007; Asbury, Slattery, Grant et al., 2008; Benzer, Platter, Oldridge

et al., 2007; Blumenthal, Sherwood, Babyak et al., 2005; Gary, 2006; Jolly, Taylor,

Lip et al., 2007; Josephson, Casey, Waechter, Rosneck & Hughes, 2006; Koukouvou,

Kouidi, Lacovides et al., 2004; Li, 2002; Milani, Lavie & Cassidy, 1996). A meta-

analysis with 19 trials showed that interventions to increase physical activity can

result in a decrease in anxiety symptoms among healthy adults (Conn, 2010). A

similar finding was found in another systematic review by Windle, Hughes, Linck,

and others (2010), who found that exercise is effective in promoting mental well-

being in older adults.

A reduction in anxiety or depression as a result of exercise is associated with an

improvement in fitness. One study (Milani & Lavie, 2007) showed that patients with

no improvement in exercise capacity attained no significant reduction in depressive

symptoms, whereas those who achieved a modest (1-10% increase in peak VO2) or

more robust (> 10% increase in peak VO2) enhancement in exercise capacity

experienced a reduction of more than 70.0% in the prevalence of depressive

symptoms. A meta-analysis examined the effects of the physical activity intervention

on psychological well-being in people with advanced age. The findings demonstrated

the benefits of aerobic exercise training for the psychological well-being of

individuals. Improvements in cardiovascular status, strength, and functional capacity

were associated with overall improvement in psychological well-being (Netz, Wu,

Becker & Tenenbaum, 2005). Clearly, the physical fitness of patients is linked to their

40

psychological well-being. Exercise training or exercise-based cardiac rehabilitation to

increase the physical fitness of CHD patients will ultimately improve their

psychological well-being. The inescapable conclusion is that exercise is beneficial for

the psychological well-being of CHD patients.

2.3.1.4 Benefits of Exercise on Angina

Exercise training alone or exercise-based cardiac rehabilitation can slow down, halt,

and even reverse the progression of atherosclerosis and reduce angina, exercise-

induced ischemic ST-segment depression, recurrent cardiac events, and a need for

coronary revascularization procedures (Franklin, Bonzheim, Warren et al., 2002).

Numerous studies have demonstrated that exercise or physical activity has promising

effects on the management of angina. A trial comparing the anti-anginal effects of

exercise with β-blockade has shown the benefits of exercise on anti-angina to be equal

to that of β-blockade (Todd & Ballantyne, 1990). Physical inactivity causes a

reduction in fitness, which may cause angina to be found at a lower exercise threshold

(Thompson & Lewin, 2000). When patients decrease in their level of activity, there

will be an increase in the rate of occurrence of angina. Such a feedback loop will go

on with the practice of inactivity (Furze, Bull, Lewin & Thompson, 2003). A

prospective survey involving 772 men with CHD indicated that physically inactive or

occasionally active men have the highest prevalence of breathlessness and chest pain

(Wannamethee, Shaper & Walker, 2000). This finding implies that physical activity

will reduce the prevalence of chest pain. A previous study demonstrated that CHD

patients who received a 12-month exercise training experienced an increase in

41

ischemic threshold by 30.0% when compared with the baseline (Hambrecht, Walther,

Mobius-Winkler et al., 2004). A single group pre-post study showed that exercise-

based cardiac rehabilitation reduced the frequency of anginal attacks and nitroglycerin

use (Smith, Layton, Newmark et al., 1987). A randomized controlled trial on 48 CHD

patients showed that 90.0% of the patients who received an intervention involving

exercise, stress management, smoking cessation, and a low-fat vegetarian diet,

reported a reduction in angina. Moreover, 82.0% of the patients in the intervention

group showed some degree of regression of coronary artery disease at the end of the

first year (Ornish, Brown, Scherwitz et al., 1990).

Cui, Ren, Wang, and others (2006) carried out a study to evaluate the effects of

exercise training on exercise tolerance in 57 patients following PCI. Patients in the

intervention group underwent exercise training 3 days/week for three months, with an

intensity of 50.0-80.0% of maximal HR according to the symptom limited exercise

test. The results showed that exercise training increased the patients‘ total exercise

time, the time to the appearance of ST-segment depression, and total exercise

tolerance, and decreased the incidence of exercise-induced angina. The findings

supported the view that exercise training could improve exercise tolerance and reduce

anginal attacks for patients who have undergone PCI.

The findings from the above studies suggest that exercise training or exercise-based

cardiac rehabilitation has a significant effect on reducing anginal attacks among

patients with CHD.

42

2.3.1.5 Benefits of Exercise on Coronary Events

Patients with CHD have a higher risk of coronary events, such as heart attacks, fatal

reinfarctions, and sudden death, than those without CHD. Physical activity or exercise

reduces the risk of coronary events (Scrutinio, Temporelli, Passantino & Giannuzzi,

2009). A prospective survey (Wannamethee, Shaper & Walker, 2000) included 772

men aged 52 to 73 years who were diagnosed with CHD. The findings indicated that

men who engaged in light to moderate intensity of activity showed a significant

reduction in the risk of total and cardiovascular mortality even after adjusting for age,

social class, smoking, obesity, history of MI, diabetes, stroke, and self-rated health

status. A longitudinal study over a 7-year period showed that individuals who

remained active or increased their level of physical activity following the first MI had

a lower risk of reinfarction or death due to all causes than those who remained

sedentary (Steffen-Batey, Nichaman, Goff et al., 2000). The findings from these

studies suggest that physical activity reduces the chances of coronary events in CHD

patients.

Previous studies have demonstrated that exercise-based cardiac rehabilitation

significantly reduces all-cause and cardiac-cause mortality, cardiovascular events,

restenosis, and fatal reinfarction (Goel, Lennon, Tilbury, Squires & Thomas, 2011;

Huang, Li, Mao et al., 2006; Huang, Mao, Deng et al., 2004; O‘Connor, Buring,

Yusuf et al., 1989). Exercise training was associated with a higher percentage of

event-free survivors (88.0%) (Hambrecht, Walther, Mobius-Winkler et al., 2004).

Exercise training or exercise-based cardiac rehabilitation may also reduce the rate of

hospitalization due to heart failure (Davies, Moxham, Rees et al., 2010; Hwang &

43

Marwick, 2009). These studies illustrate that exercise training or exercise-based

cardiac rehabilitation decreases the rate of occurrence of coronary events.

A meta-analysis with 33 observational cohort studies has revealed that individuals

who achieved 7.9 metabolic equivalents (METs) or more in maximal aerobic capacity

had a lower mortality and CHD risk than those whose aerobic capacity was less than

7.9 METs (Kodama, Saito, Tanaka et al., 2009). It was also found that a 1 -MET

increase in aerobic capacity was related to decreases of 13% and 15% in the risk of

all-cause mortality and CHD in healthy men and women, respectively (Kodama, Saito,

Tanaka et al., 2009). Another meta-analysis including 48 trials with a total of 8,940

CHD patients showed a reduction of 20.0% to 32.0% in all-cause mortality and

cardiac mortality among patients who attended an exercise-based rehabilitation

programme (Taylor, Brown, Ebrahim et al., 2004). Similar findings were reported by

another meta-analysis of CHD patients (Jolliffe, Rees, Taylor et al., 2001). The results

showed that exercise alone led to a 27.0% reduction in all-cause mortality and a

31.0% reduction in cardiac cause mortality. These two meta-analyses further confirm

the benefits of exercise for reducing mortality among populations with or without

CHD.

These findings suggest that exercise training or exercise-based cardiac rehabilitation

has beneficial effects on all-cause or cardiac-cause mortality, cardiovascular events,

and reinfarction for patients with CHD.

44

2.3.1.6 Quality of Life

Quality of life is considered an important indicator of the health of those with a

chronic disease, such as CHD (Wong & Chair, 2007) and has been used as an

endpoint in clinical trials and as a marker of health care quality (Dougherty, Dewhurst,

Nichol & Spertus, 1998). In this subsection, the benefits of exercise on quality of life

and the instruments used to measure it are reviewed.

2.3.1.6.1 Benefits of Exercise on Quality of Life

Since exercise training alone or exercise-based cardiac rehabilitation has beneficial

effects on both the physical and psychological health of patients with heart disease, it

will result in an improvement in their quality of life. A systematic review has

indicated that cross-sectional studies (n = 7) show a consistently moderate to strong

positive association between an individual‘s level of physical activity and his/her

health-related quality of life; and cohort studies (n = 2) and randomized controlled

studies (n = 4) tend to show that the level of physical activity has a positive effect on

health-related quality of life (Bize, Johnson & Plotnikoff, 2007). A number of

randomized controlled trials have demonstrated that exercise training alone or

exercise-based cardiac rehabilitation leads to a significant improvement in most

domains of health of SF-36, especially in physical functioning, bodily pain, general

health, role-physical, vitality, and mental health, among patients with heart disease

when compared with usual care (Arthur, Gunn, Thorpe et al., 2007; Arthur, Smith,

Kodis & McKelvie, 2002; Asbury, Slattery, Grant et al., 2008; Brubaker, Witta &

Angelopoulos, 2003; Dolansky & Moore, 2004; Elley, Kerse, Arroll & Robinson,

45

2003; Izawa, Hirano, Yamada et al., 2004; Jiang, Sit, Wong et al., 2004; Milani, Lavie

& Cassidy, 1996; Yonezawa, Masuda, Matsunage et al., 2009; Yu, Lau, Chau et al.,

2004).

A similar result was found when other quality of life scales (e.g., Seattle Angina

Questionnaires, Sickness Impact Profile and Minnessota Living with Heart Failure

Questionnaire) were used to measure the effects of exercise on patients with heart

disease (Arnold, Sewell & Singh, 2007; Benzer, Platter, Oldridge et al., 2007; Burke,

William & Lockyer, 2002; Franklin, Bonzheim, Warren et al., 2002; Gary, 2006;

Hung, Daub, Black et al., 2004; Koukouvou, Kouidi, Lacovides et al., 2004; Lewin,

Furze, Robinson et al., 2002; Marchionni, Fattirolli, Fumagalli et al., 2003; Senuzun,

Fadiloglu, Burke & Payzin, 2006). Several systematic reviews also have shown that

exercise training or exercise-based cardiac rehabilitation significantly improves

health-related quality of life in patients with heart disease (Davies, Moxham, Rees et

al., 2010; Hwang & Marwick, 2009; Taylor, Brown, Ebrahim et al., 2004). These

findings support the evidence that exercise training or exercise-based cardiac

rehabilitation benefits patients with heart disease by improving their quality of life.

2.3.1.6.2 Instruments for Measuring Quality of Life

Instruments developed to measure quality of life can be divided into two categories –

generic or disease specific. Generic tools provide a broad assessment of the health

status of an individual and allow comparisons of quality of life between groups of

patients with different conditions, while disease-specific instruments are designed to

measure quality of life by tapping those areas of life that may be affected by a specific

condition or illness (Dempster & Donnelly, 2000). Recently, many researchers have

46

recommended that both generic and disease-specific instruments should be used

together to evaluate quality of life (Arthur, Smith & Natarajan, 2008; Brodie, Inoue &

Shaw, 2008; Dempster & Donnelly, 2000; Lie, Arnesen, Sandvik, Hamilton & Bunch,

2009; McGillion, Watt-Watson, Stevens et al., 2008; Wong & Chair, 2007). The

benefits of using both generic and disease-specific instruments to measure quality of

life are: (i) to provide complementary information in clinical trials (Lie, Arnesen,

Sandvik, Hamilton & Bunch, 2009); (ii) to attain both sensitivity and specificity in

clinical change (Brodie, Inoue & Shaw, 2008); and (iii) to allow the results to be

compared with those for the general population, to make clinical interpretations more

meaningful (Arthur, Smith & Natarajan, 2008; Lie, Arnesen, Sandvik, Hamilton &

Bunch, 2009).

A systematic review (Dempster & Donnelly, 2000) of how the health-related quality

of life of patients with CHD is measured showed that the most commonly used

generic instruments are the Nottingham health profile (NHP), the SF-36, and the

sickness impact profile (SIP), and the main disease-specific instruments are the

quality of life after myocardial infarction (QLMI), the Seattle angina questionnaire

(SAQ), the quality of life index (QLI)-cardiac version, the angina pectoris quality of

life questionnaire (APQLQ), and the summary index. The NHP is a useful

measurement to assess whether or not patients have a severe health problem, but it

does not provide a comprehensive measure of quality of life, and it cannot

discriminate between the clinical classes of angina, and between people with heart

disease and healthy people (Dempster & Donnelly, 2000). The SF-36 is the most

well-known and widely used generic measure of health status. It consists of 36 items

under the following eight domains: physical functioning, bodily pain, role-physical,

47

general health, vitality, social functioning, role-emotional, and mental health. The

instrument has good psychometric properties but it cannot discriminate between

classes of angina (Dempster & Donnelly, 2000). The SIP consists of 136 items

grouped into 12 categories: sleep and rest, eating, work, home management,

recreation and pastimes, ambulation, mobility, body care and movement, social

interaction, alertness behaviour, emotional behaviour, and communication. The

instrument is too long and takes a great deal of time to administer. A comparison of

the three generic instruments reveals that the SF-36 and the NHP tend to have better

content validity in the field of heart disease than the SIP because they both cover the

areas of energy/vitality and bodily pain, while the SF-36 has higher internal

consistency coefficients and provides clearer evidence of discriminative validity than

the NHP. Thus, the SF-36 is the best generic instrument to use to measure quality of

life, and was the one selected and applied in this study.

With regard to disease-specific instruments, the QLMI consists of 26 items grouped

into five domains: symptoms, restriction, confidence, self esteem, and emotion. The

SAQ was developed to measure angina-related physical and emotional effects in CHD

patients and has been adapted cross-culturally for use in 13 countries, including China.

It consists of 19 items divided into five subscales: physical limitation, angina

frequency, angina stability, treatment satisfaction, and disease perception. All SAQ

domains show good reliability and validity, with the Cronbach α ranging from 0.67 to

0.91 (Kimble, Dunbar, Weintraub et al., 2002). The QLI was originally developed for

use on dialysis patients and was not commonly used on cardiac patients (Dempster &

Donnelly, 2000). The APQLQ consists of 22 items grouped into four domains:

physical activities, somatic symptoms, emotional distress, and life satisfaction. It has

48

good psychometric properties for discriminative purposes, but the responsiveness and

reliability of the instrument has been little examined (Dempster & Donnelly, 2000).

The summary index is a combination of the APQLQ, the angina impact questionnaire,

and the psychological general well-being scale to assess the health-related quality of

life of those with angina. However, it has received relatively little research attention.

The comparisons between the disease-specific instruments showed that the SAQ is

better at determining the impact of angina and more sensitive to clinical change than

the QLI (Dempster & Donnelly, 2000). Thus, the SAQ is the best disease-specific

instrument for measuring quality of life in CHD patients, as well as being simple and

easy to use.

Although the SF-36 can differentiate between patients with divergent medical,

psychiatric, and other serious medical conditions, there is some evidence to suggest

that it may inadequately distinguish between those with different severities of angina

as assessed by the Canadian Cardiovascular Society Angina Classification (Dougherty,

Dewhurst, Nichol & Spertus, 1998). The potential for the SF-36 to be insensitive to

changes in classes of angina necessitated the use of a second disease-specific

instrument, the SAQ to evaluate quality of life. Thus, in this study, both the SF-36 and

the SAQ were selected to measure the quality of life of CHD patients.

To sum up, exercise training alone or exercise-based cardiac rehabilitation can

improve the exercise capacity, psychological health, and quality of life of CHD

patients, and reduce risk factors and all-cause and cardiac-cause mortality.

Consequently, it will improve the prognosis of CHD patients. Thus, interventions to

motivate patients with heart disease to engage in exercise are very important and,

49

indeed, necessary. To catch the whole picture of the quality of life of CHD patients, it

is better to use both generic and disease-specific instruments together to assess the

quality of life of CHD patients. The commonly used generic and disease-specific

instruments for CHD patients are the SAQ and SF-36.

2.3.2 Hospital-based versus Home-based Exercise Programmes

Hospital-based cardiac rehabilitation programmes have been well developed in

Western countries. Most previous studies regarding exercise training programmes or

exercise-based cardiac rehabilitation interventions were hospital-based and lasted for

6-12 weeks. Despite the many known physical and psychosocial benefits of hospital-

based exercise programmes for patients with CHD, the low attendance rate of these

programmes is a widespread problem and is due to transport problems, cost, and

timetable conflicts involving family or work commitments (Chan, Chau & Chang,

2005; Evenson, Johnson & Aytur, 2006). Because it is safe for most cardiac patients

to engage in exercise and because of the results from the study of DeBusk and co-

workers (1990) indicating that accumulated physical activity (e.g., three 10-minute

bouts) of at least moderate intensity in one day produced similar improvements in

health-related outcomes to one longer exercise session (e.g., one 30-minute bout), a

home-based cardiac rehabilitation programme is an option for low-risk patients with

CHD.

Home-based rehabilitation increases uptake and adherence to rehabilitation

programmes (Jolly, Lip, Sandercock et al., 2003). Numerous studies have

demonstrated that patients who participated in a home-based cardiac rehabilitation

50

programme reported engaging in more exercise sessions per week throughout the

study (Arthur, Smith, Kodis & McKelvie, 2002) and scored higher scores in habitual

physical activity at the 12-month follow-up period when compared with those who

had attended a hospital-based cardiac rehabilitation programme (Smith, Arthur,

McKelvie & Kodis, 2004). A brief survey in the United Kingdom has shown that

patients aged > 60 years old and who were self-employed are more likely to prefer

home-based rehabilitation (Dalal & Evans, 2003). Thus, home-based cardiac

rehabilitation may improve uptake and exercise compliance among patients.

Several recent studies have demonstrated that home-based cardiac rehabilitation is as

effective as traditional hospital-based cardiac rehabilitation with respect to functional

capacity, heart rate recovery, lipid levels, anxiety and depression, and health-related

quality of life (HRQL) in patients with CHD (Arthur, Smith, Kodis & McKelvie,

2002; Dala, Evans, Campbell et al., 2007; Jolly, Taylor, Lip et al., 2007; Marchionni,

Fattirolli, Fumagalli et al., 2003; Oerkild, Frederiksen, Hansen et al., 2011; Smith,

Arthur, McKelvie & Kodis, 2004; Wu, Lin, Chen & Tsai, 2006), and risk factor

modification (e.g., aerobic exercise and a low-fat diet) (Yates, Heeren, Keller et al.,

2007). Two recent systematic reviews of home-based versus centre-based cardiac

rehabilitation involving 12 randomized controlled trials have indicated that there are

no differences in the outcomes of home- versus centre-based cardiac rehabilitation in

mortality, cardiac events, exercise capacity, BP, lipid profiles, and health-related

quality of life (Dalal, Zawada, Jolly, Moxham & Taylor, 2010; Taylor, Dalal, Jolly et

al., 2010), while home-based cardiac rehabilitation is superior to centre-based

rehabilitation in adherence to exercise (Dalal, Zawada, Jolly et al., 2010). These

51

studies suggest that home-based cardiac rehabilitation is as effective as centre-based

rehabilitation.

Previous studies have demonstrated that home-based cardiac rehabilitation has

positive effects on lipid levels, exercise capacity, peak oxygen consumption, exercise

duration on treadmill tests, distance of the 6-minute walk, psychological well-being,

and quality of life among patients with heart disease when compared with usual care

(Asbury, Slattery, Grant et al., 2008; Gary, 2006; Hwang & Marwick, 2009; Salvetti,

Oliveira Filho, Servantes & de Paola, 2008; Senuzun, Fadiloglu, Burke & Payzin,

2006). An additional positive effect on exercise self-efficacy was observed for

patients who attended a home-based cardiac rehabilitation programme (Senuzun,

Fadiloglu, Burke & Payzin, 2006; Sinclair, Conroy, Davies & Bayer, 2005). This

additional effect may be due to the fact that patients who attend home-based cardiac

rehabilitation need to monitor themselves during exercise. The self-monitoring of

exercise training might build their confidence in maintaining their level of exercise

and adhering to the exercise programme (Gary, 2006; Izawa, Watanabe, Omiya et al.,

2005). In addition, patients who participated in a home-based cardiac rehabilitation

programme perceived a higher level of social support when compared with those in

the hospital-based cardiac rehabilitation programme (Gary, 2006). This may be

because patients can obtain support from their family, friends or relatives when

exercising at home. Moreover, home-based cardiac rehabilitation is cost-effective for

low-risk patients (Marchionni, Fattirolli, Fumagalli et al., 2003; Salvetti, Oliveira

Filho, Servantes & de Paola, 2008).

52

To sum up, home-based cardiac rehabilitation is as effective as hospital-based cardiac

rehabilitation on mortality, risk factors, physical and psychological health, and quality

of life among patients with heart disease. Home-based cardiac rehabilitation has the

additional effect of increasing the exercise self-efficacy and social support of CHD

patients, improving exercise adherence, and being cost-effective. Thus, in this study

we selected a home-based cardiac rehabilitation programme for low-risk patients with

CHD.

2.3.3 Cardiac Rehabilitation Programmes in China

Few studies have been carried out in China on exercise training or exercise-based

cardiac rehabilitation for patients with heart disease. A limited number of studies have

shown that exercise training or exercise-based cardiac rehabilitation results in

significant improvements in lipid profiles (including TC, LDL-C, and TG) and BP

(Jiang, Sit & Wong, 2007), exercise capacity, angina, walking performance,

cardiovascular events, and daily activities (Cui, Ren, Wang et al., 2006; Huang, Mao,

Deng at al., 2004; Jiang, Sit & Wong, 2007; Li & Gao, 2007; Liu, Zhang, Yang, Yuan,

Yang & Brodie, 2007; Zhang, Li & Wang, 1999; Zhong, Lei, Qiao et al., 1999; Zhu,

2004), as well as quality of life (Huang, Li, Mao et al., 2006; Jiang, Sit, Wong et al.,

2004). Only one study (Li, 2002) evaluated the effect of exercise training on

psychological health, in which aerobic exercise training relieved the psychological

distress of CHD patients when SCL-90 was used to measure their psychological

health over six months.

53

Most of these studies were limited by their focus on PCI patients, the effectiveness of

their functional capacity, small sample sizes, and a non-RCT design. Little attention

was paid to the effects of exercise training or exercise-based cardiac rehabilitation on

self-efficacy, exercise adherence, psychological well-being, and quality of life. Thus,

studies with a high quality of design (e.g., RCT) and with a sample size of enough

power to evaluate the effects of exercise-based cardiac rehabilitation on exercise

adherence and quality of life are necessary in a Chinese CHD population.

2.3.4 Safety of Exercise for CHD Patients

Several studies have shown that it is safe for most cardiac patients to engage in

exercise training. Haskell (1994) reviewed the safety of cardiac exercise programmes

for cardiac patients. He suggested that high-risk patients should receive close

supervision when exercising for as long as required; low-risk patients should be

instructed to engage in unsupervised exercise at home; and moderate-risk patients

should begin with on-site supervision and proceed to nonmedical supervised or home-

based programmes as their clinical status improves. Pavy, Iliou, Meurin, and others

(2006) examined the rate of occurrence of complications during the performance of

exercise in the course of cardiac rehabilitation. A total of 25,420 cardiac patients were

recruited in the study. They underwent 42,419 exercise stress tests and performed

743,471 patient-hours of exercise training. Cardiovascular events were defined as

chest pain with typical ECG modifications, severe ventricular arrhythmias, syncope,

cardiopulmonary resuscitation, immediately transferring to a coronary care unit or

cardiac surgery, and using intravenous drugs. Any event that occurred during or up to

one hour after exercise stress testing or exercise training was considered a

54

cardiovascular complication resulting from exercise testing or training. The findings

showed that the rate of occurrence was 1 per 8,484 exercise stress tests and 1 per

49,565 patient-hours of exercise training. The cardiac arrest rate was 1.3 per million

patient-hours of exercise. There were no fatal complications and emergent

defibrillations in this study. In other words, it is suggested that exercise training or

exercise testing is safe for cardiac patients. The latest review (Audelin, Savage &

Ades, 2008) also suggests that exercise-based outpatient cardiac rehabilitation is safe

for very old patients (≥ 75 years). To sum up, exercise training is safe for most cardiac

patients.

2.3.5 Poor Attendance of Exercise-based Cardiac Rehabilitation

Despite the safety of exercising and the many known physical and psychosocial

benefits of exercise-based cardiac rehabilitation for CHD patients, the low attendant

rate of these programmes is a widespread problem that may be due to a lack of

motivation to engage in exercise (Evenson, Johnson & Aytur, 2006). Previous studies

(Burns, Camaione, Froman & Clark III, 1998; Franklin, Bonzheim, Warren et al.,

2002; Pell, Pell, Morrison et al., 1996) have shown that only 11.0 – 38.0% of patients

who suffered from MI or who had undergone CABG participated in formal cardiac

rehabilitation programmes after being discharged from hospital. This indicates that

these comprehensive services are vastly underutilized, especially by older adults and

women. In a cohort study in Victoria with 12,821 patients following acute MI, CABG,

or PCI, the findings demonstrated that rates of participation in at least one session of

an outpatient cardiac rehabilitation programme were only 15.0% for those with AMI,

37.0% for CABG, and 14.0% for PTCA (Sundararajan, Bunker, Begg et al., 2004). In

55

the United States, a large cohort study involving 267,427 Medicare CHD patients

showed that the overall participation rate was 18.7%, 13.9% for those following acute

MI and 31.0% for those had undergone CABG (Suaya, Shepard, Normand et al.,

2007). The latest cohort study with 601,099 Medicare patients revealed that only

12.2% of CHD patients attended at least one session of an outpatient cardiac

rehabilitation programme after being discharged from hospital (Suaya, Stason, Ades

et al., 2009). In England, nationally, 29.0% of eligible CHD patients attended cardiac

rehabilitation programmes, with the proportion ranging from 14.0% to 37.0% within

regions (Bethell, Lewin, Evans et al., 2008). In Japan, the national participation rate in

outpatient cardiac rehabilitation following acute MI was only 3.8-7.6% (Goto, Saito,

Iwasaka et al., 2007). These findings illustrate that participation rates in exercise-

based cardiac rehabilitation programmes are globally low.

Among those who participate in cardiac rehabilitation programmes, the dropout rate is

high. In a randomized exercise trial, around 20.0% of patients following MI who had

participated in the exercise programme withdrew from it after two months, and the

dropout rate reached 45.0% during the first six months of the programme (Dorn,

Naughton, Imamura & Trevisan, 2001). Another report showed that around 50.0% of

women with CHD (107/228) failed to complete the prescribed sessions of their

rehabilitation programme (Sanderson & Bittner, 2005). Similar observations were

made by Moore et al. (2003), Sanderson et al. (2003), Sarrafzadegan et al. (2007), and

Worcester et al. (2004). The situation was worse among women, elderly persons,

those with a low level of education, those suffering from depression, or those with

severe diseases (Dorn et al., 2001; Suaya, Shepard, Normand et al., 2007; Witt,

Jacobsen, Weston et al., 2004).

56

The attendance rate of cardiac rehabilitation programmes is similarly disappointing in

China. A study was conducted exploring the utilization of a 7-week phase II cardiac

rehabilitation outpatient programme in Hong Kong (Chan, Chau & Chang, 2005). The

programme consisting of education and exercise was scheduled weekly in the

afternoon on a particular weekday for two hours in the hospital. The results showed

that only 25.0% (37/145) of the participants attended at least one session during the 6-

month period following their discharge from hospital and only 7.5% (11/145) of these

attended and completed the 7-week cardiac rehabilitation programme, although 65.3%

(119/182) of them expressed an interest in or intention to attend the programme

before being discharged from the hospital (Chan, Chau & Chang, 2005). The main

reasons mentioned for not participating in the programme were: busy with work

(45.0%), forgetfulness (13.0%), too far away from home to the hospital (9.0%),

restricted by physical condition (4.0%), and no one to accompany oneself to the

hospital (4.0%). Another study had shown that more than 30.0% of CHD patients

engaged in no regular exercise at all (Chair, Lee, Lopez & Ling, 2007). These

findings suggest that another approach to delivering exercise-based cardiac

rehabilitation programmes and to increase uptake for low-risk patients is necessary,

and that, for those who are of low risk, home-based cardiac rehabilitation may be an

alternative to conventional programmes in encouraging them to engage in exercise.

Due to the low attendance rate of exercise-based cardiac rehabilitation programmes

for cardiac patients, interventions or strategies to motivate CHD patients to adopt

exercise is critically important and, indeed, necessary.

57

2.4 Patient Education and Exercise Behaviour

Patient education is one of the key components of cardiac rehabilitation for risk factor

modification. Patient education has been broadly defined as any planned activities that

include teaching, counselling, and behaviour modification, which could result in

changes in exercise behaviour (Conn, Hafdahl, Brown & Brown, 2008). This

subsection introduces the information needs of CHD patients. The effects of patient

education on promoting health and exercise behaviour are then presented. Finally,

factors affecting the effectiveness of patient education and strategies for patient

education are discussed.

2.4.1 Information Needs of CHD Patients

Many scholars (Hanssen, Nordrehaug & Hanestad, 2005; Stewart, Abbey, Shnek et al.,

2004; Tierney, Worth & Watson, 2000) have stated that patients with CHD have

unmet information needs after discharge, which may result in poorer treatment, less of

an ability to cope, and poorer psychological and physical well-being (Hanssen,

Nordrehaug & Hanestad, 2005). Findings from several qualitative studies (Thompson,

Ersser & Webster, 1995; Webster, Thompson & Mayou, 2002; Wang, Chair,

Thompson & Twinn, 2009) have shown that MI patients lack information and advice

about their condition, which influences their activities, lifestyle, and future plans.

These findings suggest that it is necessary for health professionals to provide

information to CHD patients. Previous studies have also shown that it is difficult for

patients to absorb the information during a hospital stay (Hanssen, Nordrehaug &

58

Hanestad, 2005; Turton, 1998). Hence, patient education for CHD patients after

discharge or community-based patient education is necessary.

In several qualitative studies (Jensen & Petersson, 2003; Thompson, Ersser &

Webster, 1995) MI patients expressed the need for knowledge and support after being

discharged from hospital. They sought information about how to deal with chest pain

and medication. A cross-sectional study demonstrated that more than 80.0% of

patients following PCI reported a need for information about heart disease and

lifestyle changes (Higgins, Murphy, Le Grande et al., 2005). Lifestyle changes, such

as following a healthy diet and ceasing to smoke, contributed to more than half of the

decline in the mortality rate from CHD between 1968 and 1976 (Goldman & Cook,

1984).

In a longitudinal study, Stewart and co-workers (2004) found that CHD patients

reported diet, dealing with high cholesterol, and exercise as their three top priorities.

A literature review (Duryée, 1992) showed that risk factors were viewed as a primary

patient concern in patients following MI. Medication, home activity, and symptom

management were also regarded as important needs. A meta-analysis (Scott &

Thompson, 2003) that included 14 trials, in which six trials used the same instrument

(the Cardiac Patient Learning Needs Inventory, CPLNI), was conducted to assess the

information needs of post-MI patients. The findings showed risk factors as being the

most important category of information needs, followed by information on cardiac

anatomy and physiology, medications, and physical activities.

59

A similar result was found when a modified CPLNI instrument was adopted to

measure the information needs of patients. A longitudinal study (Czar, MlittNsg &

Engler, 1997) using modified CPLNI to assess the learning needs of CHD patients

demonstrated that the top three-ranking categories were symptom recognition, cardiac

anatomy and physiology, and medications. Turton (1998) assessed the information

needs of post-MI patients and their spouse/partners using a modified CPLNI, in which

the term ‗risk factors‘ was replaced by the term ‗lifestyle factors‘ and the category

‗symptom management‘ was added to the inventory. The results showed that both

patients and their partners ranked symptom management and lifestyle factors as the

most important information needs. This suggests that post-MI patients and their

partners view practical information relating to survival as being of prime importance.

A number of studies have been conducted over the past decade in China to assess the

information needs of patients with CHD. The patients surveyed regarded information

about CHD, how to prevent recurrences of angina and heart attacks, diet and physical

activity, medication, self-monitoring and self-care, and how to deal with acute attacks

as their most important information needs (Chen & Jing, 2008; Du, Chen, & Liu,

2005; Hu, 2006; Jiang & Peng, 2005; Li & Liu, 2006; Li & Wang, 2006; Liu, 2005;

Wan & Wang, 2008).

Patients at different stages may have different kinds of information needs. On

admission, patients need information about their treatment regimen and the effects of

treatment, the current condition of their disease, and the significance of related body

examinations. During their stay in hospital, they need information about medication

and the skills of self-care. After discharge, they need information about risk factors

60

and how to prevent the recurrence of angina or heart attacks, and about the timetable

for further consultations with their doctor (He, Guo, & Guo, 2007). At the early stage

of convalescences, patients rank risk factors, medication, and anatomy and physiology

as the most important needs (Ashton, 1997; Chan, 1990). Another study by Larson

and co-workers (1996) to assess the information needs of 258 post-MI patients eight

weeks after discharge showed that, among the five top topics on which they needed

information, four were related to how to recognize and reduce the chances of getting

another heart attack. The findings further suggest that patients are concerned about

their survival and want to know how to reduce the chances of suffering from another

heart attack after discharge. In the long term, patients indicated that symptom

recognition, diet, and exercise were topics about which they considered it important to

receive information (Czar, MlittNsg & Engler, 1997; Stewart, Abbey, Shnek, Irvine &

Grace, 2004).

Our preliminary qualitative study (Zhu, Ho & Sit, 2012) with 11 CHD patients in

mainland China showed that most patients strongly expressed the need for

information pertinent to cardiac rehabilitation and preventing the recurrence of MI,

especially information regarding diet and physical activity. They wanted to know how

to adjust their lifestyle to prevent the illness from deterioration and how to reduce

their chances of suffering from another heart attack.

To sum up, patient education is important for CHD patients. They mainly need

information about symptom management, risk factors, the anatomy and physiology of

the heart, medications, lifestyle adjustment (diet and physical activity), and how to

61

reduce the chances of getting another heart attack. Therefore, all of these topics were

included in the patient education session in this study.

2.4.2 Patient Education on Health Promotion

Patient education can benefit CHD patients. The short-term effects of patient

education on the knowledge of individuals and changes in their behaviour have been

confirmed, while its long-term effects are as yet unclear. Many studies have

demonstrated that the effects of patient education on patients‘ knowledge about CHD,

diet, physical activity, and medication can be maintained for a short period of time

(Beckie, 1989; Fortmann, Williams, Hulley et al., 1982; Linde & Janz, 1979; Marshall,

Penckofer & Llewellyn, 1986; Meyer, Nash, McAlister & Maccoby, 1980; Plach,

Wierenga & Heidrich, 1996; Stern, Farquhar, Maccoby & Russell, 1976). In the

Stanford Three Community Study (Fortmann, Williams, Hulley et al., 1982; Meyer,

Nash, McAlister & Maccoby, 1980; Stern, Farquhar, Maccoby & Russell, 1976), it

was found that the effects of a mass-media community-wide patient education

campaign on the population‘s knowledge about healthy diets and physical activity

could last three years of the education campaign. However, one randomized

controlled trial (Elderen, Maes & Seegers, 1994) showed that the effects of an

inpatient education programme on the patients‘ knowledge about CHD could only be

sustained for four months. The effects disappeared one year after the implementation

of the programme.

It is known that increasing the knowledge of patients can promote related healthy

changes in behaviour and compliance with medication regimes (Campbell, Ritchie,

62

Thain et al., 1998; Hanssen, Nordrehaug, Eide & Hanestad, 2007; Linde & Janz, 1979;

Marshall, Penckofer & Llewellyn, 1986; Netto, McCloughan & Bhatnagar, 2007;

Plach, Wierenga & Heidrich, 1996). Many previous studies have shown that patient

education programmes promote changes in patients' behaviour, such as the adopting a

healthy diet, increasing exercise/physical activity, and quitting smoking (Aldana,

Greenlaw, Diehl et al., 2008; Campbell, Ritchie, Thain et al., 1998; Cupples &

McKnight, 1994; Fortmann, Williams, Hulley et al., 1982; Hanssen, Nordrehaug,

Eide & Hanestad, 2007; Mahler, Kulik & Tarazi, 1999; Meyer, Nash, McAlister &

Maccoby, 1980; Raleigh & Odtohan, 1987; Stern, Farquhar, Maccoby & Russell,

1976). Over time, these changes in behaviour resulted in a decrease in BMI, weight,

systolic and diastolic BP, resting HR, serum lipids, and blood glucose (Aldana,

Greenlaw, Diehl et al., 2008; Campbell, Ritchie, Thain et al., 1998; Giallauria, Lucci,

D‘Agostino et al., 2009; Jiang, Sit & Wong, 2007; Neubeck, Freedman, Briffa et al.,

2010; Redfern, Briffa, Ellis & Freedman, 2009), and a reduction in anginal pain and

rehospitalization due to angina (Cupples & McKnight, 1994; Hanssen, Nordrehaug,

Eide & Hanestad, 2009; Murchie, Campbell, Ritchie et al., 2004). Fuster (2007) stated

that patient education will increase the health awareness of patients and induce them

to modify their lifestyle. However, similar to knowledge, the long-term effects of

patient education on changes in behaviour are also not clear. One study indicated that

the effects of patient education on changes in behaviour were not maintained at the

one-year follow-up period (Elderen, Maes & Seegers, 1994). These findings may

suggest that patient education is beneficial for promoting the health of CHD patients,

while knowledge alone may not be enough for spur changes in behaviour, especially

over the long term.

63

A number of studies conducted in China on CHD patients have also demonstrated that

patient education programmes increased patients‘ knowledge about the disease (Fei,

You & Huang, 2007), improved compliance with medical regimens (Fei, You &

Huang, 2007; Luo, Chen, Meng & Ma, 2007), and reduced patients‘ anxiety and

depression and complications after PTCA (Hou, Zhou & Zhang, 2003). A home-based

cardiac rehabilitation programme that is mainly based on education and guidance led

to a significant decrease in hospital readmissions and significant improvements in

self-esteem and confidence in doing exercise among older cardiac patients (Sinclair,

Conroy, Davies & Bayer, 2005). These studies also suggest that patient education is

beneficial for promoting health in the Chinese CHD population.

Although patient education demonstrated a significant degree of effectiveness in

bringing about changes in knowledge and health behaviour, its effect on self-efficacy

for exercise compliance is not clear. Some studies indicated that patient education

improves patients‘ self-efficacy for low-fat diet compliance (Mahler, Kulik & Tarazi,

1999; Stewart, Abbey, Shnek, Irvine & Grace, 2004) and symptom management

(Kline, Scott & Britton, 2007). Higher cardiac self-efficacy is associated with better

health status after adjusting for CHD severity and depressive symptoms (Sarkar, Ali

& Whooley, 2007). According to Mahler et al. (1999), although patients who received

videotaped information at the point of discharge reported more engagement in

moderate and strenuous exercise one and three months after discharge than those in

the control group, no significant effect on self-efficacy for exercise compliance was

found. A randomized controlled trial on CHD patients indicated that patient education

significantly improves patients‘ knowledge, beliefs, and perceived level of control

when compared with the usual care (Tullmann, Haugh, Dracup & Bourguignon, 2007).

64

The findings imply that patient education may increase the confidence of patients to

change their behaviour. However, further research to confirm its effects on exercise

self-efficacy is necessary.

The effects of patient education on psychological distress are a subject of debate.

Some studies showed that patients receiving patient education had significantly lower

levels of anxiety than those receiving the usual care (Beckie, 1989; Raleigh &

Odtohan, 1987), while others revealed that patient education had no effect on

psychological distress (Dusseldorp, van Elderen, Maes et al., 1999; Elderen, Maes &

Seegers, 1994; Mahler, Kulik & Tarazi, 1999; Moore, 1996). Numerous studies have

indicated that patient education programmes only improve the physical health of

patients and have no effect on their psychological health when SF-36 (Hanssen,

Nordrehaug, Eide & Hanestad, 2007), the Profile of Mood States (PMS), and the

Sickness Impact Profile (SIP) (Moore, 1996) were used to measure outcomes. Thus,

studies to further examine the effect of patient education programmes on

psychological well-being are also essential.

A meta-analysis (Dusseldorp, van Elderen, Maes et al., 1999) that included 37

psychoeducational programmes involving patient education and stress management

was carried out. The findings indicated that such programmes led to a 34.0%

reduction in cardiac mortality and a 29.0% reduction in the recurrence of MI, and had

positive effects on BP, cholesterol, body weight, smoking cessation, exercise, and

dietary habits. The findings further suggest that the effects on cardiac mortality and

MI recurrence are associated with the successful control of BP, cholesterol levels,

body weight, smoking cessation, and exercise. Another large-scale RCT study also

65

showed that an intensive secondary prevention intervention led to decreases in

cardiovascular mortality, nonfatal MI, and stroke over three years (Giannuzzi,

Temporelli, Marchioli et al., 2008). Because of patient education brings about healthy

changes in behaviour, it improves the prognosis of patients. Several studies (Larson,

Nelson, Gustafson & Batalden, 1996; Stewart, Abbey, Shnek, Irvine & Grace, 2004)

have demonstrated that there is a link between meeting the needs of patients for

information about their illness and recovery and fewer depressive symptoms, greater

self-efficacy, better health care satisfaction, and healthier changes in behaviour such

as healthy dietary habits, exercise, and stress management, even after controlling for

the confounding factors (Larson, Nelson, Gustafson & Batalden, 1996; Stewart,

Abbey, Shnek, Irvine & Grace, 2004). Consequently, patient education improves the

quality of life of patients (Larson, Nelson, Gustafson & Batalden, 1996). These

studies also illustrated the benefits of patient education in bringing about changes in

behaviour on the part of patients and improvements in their health.

The effect of patient education on the quality of life of patients with heart disease has

also been the subject of debate. Several studies reported that patient education has a

short-term (≤ 6 months) effect on quality of life, whereas its long-term effect was not

clear. For example, results from two studies indicated that patient education led to a

significant improvement in the quality of life of patients with heart disease in the fifth

and sixth month when compared with the usual care (Brodie, Inoue & Shaw, 2008;

Hanssen, Nordrehaug, Eide & Hanestad, 2007). One study showed that counselling

patients on exercise significantly improved four of the eight SF-36 domains (role-

physical, bodily pain, general health, and vitality) over 12 months of general practice

(Elley, Kerse, Arroll & Robinson, 2003). However, Hanssen and others (2009) found

66

that, although patient education had a significant positive effect on quality of life

within six months, beyond six months there was no overall significant improvement

in the patients‘ physical or mental health as measured by SF-36. A similar result was

reported by Johnson, Lim, and Bowe (2009). Another study showed that patients

attending secondary prevention clinics demonstrated significant improvements in five

of the eight SF-36 domains (physical functioning, social functioning, role-physical,

bodily pain, and general health) at the 1-year follow-up period, while no significant

improvement in all domains was found in the intervention group at the 4-year follow-

up period when compared with the control group (Murchie, Campbell, Ritchie, Deans

& Thain, 2004). The discrepancy in the findings between these studies may be due to

the different research designs. Further studies to test the effects of patient education

on quality of life are clearly needed.

In conclusion, patients need information to improve their health. Patient education can

increase the knowledge of patients, which in turn induces changes in behaviour and

enhances self-efficacy. Consequently, the quality of life of the patients will improve.

However, the above-mentioned advantages were only illustrated by studies focusing

on the short-term (≤ 6 months) effects of patient education. For long-term (> 6 months)

effects, further studies are needed.

2.4.3 Patient Education and Exercise Behaviour

Patient education could improve the knowledge of individuals, which results in

behavioural changes. The positive effect of patient education on changes in exercise

behaviour was found in several studies. A recent meta-analysis conducted by Conn

67

and others (2008) demonstrated that patient education could significantly increase

physical activity among chronically ill adults when compared with the usual care. The

pooled effect size of this study was 0.45. The findings from another systematic review

showed that interventions mainly consisting of patient education significantly

increased the uptake of cardiac rehabilitation programmes (Davies, Taylor, Beswick

et al., 2010).

Our previous systematic review (Zhu, Ho & Wong, unpublished) included 37 RCT

studies to evaluate the effectiveness of patient education on changes in exercise

behaviour among patients with heart disease. The findings indicated that patient

education significantly improved individuals‘ adherence to exercise (the pooled risk

ratio was 1.48, 95% confidence intervals (CI) [1.32, 1.67]), exercise duration

(minutes/week) (the pooled standardized mean difference was 0.69, 95% CI [0.07,

1.31]), and exercise frequency (sessions/week) (the pooled mean difference was 1.46,

95% CI [0.43, 2.48]) immediately after the intervention. The significant positive

effect sizes declined at the follow-up period (≥ 6 months), with the exception of the

significant effect on exercise frequency, which disappeared altogether at the follow-

up period. No significant effects on exercise self-efficacy and exercise decisional

balance were found. Table 2.1 shows details of the 37 studies in our systematic review.

The findings suggest that patient education is effective at changing exercise behaviour

of patients with heart disease.

68

Table 2.1 Studies on the effect of patient education on exercise behaviour

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of

intervention Outcome measures Main results QS

Allen et al.

(2002)

USA

228 subjects (28% F, 72% M)

with hyper-

cholesterolemia

and coronary heart disease

were recruited

and included in

data analysis (IG=115,

CG=113).

60 228 No I: Patients received lipid management, including

individualized lifestyle

modification (step II diet

and home-based exercise program) and

pharmacologic

intervention, from a nurse

practitioner for 1 year after discharge in addition to

their usual care.

C: usual care

1 year Self-reported Physical Activity

Questionnaire at

baseline and at 12

months.

Physical activity (MET-hour/week

≥ 6 OR ＞30 min moderate

activity 3 times/week) [n(%)]:

1) baseline: IG 38/115(33%) vs 41/113(36.3%), p > 0.05;

2) 1-year: 46/115(40%) vs CG

29/113(26%), p = 0.02.

6

Allison &

Keller

(2004)

USA

108 subjects with coronary heart

disease were

recruited and 83

subjects (31% F, 69% M)

completed the

study (IG1=28,

IG2=27, CG=28).

72 83 Social-cognitive

theory

I1: The self-efficacy intervention based on

social-cognitive theory to

enhance confidence for

physical activity through a telephone intervention.

I2: A telephone follow up

protocol (a telephone call every 2 weeks) to report

their progress with the

physical activity and

exercise program prescribed in cardiac

rehabilitation, and

reminded to continue their

physical activity/exercise program.

C: usual care

12 weeks Physical Activity Scale for the Elderly

(PASE) and Self-

Efficacy Expectation

Scales (SES) at baseline, 6, and 12

weeks

(1) Self-reported physical activity (scores):

1) from baseline to the 6-week:

IG1 declined by 23.84% of

scores, IG2 declined by 18.86%, and CG declined by

28.82%, p > 0.05;

2) from 6 weeks to 12 weeks:

IG1 improved by 39.83% of scores, IG2 improved by

42.30%, and CG improved by

29.26%, p < 0.05.;

3) from baseline to 12 weeks: IG1 improved by 6.49%, IG2

by 15.46%, and CG by

-7.99%, p < 0.05.

4

69

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Allison &

Keller

(2004)

USA

(2) Self-efficacy (mean scores):

1) baseline: similar among the

three groups;

2) from baseline to 6 weeks: IG1 increased 64.51% of mean

scores, IG2 increased

55.22%, and CG increased

42.70%, p > 0.05; 3) from 6 weeks to 12 weeks:

IG1 increased 9.81% of mean

scores, IG2 increased 6.68%,

and CG increased 7.67%, p > 0.05;

4) from baseline to 12 weeks:

IG1 increased 80.64% of

mean scores, IG2 increased 65.75%, and CG increased

53.64%, p > 0.05.

Arrigo et al.

(2008)

Switzerland

261 subjects with

heart disease were recruited

and 228 subjects

(14.5% F, 85.5%

M) completed the study (IG=105,

CG=123). 91%

with coronary

heart disease.

61 228 No I: Formal cardiac

rehabilitation included using a diary sheet for

physical activities and

taking part in a physician-

supervised group exercise session once every 3

months.

C: usual care

1 year Self-reported regular

physical activity (noticeably increase

pulse rate and

breathing ≥ 3 times

per week for ≥ 30 min) at baseline and

1 year.

Exercise adherence (moderately ≥

3 times per week for ≥ 30 minutes) [n (%)]:

1) baseline: no data available;

2) 1-year: IG 74/105 (70%) vs

CG 46/123 (37%), p < 0.0005.

4

70

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Broadbent

et al.

(2009)

New

Zealand

103 MI patients

(12% F, 88% M)

were recruited,

96 completed 3-month follow up

(IG=50, CG=46),

and 79 completed

6-month follow up (IG=42,

CG=37).

55 79 No I: An illness perception

intervention which

consisted of three half-hour

individual patient sessions and one half-hour patient-

and-spouse session

delivered in hospital and

followed up to 6 months.

C: usual care.

During

hospitalizatio

n and 6

months' follow up

after

discharge

Self-reported

exercise (a single-

item scale from 0 to

10) at baseline, 3 and 6 months.

The amount of exercise (0-10):

1) baseline IG 3.40 vs CG 4.08,

p > 0.05;

2) 3-month: IG 4.32 vs CG 4.02, p > 0.05;

3) 6-month: IG 4.42 vs CG 4.14,

p > 0.05.

5

Brodie et al.

(2005, 2008)

UK

90 subjects (no

report about F &

M) with chronic

heart failure were recruited and 60

subjects

completed the

study (IG1=20, IG2=22,

CG=18).

79 60 Motivational

interviewing

I1: Standard care plus

motivational interviewing

programme on how to

increase energy expenditure by integration

of physical activities into

their daily routines.

I2: Motivational

interviewing only.

C: standard care

5 months The leisure-time

physical activity

questionnaire

(kcal/kg/day) and a 3-day physical

activity diary at

baseline and 5

months.

(1) Physical activities energy

expenditure (kcal/kg/day) [mean

(SD)]:

1) baseline: IG1 8.3 (2.5), IG2 6.6 (2.6) vs CG 9.7 (4.5), p >

0.05;

2) 5-month: IG1 10.5 (4.4), IG2

9.0 (3.3) vs CG 9.6 (4.3), p > 0.05.

(2) Leisure time activities

(kcal/kg/day) [mean (SD)]:

1) baseline: IG1 0, IG2 0.09 (4.3) vs CG 0.05 (2.4), p >

0.05;

2) 5-month: IG1 0.04 (0.1), IG2

0.16 (2.9) vs CG 0.08 (0.2), p > 0.05.

(3) Walking (kcal/kg/day) [mean

(SD)]:

1) baseline: IG1 1.2 (0.8), IG2 0.7 (0.4), CG 1.6 (1.2), p >

0.05;

2) 5-month: IG1 2.1 (1.1), IG2

1.7 (0.9) vs CG 1.9 (0.9), p > 0.05.

5

71

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Butler et al.

(2009)

Australia

110 subjects

(24.5% F, 75.5%

M) with CABG,

PCI, MI, or ACS were recruited

(IG=55, CG=55)

and 98 subjects

completed the 6-week

intervention

(IG=48, CG=50)

and 90 subjects completed 6-

month follow up

(IG=44, CG=46).

64 98 No I: The 6-week intervention

included self-monitored

physical activity using a

pedometer and step calendar and 2 behavioural

counselling and goal-

setting sessions plus 2

generic physical activity information brochures.

C: usual care plus 2 generic

physical activity information brochures.

6 weeks and

6-month

follow up

Self-reported

physical activity

through Active

Australia Survey, Self-efficacy for

exercise scale, and

Outcome

expectancies for participation in

physical activity at

baseline, 6 weeks and

6 months.

(1) Total physical activity

(minute/week) [mean (SD)]:

1) baseline: IG 324.3(271.3) vs

CG 365.8 (272.6), p > 0.05; 2) 6-week: IG 410.9 (308.3) vs

CG 370.6 (309.6), p > 0.05;

3) 6-month: IG 455.5 (361.0) vs

355.2 (271.2), p < 0.05.

(2) Total physical activity

(session/week) [mean (SD)]:

1) baseline: IG 8.5 (5.1) vs CG 10.1 (6.5), p > 0.05;

2) 6-week: IG 11.4 (7.0) vs CG

9.2 (5.1), p < 0.05;

3) 6-month: IG 9.6 (5.8) vs 8.0 (4.4), p < 0.05.

(3) Walking (minute/week) [mean

(SD)]: 1) baseline: IG 227.7 (178.7) vs

CG 303.1 (232.4), p > 0.05;

2) 6-week: IG 308.4 (229.0) vs

CG 276.9 (229.9), p < 0.05; 3) 6-month: IG 262.5 (199.2) vs

CG 257.1 (214.3), p > 0.05.

(4) Walking (session/week) [mean (SD)]:

1) baseline: IG 7.1 (4.2) vs CG

8.8 (6.1), p > 0.05;

2) 6-week: IG 9.4 (5.6) vs CG 7.0 (4.2), p < 0.05;

3) 6-month: IG 7.3 (5.1) vs CG

6.5 (4.4), p < 0.05.

5

72

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Campbell et

al.

(1998, 2003)

UK

1343 subjects

(42% F, 58% M)

with coronary


and 1173

subjects

completed the study (IG=593,

CG=580).

66 1173 No I: Nurse run clinics

promoted medical and

lifestyle aspects of

secondary prevention and offered regular follow up

over one year.

C: usual care.

1 year and re-

assessed at 4

year (mean

follow up was at 4.7 years)

Health practices

index [Moderate

physical activity

(index of physical activity > 4)] at

baseline, 1 year and 4

years.

Moderate physical exercise [n

(%)]:

1) baseline: IG 221/587 (37.6%)

vs CG 183/568 (32.2%), p > 0.05;

2) 1-year: IG 247/587 (42.1%)

vs CG 177/568 (31.2%) (OR

= 1.67, 95% CI 1.23 to 2.26), p = 0.001;

3) 4-year: IG 171/494 (34.6%)

vs CG 128/455 (28.1%) (OR

= 1.26, 95% CI 0.88 to 1.81), p < 0.05.

6

Coull et al.

(2004)

UK

319 subjects

(40% F, 60% M)

with ischaemic

heart disease (IHD) were

recruited and 289

subjects


CG=140).

67 289 No I: A mentor-led group,

through attending monthly

2 hour long meetings in

community facilities over a 1-year period.

C: usual care

One year Self-reported

physical activity in

previous week at

baseline and one year.

(1) Exercise (minute/week):

1) baseline: IG 697 vs CG 750;

2) 1-year: IG 843 vs CG 767,

difference +147 (95% CI -8 to +266), p > 0.05.

(2)Walking (minute/week):

1) baseline: IG 298 vs CG 303; 2) 1-year: IG 388 vs CG 320,

difference +73 (95%CI +1 to

+137), p < 0.05.

6

73

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Cupples &

McKnight

(1994)

UK

688 subjects

(41% F, 59% M)

with angina were

recruited and 617 subjects

completed the

study (IG=317,

CG=300). 487 subjects

completed the 5-

year follow up

(IG=250, CG=237).

63 617 No I: Patients received

practical relevant advice

regarding cardiovascular

risk factors. They were reviewed at four monthly

intervals and given

appropriate health

education.

C: usual care.

2 years and 5

years' follow

up

Self-reported

exercise levels

(session/week for at

least 20 minutes per session) at baseline, 2

and 5 years.

(1) Physical exercise (≥ 5

sessions/week) [n (%)]:

1) baseline: IG 164/317 (51.7%)

vs CG 175/300 (58.3%), p > 0.05;

2-year: IG 194/317 (61.2%) vs CG

138/300 (46.0%), p < 0.01.

(2) Physical exercise [n (%)]:

compared to baseline, at 2 years

[IG 108 (34%) increased, 120

(38%) no changed, and 89 (28%) decreased] vs [CG 63 (21%)

increased, 74 (25%) no change,

and 163 (54%) decreased], p <

0.0001.

(3) Physical exercise (score based

on No of 20 minutes episodes per

week) (N=487) [mean, mean difference between groups (95%

CI)]:

1) baseline: IG 3.6 vs CG 3.8, -

0.2 (-0.5 to 0.1), p > 0.05; 2) 2-year: IG 4.0 vs 3.2, 0.7 (0.4

to 1.0), p < 0.05,

3) 5-year: IG 3.0 vs 2.8, 0.2 (-

0.2 to 0.5), p < 0.05.

6

74

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Giallauria et

al.

(2009)

Italy

52 patients (15%

F, 85% M) after

acute MI were

recruited and included in data

analysis (IG=26,

CG=26).

58 52 No I: A multi-factorial,

educational and

behavioural intervention in

hospital once a month throughout the 24-month

follow up to receive dietary

advice, reinforcement on

maintaining a correct lifestyle, a session of

exercise training at the

follow up CPX, and a

booklet for exercise, diet, and smoking cessation.

C: usual care.

2 years Self-reported leisure

time physical

activities (LTPA)

questionnaire at the end of the initial 3-

month outpatient

cardiac rehabilitation

program and at 12-month and 24-month

follow up.

Exercise adherence (moderate to

high level of LTPA) [n (%)]:

1) 3-month: IG 23/26 (87%) vs

CG 23/26 (87%), p > 0.05; 2) 24-month: IG 15/26 (58%) vs

CG 7/26 (27%), p < 0.001.

6

Giannuzzi et

al.

(2008)

Italy

3241 subjects

(14% F, 86% M)

with recent MI

were recruited and included in

the data analysis

(IG=1620,

CG=1621).

58 3241 No I: A 3-year multifactorial

continued educational and

behavioural program

consisted of comprehensive cardiac rehabilitation

sessions with one-to-one

support monthly from

month 1 to month 6, then every 6 months for 3 years,

and a booklet. Each session

consisted of 30 minutes of

supervised aerobic exercise, plus lifestyle and

risk factor counselling

lasting at least 1 hour and

reinforcement of preventive interventions

lasting approximately 30

minutes.

C: usual care.

3 years Questionnaire on

leisure time physical

activity (3 items;

score range, 3 [most unfit] to 12 [≥ 3h/wk

of exercise]) at

baseline, 6, 12, 24

and 36 months.

Physical activity level (3.0-12.0

scores) [mean (SD)]:


6.6 (2.4), p > 0.05; 2) 6-month: IG 7.5 (2.2) vs CG

7.1 (2.3), p = 0.005;

3) 12-month: IG 7.5 vs CG 7.2,

p = 0.20; 4) 24-month: IG 7.5 vs CG 7.1,

p = 0.01;

5) 36-month: IG 7.5 vs CG 7.1,

p = 0.01.

7

75

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Gulanick et

al.

(1991)

USA

40 subjects (30%

F, 70% M) with

CHD were


completed the

study (IG1=11,

IG2=13, CG=12). 55%

underwent

cardiac surgery.

58 36 No I1: Treadmill exercise

testing, teaching, and

exercise training (three

sessions weekly for 5 weeks);

I2: Treadmill exercise

testing and teaching, without exercise training.

C: usual care.

5 weeks Self-efficacy to

perform physical

activity and

performance of physical activity at

hospital discharge, 4

weeks after the

cardiac event, and 9 weeks recovery (after

the intervention).

(1) Self-efficacy for walking (1-25


1) baseline: IG1 9.2 (2.8), IG2

8.6 (3.7) vs CG 11.4 (2.4), p > 0.05;

2) 4-week: IG1 16.8 (5.2), IG2

16.8 (5.2), vs CG 13.5 (4.3),

p > 0.05; 3) 9-week: IG1 21.1 (4.3), IG2

20.6 (3.0) vs CG 20.3 (3.8),

p > 0.05.

(2) Performance of walking (1-25


1) baseline: IG1 12.5 (7.3), IG2

11.4 (5.3), vs CG 11.4 (4.8), p > 0.05;

2) 4-week: IG1 13.5 (4.9), IG2

11.0 (3.5) vs CG 10.3 (3.4),

p > 0.05; 3) 9-week: IG1 17.2 (4.4), IG2

14.6 (3.9) vs CG 15.8 (5.3),

p > 0.05.

4

76

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Hughes et al.

(2002)

UK

31 subjects (35%

F, 65% M) with

cardiac disease

(n=20 AMI and n=11 CABG

surgery) were

recruited and 29

subjects completed the

study (IG=15,

CG=14).

62 29 TTM I: A 30-minute

individualized exercise

consultation session based

on the stage of exercise behaviour change plus

standard exercise leaflet.

C: usual care plus standard exercise leaflet.

4 weeks The Scottish Physical

Activity

Questionnaire at

baseline and 4-week follow up. (Activity

guidelines were ≥ 30

minutes of

accumulated moderate activity ≥ 5

days/week or 20-

minute bouts of

moderate to vigorous exercise ≥ 3

days/week).

Physical activity (minute/week)

[median(IQ range):

1) baseline: [IG 417.5 (245 to

690)] vs [CG 555.0 (325 to 745)], p > 0.05;

2) 4-week: [IG +123 (20, 345)

vs [CG -68 (-218, 78)], p <

0.05.

4

Hughes et al.

(2007)

UK

70 cardiac

patients (20% F,

80% M) (IG=35, CG=35) were

recruited and 64

completed 6-

months (IG=32, CG=32).

60 64 TTM I: exercise information and

a 30-min one-to-one

exercise consultation about assessing current physical

activity status, exploring

pros and cons of being

active, problem-solving barriers, social support,

exploring activity options,

setting realistic activity

goals (for 1,3 and 6months) and preventing relapse.

C: exercise information

only.

6 months and

12-month

follow up

Stages of exercise

behaviour change,

the 7-day recall, and accelerometer at

baseline, 6 and 12

months.

(1) Exercise adherence (≥ 3

days/week vigorous exercise for ≥

20 minutes or ≥ 5 days/week accumulated moderate exercise for

≥ 30 minutes) [n (%)]:

1) baseline: IG 31/35 (88%) vs

CG 27/35 (77%), p = 0.20; 2) 6-month: IG 27/32 (84%) vs

CG 22/32 (69%), p = 0.10;

3) 12-month: IG 28/33 (85%) vs

CG 22/33 (67%), p = 0.08.

5

77

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Hughes et al.

(2007)

UK

(2) Exercise (minute/week)

(median):

1) baseline: IG 300 vs CG 275,

p > 0.05; 2) IG: maintained from baseline

to 6 months (47min/week;

98%CI -43, 191) and 12

months (23min/week; 98% CI -63, 154);

3) CG: decreased by

115min/week from baseline

to 12 months (98% CI -228, -28) and 63min/week from 6

to 12 months (98% CI -126, -

5);

4) Significant difference for the change from baseline to 12

months (130min/week; 98%

CI -295, -20) between groups,

p < 0.05.

(3) Accelerometer (steps/week):

1) baseline: no available data;

2) IG: change from baseline to 6 months (98% CI -705 643,

860 599), and 12 months

(98% CI –381 927,504 719),

p > 0.05; 3) CG: from baseline to 6 month

decreased by 5.2% (98% CI–

215 141,4105 603), and 12

months decreased by 8% (98% CI -328 116, 4105 603);

p > 0.05.

78

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Izawa et al.

(2005)

Japan

50 subjects with

myocardial

infarction were

recruited and 45 subjects (16% F,

84% M)

completed the

study (IG=24, CG=21).

64 45 Bandura's

self-efficacy

theory

I: Patients participate in

supervised 5-month

recovery-phase CR

program plus Self-Monitoring Approach in

which patients were asked

to record body weight,

objective physical activity derived from the

pedometer, blood pressure,

and heart rate during the

supervised recovery-phase CR program.

C: usual care plus the

supervised 5-month recovery-phase CR

program.

5 months and

6 months'

follow up

Objective physical

activity by an

electronic pedometer

at baseline and 12 months after MI

onset.

Readiness for exercise according to

the transtheoretical

model of exercise

behaviour change. (Exercise:

preparation, action,

or maintenance

stages, nonexercise: precontemplation or

contemplation

stages).

(1) Exercise adherence

(preparation, action, or

maintenance stages) [n (%)]:

1) baseline: IG 8/24 (33%) vs CG 8/21 (37%), p > 0.05;

2) 6-month: IG 24/24 (100%) vs

CG 17/21 (80.9%), p < 0.05.

(2) Physical activity (steps/day)

[mean (SD)]:

1) baseline: IG 6,564.9 (1,114.6)

vs CG 6,282.6 (1,985.9), p > 0.05;

2) 12-month: IG 10,458.7

(3,310.1) vs CG 6,922.5

(3,192.9), p＜0.05.

4

Jeong et al.

(2002)

Korea

70 subjects with

myocardial

infarction were


81% M)

completed the


53 45 No I: An individualized

teaching program (3

sessions 20-25 minutes

during hospitalization) contained five major areas:

nature of disease, risk

factors and their

modification, diet, medication, and exercise,

and a booklet, and regular

telephone supportive care

for 12 weeks after discharge.

C: usual care

During

hospitalizatio

n and

12 weeks telephone

support after

discharge. .

Self-reported

adherence to exercise

(aerobic exercise for

20-45 minutes per session more than 3

times a week over the

previous 10 weeks) at

baseline and 12 weeks.


times/week) [n (%)]:

1) baseline: IG: 4/22 (18.2%) vs

CG 4/23 (17.4%), p > 0.05; 2) 12-week: IG 16/22 (72.3%)

vs CG 5/23 (21.7%), p <

0.05.

5

79

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Johnson et

al.

(2009)

Australia

154 women with

coronary heart

disease (AMI,

angina, PCI, or CABG) were

recruited and 144

subjects

completed the intervention

(IG=63, CG=81),

118 subjects at

the 3-month follow up

(IG=51, CG=67),

120 subjects at

the 6-month follow up

(IG=53, CG=67),

and 113 subjects

at the 12-month follow up

(IG=49, CG=64).

median

62-64

144 No I: Women were oriented to

the 12-week home walking

intervention and were

instructed to complete daily activity logs to

increase the likelihood of

adherence with physical

activity.

C: usual care.

12 weeks and

12 months'

follow up

Self-reported

maintenance of

physical activity (≥ 3

times/week) using the Stages of Change

model of exercise

behaviour at 3.6.and

12 months after outpatient cardiac

rehabilitation.

Regular physical activity ((≥ 3


1) 3-month: IG: 45/51 (90%) vs

CG 49/67 (74%), p = 0.03; 2) 6-month: IG 45/53 (87%) vs

CG 40/67 (61%), p = 0.003;

3) 12-month: 36/49 (77%) vs

CG 36/64 (56%), p = 0.03.

6

80

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Lear et al.

(2001)

Canada

49 subjects (30%

F, 70% M) with

ischemic heart

disease (MI, a revascularization

procedure,

positive coronary

angiogram, or episodes of

angina) were

recruited and 36

subjects completed the

study (IG=17,

CG=19).

64 36 No I: A Lifestyle management

intervention (LMI) in

which patients received a

risk factor report (RFR) about their current and

previous lifestyle

behaviours (exercise, diet

and smoking sessions), six additional rehabilitation

sessions, two telephone

follow ups, and a full

lifestyle and risk factor assessment and counselling

session.

C: usual care

6 months A 4-week modified

version of the Leisure

Time Physical

Activity Questionnaire at

baseline and 6 month

after the intervention.

Physical activity (kcal/week)

[mean (SD)]:

1) baseline: IG 2175 (2107) vs

CG 3834 (3414), p < 0.05; 2) 6-month: IG 2458 (1169) vs

CG 2823 (1593), p > 0.05.

4

Lear et al.

(2002, 2003,

2006)

Canada

302 subjects

(18% F, 82% M)

with ischemic

heart disease (53% have had a

previous

myocardial

infarction and 73% have

undergone

previous

revascularization) were recruited

and included in

data analysis

(IG=151, CG=151)

64 302 TTM and

Social

Cognitive

Theory

I: An extensive lifestyle

management intervention

(ELMI) consists of cardiac

rehabilitation sessions, telephone follow ups and

lifestyle and risk factor

counselling sessions.

C: usual care.

4 years A 4-week modified

version of the Leisure

Time Physical

Activity Questionnaire.

General Self-efficacy

Scale and Exercise

Self-Efficacy Scale. Outcomes were

assessed at baseline,

1 and 4 years.

(1) Physical activity (kcal/week)

[mean (SD)]:

1) baseline: IG 3143 (2294) vs

CG 3022 (2308), p > 0.05; 2) 1-year: IG 2440 (1698) vs CG

2288 (1554), p > 0.05;

3) 4-year: IG 2099 (2074) vs CG

2349 (2018), p = 0.574.

(2) General Self-Efficacy (scores)

[mean (SD)]:

1) baseline: IG 43 (4) vs CG 42 (5), p > 0.05;

2) 1-year: IG 41 (5) vs CG 41

(5), p > 0.05;

3) 4-year: IG 42 (4) vs CG 42 (5), p = 0.885.

6

81

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Lear et al.

(2002, 2003,

2006)

Canada

(3) Exercise Self-Efficacy (scores)

[mean (SD)]:

1) baseline: IG 67 (10) vs CG 65

(13), p > 0.05; 2) 1-year: IG 63 (15) vs CG 63

(16), p > 0.05;

3) 4-year: IG 63 (14) vs CG 62

(15), p = 0.457.

Lisspers et

al.

(1998, 1999,

2005)

Sweden

93 subjects with

coronary heart

disease recently

treated with PTCA were

recruited and 87

subjects (16% F,

84% M) completed the

study (IG=46,

CG=41).

53 87 No I: The residential

rehabilitation programme

had a 12-month period and

initiated by a 4-week residential stay at the

intervention unit which

consisted of intense health

education and activities promoting behavioural

changes and an 11-month

structured maintenance

program followed the in-patient phase.

C: usual care

1 year and 2

and 5 years'

follow up

Self-reported

questionnaire about

frequency of exercise

at baseline, 1, 2, 3 and 5 years.

An exercise session

was defined as effort corresponding to a

brisk walk for at least

20 min.

(1) Exercise (session/week):

1) Not reported (graphic display

only), p = 0.02.



1) baseline: IG 13/46(28%) vs

CG 13/41(32%), p > 0.05; 2) 12-month: IG 26/46(56%) vs

CG 17/41(41%), p < 0.05.

(3) Exercise level (1-3 scores, the higher score the better exercise

level) [mean (SD)]:

1) baseline: no data available;

2) 12-month: IG 1.74 (1.33) vs CG 0.94 (1.13);

4

82

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Lisspers et

al.

(1998, 1999,

2005)

Sweden

3) 24-month: IG 1.46 (1.37) vs

CG 0.82 (1.20);

4) 36-month: IG 1.35 (1.37) vs

CG 0.78 (1.23); 5) 60-month: IG 1.40 (1.30) vs

CG 1.00 (1.25).

Luszczynska

et al.

(2006)

UK

130 subjects after

uncomplicated

MI were


64% M)

completed the


54 114 No I: An implementation

intention intervention on

behaviour change with the

use of a planning strategy. The intervention was given

on an individual basis and

lasted 10–15 min.

C: usual care after 2 weeks

short-term rehabilitation.

All patients received 2 weeks short-term

rehabilitation.

6 months Self-reported

physical activity

(Frequency of

moderate physical activity for ≥30 min)

at 4-10 days after MI,

the eighth week after

MI (2 weeks after a short-term

rehabilitation), and

eighth or ninth month

after MI (post- intervention).

(1) Physical activity (1-7, 1=

never, 2 = once in past two weeks,

3 = once/week, 4 = twice/week, 5

= three times/week, 6 = four times/week, 7 = five or more

times/week) [mean (SD)]:

1) baseline: IG 3.42 (2.14) vs

CG 4.23 (2.16), p > 0.05; 2) 8-week: IG 5.17 (1.59) vs CG

5.44 (1.10), p > 0.05;

3) 8-month: IG 4.75 (1.83) vs

CG 4.09 (1.69), p < 0.10.

4

Mildestvedt

et al.

(2008)

Norway

217 subjects with

coronary heart

disease were


78% M)

completed the


56 176 No I: Standard rehabilitation

treatment plus an

additional individualized

self-efficacy and autonomy supportive intervention.

C: standard rehabilitation

treatment.

2 years Self-reported

exercise at baseline

and 6 and 24 months'

follow up.

(1) Exercise level (score 1-5, the

higher scores the better exercise

level) [mean (SD)]:

1) baseline: IG 3.3 (0.8) vs CG 3.2 (0.9), p = 0.49;

2) 6-month: IG 3.5 (0.7) vs CG

3.6 (0.7);

3) 24-month: IG 3.4 (0.8) vs CG 3.4 (0.8);

4) p(time) < 0.001, p(group) =

0.79, p(interaction) = 0.66.

5

83

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Mildestvedt

et al.

(2008)

Norway

(2) Exercise self-efficacy [mean

(SD)]:


4.0 (0.7), p = 0.48; 2) no detailed data available at 6

and 24 months, p > 0.05.

Moore et al.

(2006)

USA

273 subjects who

had a recent

cardiac event

(MI, CABG, and/or

angioplasty)

were recruited

and 250 subjects (38% F, 62% M)

completed the

study (IG=119,

CG=131).

81.2%

Caucasian.

51.6% MI, 54.8% CABG,

59.2%

Angioplasty.

62 250 Social

problem-

solving

model, self-efficacy

theory,

expectancy-

value theory, and relapse

prevention

theory.

I: ―Change Habits by

Applying New Goals and

Experiences‖ (CHANGE)

intervention consists of five small-group (6–8

people) 1½-hr counselling

and behaviour modification

sessions for self-efficacy enhancement, problem-

solving skills, and relapse

prevention strategies to

address their identified exercise maintenance

problems.

C: usual care after the completion of CRP

3 months and

1-year follow

up

Exercise adherence

(exercise ≥ 5

times/week for 30

min) through portable wristwatch HR

monitors (Polar

Vantage NV™, Polar

Electro, Kempele, Finland) and exercise

diaries; Exercise

Benefits/Barriers

Scale; Exercise Self-Efficacy by Exercise

Barriers and

Adherence Self-

Efficacy Scale at baseline, 3 months

and 1 year.

(1) Exercise adherence (moderate

exercise ≥ 150 minutes/week) [n

(%)]:

1) 3-month: IG 52/119 (43.8%) vs CG 45/131 (34.4%), p >

0.05;

2) 1-year: IG 34/119 (28.8%) vs

CG 35/131 (26.7%), p > 0.05. (2) Exercise adherence (moderate

exercise ≥ 5 times/week or 20

times/month) [n (%)]

1) 3-month: IG 19/119 (16.1%) vs CG 19/131 (14.8%), p >

0.05;

2) 1-year: IG 9/119 (7.5%) vs

CG 10/131 (8.1%), p > 0.05. (3) Exercise (hour/month) [mean

(SD)]:

1) 3-month: IG 9.5 (7.4) vs CG

8.5 (8.9), p > 0.05; 2) 1-year: IG 7.0 (7.2) vs CG 6.4

(9.2), p > 0.05.

(4) Exercise frequency

(session/month) [mean (SD)] 1) 3-month: IG 11.5 (7.8) vs CG

10.6 (9.2), p > 0.05;

2) 1-year: IG 7.6 (7.0) vs CG 7.1

(8.2), p > 0.05.

6

84

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Moore et al.

(2006)

USA

(5) Exercise Benefits/Barriers

[mean (SD)]:

Benefits:

1) baseline: IG 90.4(10.6) vs CG 90.5(11.4), p > 0.05;

2) 3-month: IG 89.0(10.5) vs

CG 89.4(10.8), p > 0.05;

3) 1-year: IG 90.7(10.3) vs CG 90.5(9.8), p > 0.05.

Barriers:

1) baseline: IG 42.9(5.1) vs CG

42.3(5.4), p > 0.05; 2) 3-month: 42.4(5.3) vs CG

42.4(4.5), p > 0.05;

3) 1-year: 41.9(5.6) vs CG

41.9(4.8), p > 0.05.

(6) Exercise Self-Efficacy [mean

(SD)]:

Barriers: 1) baseline: IG 73.4(18.6) vs CG

72.1(20.6), p > 0.05;

2) 3-month: IG 71.6(19.6) vs

CG 71.1(21.8), p > 0.05; 3) 1-year: IG 72.0(21.9) vs CG

69.5(25.2), p > 0.05.

Adherence:

1) baseline: IG 91.8(14.7) vs CG 90.0(15.5), p > 0.05;

2) 3-month: IG 76.9(29.9) vs

76.5(30.3), p > 0.05;

3) 1-year: IG 69.4(37.0) vs CG 70.0(36.3), p > 0.05.

85

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Mosca et al.

(2010)

USA

304 women with

coronary heart

disease were


completed the

study (IG=121,

CG=122).

47.7% white,

33.6% black,

15.1% Hispanic.

62 243 Social

learning

theory

I: Education and

counselling during

hospitalization about

patients' adherence to secondary prevention goals

based on social learning

theory and the five A‘s

construct (ask, advise, agree, assist, arrange) and

receiving an educational

booklet.

C: usual care

During

hospitalizatio

n and

12 weeks postdischarge.

Follow up at

6 weeks and 6

months postdischarge.

Self-reported

adherence to physical

activity (at least 30

minutes three times per week or

enrollment in formal

cardiac

rehabilitation) at baseline, 6 weeks and

6 months after

postdischarge.

Exercise/cardiac rehabilitation

adherence (≥3 times/week) [n

(%)]:


2) 6 weeks: IG 27/119 (23%) vs

CG 27/121 (22%), p > 0.05;

3) 6 months: IG 41/108 (38%) vs CG 32/109 (29%), p >

0.05.

6

Naser et al.

(2008)

Iran

100 subjects

(16% F, 84% M)

with coronary


and completed

the study (IG=50,

CG=50)

54 100 TTM I: An intensive

multifactorial lifestyle

modification program

(IMLM) based on the stages of change, which

was a 30-minute hospital-

based consultation along

with written guidelines and a two year post-hospital

intervention program

consisted of CRP exercise

sessions, lifestyle counselling and telephone

follow ups.

C: usual care


questionnaire on type

of exercise (Not

described what kind of questionnaire) at

baseline and second

year.

Exercise adherence (vigorously 20

min 3 times/week) [n (%)]:

1) baseline: IG 10/50 (20%) vs

CG 11/50 (22%), p > 0.05; 2) 2-year: IG 44/50 (88%) vs

CG 10/50 (20%), p < 0.05.

6

86

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Ornish et al.

(1990, 1998)

USA

48 subjects (9%

F, 91% M) with

moderate to

severe coronary heart disease

were recruited

and 37 subjects

completed the intervention

(IG=20, CG=17)

and 35 subjects

completed the 4-year follow up

(IG=20, CG=15).

56 35 No I: An intensive lifestyle

program included a week-

long residential retreat at

hotel followed by twice-weekly 4-h meetings. The

main contents of the

program included a 10%-

fat vegetarian diet, moderate aerobic exercise,

stress management

training, smoking

cessation, and group psychosocial support.

C: usual care

1 year and 5

years follow

up

Self-reported

exercise (frequency

and duration of

exercise) at baseline, 1-year and 5-year

follow up.

(1) Exercise frequency

(times/week) [mean (SD)]:

1) baseline: IG 2.66 (0.84) vs

CG 2.38 (0.77), p > 0.05; 2) 1-year: IG 4.97 (0.35) vs CG

2.87 (0.70), p = 0.06;

3) 5-year: IG 4.34 (0.49) vs CG:

3.57 (0.56), p = 0.64.

(2) Exercise (hours/week) [mean

(SD)]:

1) baseline: IG 2.26 (0.85) vs 2.42 (0.99), p > 0.05;

2) 1-year：IG 5.02 (0.61) vs

2.52 (0.70), p = 0.12; 3) 5-year: IG 3.56 (0.56) vs CG

2.90 (0.65), p = 0.50.

5

Redfern et

al.

(2008, 2009,

2010)

Australia

144 subjects

(25% F, 75% M)

after acute

coronary syndrome were

recruited and

included in data

analysis (IG=72, CG=72).

65 144 No I: The CHOICE

intervention included a 1

hour initial consultation

and multiple follow up phone calls over 3 months.

The programme was a

brief, patient-centred,

modular programme comprising a clinic visit

plus telephone support,

encompassing mandatory

cholesterol lowering and tailored preferential risk

modification.

C: usual care.

3 months and

1 and 4 years'

follow up

International Physical

Activity

Questionnaire

(IPAQ) score at baseline, 3 months,

and 1 and 4 years.

(1) Physical activity

(METS/kg/min) [mean (SD)]:

1) baseline: IG 314.7 (37.9) vs

CG 267.0 (31.6), p > 0.05; 2) 3-month: IG 1,186.6 (164.1)

vs CG 636.2 (115.4), p <

0.01;

3) 12-month: IG 1369.1(167.2) vs CG 715.1(103.5), p =

0.001);

4) 4-year: IG 1200 (209) vs CG

968 (196), p = 0.02. 5)

(2) Regular physical activity (≥ 5

days 30 minutes) [n (%)]:


7

87

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Redfern et

al.

(2008, 2009,

2010)

Australia

2) 3-month: IG 56/72 (78%) vs

CG 23/72 (32%), p < 0.05;

3) 12-month: IG 47/67 (70%) vs

CG 21/69 (30%), p < 0.01]; 4) 4-year: IG 23/40 (57%) vs

CG 15/46 (33%), p = 0.01.

Salminen et

al.

(2005)

Finland

268 subjects with

coronary heart

disease were


49% M)

completed the

study (IG=118, CG=109).

74 227 No I: health advocacy,

counselling, and activation

program which consisted

of 16 lectures by experts, eight group discussions, six

group exercise sessions,

and three social activity

events.

C: usual care


frequency of exercise

at baseline and 2

years.

There were no significant

differences in frequency of

exercise between two groups.

4

Senuzun et

al.

(2006)

USA

60 subjects (8%

F, 92% M) with

coronary heart

disease completed the

study (IG=30,

CG=30)

54 60 No I: The Phase II home-based

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.

C: usual care

12 weeks The cardiac exercise

self-efficacy index

(CESEI) at baseline

and 12 weeks.

Self-efficacy scores (mean):

1) baseline: IG 55.7 vs CG 55.7,

p = 0.695;

2) 12-week: IG 77.7 vs CG 60.6, p < 0.001.

4

88

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Smeulders et

al.

(2006, 2009)

Netherlands

317 subjects

(27% F, 73% M)

with congestive

heart failure were recruited and

included in data

analysis

(IG=186, CG=131).

67 317 Bandura's

self-efficacy

theory

I: The 'Chronic Disease

Self-Management Program'

(CDSMP) consists of six

weekly group sessions to incorporate skills mastery,

reinterpretation of

symptoms, modelling, and

social persuasion to enhance self-efficacy

expectancies.

C: usual care

6 weeks and 6

and 12

months'

follow up

A modified version

of the 'Physical

activities scale'

comprised questions about the frequency

of the following three

categories: walking

for exercise, swimming, and

bicycling. Outcomes

were assessed at

baseline, 6 weeks, 6 and 12 months.

(1) Walking for exercise

(minute/month) [mean (SD)]:

1) baseline: IG 572.4 (791.0) vs

CG 563.3 (713.8), p = 0.877; 2) direct follow up (6 weeks):

IG 772.0 (998.0) vs CG 588.1

(681.7), p = 0.034;

3) 6-month: IG 753.3 (1050.1) vs CG 531.0 (780.4), p =

0.068;

4) 12-month: IG 628.2(762.7) vs

CG 552.8 (706.5), p = 0.269.

(2) Swimming (minute/month)

[mean (SD)]:


2) direct follow up: IG 33.8

(109.6) vs CG 30.1(141.8), p

= 0.331; 3) 6-month: IG 26.8 (86.5) vs

CG 52.8 (205.7), p = 0.217;

4) 12-month: IG 47.8 (181.5) vs

CG 51.1 (196.3), p = 0.991.

(3) Bicycling (minute/month)

[mean (SD)]:


2) direct follow up: IG 302.3

(520.4) vs CG 220.8 (382.8),

p = 0.176; 3) 6-month: IG 280.6 (604.2) vs

CG 228.5 (471.7), p = 0.675;

7

89

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Smeulders et

al.

(2006, 2009)

Netherlands

4) 12-month: IG 290.7 (614.0)

vs CG 233.5 (469.5), p =

0.356.

(4) Other physical activities

(minute/month) [mean (SD)]:

1) baseline: IG 144.0 (580.5) vs

CG 146.0 (846.2), p = 0.076; 2) direct follow up: IG 224.5

(597.6) vs CG 93.7 (219.1), p

= 0.006;

3) 6-month: IG 205.9 (649.5) vs CG 86.3 (198.0), p = 0.036;

4) 12-month: IG 282.5 (937.0)

vs CG 141.9 (309.7), p =

0.248.

Ståhle et al.

(1999)

Sweden

109 subjects after an acute coronary

episode (within

six weeks after

the acute event) were recruited

and 101 subjects

(20% F, 80% M)


CG=51).

71 101 No I: 12-week out-patient exercise training with

exercise intensity of ＞

50% based on the relation

between maximal heart rate and maximal oxygen

uptake for at least 40

minutes, and ≥80% of the estimated maximal oxygen

uptake during three periods

of 3-4 minutes.

C: usual care.

12 weeks Self-estimated levels of physical activity

on a six-graded scale

[1 = hardly any

physical activity, 6 = strenuous exercise at

least 3 hours a week

(jogging, skiing, ice-

skating, tennis, swimming,

badminton, aerobic

training)] at baseline

and 3 months.

Self-estimated physical activity (box-plot):

1) Graphic display only

2) baseline: between group

comparison, p > 0.05; 3) 3-month: between group

comparison, p = 0.002.

4

90

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Stenlund et

al.

(2005)

Sweden

109 subjects 73

years or older

with coronary


and 95 subjects

(30% F, 70% M)


CG=47).

78 95 No I: Qi Gong and group

discussion which group

met weekly over 3 months

(a total of 12 group sessions). Each session

included 1h of Qi Gong

and 2h of discussions on

various themes.

C: usual care

3 months Self-reported current

level of physical

activity on a six-point

scale (‗1‘ corresponded to

sedentary and‗6‘ to

strenuous exercise) at

baseline and 3 months.

Physical activity level (score 1-6)

[mean (SD)]:


3.6 (0.7), p > 0.05; 2) 3-month: IG 4.0 (0.7) vs CG

3.7 (0.7), p = 0.011.

4

The Vestfold

Heartcare

Study

Group

(2003)

Norway

Subjects (18% F,

82% M) with

stable CHD

(15.2%) or 5-39 days following

acute myocardial

infarction,

unstable angina pectoris, PCI or

CABG were

recruited and 191

completed 6-month follow up

(IG=95, CG=96)

and 182

completed 2-year follow up

(IG=91, CG=91).

55 191 No I: A comprehensive

lifestyle intervention

consisted of physical

exercise training and scheduled meeting

throughout the two-year

follow up period for a low

fat dietary advice, smoking cessation, physical activity

counselling, risk factor

management, psychosocial

support and health education related to

cardiovascular disease,

medication, reduction of

mental stress, relaxation and psychosocial factors.

C: usual care

6 weeks plus

9 weeks, 2

years

Self-reported

exercise and exercise

diaries at baseline, 6

months and 2 years.

Exercise adherence (≥ 60

minutes/week) (%):

1) baseline (similar between two

groups), p > 0.05; 2) 6-month: IG 88/95 (93%) vs

CG 69/96 (72%), p <0.001;

3) 2-year: IG 61/91 (67%) vs

CG 42/91 (46%), p <0.01.

5

91

Author

(year)

Country

Subjects

Mean

age

(years

Sample

size

Theory/

model Interventions

Duration of


van Elderen-

van

Kemenade

et al.

(1994)

Netherlands

60 subjects after

acute myocardial

infarction were


84% M)

completed the


57 48 No I: Two individual

counselling sessions and

two group health education

sessions (90 minutes/session) focusing

on medication, healthy

habits, anxiety and

depression during hospitalization and weekly

telephone calls for a period

of six weeks after

discharge from hospital.

C: usual care.

8 weeks and 1

year's follow

up

Self-reported

physical exercise:

spending more time,

the same amount of time or less time in

four areas of physical

activity: taking

walks, bicycling, participating in

organized sports

(e.g., tennis or

football and pursuing active hobbies) at

baseline, immediately

after the group

sessions prior to discharge, 8 weeks

after discharge, and 1

year after discharge.

Physical exercise (n):

(1)Taking walks:

1) baseline: no significant

difference between groups; 2) 8-week: (IG 15 more, 14

same, 1 less) vs (CG 11 more,

15 same, 4 less), p >

0.05; 3) 1-year: (IG 10 more, 2 same,

10 less) vs (CG 7 more, 7

same, 12 less), p > 0.05.

(2) Bicycling (n):


difference between groups;

2) 8-week: (IG 10 more, 18 same, 2 less) vs (CG 5 more,

16 same, 9 less), p < 0.05;

3) 1-year: (IG 8 more, 7 same, 7

less) vs (CG 8 more, 4 same, 14 less), p > 0.05.

(3) Active in organized sports (n):

1) baseline: no significant difference between groups;

2) 8-week: (IG 3 more, 27 same,


same, 4 less), p < 0.05; 3) 1-year: (IG 6 more, 16 same,


same, 2 less), p > 0.05.

(4) Pursuing active hobbies (n):


difference between groups;

2) 8-week: (IG 1 more, 24 same,

92

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


van

Elderen-van

Kemenade

(1994)

Netherlands


same, 5 less), p > 0.05;

3) 1-year: (IG 9 more, 6 same, 7

less) vs (CG 8 more, 12 same, 6 less), p > 0.05.

Yates et al.

(2005)

USA

64 subjects (31% F, 69% M) who

had a recent

cardiac event

(MI, CABG, and/or PCI) were

recruited

(IG1=20, IG2=24, CG=20)

and 59 subjects

completed the

study (IG1=18, IG2=23,

CG=18).

97% white. 44 (69%) CABG

20 (31%) MI

and/or PCI.

67 59 Bandura's self-efficacy

theory

I1: Bandura's self-efficacy theory based booster

intervention by clinic.

I2: Bandura's self-efficacy

theory based booster intervention by telephone.

C: usual care

9 weeks and 3 and 6 months

after the

baseline

Self-reported exercise adherence

(aerobic activity

(brisk walking,

jogging, bicycling, or swimming) for more

than 20 min/session

and ≥ 3 times/week) at baseline, 3 and 6

months.

(1) Exercise adherence (≥ 3 times/week) [n (%)]:

1) 3-month: IG1 14/20 (70%)

(n=14), IG2 18/24 (75%) vs

CG 10/20 (50%), p > 0.05; 2) 6-month: IG1 8/20 (40%),

IG2 15/24 (63%) vs CG

10/20 (50%), p > 0.05. (2) Exercise frequency

(session/week)[mean(SD)]:

1) baseline: IG1 5.33(1.85), IG2

5.02(1.83) vs CG 5.70(1.78), p > 0.05;

2) 3-month: IG1 4.78(1.82), IG2

4.58(1.72) vs CG 4.03(1.62),

p > 0.05; 3) 6-month: IG1 4.65(1.82), IG2

3.67(1.96) vs CG 4.15(1.99);

p ＞ 0.05.

(3) Exercise duration

(minute/session)[mean(SD)]:

1) baseline: IG1 31.45(1.85),

IG2 29.50(4.88) vs CG 31.45(4.99), p > 0.05;

2) 3-month: IG1 33.00(5.71),

IG2 29.71(6.23) vs CG

33.80(13.03), p > 0.05; 3) 6-month: IG1 30.10(11.08),

IG2 29.71(14.49) vs CG

27.55(13.12), p > 0.05.

4

93

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Zhao &

Wong

(2009)

China

220 subjects with

myocardial

infarction or

angina pectoris were recruited

and 200 subjects

(51% F, 49% M)


CG=100).

72 200 No I: The transitional care

programme (TCP)

consisted of pre-discharge

assessment, structured home visits and telephone

follow ups within four

weeks after discharge.

C: usual care

4 weeks and

8-week

follow up

Self-reported

physical exercise

adherence and a daily

record of exercise at baseline, 2 days, 4

and12 weeks after

discharge from

hospital.

Physical exercise adherence [n

(%)]:

1) baseline: [IG high 56(56%),

moderate 39(39%), low 5(5%)] vs [CG high 63(63%),

moderate 33(33%), low 4

(4%)], p = 0.600;

2) 2-day: [IG high 63(63%), moderate 34(34%), low

3(3%)] vs [CG high 63(63%),

moderate 33(33%), low 4

(4%)], p = 0.924; 3) 4-week: [IG high 74(74%),

moderate 23(23%), low

3(3%)] vs [CG high 62(62%),

moderate 32(32%), low 6(6%)], p = 0.171;

4) 12-week: [IG high 90(90%),

moderate 7(7%), low 3(3%)]

vs [CG high 62(62%), moderate 32(32%), low

6(6%)], p = 0.000.

5

Zwisler

(2008)

Denmark

770 subjects

(37% F, 63% M)

with congestive

heart failure (12%), ischemic

heart disease

(58%), or high

risk of ischemic heart disease

(30%) were

recruited and


median

66

770 TTM and

self-efficacy

theory

I: Hospital-based

comprehensive cardiac

rehabilitation (6 weeks)

consisted of patient education, exercise

training, dietary

counselling, smoking

cessation, psychosocial support, and risk factor

management and clinical

assessment.

C: usual care

6-week and

12-month

follow up

interventions

Self-reported

adherence to the

advised increased

level of physical activity (from 4 hours

of moderate physical

activity a week to

>30 min/d) at baseline and 12

months.

(1) Community-based or private

services' physical exercise activity

[n (%)]:

1) no data available at baseline, p > 0.05;

2) 1-year: IG 125/380 (33%) vs

CG 23/390 (6%), p < 0.01.

6

94

Author

(year)

Country

Subjects

Mean

age

(years)

Sample

size

Theory/

model Interventions

Duration of


Zwisler

(2008)

Denmark

CG=390). (2) Physical active adherence

(from 4 hours of moderate

physical activity a week to > 30

min/day) [n (%)]: 1) baseline: IG 186/380 (49%)

vs CG 183/390 (47%), p >

0.05;

2) 1-year: IG 251/380 (66%) vs CG 222/390 (57%), OR 0.66

(95% CI 0.46-0.91), p = 0.01.

Note: I-intervention; C-comparison; IG-intervention group; CG-control group; F-female; M-male; CHD- coronary heart disease; MI-myocardial infarction; CABG-coronary artery bypass graft; PCI-percutaneous

coronary interventions; PTCA-percutaneous transluminal coronary angioplasty; TTM: the Transtheoretical Model.

95

2.4.4 Factors Affecting the Effectiveness of Patient Education

The effectiveness of patient education is determined by many factors. A number of

factors relate to difficulties in providing effective patient education, such as a

reduction in the time available for patient education due to shorter hospital stays, the

patient‘s physical and emotional status, the provision of non-tailored patient education,

and the shortage of nursing personnel (Padberg & Padberg, 1990). Kreuter and co-

workers (2000) suggest that for most patients, a tailored patient education is more

effective than a non-tailored one. Patients with high trait negative affectivity will tend

to show little change in health behaviour from participating in an education

programme following MI (Cameron, Petrie, Ellis et al., 2005). However, Duryée

(1992) found that, despite feeling anxious most patients were able to learn new

information, particularly information about the activities they should engage in after

being discharged. In China, An and others (2005) explored the factors affecting

patient education on lifestyle compliance among patients with CHD. They found that

many factors contribute to the effects of patient education on lifestyle compliance,

including gender (female patients are better than males at complying with a low-fat

diet), attitude, health beliefs, education levels (the higher the level of education, the

better the compliance), information sources, number and frequency of education

sessions, ability to receive health education, and living conditions (patients living in

cities show better compliance than those living in villages).

In a one-group pre-post intervention study (McPherson, Swenson, Pine & Leimer,

2002) with 436 patients, the findings illustrated that patients who were younger or

who were smokers were less likely to attend the programme than their older and

96

nonsmoking counterparts. The duration and frequency of the intervention, and the

design of the programme are predictors of its effects. In addition, the availability of

telephone calls or additional nurse visits during the follow-up period was also related

to the maintenance of healthy changes in behaviour and medical compliance. A

previous study also suggests that interactive intervention is more effective than non-

interactive intervention and stage-matched intervention is more effective than

mismatched intervention, especially in terms of long-term effects (Prochaska,

DiClemente, Velicer & Rossi, 1993).

Adherence to the programme is another factor contributing to its effectiveness.

Previous studies on the impact of gender differences on adherence to cardiac

rehabilitation programmes have produced inconsistent results (Leijon, Bendtsen,

Ståhle et al., 2010; Sarrafzadegan, Rabiei, Shirani et al., 2007; Taylor, Wilson &

Sharp, 2011). Some studies found no significant difference between men and women

in the dropout rate from such programmes (Cannistra, Balady, O‘Malley, Weiner &

Ryan, 1992; Leijon, Bendtsen, Ståhle et al., 2010), whereas other studies showed that

women are more likely than men to withdraw from such programmes (Halm, Penque,

Doll & Beahrs, 1999; Yohannes, Yalfani, Doherty & Bundy, 2007).

Marital status and other demographic and clinical characteristics may also influence

adherence. The findings from Ramm, Robinson and Sharpe (2001) indicated that

patients who are single or widowed, or living alone are more likely to withdraw from

cardiac rehabilitation programmes. Numerous studies have demonstrated that patients

who are younger, have lower levels of education, and are smokers are more likely to

withdraw from cardiac rehabilitation programmes (Dorn, Naughton, Imamura &

97

Trevisan, 2001; Leijon, Bendtsen, Ståhle et al., 2010; Moore, Dolansky, Ruland et al.,

2003; Ramm, Robinson & Sharpe, 2001; Sanderson, Phillips, Gerald, DiLillo, Bittner,

2003; Sarrafzadegan, Rabiei, Shirani et al., 2007; Taylor, Wilson & Sharp, 2011;

Worcester, Murphy, Mee, Roberts & Goble, 2004; Yohannes, Yalfani, Doherty &

Bundy, 2007). Several studies also showed that whether or not the patients had

financial problems and possessed medical insurance were also related to the uptake

and adherence to cardiac rehabilitation (Davies, Taylor, Beswick et al., 2010; Halm,

Penque, Doll & Beahrs, 1999; McCarthy, Dickson & Chyun, 2010; Mochari, Lee,

Kligfield & Mosca, 2006).

The mode of delivering patient education may also influence its effects. There are

many modalities for delivering patient education, including face-to-face sessions, the

telephone, written materials (e.g., handbooks and pamphlets), media-based education,

computer-tailored interventions, and internet-delivered interventions. Written material

is usually used as the basic mode in patient education. Face-to-face education with

written material has been widely used among CHD patients (Cupples & McKnight,

1994; Elderen, Maes & Seegers, 1994; Linde & Janz, 1979; Marshall, Penckofer &

Llewellyn, 1986). Face-to-face patient education followed by telephone consultations

is the most preferred approach for patients with CHD in China, (Chen & Jing, 2008;

Du, Chen, & Liu, 2005; Hu, 2006; Li & Liu, 2006; Li & Wang, 2006; Liu, 2005; Wan

& Wang, 2008). Hence, in this study written material was used as the basic mode,

with the addition of face-to-face patient education and telephone contact.

In summary, there are many factors that influence the effectiveness of patient

education. One of these factors is the method of delivering patient education. Since

98

the methods of face-to-face interaction together with telephone contact are preferred

by Chinese CHD patients, they were adopted in this study.

2.4.5 Theoretical Basis for Patient Education

Patient education is beneficial for CHD patients, yet several researchers have reported

that knowledge alone is not enough to induce patients to change their behaviour

(Chair, Thompson, Leung, Ng & Choi, 2011; Chair, Thompson, Tang & Leung, 2007;

Fortmann, Taylor, Folra & Winkleby, 1992; Johansson, Swahn & Strömberg, 2007).

In the Stanford Five-City Project, Fortmann and co-workers (1992) assessed the

effects of a patient education campaign on diet-related knowledge and behaviour and

cholesterol levels. They found that although community-based patient education

increased nutritional knowledge over time among both men and women in all cities, it

did not lead to changes in their behaviour with regard to the intake of dietary saturated

fats. They concluded that imparting knowledge alone might not be enough to promote

changes in dietary habits. A similar finding was reported by Ji, Huang, Chen, and

others (2005) on Chinese patients with diabetes mellitus. Scalzi, Burke, and

Greenland (1980) further showed that a structured inpatient education programme had

no effect on compliance with a low-fat, low-sodium diet when compared with the

usual care. Another study revealed that education and counselling during

hospitalization about patients‘ adherence to secondary prevention goals had no effect

on adherence to exercise (Mosca, Christian, Mochari-Greenberger et al., 2010). Hence,

patient education alone may not be enough to induce patients to modify their

behaviour.

99

The findings from a recent meta-analysis (Conn, Hafdahl, Brown & Brown, 2008)

showed that the effect of patient education on exercise behaviour was not related to

interventions tailored for the individual or to the mode of delivery of the intervention,

whereas it was associated with interventions based on different theoretical models.

Painter et al. (2008) stated that theory-based programmes on changing health

behaviour are regarded as more effective than those that do not use theory.

The Transtheoretical Model (TTM), Social Cognitive Theory (SCT), Health Belief

Model (HBM), the Theory of Reasoned Action (TRA), and the Theory of Planned

Behaviour (TPB) are most commonly used models and theories for patient education

concerned with bringing about changes in various behaviours (Painter, Borba, Hynes

et al., 2008). The social cognitive theory (SCT) was developed by Bandura from the

social learning theory in 1986 (Glanz, Rimer & Lewis, 2002). The SCT explains

human behaviour as a triadic, dynamic, and reciprocal model in which personal

factors (including cognition), behaviour, and environment influence each other. The

SCT includes numerous constructs, such as environments/situations, behavioural

capability, expectations, expectancies, self-control, observational learning,

reinforcements, self-efficacy, emotional coping responses, and reciprocal determinism.

Since it consists of so many constructs, some health educators and behavioural

scientists have complained that SCT is too comprehensive in its formulation (Glanz,

Rimer & Lewis, 2002) and too complicated for practitioners to use.

The HBM, developed in the 1950s, is one of the oldest models of health behaviour

and is a value-expectancy theory (Glanz, Rimer & Lewis, 2002). The main

components of the HBM are perceived threat and expectation. It postulates that the

100

likelihood of adopting behaviour appropriate to the prevention or control of some

disease depends on the individual‘s perception of a threat to personal health and a

conviction that the recommended action will reduce this threat (Burkholder & Nigg,

2002). However, according to the HBM, behavioural change is viewed as an ―all or

nothing‖ phenomenon (e.g., one either does or does not change one‘s behaviour). In

addition, although the HBM has been widely used to study behaviours involving risk

such as smoking and alcohol use, dental hygiene, contraceptive use, compliance with

medication for diabetes and hypertension, and dietary compliance, its use as a

theoretical framework for motivation to engage in exercise has been limited

(Burkholder & Nigg, 2002; Wood, 2008).

The Theory of Reasoned Action (TRA) and the Theory of Planned Behaviour (TPB),

developed in late 1960s, focus on theoretical constructs that are concerned with

individual motivational factors as determinants of the likelihood of performing a

specific behaviour (Glanz, Rimer & Lewis, 2002). The TRA comprises measures of

attitude and social normative perceptions that determine behavioural intention. The

TPB is an extension of the TRA and includes an additional construct on perceived

control over the performance of the behaviour. Both theories were developed to

understand the relationship between attitudes and behaviour. They assume a causal

chain that links behavioural beliefs and normative beliefs to behaviour through

attitudes and subjective norms. The most important predictor of behaviour in these

theories is intention, which includes attitude and subjective norms. Similar to the

HBM, both the TRA and TPB view behavioural change as an ―all or nothing‖

phenomenon.

101

The Transtheoretical Model (TTM) of behavioural change was developed by

Prochaska and DiClemente (1983) in the late 1970s and early 1980s. It is a model of

intentional behavioural change, originally designed for smoking cessation (Prochaska

& DiClemente, 1983 & 1984). Subsequently, the TTM has been expanded to cover

changes in various behaviour, including quitting cocaine, controlling weight,

following a low-fat diet, engaging in safe sex, using condoms, adopting exercise,

using sunscreen, and taking mammography screening (Prochaska & DiClemente,

1983; Prochaska & Velicer, 1997; Prochaska, Velicer, Rossi, Goldstein et al., 1994).

The TTM of behavioural change is an internationally recognized model that holds

much promise for changing health behaviour of all types, and can be used as a guide

for nurses in counselling individuals about exercise behaviour (Burbank, Reibe,

Padula & Nigg, 2002).

The strength of the TTM is that it treats behavioural change as dynamic, rather than as

an ―all or nothing‖ phenomenon (Marshall & Biddle, 2001). It allows practitioners to

treat individuals as they are – in different stages of readiness to make changes in

health behaviour (Glanz, Rimer & Lewis, 2002). The main difference between the

TTM and other theories/models, such as SCT, TPB, and HBM, is that the SCT, TPB,

and HBM were developed to explain a purely behavioural criterion using an all or

nothing phenomenon, that is, engaging in a behavioural change or not, whereas the

TTM attempts to explain a complex, mixed criterion in a dynamic sense. In addition,

the TTM allows practitioners to develop a stage-matched intervention with reference

to the stages of readiness for behavioural change.

102

Traditional interventions for encouraging the adoption and maintenance of an exercise

regime have been relatively ineffective. This may be due to the fact that providers

usually use action-oriented approaches, while most people who need to change their

behaviour are in the pre-action stages (precontemplation and contemplation) (Burbank,

Reibe, Padula & Nigg, 2002; Prochaska, DiClemente & Norcross, 1992).

Consequently, the programmes are not matched to their needs (Prochaska & Velicer,

1997). The TTM could be effectively used in tailoring treatment for these

―precontemplators‖ and ―contemplators‖ to encourage them to engage in exercise

(Marcus & Simkin, 1994). For individuals at the stages of precontemplation and

contemplation, no action-oriented intervention will be implemented because of the

lack of intention or preparation to change his/her behaviour at these stages. Thus, the

employment of the TTM to change exercise behaviour may outweigh the mismatched

or action-oriented interventions in effectiveness (Marcus, Emmons, Simkin-Silverman

et al., 1998). Therefore, in this study, the exercise stage-matched patient education

will be delivered based on the TTM.

2.5 The Transtheoretical Model (TTM)

In this section, the overview of the TTM is presented, followed by the effects of the

TTM-based Exercise Stage-Matched Intervention (ESMI) for changing exercise

behaviour, and the use of the TTM for changing exercise behaviour among patients

with heart disease.

103

2.5.1 Overview of the Transtheoretical Model (TTM)

The TTM consists of four core constructs: stages of change, self-efficacy, decisional

balance, and processes of change (Prochaska & DiClemente, 1983; Prochaska &

Velicer, 1997). The detailed contents of the TTM and the relationship between

constructs are shown in Figure 2.1 and Figure 2.2. A meta-analysis (Marshall &

Biddle, 2001) illustrates that different stages of change are related to different levels

of physical activity, self-efficacy, perceptions of the cons and pros of exercise, and

processes of change.

104

Consciousness raising

Dramatic relief

Environment reevaluation

Self-reevaluation

Social liberation

Processes of change

Counterconditioning

Helping relationships

Reinforcement management

Self-liberation

Stimulus control

Pros of behaviour

change

Decisional balance

Cons of behaviour change

1. Precontemplation

2. Contemplation

3. Preparation

Stages of change

4. Action

5. Maintenance

Confidence

Self-efficacy for

behaviour change

Temptation

Figure 2.1: The Transtheoretical Model of Behaviour Change (adapted from Burkholder & Nigg, 2002)

Experiential construct

Behaviouralconstruct

105

Precontemplation

Processes:

Consciousness

raising

Dramatic relief

Environmental

reevaluation

Decisional balance:

Pros << Cons

Self-efficacy (SE): Lowest SE

Contemplation

Processes:

Consciousness

raising

Self-reevaluation

Social liberation

Decisional balance:

Pros < Cons

Self-efficacy (SE):

Increasing SE

Preparation

Processes:

Self-reevaluation

Helping

relationships

Self-liberation

Decisional balance:

Pros ≤ Cons

Self-efficacy (SE):

Increasing SE

Action

Processes:

Reinforcement

management

Helping

relationships

Counter-

conditioning

Stimulus control

Decisional balance:

Pros > Cons

Self-efficacy (SE):

Increasing SE

Maintenance

Processes:

Reinforcement

management

Counter-

conditioning

Helping

relationships

Decisional balance:

Pros > Cons

Self-efficacy (SE):

Increasing SE

Figure 2.2: Relationship among stages of change, processes of change, decisional balance, and self-efficacy (Adapted from Burbank, Padula & Nigg, 2000; Burkholder & Nigg, 2002)

106

2.5.1.1 Stages of Change

Stages of change is a core construct of the TTM and is the most frequently applied

construct among the four constructs of the TTM (Buckworth & Wallace, 2002). Based

on the stages of change, individuals are classified into one of five stages, namely, the

precontemplation, contemplation, preparation, action, and maintenance stages

(Prochaska & DiClemente, 1983). The distinction between the different stages is

based on the behavioural change itself or the motivation to change one‘s behaviour.

Stages of change describes the temporal dimension of change as distinct stages based

on past behaviour and plans for future actions.

According to the TTM, people do not change all at once, but often move through a

series of stages toward changing their behaviour, (Burbank, Reibe, Padula & Nigg,

2002). People in the first stage of precontemplation have no intention of changing

their behaviour in the next six months. Contemplation is the stage at which

individuals are aware that a problem exists with their current behaviour and are

seriously thinking about overcoming it, to the point that they are thinking about

starting to exercise regularly in the next six months. In the preparation stage,

individuals are intending to take action to change their behaviour in the next 30 days,

or change their actions to some extent but not regularly. The next stage, action, is the

stage at which individuals have successfully changed their behaviour for less than six

months. Finally, in the maintenance stage, people have successfully sustained their

change in behaviour for six months or more (Nelson, 2000; Prochaska, DiClemente &

Norcross, 1992). Thus, individuals who are in the action and maintenance stages have

adopted a regular exercise regime. In this study, regular exercise is defined as

107

accumulating at least 30 minutes of moderately intense physical activity throughout

the day for more than five days of the week (American College of Sports Medicine,

2006; Marcus, Forsyth & Blair, 2003).

Movement through five stages does not always occur in a linear manner, but may also

be cyclical as many individuals must make several attempts at changing their

behaviour before they attain their goals (Marcus, Banspach, Lefebvre, Rossi, Carleton

& Abrams, 1992). Most people actually move through the stages of change in a spiral

pattern (Prochaska, DiClemente & Norcross, 1992). Individuals can also regress to

any previous stage, but learn from each attempt (Nigg, 2005). Individuals within the

same stage of changing their exercise behaviour hold similar beliefs about exercise

and use similar strategies and techniques to progress to the next stage. This implies

that interventionists could conduct stage-matched interventions based on the TTM to

encourage people to adopt and maintain regular physical activity or exercise

behaviour (Blissmer & McAuley, 2002).

2.5.1.2 Self-efficacy

Self-efficacy is a central construct of social learning theory (Bandura, 1997). This

construct involves two components: confidence and temptation. Confidence refers to

the level at which a person feels he/she can perform a specific action required to attain

a certain outcome (Bandura, 1986). It is the situation-specific confidence to

participate in behaviour with known outcomes (Buckworth & Wallace, 2002).

Temptation tempts individuals to engage in problematic behaviour in specific

situations (Prochaska & Marcus, 1995).

108

Self-efficacy is an important predictor of progress with a linear increase from the

precontemplation to the maintenance stage (Figure 2.2). In other words, it progresses

in stages, with individuals in the higher stages showing higher self-efficacy than those

in the lower stages (Plotnikoff, Hotz, Birkett & Courneya, 2001), while temptation

decreases across the stages (Prochaska & Marcus, 1995). A cross-sectional study

(Marcus, Pinto, Simkin, Audrain & Taylor, 1994) explored the utility of three

theoretical models, namely the stages of change model, self-efficacy theory, and the

decisional balance model, for understanding exercise behaviour among 431 employed

women averaging 41.1 years of age. The findings showed that women in the

precontemplation stage scored lowest in self-efficacy and those in the maintenance

stage scored highest. A longitudinal study (Marcus, Eaton, Rossi & Harlow, 1994),

suggests that self-efficacy is an important and strong predictor of current and future

exercise behaviour.

2.5.1.3 Decisional Balance

Decisional balance was originally based on Janis and Mann‘s theory of the decision-

making model (Janis & Mann, 1977, cited in Prochaska & Velicer, 1997), in which

decision making includes balancing eight central constructs: instrumental benefits for

self, instrumental benefits for others, instrumental costs to self, instrumental costs to

others, approval from self, approval from others, disapproval from self, and

disapproval from others. Prochaska further developed decision-making measures for

changing new behaviour in two constructs: the pros and cons of changing (Prochaska

& DiClemente, 1984; Prochaska, 2008; Prochaska, Velicer, Rossi et al., 1994). Two

109

main constructs of decisional balance, namely pros and cons, or benefits and costs of

performing behaviour, have been widely used in changing various types of behaviour,

including exercise behaviour (Marcus & Simkin, 1994; Prochaska, 2008). Prochaska

(2008) found that it is easier for most smokers to agree with the benefits of quitting

smoking than with the costs of quitting.

Decisional balance also varies across stages of change (Figure 2.2). In the

precontemplation stage, the pros are low, with cons outweighing pros. By the

contemplation or preparation stage, the pros increase to the same level as the cons,

with pros eventually outweighing cons in the action and maintenance stages

(Plotnikoff, Hotz, Birkett & Courneya, 2001). The results from 12 studies of problem

behaviour (Prochaska, Velicer, Rossi et al., 1994) have demonstrated that the cons of

changing the problem behaviours are higher than the pros for individuals who are in

the precontemplation stages. The opposite is true for individuals in the action stage in

11 of the 12 studies, with the exception of quitting cocaine. For most problem

behaviours, individuals need to perceive that the pros of changing the behaviour

outweigh the cons before they will take action to modify their behaviour (Prochaska,

Velicer, Rossi et al., 1994). Thus, in order to progress from the precontemplation to

the contemplation stage of changing behaviour, the pros of changing must increase;

whereas the cons of changing must decrease when individuals progress from the

contemplation to the action stage. Before progressing to the action stage, the pros and

cons will cross over, with the pros higher than the cons being a sign of being well

prepared for action (Prochaska & Velicer, 1997).

110

2.5.1.4 Processes of Change

The stages of change represent a temporal dimension that helps us to understand when

particular changes in attitudes, intentions, and behaviour occur, while the processes of

change are a second major dimension of the TTM that allow us to understand how

these changes occur (Prochaska, DiClemente & Norcross, 1992). Prochaska and

Velicer (1997) defined processes of change as covert and overt activities that people

use to progress through the stages.

Processes of change consist of two hierarchical constructs: experiential and

behavioural constructs. Each construct has five processes. These ten processes are

consciousness raising, dramatic relief, self-reevaluation, social liberation,

environmental reevaluation, helping relationships, counterconditioning, reinforcement

management, self-liberation, and stimulus control (see Table 2.2). Ten processes of

change have been identified as the strategies and techniques used most frequently and

successfully by people as they move through the stages (Burbank, Padula & Nigg,

2000). In a pre-post randomized control study, Woods, Mutrie, and Scott (2002)

examined the effectiveness of a stage-matched intervention for helping sedentary

young adults (precontemplators and contemplators) to initiate exercise. The results

demonstrate that stage improvers scored significantly higher on all of the behavioural

and four out of the five of the experiential processes of change. The findings suggest

that people used processes of change to assist their movement toward the next stage.

Numerous studies have illustrated that an integration of the stages and processes of

change can provide a useful guide for interventions (Burbank, Reibe, Padula & Nigg,

111

2002; Prochaska & Marcus, 1995). Once a particular individual‘s stage has been

assessed, interventionists have a better idea of which processes to emphasize in order

to help the individual progress to the next stages of change (Marcus & Simkin, 1994).

Subjects in different stages of change used the processes of change in significantly

different ways (Marcus, Rossi, Selby, Niaura & Abrams, 1992; Marcus & Simkin,

1994; Peterson & Aldana, 1999). For engagement in exercise, the precontemplators

used all ten processes significantly less than individuals in the other stages. Preparers

used behavioural processes more than contemplators, although they used the same

experiential processes. Subjects in the action stage used both experiential and

behavioural processes more than those in the preparation stage. Individuals in the

maintenance stage used experiential processes less and behavioural processes as often

as those in the action stage.

Prochaska and DiClemente (1983) suggested that, for smoking cessation based on the

TTM, individuals in the precontemplation stage use 8 of 10 processes significantly

less than any other group. Consciousness raising is emphasized most by people in the

contemplation stage. Self-reevaluation appears to bridge contemplation and

preparation because it is emphasized in both stages. Self-liberation is emphasized

when individuals prepare to take action. Helping relationships and reinforcement

management are emphasized when individuals take action. Counterconditioning and

stimulus control appear to bridge action and maintenance, since these two processes

are emphasized in both stages (see Table 2.3).

112

Table 2.2 Definitions of the processes of change for physical activity (Adapted

from Burbank, Padula & Nigg, 2000)

Processes of Change Definition

Experiential

Consciousness raising Efforts to seek new information and to gain

understanding and feedback about physical

activity

Dramatic relief Affective aspects of change involving

experiences and intense feelings about loss of

cardiovascular fitness due to inactivity

Self-reevaluation Emotional and cognitive reappraisal of values

regarding physical activity

Environmental reevaluation Consideration and assessment of how physical

inactivity affects the individual‘s physical and

social environment

Social liberation Developing awareness and acceptance of an

active lifestyle

Behavioural

Counterconditioning Substitution of alternative behaviours for

sedentary activities

Helping relationship Trusting, accepting, and using support from

others to be more active

Reinforcement management Changing the contingencies that control or

maintain physical inactivity and rewarding

physical activity

Self-liberation The individual‘s choice and commitment to

being more active, involving the belief that one

can change

Stimulus controls Control of situations and other causes that

trigger inactivity

113

Table 2.3 The emphasis of different processes of change according to stages of

change (Adapted from Prochaska, DiClemente & Norcross, 1992)

Stages of change

precontemplation contemplation preparation action maintenance

Processes Consciousness raising

Dramatic relief

Environmental reevaluation

Self-reevaluation

Self-liberation

Reinforcement management

Helping relationship

Counterconditioning

Stimulus control

2.5.2 The Transtheoretical Model (TTM) and Exercise Behaviour

Sonstroem first used the TTM to explain exercise behaviour at the University of

Rhode Island in the late 1980s (Prochaska & Marcus, 1995). In the early 1990s,

Marcus and colleagues first applied the TTM to change exercise behaviour in

worksite and community participants and the study showed promising result in

exercise behaviour (Marcus, Rossi, Selby, Niaura & Abrams, 1992; Marcus, Selby,

Niaura & Rossi, 1992; Marcus & Simkin, 1993). Subsequently, the TTM was widely

used for changing exercise behaviour in various populations from adolescents (Nigg

& Courneya, 1998) to the elderly (Burbank, Reibe, Padula & Nigg, 2002; Cardinal,

1997; Findorff, Stock, Gross & Wyman, 2007; Resnick & Nigg, 2003).

114

A number of studies have demonstrated that the exercise behaviour of individuals is

significantly associated with the constructs of the TTM, and that the TTM has good

internal and external validity for explaining exercise behaviour (Findorff, Stock,

Gross & Wyman 2007; Kim, 2007; Kim, Cardinal & Lee, 2006; Marcus, Rossi, Selby

et al., 1992; Nigg & Courneya, 1998). In a longitudinal study, Marcus, Eaton, Rossi,

and Harlow (1994) examined the stages of readiness to exercise and their relationship

to self-efficacy, the costs and benefits of exercise, and self-reported physical activity

among 698 employees in four Rhode Island worksites. The results demonstrated that

the level of physical activity of individuals could be predicted by knowing their stages

of readiness for exercise, their perceptions of the costs (cons) and benefits (pros) of

exercise, and their self-efficacy for exercise. The results also indicated that the TTM

could successfully predict exercise behaviour six months later, with no exercise

intervention during the 6-month period.

Although the TTM has been widely used in the past decade for explaining exercise

behaviour, most studies used cross-sectional design and few experimental studies

were carried out. A meta-analysis (Marshall & Biddle, 2001) of 71 studies examined

the applications of the TTM in the domain of physical activity and exercise. Of these

studies, 54 were cross-sectional, six were longitudinal, ten were quasi-experimental,

and only one was a randomized controlled trial. Due to the limitations of the cross-

sectional design, experimental studies need to be conducted to determine the

relationship of cause and effect between the TTM and exercise behaviour.

As stated by Burbank, Reiba, Padula, and Nigg (2002), the TTM can be used as a

guide for nurses in counselling individuals to motivate changes in their exercise

115

behaviour. Based on an individual‘s stages of change, a stage-matched intervention

can be developed. The stage-matched intervention refers to the use of different

strategies and techniques (processes of change) matched to an individual‘s stage of

readiness to change his/her behaviour according to the TTM to bring about changes in

behaviour (Kim, 2008). Similarly, the exercise stage-matched intervention refers to

strategies and techniques that are matched to the individual‘s current stage of

readiness to change his/her exercise behaviour (Kim, 2008). The effects of the TTM-

based Exercise Stage-Matched Intervention (ESMI) for changing exercise behaviour

are thoroughly reviewed below.

2.5.2.1 Effects of the ESMI on Exercise Stages of Change (ESC)

Previous studies have shown that the TTM-based ESMI had a significantly positive

effect on changing exercise behaviour in various populations, with respect to the

exercise stages of change scale. Marcus, Banspach, Lefebvre, and others (1992) first

used the TTM as a framework for encouraging the adoption of an exercise regime

among 610 community participants aged 18 to 82 years in early 1990s. A 6-week

intervention programme included written materials targeted at an individual‘s specific

stage of readiness to exercise, such as weekly ―fun walks‖, and an ―activity night‖.

The results indicated that most subjects progressed in their stage of exercise adoption

after the 6-week stage-matched intervention. Nevertheless, the lack of a control group

in this study induced uncertainties in the results.

Several studies have demonstrated that 4-10 weeks of the TTM-based ESMI using

self-help stage-matched manuals or internet-based motivational messages had a

116

significantly positive effect on exercise stages of change in a worksite setting when

compared with the generic intervention or usual care (Ishii, Nakiri, Nagatomi et al.,

2007; Marcus, Emmons, Simkin-Silverman et al., 1998; Peterson & Aldana, 1999).

Another single group pre-post test also showed similar results in worksites (Faghri,

Omokaro, Parker et al., 2008). Consistent with these studies, similar results with

respect to exercise stages of change were found when the ESMI was adopted among

university students over an 8-week to 6-month intervention period (Huang, Hung,

Chang & Chang, 2009; Ma, Ma & Zhu, 2006; Woods, Mutrie & Scott, 2002; Kim,

2008), among young to middle-aged women over an 8-12 week intervention period

(Fahrenwald, Atwood, Walker et al., 2004; Shirazi, Wallace, Niknami et al., 2007),

and among the general population through a website over a five week period (Lippke,

Schwarzer, Ziegelmann et al., 2010) when compared with the stage-mismatched

intervention group or control group.

In a series of PACE (the Patient-Centered Assessment and Counseling for Exercise)

studies, non-randomized controlled trials were conducted using a brief intervention

(3-5 minutes of counselling based on the TTM) and a booster phone call to patients

two weeks after they had received counselling from a physician. The findings showed

that the intervention significantly improved the exercise stages of change of healthy,

sedentary adults over the six-week intervention period (Calfas, Long, Sallis et al.,

1996; Purath, Miller, McCabe & Wilbur, 2004). In another series of PACE studies

involving non-randomized controlled trials, a 12-week exercise promotion

intervention based on the TTM led to a significant improvement in exercise stages of

change among adults with chronic disease (Shin, Yun, Jang & Lim, 2006) and among

resident physicians of internal medicine (Rogers, Gutin, Humphries et al., 2005).

117

Burbank et al. (2002) found that the TTM can be used as a framework for changing

exercise behaviour among the elderly. Several single-group design studies have

demonstrated that the stage-based intervention resulted in a significant improvement

in exercise stages of change among the elderly after the intervention as compared with

the baseline (Märki, Bauer, Angst et al., 2006; Märki, Bauer, Nigg et al., 2006). A

number of randomized controlled trials have also indicated that the exercise stage-

matched intervention significantly improved the exercise stages of change among

elderly people when compared with the comparison group (Findorff, Stock, Gross &

Wyman, 2007; Greaney, Riebe, Garber et al., 2008; Resnick & Nigg, 2003). Greaney

and others (2008) found that significant effect on exercise stages of change was

detected when the individuals who were in the maintenance stage at baseline were

excluded, whereas no significant difference in stage progression was identified if

those in the maintenance stage were not excluded. This finding suggests that there is a

ceiling effect on exercise stages of change if individuals in the maintenance stage at

baseline are recruited in the study.

A number of studies also showed that a 20-30 minute counselling session based on the

TTM or a tailored leaflet-based physical activity intervention based on the TTM could

significantly improved exercise stages of change among diabetes patients after the 4-

week to 6-month intervention (Dutton, Provost, Tan & Smith, 2008; Jackson,

Asimakopoulou & Scammell, 2007; Kirk, Higgins, Hughes et al., 2001; Kirk,

MacIntyre, Mutrie & Fisher, 2003). The positive effect on exercise stages of change

was maintained at the 12-month follow-up period (Kirk, Mutrie, MacIntyre & Fisher,

2004). Similar results for the TTM-based ESMI on exercise stages of change were

118

found in studies of diabetes patients (Huang & Tang, 1996; Zhu & Chen, 2007),

breast cancer patients who received 12 weekly phone calls (Pinto, Frierson, Rabin et

al., 2005; Pinto, Rabin & Dunsiger, 2009), patients with chronic disease over a 12-

week intervention period (Shin, Yun, Jang & Lim, 2006), and adults at increased risk

of developing coronary heart disease (Steptoe, Kerry, Rink & Hilton, 2001). These

studies indicate that the TTM-based ESMI is effective at motivating various

populations to engage in exercise or maintain their adherence to regular exercise.

However, the long-term (> 6 months) effect of the TTM-based exercise stage-matched

intervention on exercise stages of change was not clear. Several studies showed that

the TTM-based exercise intervention had a significantly positive effect on exercise

stages of change at the 12-month follow-up period (Kirk, Mutrie, MacIntyre & Fisher,

2004; Märki, Bauer, Nigg et al., 2006) and that this effect was maintained at the 24-

month follow-up period (Greaney, Riebe, Garber et al., 2008). However, findings

from some studies revealed that the positive effect of the TTM-based physical activity

intervention on exercise stages of change had disappeared at the 6-8 month follow-up

period (Goldstein, Pinto, Marcus et al., 1999; Pinto, Friedman, Marcus et al., 2002).

Although positive effects were found, a number of negative findings relating to the

stage-matched intervention have also been reported. In one study (Naylor, Simmonds,

Riddoch et al., 1999), a single-contact counselling session (of approximately five

minutes) based on the stages of change model for exercise adoption was carried out in

four primary care centres. Two hundred and ninety-four subjects were recruited and

randomly allocated to one of four groups, which respectively received the following:

stage-oriented exercise materials with counselling (stage plus counselling), stage-

119

oriented materials without counselling (stage no counselling), non-staged materials

with counselling (counselling only), and the current level of advice. The results

showed that there was no significant group or interaction effect for exercise stages of

change after controlling for baseline differences in self-efficacy, age, and gender. The

authors concluded that the stage-based interventions were not superior to the other

interventions. However, these results require further examination because the attrition

rate was high in this study, 39.0% at eight weeks and 54.0% at 24 weeks. The

distribution of the subjects across the stages of change at baseline was higher in the

preparation and maintenance stages than in the precontemplation, contemplation, and

action stages. There was a ceiling effect for those in the maintenance stage. The

intervention only consisted of a single contact (lasting appropriately five minutes). A

longer contact session and interactive counselling may produce more obvious effects.

Thus, the results might not be reliable.

Griffin-Blake and DeJoy (2006) compared the effectiveness of stage-matched

interventions with social-cognitive physical activity interventions in a study involving

208 employees in two academic colleges in the USA. Participants were randomly

allocated to either a stage-matched self-help intervention group or a social-cognitive

self-help intervention group. The findings showed that the two interventions were

equally effective in increasing exercise stages of change (34.9% versus 33.9%). This

finding may be jeopardized by the unsatisfactory sampling at baseline. Only a few

participants (about 1.0%) in the precontemplation stage were found in both groups at

baseline and nearly half of the participants were in the maintenance stage. Such a

sampling may explain why the social-cognitive physical activity intervention

produced the same effect as the stage-matched intervention in this study. One session

120

of motivation based on the TTM for physical activity in 38 obese patients also showed

no significant effect in motivational stages of change, although the intervention group

demonstrated a significant improvement in minutes of physical activity engaged in

weekly (Schelling, Munsch, Meyer et al., 2009). Similarly, negative results were

found in the studies of van Sluijs and others (2005) and Jimmy and Martin (2005), in

which the results of the TTM-based intervention group were not superior in exercise

stages of change when compared with those of the control group.

Nelson (2000) compared the effects of the stage-matched intervention on physical

activity with the exercise prescription in military primary care. The results indicated

that the stage-matched intervention led to no significant improvements in motivation

and exercise stages of change, although positive trends for these parameters were

found and the participants in the stage-matched group tended to engage in more daily

physical activity. In sum, the data in this study was inconclusive because post hoc

power analysis was low. Thus, further studies are recommended.

A critical review was carried out by Adams and White (2003) of 26 papers

documenting 16 intervention programmes based on the TTM. Of these programmes,

seven used TTM-based counselling, four used TTM-based written materials only, and

five used a mixture of TTM-based counselling and written information. They found

that TTM-based activity promotion interventions were effective in promoting the

adoption of activity in the short term (≤ 6 months), while the long-term (> 6 months)

adherence was disappointing. Adams and White (2005) addressed some possible

reasons for why stage-based activity promotion interventions are less effective than

originally proposed. These reasons are that: (a) exercise behaviour is a more complex

121

behaviour than currently recognized; (b) many algorithms for determining current

exercise stages of change have not been validated; (c) exercise behaviour is

determined by stage-based interventions; and (d) truly stage-based interventions are

highly complex requiring more than one level of development and evaluation. A

systematic review (van Sluijs, van Poppel & van Mechelen, 2004) of 13 studies on

physical activity interventions showed that the methodology of these studies varied

widely and the results were inconsistent. The authors of the review concluded that no

evidence was found for the effects on stages of change and actual levels of physical

activity during the short-, medium, and long-term follow-up periods.

A recent systematic review (Hutchison, Breckon & Johnston, 2009) showed numerous

inconsistencies involving the development and implementation/application of TTM-

based interventions. The majority of interventions reported to be based on the TTM

failed to accurately present all constructs of the model. This systematic review also

indicated that, of the seven studies that employed interventions that had been

developed using all four constructs of the TTM, six revealed statistically significant

short-term findings, and one demonstrated significant short- and long-term findings,

while of the 17 studies using interventions had not been tailored to all four constructs

of the TTM, 12 reported significant short-term findings, and one revealed significant

short- and long-term findings. These findings suggest that interventions tailored to the

four constructs of the TTM are more likely to show positive results.

In summary, the effect of the TTM-based ESMI on exercise stages of change is

inconclusive. Further studies to examine its effect on exercise stages of change are

necessary. Interventions based on four constructs of the TTM are superior to those

122

that are not based on all four constructs of the TTM. A further discussion regarding

the effects of the TTM-based ESMI on exercise behaviour in patients with heart

disease will be presented in section 2.5.3.

2.5.2.2 Effects of the ESMI on Exercise Self-Efficacy (ESE)

Exercise self-efficacy is an important predictor of progress, with linear increases from

the precontemplation stage to the maintenance stage (Plotnikoff, Hotz, Birkett &

Courneya, 2001). Thus, the levels of exercise self-efficacy predict progress in the

exercise stages of change (Marcus, Eaton, Rossi & Harlow, 1994; Tung & Hsu, 2009).

There have been few studies examining the effect of the TTM-based ESMI on

exercise self-efficacy in various populations. Previous studies have come to

inconsistent conclusions. A randomized controlled study demonstrated that the 8-

week TTM-based ESMI significantly increased the exercise self-efficacy of the

participants, who were university students (Kim, 2008). A similar result was found

when a web-based ESMI based on the TTM was designed to promote physical

activity among Taiwanese female freshmen in a university (Huang, Hung, Chang &

Chang, 2009). Another randomized pilot test of ―Moms on the Move‖ (Fahrenwald,

Atwood, Walker, Johnson & Berg, 2004) showed that an 8-week TTM-based

intervention delivered in the form of four structured, biweekly, provider-delivered

telephone contacts supplemented with an interactive brochure, led to significant

improvements in all TTM constructs including exercise self-efficacy when compared

with the results for the control group. A quasi-experimental study also indicated that a

5-month TTM-based intervention led to significant improvement in exercise self-

123

efficacy among 193 telecom workers in Taiwan (Kao, Lu & Huang, 2002). Another

study (Blisser, 2000) to examine the effects of stage-matched, stage-mismatched, and

standard care among 288 university staff members also revealed that the stage-

matched intervention was more effective at increasing exercise self-efficacy than the

stage-mismatched intervention and standard care.

However, several studies showed inconsistent results. Naylor et al. (1999) found that

with respect to exercise self-efficacy the use of stage-oriented exercise materials with

counselling did not produce superior results to those seen among the group that

received non-staged materials with counselling or the control group. The limitation of

their study was that the use of a single-contact counselling session (of approximately

five minutes) and the high dropout rate (39.0% at 8 weeks and 54.0% at 24 weeks),

which may contribute to the negative results. In a non-randomized controlled study

(Shin, Yun, Jang & Lim, 2006), a tailored stage-matched intervention based on the

TTM had no significant effect on exercise self-efficacy among Korean adults with

chronic diseases, although the intervention showed potential for promoting progress

in the exercise stages of change. A similar result was found in the study of Nelson

(2000), in which the exercise stage-matched intervention led to no significant

improvement in exercise self-efficacy when compared with the exercise prescription

in military primary care. However, this study had low power analysis. Thus, the

author stated that caution is needed in interpreting the results and that further studies

are needed.

124

Due to the limited number of studies evaluating the effect of the TTM-based ESMI on

exercise self-efficacy, and the inconsistent conclusions from the previous studies,

further studies are necessary.

2.5.2.3 Effects of the ESMI on Exercise Decisional Balance

Exercise decisional balance includes exercise benefits and exercise barriers. There

have been few studies on the TTM-based exercise interventions that have evaluated

its effect on exercise benefits or exercise barriers (Hutchison, Breckon & Johnston,

2009). Previous studies regarding TTM-based interventions to increase exercise have

shown inconsistent results with respect to the exercise decisional balance. Some

studies have shown that the TTM-based ESMI significantly increased the pros of

exercising and decreased the cons of exercising in the view of the participants, when

compared with the results seen among the control group (Fahrenwald, Atwood,

Walker, Johnson & Berg, 2004; Kao, Lu & Huang, 2002; Kim, 2008). However, other

studies showed no significant effects on the exercise decisional balance when the

TTM-based ESMI was used to promote changes in exercise behaviour (Griffin-Blake

& DeJoy, 2006; Nelson, 2000). These negative results may be due to the

unsatisfactory sampling at baseline. Only 1.0% of the participants were in the

precontemplation stage and nearly half of them were in the maintenance stage at

baseline (Griffin-Blake & DeJoy, 2006). Another possible reason for the negative

results may be low power analysis (Nelson, 2000). Thus, further studies to examine

the effect of the TTM-based ESMI on exercise decisional balance are recommended.

125

2.5.2.4 Effects of the ESMI on Exercise

Previous studies have shown that the TTM-based ESMI had significantly positive

effects on exercise duration, steps taken per week, or daily energy expenditure in

various populations. Several single-group design studies showed that the TTM-based

exercise intervention significantly increased the duration of moderate exercise per

week or steps taken during planned exercise when compared with the baseline data in

various populations (Faghri, Omokaro, Parker et al., 2008; Märker, Bauer, Angst et al.,

2006; Märker, Bauer, Nigg et al., 2006; Pinto, Rabin & Dunsiger, 2009). Some quasi-

experimental trials also indicated that the TTM-based exercise stage-matched

intervention significantly improved the duration of moderate exercise engaged in by

the participants per week over a 4-6 week intervention when compared with the

control group (Calfas, Long, Sallis et al., 1996; Ishii, Nakiri, Nagatomi et al., 2007).

A number of randomized controlled trials demonstrated that the TTM-based exercise

stage-matched intervention had significant effects on both total and moderate exercise

duration per week, activity counts, and daily energy expenditure when compared with

the stage-mismatched intervention group or the control group among patients with

type 2 diabetes mellitus (Jackson, Asimakopoulou & Scammell, 2007; Kirk, Higgins,

Hughes et al., 2001; Kirk, MacIntyre, Mutrie & Fisher, 2003; Kirk, Mutrie, MacIntyre

& Fisher, 2004), young to middle-aged women (Fahrenwald, Atwood, Walker et al.,

2004; Huang, Hung, Chang & Chang, 2009; Purath, Miller, McCabe & Wilbur, 2004;

Shirazi, Wallace, Niknami et al., 2007), obese patients (Schelling, Munsch, Meyer et

al., 2009), sedentary adults (Pinto, Friedman, Marcus et al., 2002), breast cancer

patients (Pinto, Frierson, Rabin et al., 2005), adults at increased risk of developing

126

CHD (Steptoe, Doherty, Rink et al., 1999), and patients with heart disease (Hughes,

Gillies, Kirk et al., 2002; Hughes, Mutrie & MacIntyre, 2007; Naser, Jafar, Kumar et

al., 2008).

The first multiple behaviour intervention study, including exercise behaviour

(Johnson, Paiva, Cummins et al., 2008), used TTM as a framework for weight

management among a population of overweight and obese adults (BMI 25-39.9; N =

1277). Participants were randomly assigned into either a no-treatment control or

home-based, stage-matched multiple behaviour interventions (n = 628) for up to three

behaviours based on the assessments at baseline, three, six, and nine months. The

authors of the study found that the participants in the intervention group showed

significant positive effects on weight lost, healthy eating (47.5% versus 34.3%),

exercise (44.9% versus 38.1%), managing emotional distress (49.7% versus 30.3%),

and intake of untreated fruits and vegetables (48.5% versus 39.0%). Such positive

effects continued to progress to the action/maintenance stage at 24 months. The

findings from two systematic reviews have demonstrated that interventions focusing

on a single exercise behaviour have a better effect on exercise than multiple behaviour

interventions among cardiac patients (Conn, Hafdahl, Moore et al., 2009) and

European teenagers (De Meester, van Lenthe, Spittaels et al., 2009). These studies

suggest that the TTM-based exercise staged-matched intervention has a positive effect

on increasing engagement in exercise among various populations.

However, most of these studies focused on the short-term (≤ 6 months) effect of the

TTM-based ESMI on exercise duration per week or step counts. The long-term (> 6

month) effect was not clear. As Pinto, Friedman, Marcus, and others (2002) reported,

127

the significant effects of the exercise intervention based on the TTM and social

cognitive theory on the duration of moderate exercise were found immediately after

the 3-month intervention, while the significantly positive effects were not maintained

at the 6-month follow-up period. A similar result was seen in Huang, Hung, Chang

and, Chang‘s (2009) study, in which they found that the effect did not persist in the

follow-up period.

The negative effect of the TTM-based ESMI on the duration of moderate exercise was

also found in some studies (Dutton, Provost, Tan & Smith, 2008; Goldstein, Pinto,

Marcus et al., 1999; Griffin-Blake & DeJoy, 2006; Jimmy & Martin, 2005; Kosma,

Cardinal & Mccubbin, 2005; Naylor, Simmonds, Riddoch et al., 1999; Taylor,

Demoor, Smith et al., 2006; van Sluijs, van Poppel, Twisk et al., 2005; Wanner,

Martin-Diener, Braun-Fahrlander et al., 2009). These studies found that the TTM-

based exercise intervention was not superior to standard or generic education or usual

care with regard to the duration of moderate exercise. Although several studies have

shown that the TTM-based exercise intervention progressed participants‘ exercise

stages of change, no significant effect on moderate exercise duration was detected

(Dutton, Provost, Tan & Smith, 2008; Goldstein, Pinto, Marcus et al., 1999; Kim,

2008).

However, these negative results required further examination because most of these

studies used a single-contact counselling or brief counselling session (of

approximately five minutes) (Goldstein, Pinto, Marcus et al., 1999; Naylor,

Simmonds, Riddoch, Velleman & Turton, 1999), had a high attrition rate (39.0% at

eight weeks and 54.0% at 24 weeks) (Naylor et al., 1999), a small sample size (N=75)

128

(Kosma, Cardinal & Mccubbin, 2005), and had a large number of participants in the

preparation or maintenance stages at baseline (Goldstein, Pinto, Marcus et al., 1999;

Griffin-Blake & DeJoy, 2006), all of which contributed to the negative results. Thus,

further studies with longer counselling contacts, a larger sample size, and the

recruitment of sedentary participants (namely, individuals in the precontemplation,

contemplation, and preparation stages) may result in positive effects when the TTM-

based ESMI is used to promote exercise.

2.5.2.5 Other Effects of the ESMI

In addition to the effects of the TTM-based ESMI on the exercise stages of change,

exercise self-efficacy, exercise decisional balance, and physical exercise levels or

exercise duration, the stage-matched intervention can increase the uptake of

programmes (Prochaska, DiClemente & Norcross, 1992; Prochaska & Velicer, 1997)

and reduce dropout rates (Schelling, Munsch, Meyer et al., 2009). As reported by

Rakowski, Ehrich, Goldstein, and others (1998), a TTM-based stage-matched

intervention led to a significant increase in the uptake of screening mammography

among women aged 40-74. Peterson and Aldana (1999) also found that participants

who had received the stage-matched information were more likely to report having

read the information sent to them than those who had received generic information.

Beckie and Beckstead (2010) reported that women in the stage-matched programme

attended significantly more sessions of the prescribed exercise (90% versus 77%)

when compared with women in the traditional cardiac rehabilitation programme.

These findings suggest that the TTM-based ESMI could increase the uptake of such

programmes and decrease the dropout rates.

129

Since the TTM-based exercise intervention could motivate individuals to adopt an

exercise regime and previous studies have shown that regular exercise could increase

the ischemia threshold, exercise tolerance, physical fitness, and quality of life of CHD

patients (Bize, Johnson & Plotnikoff, 2007; Cui, Ren, Wang et al., 2006; Hambrecht,

Walther, Mobius-Winkler et al., 2004), the TTM-based ESMI may reduce their

anginal pain and yield a better quality of life. However, few studies have been carried

out to evaluate the instrument‘s effects on anginal pain and quality of life.

The results from the previous studies regarding the effects of the TTM-based ESMI

quality of life have led to inconsistent conclusions. Some studies demonstrated

positive effects on quality of life when the TTM was applied to exercise interventions

(Beckie & Beckstead, 2011; Kirk, Higgins, Hughes, et al., 2001). Beckie and

Beckstead (2010 & 2011) focused on multiple behavioural changes, such as healthy

eating, engagement in physical activity, and stress management, based on the TTM.

They found a significantly positive impact on quality of life as assessed by the SF-36,

the Multiple Discrepancies Theory questionnaire (MDT), and the Self-Anchoring

Striving Scale (SASS). Kirk et al. (2001) examined the effect of a 30-minute TTM-

based one-to-one exercise consultation on the promotion of physical activity among

patients with type II diabetes. They found that the patients who had received the

exercise consultation significantly increased their exercise stages of change, physical

activity counts, and minutes of physical activity per week, and significantly improved

their quality of life with respect to SF-36 as compared with those who received the

care accorded to the control group.

130

On the other hand, other studies have found negative results with regard to quality of

life. Taylor and others (2006) reported that a lifestyle physical activity programme

based on the TTM and social cognitive theory led to no significant improvements in

quality of life with respect to the SF-36 immediately after the 6-month intervention

for patients with prostate cancer. The authors explained that the lack of significant

differences may be due to the limited power of their study, because they did not reach

their projected sample size. Another studies conducted by Hughes and others (2007)

also revealed that a TTM-based exercise consultation programme led to no significant

change in all domains of SF-36 after the 6-month intervention. The authors explained

that this result was due to the high scores of all domains of SF-36 at baseline.

To conclude, TTM as a framework for changing exercise behaviour was found to be

more effective in inducing changes in behaviour in various populations when

compared with action-oriented interventions or the usual care. When employing TTM,

an interactive intervention is preferred. The intervention period varied from a few

days during the period of hospitalization to two years. The desirable implementation

period ranged from 6 to 12 weeks. Thus, an 8-week intervention period was designed

for this study.

Previous studies regarding the effects of the TTM-based ESMI on the exercise stages

of change, exercise self-efficacy, exercise decisional balance, and exercise duration

were inconclusive. Most studies have shown positive effects on these parameters in

the short term (≤ 6 months). The long-term (> 6 months) effects were not clear. The

negative results of the TTM-based ESMI on these parameters may be due to a poor

research design, a relatively short or brief counseling period, a high attrition rate, a

131

small sample size, and large number of participants in the preparation, action, or

maintenance stages at baseline. Thus, future studies regarding the effects of the TTM-

based ESMI should use more counselling contacts and a sufficiently large sample size,

reduce the dropout rate, and recruit sedentary participants (i.e., exclude those who are

in the action or maintenance stages). In addition, few studies have been conducted to

test the effects of the TTM-based ESMI on anginal pain and quality of life, with the

previous studies having shown discrepancies in their findings on quality of life. Thus,

future research to examine the effect of the instrument on anginal pain and quality of

life is necessary.

2.5.3 The TTM for Changing Exercise Behaviour among Patients with Heart

Disease

Several cross-sectional and longitudinal studies (Hellman, 1997; Jue & Cunningham,

1998; Kanning, 2010) have shown that the TTM could be applied for changing

exercise behaviour among adults with heart disease. Paradis, Cossette, Frasure-Smith,

Heppell, and Guertin (2010) examined the preliminary effects of a motivational

nursing intervention based on the stages of change model in heart failure patients (n =

30). They included multiple behavioural changes, such as the restriction of fluids,

following a low-salt diet, daily measurements of weight, exercise, and medication.

The study focused on self-care in relation to heart failure. A positive trend was found

in the intervention group, while the outcome measure did not include changes in

exercise behaviour. Beckie (2006) utilized the TTM and motivational interviewing to

guide the stage-matched intervention to promote multiple behavioural changes (e.g.,

healthy eating, physical activity, and stress management) for women with CHD. The

132

clinical nurse specialist carried out three 1-hour individualized motivational

interviews with each participant based on stage assessments carried out over 12 weeks.

However, the outcome measurements focused on psychological well-being and

quality of life (Beckie & Beckstead, 2011; Beckie, Beckstead & Schocken, 2011).

Exercise behaviour was not assessed at post-intervention or in the follow-up period,

and this study only focused on women with CHD.

There have been few studies examining the effects of the TTM-based interventions on

changes in exercise behaviour among patients with heart disease. Our previous

systematic review (Zhu, Ho & Wong, unpublished) found that only three studies used

the TTM as a framework for changing exercise behaviour in heart disease patients.

The findings from these three studies showed inconsistent conclusions in exercise

adherence (Hughes, Gillies, Kirk et al., 2002; Hughes, Mutrie & Maclntyre, 2007;

Naser, Jafar, Kumar et al., 2008). Naser and others (2008) conducted an intensive

multifactorial lifestyle modification programme (IMLM) based on the TTM over two

years in 100 CHD patients. The findings demonstrated a significant effect on

adherence to regular exercise based on a self-reported questionnaire on type of

exercise. Hughes and others (2002) recruited 31 cardiac patients and delivered a 30-

minute individualized exercise consultation session based on the TTM over four

weeks. The results showed a significant increase in exercise duration per week

(minutes/week) after the intervention based on the Scottish physical activity

questionnaire. Another study by Hughes and others (2007) also recruited 70 cardiac

patients and delivered a 30-minute individualized exercise consultation session based

on the TTM with regular follow-ups for six months. Although a significant effect on

exercise duration per week was found based on the 7-day recall, no significant effects

133

were detected in accelerometer counts/week and adherence to regular exercise both

immediately after the intervention and at the follow-up period.

Despite these inconsistent results, all of the participants in these three studies were

recruited after the completion of the formal cardiac rehabilitation programme. Thus,

all of the participants in these three studies were in the preparation, action, or

maintenance stages at the start of the study, which means that they were ready to

change their exercise behaviour or were already active at baseline. Based on the TTM,

the strategies and techniques (processes of change) used to motivate individuals in the

precontemplation or contemplation stage to change their behaviour differ from those

in the preparation, action, or maintenance stage because individuals in the

precontemplation stage may have no intention or interest in changing their behaviour

(Prochaska & DiClemente, 1983). It may be much easier to motivate individuals in

the preparation or action stage to adopt or maintain changes in behaviour than to

persuade those in the precontemplation or contemplation stage to change their

behaviour. This is because those in the preparation stage are ready to change their

behaviour and those in the action or maintenance stage have already changed their

behaviour, while those in the precontemplation stage tend to be defensive and avoid

changing their thinking and behaviour and tend to make use of fewer processes of

change than those in any of the other stages (Prochaska & DiClemente, 1983).

Cardiac rehabilitation services in China are poor and underdeveloped (Wang, Chair,

Thompson & Twinn, 2009). Few hospitals in China provide cardiac rehabilitation

programmes. It is much more important to use the TTM to motivate sedentary

individuals to adopt exercise than active individuals. In addition, these three studies

did not assess the outcomes on exercise stages of change, exercise self-efficacy, and

134

exercise decisional balance. Thus, it is necessary and important to conduct a study

recruiting sedentary CHD patients to motivate them to change their exercise

behaviour.

Only one randomized controlled trial claiming to use the TTM as a theoretical

framework was conducted in China with 45 patients who had undergone PCI (Kang,

Li, Liang et al., 2006). Although the researchers stated that the study used the TTM as

a framework, the intervention did not match the stage that each patient was in. All of

the patients in the intervention group received the same intervention, one-session

group intervention including one 30-minute education session, a 20-minute video

about exercise rehabilitation, one 25-minute session of supervised exercise training

during hospitalization, and two telephone calls after their discharge from hospital to

check their exercise compliance. The whole intervention lasted for four weeks. Data

collection was conducted at pre- and post-intervention. The results showed that

patients who had received the intervention significantly improved in activity capacity,

activity adherence, and exercise self-efficacy (confidence), and significantly reduced

levels of depression as compared with those in the control group, while no difference

in quality of life (SF-36) was found between the two groups. Since this study did not

deliver stage-matched interventions, no information relating to the assessment of

stages of change was available. In addition, the study only focused on the patients

following PCI. Thus, there have in fact been no studies conducted in China guided by

the TTM to motivate CHD patients to engage in exercise.

To sum up, few studies have been carried out to examine the effects of the TTM-

based ESMI on changes in exercise behaviour among patients with heart disease.

135

Findings from previous studies have come to inconsistent conclusions and all of the

three studies that were found only recruited patients in the preparation, action, and

maintenance stages at baseline. Due to the limited number of RCT studies employing

TTM with exercise stage-matched interventions for changing exercise behaviour in

CHD patients, inconsistent conclusions, and active participants at the start of the study,

further studies are required. Moreover, there were no studies examining the effects of

the TTM-based ESMI on changes in exercise behaviour and quality of life among

sedentary CHD patients (namely, patients that are in the precontemplation,

contemplation, and preparation stages). This is the first study to evaluate the effects of

the instrument on sedentary CHD patients. Thus, in this study, we focused on

evaluating the effects of the TTM-based ESMI on changes in exercise behaviour,

anginal attacks and quality of life among sedentary CHD patients using a randomized

controlled study design.

2.6 Summary

CHD is a leading cause of death and disability among adults worldwide. It impacts

the health of individuals in many ways. Physical activity or exercise has been proven

to be of great benefit to CHD patients, so it is included as a core component of cardiac

rehabilitation programmes (Taylor, Brown, Ebrahim et al., 2004). However, poor

attendance and adherence to exercise-based cardiac rehabilitation programmes is a

worldwide problem. The Transtheoretical Model (TTM) for behavioural change has

been shown to be an effective model for changing exercise behaviour among various

populations. For cardiac patients, however, there have been few studies on cardiac

rehabilitation programmes using the TTM as a framework. Thus, in this study, the

136

Exercise Stage-Matched Intervention (ESMI) to increase the adoption of an exercise

regime among sedentary CHD patients according to the TTM was developed.

The failure of patients to improve after training has been provided may be related to

the strategy used to implement the cardiac rehabilitation programme. An action-

oriented intervention is not useful for people who have no intention or interest in

changing their behaviour (e.g., precontemplators or contemplators). A stage-matched

intervention that attempts to change behaviour based on an individual‘s current stages

of change may have more promising results than general patient education or

conventional care.

Based on the literature review regarding the TTM, an ESMI lasting a total of eight

weeks and delivered through face-to-face or telephone contacts plus exercise stage-

matched pamphlets were utilized in this study. The participants were followed up for

six months with an assessment every 3 months. This study aims to evaluate if the

TTM-based ESMI is effective in motivating sedentary CHD patients to change their

exercise behaviour, and subsequently improving their angina and quality of life.

137

Chapter 3 Research Methodology

3.1 Introduction

This study aims to examine the effects of the TTM-based Exercise Stage-Matched

Intervention (ESMI) on sedentary patients with coronary heart disease (CHD) in

China. This chapter describes the study design that was adopted to evaluate the effects

of the interventions. Details of the selection criteria, procedures, instruments, data

analysis, and ethical considerations are explained.

3.2 Study Design

This is an experimental study with consecutive sampling. Eligible patients were

randomly assigned to either the control groups or the experimental group, taking

stage-matching (the precontemplation, contemplation, and preparation stages) into

consideration by using a random number table. There were three groups in this study:

the control group (Conventional, C, group), in which patients received conventional

care; the ―sham‖ group (Patient Education, PE, group), in which patients received

conventional care, one 2-hour session of patient education about CHD and a booklet,

and eight weekly sessions of general patient education about exercise; and the

experimental group (Exercise Stage-Matched Intervention, ESMI, group), in which

patients received conventional care, one 2-hour session of patient education about

CHD and the booklet (the same as that of the PE group), and eight weekly sessions of

ESMI together with exercise stage-matched pamphlets. This intervention was carried

out with reference to the Transtheoretical Model (TTM) (Prochaska & DiClemente,

138

1983). To investigate the effects of the intervention, the collecting of data was

conducted at T0 (immediately before the commencement of the experiment), T1 (after

the completion of the 8-week ESMI), T2 (three months after T1), and T3 (six months

after T1). Figure 3.1 is the flowchart of the study design.

Note: C group: Conventional group; PE group: Patient Education group; ESMI group: Exercise Stage-

Matched Intervention group.

Patients were randomly assigned to one of the following groups taking into consideration their exercise stages

Subject Recruitment

- Screening assessment

- Sign consent form

T0: Baseline Measurements

C Group PE Group ESMI Group

One 2-hour patient education session on CHD

T2: 3 months after T1 (5 months after T0)

T3: 6 months after T1 (8 months after T0)

Figure 3.1 Flowchart of the study design

T1: after the completion of the 8-week ESMI (2 months after T0)

8 weekly sessions

of ESMI

8 weekly sessions of

general PE about exercise

139

3.3 Settings

The patients were recruited from three medical institutions in Xiamen City: The

Xiamen Heart Centre, the Cardiac Unit of the First Affiliated Hospital of Xiamen

University, and The Medical Service Centre of Lujiang Community, Xiamen City,

China. The Xiamen Heart Centre is the largest cardiac unit and the only heart centre

in Xiamen City. The centre has 100 beds and around 200-300 cardiovascular patients

visit the cardiac clinic every day. The First Affiliated Hospital of Xiamen University

is a teaching hospital of Xiamen University and is the largest comprehensive hospital

with a cardiac unit in Xiamen City. This cardiac unit has 60 beds and the cardiac

clinic receives about 100-200 cardiovascular patients a day. These two institutions

treat most cardiovascular patients in Xiamen City. The Medical Service Centre of

Lujiang Community is one of the medical service centres in Xiamen City. The

conventional care given in these three hospitals is similar. It consists of simple and

unstructured patient education about diet, exercise, and medication of relevance to

cardiac patients. All these three hospitals had no structured or formal patient

education programme or cardiac rehabilitation programme for cardiac patients.

3.4 Sampling

Consecutive sampling was used to recruit patients from September 2009 to January

2011 for this study.

140

3.4.1 Selection Criteria

3.4.1.1 Inclusion Criteria

The inclusion criteria were:

patients who were medically stable as determined by the cardiologist;

patients who had been diagnosed with angina pectoris, myocardial infarction, or

had undergone Percutaneous Transluminal Coronary Angioplasty (PTCA) or

Percutaneous Coronary Intervention (PCI) for at least three months;

patients who were sedentary according to the exercise stages of change scale – that

is, patients in the precontemplation, contemplation, and preparation stages

(Marcus et al., 1994);

patients who were 18 years old or above;

patients who were able to communicate and read in Chinese;

patients who were living in Xiamen City, Fujian Province, and who could be

contacted by telephone.

3.4.1.2 Exclusion Criteria

The exclusion criteria were set with reference to the guidelines for cardiac

rehabilitation (Wenger, Smith, Froelicher & Comoss, 1999) and the contraindications

of exercise from the expert working group of the National Heart Foundation of

Australia (Briffa, Maiorana, Sheerin et al., 2006). The details of the guidelines and the

contraindications of exercise are shown in Appendix I.

141

The exclusion criteria were:

patients who had previously participated in any cardiac rehabilitation programme;

patients who had cognitive impairment (e.g., dementia) or who had been diagnosed

with a psychiatric illness (e.g., psychosis);

patients who had depression that might influence their participation in or adherence

to the exercise programme – that is, their scores on the Hospital Depression

Subscale (HADS-D) were equal to or higher than 11;

patients who had unstable angina (Briffa et al., 2006; Wenger, Smith, Froelicher &

Comoss, 1999);

patients who had critical aortic stenosis (Briffa et al., 2006; Wenger, Smith,

Froelicher & Comoss, 1999);

patients who had uncontrolled symptomatic heart failure (e.g., NYHA III/IV),

diabetes with poor blood glucose control (e.g., fasting blood glucose > 15 mmol/L),

or uncontrolled atrial or ventricular arrhythmias (e.g., resting heart rate > 120bpm,

atrial fibrillation, third-degree AV block) (Briffa et al., 2006; Wenger, Smith,

Froelicher & Comoss, 1999);

patients who had a resting SBP > 180 mmHg or resting DBP > 110 mmHg (Briffa

et al., 2006);

patients who had acute myocarditis or pericarditis that could be worsened by

exercise;

patients who had suffered embolism during the previous three months;

patients who had an acute noncardiac disorder that could affect their performance of

exercise or be aggravated by exercise (e.g., infection, renal failure, thyrotoxicosis).

142

3.4.2 Sample Size

The researcher used the keywords to search for relevant articles in the MEDLINE and

CINAHL databases. There are no similar experimental studies using TTM on patients

with heart disease. The sample size of this study could not be calculated with

reference to previous studies. It was calculated based on the conventional method of

power analysis by using a medium effect size of 0.25 for an ANOVA analysis (Cohen,

1988), a power of 0.80, three groups (u = 2), and a significance level of 0.05. The plan

was to recruit 156 participants, with 52 in each group, according to the power table

(Cohen, 1988). In the pilot study, the dropout rate was 16.0%. With reference to a

cardiac rehabilitation study in mainland China (Jiang, 2005), the dropout rate was set

as 20.0%. Thus, the size of the sample in this study was amended to 63 patients in

each group. As a result, the total number of patients recruited was 189.

3.5 Procedures

Before the commencement of the study, ethical approval (Appendix II) was granted

from the Human Ethics Committee of The Hong Kong Polytechnic University and

access approvals (Appendix III) were obtained from the hospitals. The cardiologists in

each hospital were responsible for screening patients in accordance with the screening

guidelines (Appendix IV). Patients who met the selection criteria were recruited from

the outpatient cardiac clinics. The purpose and procedures of the study were explained

to them by the researcher (ZLX) using an information sheet (Appendix V) and they

were asked to sign a consent form (Appendix VI) to indicate that they were willing to

participate in the study. After being recruited, each patient received a gift (around

143

HKD 20) as a token of thanks for their participation. Before the group allocation, a

registered nurse (RN) who was blinded to the study design collected the baseline data

(T0): exercise stages of change, exercise self-efficacy, exercise decisional balance,

exercise duration, conditions of angina, and quality of life. Taking into consideration

their exercise stages of change, the patients were randomly allocated by the researcher

(ZLX) using a random number table to one of the following three groups: the

Conventional (C) Group, the Patient Education (PE) Group, and the Exercise Stage-

Matched Intervention (ESMI) Group.

After the group allocation, patients in the C group (control group) received

conventional care only; patients in the PE group (―sham‖ group) received

conventional care, one 2-hour session of patient education about CHD and the booklet,

and eight weekly sessions of general patient education about exercise; patients in the

ESMI group (experimental group) received the same interventions as the PE group

except that the eight weekly sessions were focused on the ESMI together with the

exercise stage-matched pamphlets. Data collection was conducted by the RN

immediately after the completion of the 8-week ESMI (T1), three months after T1 (T2),

and six months after T1 (T3).

To minimize cross contamination among the C, PE, and ESMI groups, appointments

for face-to-face contacts or data collection were scheduled in different time slots for

patients in the different groups. For example, patients in the ESMI group were invited

to come to the hospital on Mondays, Wednesdays, and Fridays, and those in the PE

group were scheduled to come to the hospital on Tuesdays, Thursdays, and Saturdays

for a face-to-face consultation.

144

3.6 Intervention

The details of the intervention received by each group are described in this section.

3.6.1 Conventional (C) Group

All of the patients in this study received conventional care, which consisted of simple

and unstructured patient education about diet, exercise, and medication suited to

cardiac patients. Patients in the C group received conventional care only. Since the

booklet about cardiac rehabilitation (which had been developed by the Hong Kong

Cardiac Rehabilitation and Prevention Centre of Tung Wah Hospital and the

organization Care for Your Heart) that was used in the PE and ESMI groups is

beneficial to CHD patients, it was also provided to the patients in the C group after

the completion of the study.

3.6.2 Patient Education (PE) Group

Patients in the PE group received conventional care, one 2-hour patient education

session and the booklet about cardiac rehabilitation, and eight weekly sessions of

general patient education about exercise. The contents of the 2-hour patient education

session were: (i) an introduction to the heart, including the anatomy and physiology of

heart; (ii) an introduction to CHD; (iii) the risk factors of CHD; (iv) the diagnostic

investigation and treatment of CHD; (v) dietary principles for patients with heart

disease; and (vi) exercise for patients with CHD. Patient education was delivered in

groups. There were 6-10 patients in each group. The booklet was given to the patients

145

immediately after the 2-hour patient education session. The eight weekly sessions of

general patient education on exercise were delivered after the one 2-hour session of

patient education in the mode of face-to-face or telephone contacts. Each patient

received at least two sessions of face-to-face contact. Each session of face-to-face

contact lasted about 30 minutes, while each telephone contact lasted 5-10 minutes.

The contents of the 8-week period of patient education included compliance checking

and the delivery of information related to the benefits and importance of regular

exercise (Appendix VII).

3.6.3 Exercise Stage-Matched Intervention (ESMI) Group

Similar to the PE group, patients in the ESMI group received conventional care, one

2-hour session of patient education including the booklet, and eight weekly sessions

of ESMI together with the exercise stage-matched pamphlets. The ESMI was

implemented according to the Transtheoretical Model (TTM), taking the factors of

coronary heart disease and Chinese culture into consideration. The intervention was a

collaboration between the researcher (ZLX) and the cardiologists. The researcher was

responsible for the patient education session, the weekly assessment of the patients'

exercise stages of change, and the delivery of strategies and techniques to the patients

according to the TTM. The cardiologists were responsible for the assessment of the

patients' physical condition and for prescribing exercise for those at the stage of

preparation with reference to Appendix VIII. To facilitate the implementation of

ESMI in Chinese patients, some examples of exercises popular among the Chinese

(e.g., Taichi and the Twist) were included in the recommendations.

146

3.6.3.1 Exercise Stage-Matched Intervention (ESMI)

According to the TTM, behavioural changes can be divided into five stages, namely,

precontemplation, contemplation, preparation, action, and maintenance (Prochaska &

DiClemente, 1983). Stage-matched intervention refers to the intervention that is

matched to the individual‘s current stage of behavioural change. In this study, the

Exercise Stage-Matched Intervention (ESMI) refers to strategies and techniques that

are matched to the individual‘s current stage of readiness for changes in exercise

behaviour as described by the TTM (Kim, 2008).

In this study, the ESMI was implemented weekly for eight weeks in the form of either

face-to-face or telephone contacts. An 8-week period was selected because the period

for inducing changes in exercise behaviour by using the TTM-based stage-matched

intervention ranges from one week to two years (Blissmer, 2000; de Vet, de Nooijer,

de Vries & Brug, 2008; Kim, 2008; Marcus, Banspach, Lefebvre, Ross et al., 1992;

Naser, Jafar, Kumar et al., 2008; Peterson & Aldana, 1999), with most interventions

lasting 6-12 weeks (Blissmer & McAuley, 2002; Kim, 2008; Marcus, Banspach,

Lefebvre, Ross et al., 1992; Peterson & Aldana, 1999). Therefore, the Exercise Stage-

Matched Intervention was scheduled for eight weeks in this study.

The ESMI was carried out weekly over an 8-week period after the one 2-hour session

of patient education. The stage-matched intervention together with the assessment of

the patient‘s exercise stage of readiness for change according to the exercise stages of

change scale (Marcus, Rossi, Selby, Niaura & Abrams, 1992) was delivered through

face-to-face or telephone contacts. The form of contact was determined by the

147

availability of the patients, but each patient must receive at least two sessions of face-

to-face contact over the eight weeks. Each session of face-to-face contact lasted about

30 minutes, while each telephone contact lasted 5-15 minutes.

During the 8-week intervention period, the researcher assessed each patient‘s exercise

stages of change weekly according to the exercise stages of change scale before

delivering the ESMI. The detailed protocol of the ESMI that was delivered weekly is

shown in Table 3.1. In formulating the ESMI, the guidelines (Table 3.2), such as

goals, processes of change, and strategies and techniques for changing exercise

behaviour in each stage, were set with reference to those developed by Burbank,

Reibe, Padula, and Nigg (2002) to motivate the elderly to engage in exercise. When

the patient was in the preparation stage and prepared to engage in exercise, a physical

examination for prescribing exercise was scheduled. The cardiologists assessed the

patient to ensure that it was safe for him/her to engage in exercise. Exercise was then

prescribed by the cardiologists in accordance with the patient‘s physical condition and

the guidelines for prescribing exercise (Appendix VIII).

With regard to the implementation of ESMI, the researcher (ZLX) and the patient

discussed the matter with reference to the guidelines developed by Burbank and co-

workers (2002) (Table 3.2). Different strategies and techniques were used for patients

at different stages of change. A Chinese version of the exercise stage-matched

pamphlet (Appendix IX) was prepared to reinforce the strategies and techniques being

implemented in each stage. The original English version of the pamphlet was

designed by Blissmer (2000). The Chinese version was prepared with reference to the

one designed by Blissmer (2000), and taking into account the factor of coronary heart

148

disease, and the guidelines of the ESMI (Table 3.2). A case to illustrate the details of

the 8-week TTM-based ESMI is shown in Appendix X.

Table 3.1 Protocol of the weekly exercise stage-matched intervention session

(I) Checking for Compliance

1. Did you perform exercise in the past one week?

2. What kind of exercise did you perform?

3. How many days did you perform it in the past one week?

4. How long did you perform it per day?

5. What was/were the RPE score(s) that you recorded on the exercise log sheet?

6. How did you feel during the exercise? Did you experience any increase in

respiratory rate? Any sweating?

7. Did you experience any discomfort during the exercise?

8. Did you take any anti-anginal medication because of exercise in the past one

week? If yes, how many pills did you take?

(II) Exercise Stage-Matched Intervention

1. Check the exercise stages of change.

2. Individual stage-matched discussion between patients and the researcher (30

minutes for face-to-face contact and 5-15 minutes for telephone contact)

according to the guidelines of the ESMI (Table 3.2).

3. Stage-matched pamphlet for home-based reinforcement and/or exercise

prescription.

149

Table 3.2 Guidelines of goals, processes, and strategies for changing exercise behaviour in each stage

Stage Goal Processes Strategies

Precontemplation Increase awareness

of the need to

change


Dramatic relief

Environmental

reevaluation

Self-reevaluation

Provide education about the risks of not exercising

Provide information on the benefits of physical activity

Give personalized feedback about the risks of the current behaviour (e.g.,

physical deconditioning, recurrent MI, and so on)

Discuss feelings and perceptions of active/inactive behaviour

Discuss how a sedentary lifestyle affects role implementation and social

activities

Encourage thinking about the benefits of physical activity for oneself

Encourage thinking about change

Contemplation

Increase

motivation and

confidence in the

ability to change


Dramatic relief

Self-reevaluation

Social liberation

Identify questions about exercise and continue to provide education about

the personal risks of inactivity and the benefits of physical activity

Discuss feelings and perceptions about loss of cardiovascular fitness due to

inactivity

Find out what is stopping the individual from engaging in physical activity

Decrease the barriers to physical activity

Encourage reflection on the ways in which inactivity affects their life

Point out people who included regular physical activity in their lives

Increase awareness of opportunities that exist to encourage regular physical

activity

150

Stage Goal Processes Strategies

Preparation Negotiate a plan

for exercising


Self-reevaluation


Self-liberation

Further provide information about the benefits of physical activity and the

personal risks of physical inactivity.

Create a new self-image as an exerciser

Make a public commitment to exercise

Identify alternatives to exercising

Make a plan for engaging in exercise or regular physical activity

Gather support from others

Encourage a component of behavioural change where they can experience

success

Discuss the safety of exercise/physical activity, including an exercise

prescription by a cardiologist

Action Reaffirm

commitment and

follow up

Reinforcement

management


Counterconditioning

Stimulus control

Frequent positive reinforcement with rewards for exercising regularly

Find exercise buddies

Mobilization of social support to participate in the process or reinforce the

process

Introduce additional exercise alternatives

Check off each time you exercise

Plan for resisting the temptation to skip exercise sessions

151

3.6.3.2 The Relevance and Validity of the ESMI for Use in the Chinese Context

The TTM has been applied to Chinese people. Most such studies were of a cross-

sectional design to test the application of the TTM, involving physical activity among

family caregivers in Taiwan (Tung & Gillett, 2005; Tung, Gillett & Pattillo, 2005),

general health promotion activities among Hong Kong Chinese adults (Lam, Chan,

Ho & Chan, 2004), and physical activity among students in mainland China (Fang,

Sun & Zhao, 2006; Ma, Wang & Li, 2008; Sun, Zhang, Liu & Wang, 2008). The

findings from these studies show that the TTM can be utilized in Chinese populations

to explain exercise behaviour. One case study using the TTM to change behaviour

relating to physical activity (Huang & Tang, 1996) among patients with diabetes

mellitus in Taiwan showed a significant increase in physical activity. Ma, Ma, and

Zhu (2006) evaluated the effectiveness of a stage-matched intervention on physical

activity in 426 university students. The results indicated that the stage-matched

intervention significantly increases the adoption of exercise and progress in exercising.

These studies suggest that the TTM as a framework is effective in inducing changes in

exercise behaviour among Chinese populations.

Before the commencement of the study, five local health professionals, who are

cardiologists, reviewed the intervention programme for its validity according to the

research aim and expected outcomes for CHD patients. All of them agreed that the

intervention programme was valid and feasible in terms of aim and expected

outcomes.

152

After the completion of the pilot study, eight CHD patients who had completed the

eight sessions of ESMI were invited to evaluate the intervention programme (both the

contacts and the format of the delivery) in terms of the relevance, appropriateness,

and feasibility of the intervention for CHD patients. Seven of them expressed the view

that the contents and the delivery format of the intervention were useful, appropriate,

and acceptable for CHD patients. Their views also suggest that the ESMI is valid and

feasible for use among CHD patients in Xiamen City, China.

3.6.3.3 Fidelity of the Intervention

The fidelity of the intervention refers to the demonstration that the delivery of the

intervention was the same across participants throughout the study (Dumas, Lynch,

Laughlin, Smith & Prinz, 2001). This section presents the fidelity of the intervention

in this study.

3.6.3.3.1 Consistency in the Delivery of the Intervention

The intervention was delivered by only one person, the researcher (ZLX), who

designed the entire study and the protocol of this study and who is familiar with the

TTM. The TTM is a user-friendly model that is simple, straight forward, and easy to

use. The researcher delivered the intervention following the protocol and the

guidelines of the TTM-based ESMI (Table 3.2) throughout the study. During the

intervention period, the details of the stage assessment, the goal, processes, strategies,

and techniques delivered to each patient for motivating exercise behaviour were

recorded. An example was illustrated in Appendix X. In addition, the delivery of the

153

intervention, the cases, and the use of the protocol were reported to the supervisors

biweekly during the intervention period. The consistency in delivering the

intervention was closely monitored.

3.6.3.3.2 The Patients' Adherence to the Intervention

This study focused on home-based exercise and the researcher could not monitor the

patients' exercise at home day by day. Thus, to ensure that the patients adhered to the

intervention, a log book was used to record their exercise at home. The patients were

asked to record the details of their daily exercise in the log book (Appendix XII), such

as the type of exercise that they had engaged in, the frequency, intensity, and duration

of each episode of exercise, whether they had experienced angina, and the taking of

any anti-anginal drugs as a result of the exercise. The log book could serve as a

motivator for patients to engage in exercise at home. With the help of the log book,

the patients could also be monitored on whether or not they had adhered to the

intervention at home. During the 8-week intervention period, the patients' adherence

to the intervention was monitored by cross-checking the weekly compliance records

and the log book information through either face-to-face or telephone contacts (Table

3.1).

3.7 Instruments

In accordance with the objectives of this study, several instruments were employed to

screen subjects or measure outcomes.

154

3.7.1 Screening Assessment

In the screening assessment, demographic and clinical data were collected from the

patients‘ medical records. The emotional state of the patients in terms of whether they

suffered from depression was assessed according to the Hospital Depression Subscale

(HADS-D). The details of the screening guidelines are shown in Appendix IV.

3.7.1.1 Demographic Data

To better understand the patients‘ demographic information, the following

demographic data were collected, including the patients‘ gender, age, marital status,

educational level, employment status, occupation, religious belief, family income,

type of medical payment, and habitation (Appendix XI).

3.7.1.2 Clinical Data

The clinical data collected in this study included the patients‘ medical diagnosis,

family history related to CHD, PCI/Stent treatment, smoking status, alcohol

consumption, chronic illnesses such as diabetes mellitus and hypertension, and

medication taken (Appendix XI).

3.7.1.3 Hospital Depression Subscale (HADS-D)

The Hospital Anxiety and Depression Scale (HADS) was developed by Zigmond and

Snaith in 1983. It is a widely used self-reported instrument for anxiety and depression

155

in non-psychiatric populations (Martin & Thompson, 2000). The HADS has been

used extensively in studies of cardiac patients (Barth & Martin, 2005; Furze, Bull,

Lewin & Thompson, 2003; Lewin, Furze, Robinson et al., 2002; Martin & Thompson,

2000) and its psychometric properties are well established (Martin & Thompson, 2000;

Stafford, Berk & Jackson, 2007). The scale is comprised of two parts – depression

and anxiety. The Hospital Depression Subscale (HADS-D) (Appendix XI) was used

in this study for screening. The reliability of the HADS-D was tested by Marin and

Thompson (2000) on 194 patients with coronary heart disease. The Cronbach alpha

coefficient was 0.72. A systematic review of its validity ranged from 0.67 to 0.90

(mean = 0.82) (Bjelland, Dahl, Haug & Neckelmann, 2002). The HADS-D has been

shown to be strongly correlated with the Beck Depression Inventory (BDI), with the

correlations between BDI and HADS-D ranging from 0.62 to 0.73 (Bjelland, Dahl,

Haug & Neckelmann, 2002).

HADS-D can reveal an individual‘s emotional state during the past week. There are

seven questions in HADS-D, with the score for each question ranging from zero to

three. A score of seven or less indicates a non-depression case, 8-10 a borderline case

of depression, and 11 or above a definite case of depression (Arving, Glimelius &

Brandberg, 2008; Zhang, 2005). The reliability and validity of the Chinese version of

HADS (Ye & Xu, 1993) were tested on 287 pregnant women. For the Chinese version

HADS-D (Appendix XI), the Cronbach alpha coefficient was 0.82 and the half

reliability was 0.82. The cut-off point for depression is similar to that in the original

version, with a score of 11 or above indicating depression (Xia, 2006).

156

The HADS-D was selected to screen the emotional state of patients because it is a

simple and easy scale to administer, has a clear cut-off point for depression, and has

good reliability and validity.

3.7.1.4 Screening Form

To facilitate the screening assessment of the potential subjects, a screening form

(Appendix XI) was drawn up with reference to the selection criteria. Guidelines for

screening were prepared (Appendix IV) so that the cardiologists could screen each

patient in accordance with these guidelines.

3.7.2 Outcome Measurements

Based on the objectives of this study, the outcome measurements included exercise

stages of change, exercise self-efficacy, exercise decisional balance, exercise duration

(minute/week), conditions of angina, and quality of life. The primary outcome

indicators are exercise stages of change, exercise self-efficacy, exercise decisional

balance, and exercise duration (minute/week). The secondary outcome indicators are

angina and quality of life. The data were recorded at different periods of time (Table

3.3).

157

Table 3.3 Outcome measurements

Items Baseline

measurements (T0)

After the completion

of the 8-week ESMI

(T1)

3 months after T1 (T2) 6 months after T1 (T3)

Exercise Stages of Change

Exercise Stages of Change Scale

Exercise Self-Efficacy

Exercise Self-Efficacy Scale

Exercise Decisional Balance

Exercise Benefits Scale

Exercise Barriers Scale

Exercise

Frequency (sessions/week)

Intensity (RPE 6-20)

Duration (minutes/week)

Angina occurred during exercise (yes / no)

Anti-anginal drugs (additional number of

tablets taken per week)

Angina

Frequency of angina (episodes/week)

Severity of angina (0-10)

Duration of angina (minutes)

Anti-anginal drugs (total number of tablets

taken/week)

Quality of Life

Seattle Angina Questionnaire (SAQ)

Short Form 36-item Health Survey (SF-36)

158

3.7.2.1 Exercise Stages of Change Scale

The Exercise Stages of Change Scale (Marcus, Selby, Niaura & Rossi, 1992) was

developed from the original stages of change scale for smoking cessation (Prochaska

& DiClemente, 1983) with five questions to identify the stages. The test-retest

reliability of the stages of change for smoking cessation was 0.72 (Donovan, Jones,

Holman & Corti, 1998).

The statements specific to the exercise stages of change scale were formulated

accordingly: (a) precontemplation: ―I currently do not exercise, and I do not intend to

start exercising in the next six months‖; (b) contemplation: ―I currently do not engage

in exercise, but I am thinking about starting to exercise in the next six months‖; (c)

preparation: ―I currently exercise some, but not regularly‖; (d) action: ―I currently

exercise regularly, but I have only begun doing so within the last six months‖; and (d)

maintenance: ―I currently exercise regularly, and have done so for longer than six

months‖. Patients were required to mark only one stage that best describes their

current state of readiness for regular exercise. Courneya (1995) further modified the

scale into a form consisting of one item (e.g., Do you engage in exercise regularly?)

with five statements representing each stage (Appendix XII). The five statements, one

based on each stage of change, are described and the patients are asked to select one

of the five statements that best describes their current level of exercise. The five

statements are arranged from the precontemplation to the maintenance stages as

follows: (i) ―No, and I do not intend to in the next six months‖ means that the

individual is in the precontemplation stage; (ii) ―No, but I intend to in the next six

months‖ means that the individual is in the contemplation stage; (iii) ―No, but I intend

159

to in the next 30 days‖ means that the individual is in the preparation stage; (iv) ―Yes,

I have been for less than six months‖ means that the individual is in the action stage;

and (v) ―Yes, I have been for more than six months‖ means that the individual is in

the maintenance stage. This modified version has been widely used by many scholars

in many studies (Burbank, Reibe, Padula & Nigg, 2002; Nigg, 2001; Nigg &

Courneya, 1998; Tung, 2003). Thus, it is employed in this study.

The original scale has been tested and found to have good reliability. As reported, the

Kappa index of reliability for this scale over a two-week period was 0.78 (n = 20)

(Marcus, Selby, Niaura & Rossi, 1992). The two-week test-retest reliability

coefficient of the modified version is 0.79, obtained from the 148 patients (Courneya,

1995). In addition, the scale has been shown to be significantly associated with

exercise with respect to the 7-Day Recall Exercise Questionnaire (Marcus & Simkin,

1994). Hellsten, Nigg, Norman and others (2008) conducted a study to accumulate

evidence of behavioural validity for exercise stages of change scale, which examined

nine studies. The findings showed that the exercise stages of change scale was

behaviourally valid, as evidenced by self-reported physical activity, self-reported

exercise, self-reported sedentary behaviours, pedometers, and physical functioning.

The original English version of this modified scale was first translated into Chinese

by Tung (2003) using a two-part method: translation by a committee and back-

translation. Both the committee members and translators were bilingual persons who

were fluent in both Chinese and English. After the completion of the original and

back-translation processes, a panel of three professional nursing experts from Taiwan

reviewed the clarity and linguistic appropriateness of the Chinese version. This

160

Chinese version of the exercise stages of change was adopted in this study (Appendix

XII).

3.7.2.2 Exercise Self-efficacy Scale

The Exercise Self-Efficacy Scale (Appendix XII) was developed by Bandura (1997)

to measure the degree of confidence in one‘s ability to perform exercise under

specific situations. This scale contains 18 items covering different situations.

Individuals mark their degree of confidence on a 100-point scale in 10-unit intervals

ranging from 0 (cannot do) through intermediate degrees of assurance such as 50

(moderately certain can do) to complete assurance, 100 (certainly can do), with the

higher score showing more confidence to execute regular physical activity (Bandura,

1997; Shin, Jang & Pender, 2001; Tung, 2003).

The original version of this scale was translated into Chinese by Tung (2003)

(Appendix XII). This translated version has been back-translated and reviewed for

clarity and linguistic appropriateness by three nursing experts. It has a high degree of

internal consistency as shown by its Cronbach‘s alpha coefficient of 0.96 (Tung,

2003). This translated version had also been used in mainland China on 46 patients

who had undergone percutaneous coronary intervention (PCI) and was shown to be

valid and reliable for Chinese populations (Kang, Li, Liang et al., 2006). This Chinese

version of exercise self-efficacy scale was adopted in this study.

161

3.7.2.3 Exercise Decisional Balance

Two scales are utilized to determine exercise decisional balance: the Exercise

Benefits Scale and the Exercise Barriers Scale (Appendix XII), which were developed

by Sechrist, Walker, and Pender (1987) to assess the benefits of and barriers to

exercise as perceived by individuals. The Exercise Benefits Scale consists of 29 items

and the Exercise Barrier Scale consists of 14 items. Patients were asked to rate the

items using a 4-point Likert scale, with one being strongly disagree to four being

strongly agree with each statement. The instrument, which includes the two scales,

can be used as a whole (43 items) with the reversed score of the barriers scale, or the

two scales can be used separately. The possible range of scores on the whole

instrument is 43-172, with the range for the benefits scale being 29-116 and that for

the barriers scale being 14-56. The higher scores on the exercise benefits scale show

that the patients perceived there to be greater benefits to exercise, while the lower

scores on the exercise barriers scale show that patients perceived there to be fewer

barriers to exercise.

Sechrist, Walker, and Pender (1987) conducted a psychometric evaluation of the

exercise benefits and barriers scale on 650 adults and found that the instrument has

good internal consistency. The whole instrument (43 items) achieved a standardized

Cronbach‘s alpha coefficient of 0.95. The benefits scale (29 items) achieved a

standardized alpha coefficient of 0.95 while the figure for the barriers scale (14 items)

was 0.87. The test-retest reliability was also measured on a sample of 63 individuals

recruited from the community, at intervals of two weeks. The correlation coefficients

162

were 0.89 for the whole instrument, 0.89 for the benefits scale, and 0.77 for the

barriers scale (Sechrist, Walker & Pender, 1987).

Tung (2003) translated the original English version of the Exercise Benefits/Barriers

Scales into Chinese (Appendix XII). This translated version has been back-translated

and reviewed for clarity and linguistic appropriateness by three nursing experts. It was

then revised after a pilot test involving eight Taiwanese students (Tung, 2003). Its

reliability was tested on a sample of 108 Taiwanese family caregivers. The Chinese

version of these two scales has a high degree of internal consistency, with Cronbach‘s

alpha coefficients of 0.97 and 0.93, respectively (Tung, 2003). Thus, the Chinese

version of these two scales was used in this study.

3.7.2.4 Exercise

To record the details of the patients‘ daily exercise conditions, a log book (Appendix

XII) was designed to record the type of exercise, the frequency, intensity and duration

of each episode of exercise, whether angina occurred, and the number of additional

anti-anginal medicine tablets/pills taken due to exercise. The intensity of exercise was

assessed by Borg‘s Rating of Perceived Exertion (RPE) Scale, which ranged from 6 to

20, with 6 being very, very light (rest) and 20 being a level of exercise leading to

exhaustion.

The RPE is an easy and reliable tool for both the assessment and prescription of

exercise (Carvalho, Bocchi & Guimaraes, 2009; Eston & Thompson, 1997; Okura &

Tanaka, 2001). It is a reliable method for quantifying exercise of various levels of

163

intensity (Day, McGuigan, Brice & Foster, 2004; Minganti, Capranica, Meeusen,

Amici & Piacentini, 2010; Wallace, Slattery & Coutts, 2009). It is also an important

tool for self-monitoring and self-regulating the exercise engaged in by patients with

heart disease (Carvalho, Bocchi & Guimaraes, 2009). The RPE was found to be

significantly correlated with the method based on HR (r = 0.55-0.94) (Borresen &

Lambert, 2008; Minganti, Capranica, Meeusen, Amici & Piacentini, 2010; Wallace,

Slattery & Coutts, 2009), distances measures (r = 0.37-0.81) (Wallace, Slattery &

Coutts, 2009), maximal oxygen uptake (VO2max), and oxygen uptake at the anaerobic

threshold (VO2AT) (r= 0.89 and r = 0.87, respectively) (Okura & Tanaka, 2001). A

Chinese version of RPE was tested for validity and reliability among 54 Hong Kong

adults by Leung, Leung, and Chung (2004). The findings demonstrated that the RPE

was significantly correlated with heart rate (r ≥ 0.73), power output (r ≥ 0.69), and

oxygen consumption (r ≥ 0.68). The overall test-retest intraclass correlation

coefficient (ICC) was 0.92, which suggests that the scale is reliable.

3.7.2.5 Angina

The log book (Appendix XII) recorded the details of the patients‘ daily angina. The

information recorded included the frequency, severity, and duration of each episode

of angina, and the frequency and number of anti-anginal medicine tablets/pills taken

per week. The patients were told to rate each episode of angina for severity on a

Chinese Pain Intensity Verbal Rating Scale (C-PIVRS), which was developed by Liu,

Chung, and Wong (2003). It has been shown to have good reliability and validity in

Chinese populations, with the intraclass correlation coefficient (ICC) ranging from

0.78 to 0.90 (Liu, Chung & Wong, 2003). The test-retest correlation coefficients

164

between the C-PIVRS and the visual analog scale (VAS) are r = 0.92 and 0.91,

respectively. The scale is rated from 0 to 10, with 0 being no pain, 5 being very

painful, and 10 being ‗crucifying pain‘. The patients were also required to rate the

duration of the episode of angina in minutes, and the number of tablets/pills of anti-

anginal medicine taken per day.

3.7.2.6 Quality of life

The Seattle Angina Questionnaire and the Medical Outcomes Study 36-Item Short-

Form (SF-36) were employed to assess the quality of life of the patients in this study.

3.7.2.6.1 Seattle Angina Questionnaire (SAQ)

The Seattle Angina Questionnaire (SAQ) (Appendix XII) is a disease-specific self-

administered instrument for patients with CHD, which was developed by Spertus et al.

(1995). It was used to assess the patients‘ quality of life in the past four weeks.

Previous studies have demonstrated that the SAQ is valid, reproducible, and sensitive

to clinical change (Dougherty, Dewhurst, Nichol & Spertus, 1998; Kimble, Dunbar,

Weintraub, et al., 2002; Spertus, Winder, Dewhurst et al., 1995; Spertus, Jones,

McDonell et al., 2002). This scale has been adapted cross-culturally in more than 13

countries, including China (Schroter & Lamping, 2006).

The SAQ was developed to quantify the physical and emotional effects of CHD. It

consists of a 19-item questionnaire with five subscales that measure clinically relevant

domains of CHD, including physical limitations, angina stability, angina frequency,

165

treatment satisfaction, and disease perception. The physical limitation subscale

measures how daily activities are limited by symptoms of CHD. The angina stability

subscale assesses change over time in the frequency of angina at the patient‘s most

strenuous level of activity, whereas the angina frequency subscale quantifies the

number of impacts CHD has on his or her health-related quality of life (HRQL). The

treatment satisfaction subscale quantifies satisfaction with the current treatment of

angina. The disease perception subscale characterizes the patient‘s perception of the

impact of CHD on their quality of life (Dougherty, Dewhurst, Nichol & Spertus,

1998).

Each subscale of the SAQ has been independently validated and demonstrated to be

reliable and responsive to clinical change. As tested on 107 patients with chronic

stable angina pectoris, the internal consistency reliability (Cronbach‘s alpha) of the

SAQ of each subscale ranged from 0.66 to 0.89, and the 2-week intraclass correlation

coefficients (r) of physical limitations, angina frequency, angina stability, treatment

satisfaction, and disease perception were 0.72, 0.80, 0.33, 0.58 and 0.67, respectively

(Dougherty, Dewhurst, Nichol & Spertus, 1998). The SAQ takes less than five

minutes to complete and is brief and easily self-administrated.

The Chinese version of the SAQ (Rao & Yuan, 1996) (Appendix XII) was employed

in this study to investigate the quality of life of CHD patients. Liu (2003) tested its

reliability and validity on 35 CHD patients. The results showed that the 2-week test-

retest reliability coefficients for physical limitations, angina stability, angina

frequency, treatment satisfaction, and disease perception were 0.99, 0.58, 0.97, 0.98,

and 0.94 respectively and the total Cronbach‘s alpha coefficient was 0.76. The

166

findings suggest that the Chinese version of the SAQ has good reliability and validity

and can be used for Chinese CHD patients.

The SAQ is scored by assigning an ordinal value to each response and summing up

the scores of items within each of the five subscales. The scoring instructions were

published by Cardiovascular Outcomes Inc. (2010), which was developed by Spertus

and colleagues (Appendix XIII). The possible range of scores for each subscale is

from 0 to 100, with higher scores indicating better levels of functioning.

3.7.2.6.2 SF-36

SF-36 (Appendix XII) was developed by Ware and colleagues (McHorney, Ware &

Raczek, 1993; Ware & Sherbourne, 1992). It is used to measure changes in the

previous four weeks and is also the most convenient instrument for assessing health-

related quality of life (HRQL) changes (Kiebzak, Pierson, Campbell & Cook, 2002).

The SF-36 is a generic and comprehensive instrument used to measure health-related

quality of life in all social and demographic groups, regardless of age, disease, or

treatment condition (Corcoran & Durham, 2000).

Compared with other generic instruments, such as the Nottingham Health Profile

(NHP) and the Sickness Impact Profile (SIP), the SF-36 achieves the best results

(Thompson & Roebuck, 2001). It has few floor or ceiling effects, good internal

consistency, and high test-retest reliability (sensitivity to change) (Thompson &

Roebuck, 2001). As reported, the internal consistency of the SF-36, the Cronbach‘s

alpha coefficient, ranges from 0.65 to 0.96 (Dougherty, Dewhurst, Nichol & Spertus,

167

1998; Failde & Ramos, 2000). Compared with WHO100, the SF-36 is simple and

easy to administer. The SF-36 is self-administered and takes around ten minutes to

complete. Thus, the SF-36 was selected in this study to measure the quality of life of

CHD patients.

The SF-36 measures eight domains of health: physical functioning (PF), role

limitations as a result of physical problems (RP), bodily pain (BP), general health

perception (GH), vitality (VT), social functioning (SF), mental health (MH), and role

limitations as a result of emotional problems (RE). Physical functioning (10 items)

refers to the extent to which health limits physical activities such as self-care, walking,

climbing stairs, bending, lifting, and moderate and vigorous activities. Role limitation

- physical (4 items) refers to the extent to which physical health interferes with work

or other daily activities, including accomplishing less than wanted, limitations in the

kinds of activities engaged in, and having difficulty in carrying out one‘s role. Bodily

pain (2 items) refers to the intensity of pain and the effect of pain on normal work,

both inside and outside the house. General health perception (5 items) refers to

personal evaluations of health, including current health, health outlook, and resistance

to illness. Vitality (4 items) refers to feeling energetic and full of pep versus feeling

tired and worn out. Social functioning (2 items) refers to the extent to which physical

health or emotional problems interfere with normal social activities. Mental health (5

items) refers to general mental health, including depression, anxiety, behavioural-

emotional control, and general positive affect. Role limitation - emotional (3 items)

refers to the extent to which emotional problems interfere with work or other daily

activities, including a decrease in the amount of time spent on work, accomplishing

less than wanted, and failing to work as carefully as usual. The SF-36 can be grouped

168

into two summary dimensions: the physical component summary (PCS) and the

mental component summary (MCS). The physical component summary includes four

domains of health, such as physical functioning, role limitation - physical, bodily pain,

and general health perception. The mental component summary (MCS) includes

another four domains of health: vitality, social functioning, mental health, and role

limitation - emotional. The SF-36 includes another one item - reported health

transition (HT) which refers to the perception of health conditions as compared with

the previous one year.

The Chinese version of the SF-36 Health Survey (Chinese Version SF-36) (Appendix

XII), which was translated by Fang (2005), was employed in this study to measure

quality of life. According to the study by Zhang, Xu, Huang, and Li (2004), the split -

half reliability coefficient of the Chinese Version of the SF-36 was 0.94 and test-retest

reliability coefficients for most subscales ranged from 0.60 to 0.90 when tested on

167 elderly adults. Liu, Li, Ren and others (2001) tested its reliability on various

groups in China. They found that the internal consistency reliability coefficient alpha

of the Chinese version of the SF-36 ranged from 0.62 to 0.94 when tested on 1,603

rural residents, 0.68 to 0.82 on 646 urban residents, 0.79 to 0.95 on 122 patients with

osteoporosis, and 0.78 to 0.95 on 150 stroke patients. Jiang, Sit, Wong, and others

(2004) also tested it on 167 patients with CHD. They found that the internal consistent

reliability coefficient alpha values for general health, physical functioning, role

physical, role emotional, social functioning, bodily pain, vitality, and mental health at

the two assessment times were 0.84 and 0.77, 0.91 and 0.90, 0.90 and 0.63, 0.85 and

0.85, 0.79 and 0.67, 0.81 and 0.81, 0.67 and 0.68, and 0.69 and 0.70, respectively; the

corresponding test-retest reliability coefficients for these eight scales were 0.76, 0.79,

169

0.63, 0.66, 0.67, 0.66, 0.62, and 0.65. To prepare the data for analysis, the raw scores

obtained from each SF-36 domain were finally transformed in a 0 to 100 scale based

on the transformation formula recommended by Fang (2005). Scores for all areas

were calculated using the medical outcomes study (MOS) scoring system (Fang, 2005)

(Appendix XIII). Each subscale was computed to give a scaled score from 0 (lowest

well-being) to 100 (highest well-being).

The SAQ is a disease-specific questionnaire for CHD patients. It was developed to

assess the quality of life of CHD patients in relation to angina. The SF-36 is a generic

health survey scale and is widely used to assess the quality of life of people in China

and other countries. It includes both physical and mental components. In recent years,

many researchers have recommended that both the generic and disease-specific

instruments should be used together to evaluate quality of life (Arthur, Smith &

Natarajan, 2008; Brodie, Inoue & Shaw, 2008; Dempster & Donnelly, 2000; Lie,

Arnesen, Sandvik, Hamilton & Bunch, 2009; McGillion, Watt-Watson, Stevens et al.,

2008; Wong & Chair, 2007). The combination of both the generic and disease-

specific instruments to measure quality of life provides complementary information

(Lie, Arnesen, Sandvik, Hamilton & Bunch, 2009) to obtain both sensitivity and

specificity in clinical change (Brodie, Inoue & Shaw, 2008); and allows comparison

of the results with both the general population and CHD patients, making clinical

interpretation more meaningful (Arthur, Smith & Natarajan, 2008; Lie, Arnesen,

Sandvik, Hamilton & Bunch, 2009). In addition, although the SF-36 is a

comprehensive instrument to measure health-related quality of life and can

discriminate between patients with divergent medical, psychiatric, and other serious

medical conditions, some evidence suggests that it may inadequately discriminate

170

between those with different severities of angina as assessed by the Canadian

Cardiovascular Society Classification (Dougherty, Dewhurst, Nichol & Spertus,

1998). The potential for the SF-36 to be insensitive to changes in angina class

necessitated the use of a disease-specific instrument, the SAQ, to evaluate quality of

life. Thus, both the SAQ and SF-36 were used to assess the quality of life of CHD

patients in this study.

3.8 Data collection

Data collection was done at four time points by the RN (Figure 3.1). The first (T0)

round of data collection was conducted after the patients were recruited and before the

group assignment. The second (T1) round of data collection was conducted

immediately after the completion of the 8-week ESMI. The third (T2) round of data

collection was conducted three months after the completion of the intervention. The

final (T3) round of data collection was conducted six months after the intervention.

Before the commencement of data collection, the RN underwent training on how to

collect data. To set clear guidelines for the nurse, a training package (Appendix XIV)

was prepared for her. The RN was blind to the group assignment, research design,

research hypotheses, and the interventions in order to prevent any subjective bias

from occurring, so that a single-blind condition could be achieved.

171

3.9 Ethical Considerations

Ethical approval (Appendix II) was granted from the Human Subjects Ethics

Committee of The Hong Kong Polytechnic University and access approvals

(Appendix III) were obtained from the Xiamen Heart Centre, the First Affiliated

Hospital of Xiamen University, and the Medical Service Centre of Lujiang

Community. The study was explained to each patient using a written information

sheet (Appendix V). Written consent (Appendix VI) was obtained from each patient

before he/she participated in the study. Patients were allowed to withdraw from the

study at any time and for any reason, with no penalty. A code number was assigned to

each patient. All of the information provided by the patients was kept confidential and

anonymous. Only the members of the research team could access the data. Since it

was believed that the booklet provided in the patient education session would be of

benefit to all patients, patients in the Conventional group also received the booklet

after the completion of the study.

Regular exercise/physical activity has been shown to be beneficial to cardiac patients.

This study aims to motivate CHD patients to engage in exercise, so the study is

believed to benefit them. Some patients might experience mild chest discomfort while

exercising. To minimize the risk to the patient, cardiologists assessed the physical,

psychological, and emotional status of each patient according to the screening

guidelines (Appendix IV) before referring him/her to this study. During the

intervention, when the patients were in the preparation stage and ready to engage in

exercise, the cardiologists assessed them again and prescribed exercise according to

the guidelines for exercise prescription (Appendix VIII). Each patient‘s progress in

172

exercise intensity and exercise duration was monitored weekly so that he or she would

not be overloaded by the prescribed exercise. Each patient was instructed to contact

the researcher at any time by phone if he/she experienced any discomfort during the

intervention.

The researcher contacted each patient in the intervention groups weekly during the 8-

week intervention period to check whether he/she was experiencing any discomfort

while exercising. If the patients were experiencing discomfort, they would be

instructed to cut down on the intensity and duration of the exercise or to stop

exercising altogether, and were again assessed by the cardiologists on their exercise

prescription.

Clear guidelines for the termination of exercise done at home were given to each

patient in both the PE and ESMI groups, with reference to the recommendations from

the expert working group of the National Heart Foundation of Australia (Briffa,

Maiorana, Sheerin et al., 2006) (Appendix VIII).

3.10 Data Analysis

Data analyses were carried out based on the intention-to-treat principle of analysis.

Last observation carried forward (LOCF) was used to handle missing data. The data

analyses were conducted using the Statistical Package for the Social Sciences, version

17.0 (SPSS Inc., Chicago, II USA). Data analyses include both descriptive and

inferential statistical analyses. Descriptive statistics such as frequencies, means,

standard deviations, and percentages were used to describe the demographic and

173

clinical data and to outline outcome measures at different time points. A further

selection of inferential statistics for between- and within-group comparisons was

based on the data as well as on the normality and homogeneity of variance tests. For

data that are intervals or ratio data, normally distributed and insignificant on the

homogeneity of variance test, parametric inferential statistics were used. Otherwise,

non-parametric tests were applied.

The baseline demographic and clinical data, with the exception of level of education,

age, and depression, were treated as nominal data. Data on levels of education and

exercise stages of change were treated as ordinal data. Data on age, depression,

exercise self-efficacy, exercise benefits, exercise barriers, exercise duration per week,

angina frequency, angina severity, angina duration per week, and quality of life on

both SAQ and SF-36 were treated as interval data.

After conducting the normality and homogeneity tests, only data on exercise self-

efficacy was normally distributed. Data on age, depression, exercise benefits, exercise

barriers, exercise duration per week, angina frequency, angina severity, angina

duration per week, and quality of life on both SAQ and SF-36 were not normally

distributed and the related homogeneity of variance among the three groups was

violated.

Regarding the nominal and ordinal demographic and clinical data, such as gender,

marital status, current employment status, and occupation, a Chi-square test was used

to compare the differences among the C, PE, and ESMI groups. For the interval and

174

ratio demographic data, such as depression, the Kruskal-Wallis test was used to

compare the differences among the three groups.

Data on the exercise stages of change were treated as ordinal data. The Kruskal-

Wallis Test was used to examine the differences in the mean change values among the

C, PE, and ESMI groups at T0, T1, T2, and T3, respectively. Compared to the baseline,

the patients were also classified into progressed, stable, and regressed cases based on

the exercise stages of change scale at T1, T2, and T3, respectively. All of these data

were viewed as nominal data. The Chi-square test was used to analyze such data

among the C, PE, and ESMI groups at T1, T2, and T3, respectively. The Friedman test

was applied to examine the differences within groups across time from T0 to T3.

Since data on the exercise self-efficacy scale were normally distributed and the related

homogeneity of variance was achieved, one way ANOVA was applied to examine the

differences in the mean change values among the C, PE, and ESMI groups at T0, T1,

T2, and T3, respectively. One way repeated ANOVA was applied to examine the

differences within groups across time from T0 to T3.

Since data on exercise benefits, exercise barriers, exercise duration per week, angina

frequency, angina severity, angina duration per week, and quality of life on both SAQ

and SF-36 are not normally distributed and the related homogeneity of variance

among the three groups was violated, a non-parametric test was applied. The Kruskal-

Wallis Test was used to examine the differences in the mean change values of these

variables among the C, PE, and ESMI groups at T0, T1, T2, and T3, respectively. The

175

Friedman test was applied to examine the differences within groups across time from

T0 to T3.

Data in the log book on whether patients experienced angina and whether they took

anti-anginal drugs in the past one week were viewed as nominal and binary data. The

Chi-square test was used to analyze the data among the C, PE, and ESMI groups at T0,

T1, T2, and T3, respectively. The Cochran‘s Q test was then applied to examine the

differences within each group across time from T0 to T3.

Intention-to-treat analysis was employed in this study because the availability of the

patients to attend patient education sessions and their willingness to spend time on

patient education were the key factors affecting the accuracy of the findings. In

addition, intention-to-treat analysis was used to maintain the benefits of

randomization. Last observation carried forward (LOCF) is one of the commonly used

ways of handling missing data for intention-to-treat analysis, especially when a

variable is assessed at multiple time points for each patient (Barnes, Mallinckrodt,

Lindborg & Carter, 2008; Elobeid, Padilla, McVie et al., 2009; Herman, Botser,

Tenenbaum & Chechick, 2009; Yan, Lee & Li, 2009). In the LOCF analysis, a

subject‘s last available assessment is imputed for all remaining unobserved response

measurements. In this study, most of the dropouts in the PE and ESMI groups

withdrew from the study before the completion of the 8-week period of ESMI (Figure

5.1). Thus, with the use of LOCF to handle missing data, most of the missing data in

the experimental group is replaced by the baseline data, which may well result in a

conservative estimate of the effects of treatment (Barnes, Mallinckrodt, Lindborg &

176

Carter, 2008; Boers, 2008). Thus, the LOCF was employed to analyze the data in this

study. The significance level, p value, was set at 0.05 with two tails.

3.11 Summary

This chapter described the methods used in this study. An experimental design was

applied in this study. The sampling, procedure, data collection, data analyses, and

ethical considerations were also introduced in this chapter.

177

Chapter 4 The Pilot Study

4.1 Introduction

This chapter presents the results of the pilot study. The pilot study is a trial run of the

main study. This chapter includes a discussion of the aims of the study, the

characteristics of the subjects, the procedures of the study, the preliminary results, and

the implications for the main study.

4.2 Aims

Since there is no formal or structured patient education programme for CHD patients

in China, the aims of the pilot study can be set as follows: (1) to test whether it is

feasible to implement a formal patient education programme in Xiamen City, China;

and (2) to examine the preliminary effects of the TTM-based Exercise Stage-Matched

Intervention (ESMI) on patients with coronary heart disease (CHD).

4.3 Description of the setting

The pilot study was conducted from May 2009 to August 2009 in the Medical Service

Centre of Gulangyu Community, Xiamen City, China. The Gulangyu community is

located on Gulangyu Island, Xiamen City. There are no cars or bicycles on the island.

To reach Gulangyu, people need to take a 5-minute ferry ride from the centre of

Xiamen City. Due to the inconvenient transportation arrangements, many people

move away from Gulangyu Island. There are only around 16,000 permanent residents

178

on this island and most of them are elderly or children. Around 25% of the population

are more than 60 years old. According to the database of the medical records of the

community hospital, the mean age of CHD patients in the hospital is 71.8 years and

most have suffered from the illness for around 10 years.

4.4 Procedures

Before conducting the pilot study, ethical approval was obtained from the Human

Ethics Committee of The Hong Kong Polytechnic University. Access approval was

also obtained from the Medical Service Centre of the Gulangyu Community. The

criteria for screening patients for the pilot study were the same as those for the main

study, except that patients in the action and maintenance stages were also recruited in

the pilot study.

Potential patients were identified from the medical records of the Medical Service

Centre of the Gulangyu Community. They were invited to attend the screening

assessment in the hospital and were given a verbal explanation by phone of the

purposes of the study with reference to the information sheet. They were promised

that there would be no penalty if they refused to participate in or withdrew from the

study during the study period. A cardiologist screened patients according to the

screening guidelines (Appendix IV).

Eligible patients were labelled in accordance with the exercise stages of change scale.

Those labelled as being at the Pre-action level were in the precontemplation,

contemplation, and preparation stages. When patients were in the action and

179

maintenance stages, they were labelled as being at the Action level. Using a random

number table, patients of each level were then randomly allocated to one of the

following three groups: the Conventional (C) Group, the Patient Education (PE)

Group, and the Exercise Stage-Matched Intervention (ESMI) Group. In the original

research proposal, eligible patients were to be randomly allocated to one of the three

groups according to the random number table with reference to a five-stage match

(precontemplation, contemplation, preparation, action, and maintenance) based on the

exercise stages of change scale. The randomization of patients with reference to a pre-

action or action level match instead of a five-stage match is due to the small size of

the sample in the pilot study.

Patients in the C group received the conventional care, consisting of a simple and

unstructured patient education session that included information about diet, exercise,

and medications for CHD patients. Patients in the PE group received the conventional

care, one 2-hour session of patient education about CHD, and a booklet developed by

the Hong Kong Cardiac Rehabilitation and Prevention Centre of Tung Wah Hospital

and the organization Care for Your Heart. The content of the one 2-hour session of

patient education was the same as the one proposed for the main study. Patients in the

ESMI group received the conventional care, one 2-hour session of patient education

about CHD and the booklet (the same as that given to the PE group), eight weekly

ESMI sessions, and a stage-matched pamphlet, as proposed for the main study.

Patient education was delivered in groups. The size of each group ranged from 4 to 8

patients.

180

Data was collected at two time points: before the commencement of any interventions

(T0) and after the completion of the 8-week ESMI (T1) by an RN who was blinded to

the study design and the group allocation. Data collection at the 3-month follow up

(T2) and the 6-month follow-up period (T3) were not conducted due to time

constraints. In addition, the purposes of this pilot study were to test the feasibility of

implementing a patient education programme and to examine the preliminary effects

of the TTM-based ESMI in the patient education programme on CHD patients. After

the completion of the 8-week ESMI sessions, the researcher would have a good idea

of whether or not it would be feasible to implement the patient education programme

in Xiamen City. Comparison of the net changes in each outcome variable among the

three groups after the implementation of the interventions could indicate the trend of

the effects of the TTM-based ESMI on CHD patients. Thus, post-test data collection

was only conducted immediately after the completion of the 8-week ESMI.

After the completion of the pilot study, eight CHD patients who had received and

completed the eight sessions of ESMI were invited to discuss the intervention

programme in terms of both the contacts and the format of the delivery of the

intervention. The purpose of the discussion was to evaluate the relevance,

appropriateness, and feasibility of the intervention for CHD patients.

4.5 Results

Fifty-five patients were contacted for screening. Twenty-five CHD patients, who met

the selection criteria, were recruited in this study. Before the commencement of any

interventions, four patients withdrew from the study for the reasons listed in Figure

181

4.1. In the end, 21 patients completed the study. In this study, patients who did not

attend the one 2-hour patient education session about CHD, did not receive at least

two face-to-face contacts over the eight weeks, did not attend at least four of the eight

ESMI sessions, or did not complete the data collection procedures were viewed as

having dropped out of the study.

An intention-to-treat analysis was performed in this study. The missing data were

replaced by the baseline data. The Chi-square test and Kruskal-Wallis test were

applied for comparisons of the demographic and clinical data and net changes in the

outcome variables after the implementation of the interventions among the three

groups.

This pilot study went smoothly. The screening guidelines for the cardiologist to

screen patients were clear and appropriate. Most patients attended the patient

education programme and completed the study. No cardiac events or angina attacks

occurred during the time that the patients were engaged in exercise. These results

suggest that it is feasible to carry out the patient education programme based on the

TTM for CHD patients in Xiamen City, China.

Most of the patients who had received the 8-week TTM-based ESMI said that the

contents and the delivery format of the intervention were useful, appropriate, and

acceptable for CHD patients. Their views suggest that the ESMI is valid and feasible

for use among CHD patients in Xiamen City, China.

182

55 patients participated in screening

30 were excluded from the study according to the selection criteria

25 eligible subjects signed the written consent form

C group (n=8) PE group (n=8) ESMI group (n=9)

T0: Baseline data collection

3 dropouts (One was visiting her son and

looking after her grandson in

other city; one felt it was too

time-consuming and was

reluctant to participate in the

study; the remaining one was

away for a few days.)

1 dropout (The patient complained of

discomfort and received an

IV infusion immediately in

the out-patient

department.)


Randomization with reference to exercise level (pre-action or action)

T1: Outcomes measured immediately after the intervention (n=21)

Figure 4.1 Flowchart of the pilot study

Note: C group: the Conventional group; PE group: the Patient Education group; ESMI group: the

Exercise-Stage-Matched Intervention group.

183

4.5.1 Demographic and clinical characteristics

Of the 25 eligible patients, one patient had been diagnosed with myocardial infarction

(MI) and 24 had been diagnosed with angina pectoris. Age ranged from 55 to 83 years,

with the mean age being 67.4 ± 6.6 years. In each group, over 75.0% of the patients

were married and living with their spouse. All of the patients were retired and

currently not working. The details of the characteristics of the patients are shown in

Tables 4.1 and 4.2. The Chi-square test and Kruskal-Wallis test were used to compare

the demographic and clinical data among the three groups. No statistically significant

difference was found among the three groups (Tables 4.1 & 4.2).

184

Table 4.1 Demographic Characteristics of the Subjects

C group

(n = 8)

n (%)

PE group

(n = 8)

n (%)

ESMI group

(n = 9)

n (%)

Chi-square test

χ2 p

Age [mean (SD)] year a 67.0 (7.0) 66.6 (8.1) 68.3 (5.2) 0.529a 0.768a

Gender

Male

Female

3 (37.5)

5 (62.5)

2 (25.0)

6 (75.0)

2 (22.2)

7 (77.8)

0.543 0.762

Marital status

Single/Widow

Married

2 (25.0)

6 (75.0)

0 (0.0)

8 (100)

2 (22.2)

7 (77.8)

2.265 0.322

Education

Elementary School

High School

College or above

1 (12.5)

7 (87.5)

0 (0.0)

1 (12.5)

6 (75.0)

1 (12.5)

1 (11.1)

4 (44.4)

4 (44.4)

5.763 0.218

Occupation before

retirement

Manual labour

Technical

Clerical

Managerial

Professional

Other

2 (25.0)

2 (25.0)

1 (12.5)

1 (12.5)

2 (25.0)

0 (0.0)

2 (25.0)

1 (12.5)

1 (12.5)

2 (25.0)

1 (12.5)

1 (12.5)

0 (0.0)

1 (11.1)

2 (22.2)

3 (33.3)

3 (33.3)

0 (0.0)

6.858 0.739

Religious beliefs

Yes

No

3 (37.5)

5 (62.5)

4 (50.0)

4 (50.0)

3 (33.3)

6 (66.7)

0.521 0.771

Family income

(per month)

≤ ￥5,000

≥ ￥5,001

4 (50.0)

4 (50.0)

3 (37.5)

5 (62.5)

5 (55.6)

4 (44.4)

0.572 0.751

Medical payments

Totally reimbursed

Partially reimbursed

Totally self-paid

0 (0.0)

7 (87.5)

1 (12.5)

1 (12.5)

6 (75.0)

1 (12.5)

0 (0.0)

9 (100)

0 (0.0)

3.551 0.470

Living conditions

Living alone

Living with spouse/

children

1 (12.5)

7 (87.5)

0 (0.0)

8 (100)

2 (22.2)

7 (77.8)

1.983 0.318

a: Kruskal-Wallis test

185

Table 4.2 Clinical Characteristics of the Subjects

C

(n=8)

n (%)

PE

(n=8)

n (%)

ESMI

(n=9)

n (%)

Chi-square test

χ2 p

Diagnosis 2.214 0.331

Angina pectoris 8 (100) 7 (87.5) 9 (100)

MI 0 (0.0) 1 (12.5) 0 (0.0)

PCI/stent 0.405 0.817

Yes 1 (12.5) 1 (12.5) 2 (22.2)

No 7 (87.5) 7 (87.5) 7 (77.8)

CHD family history 3.230 0.199

Yes 4 (50.0) 2 (25.0) 1 (11.1)

No 4 (50.0) 6 (75.0) 8 (88.9)

Diagnosed with DM 0.011 0.995

Yes 1 (12.5) 1 (12.5) 1 (11.1)

No 7 (87.5) 7 (87.5) 8 (88.9)

Diagnosed with hypertension 3.222 0.200

Yes 7 (87.5) 7 (87.5) 5 (55.6)

No 1 (12.5) 1 (12.5) 4 (44.4)

Smoking status 2.249 0.690

Never smoking 6 (75.0) 7 (87.5) 8 (88.9)

Once smoking 1 (12.5) 1 (12.5) 1 (11.1)

Current smoking 1 (12.5) 0 (0.0) 0 (0.0)

Alcohol drinking status 2.214 0.331

Never drinking 7 (87.5) 8 (100) 9 (100)

Once drinking 1 (12.5) 0 (0.0) 0 (0.0)

Current drinking 0 (0.0) 0 (0.0) 0 (0.0)

Current medications

Nitrates 0 (0.0) 1 (12.5) 1 (11.1) 1.034 0.596

Beta-blockers 3 (37.5) 2 (25.0) 1 (11.1) 1.623 0.444

ACE inhibitors 3 (37.5) 2 (25.0) 2 (22.2) 0.543 0.762

Calcium antagonists 3 (37.5) 4 (50.0) 2 (22.2) 1.430 0.489

Anti-platelets 2 (25.0) 2 (25.0) 0 (0.0) 2.679 0.262

Lipid-lowering drugs 1 (12.5) 0 (0.0) 1 (11.1) 1.034 0.596

Others# 1 (12.5) 4 (50.0) 4 (44.4) 2.877 0.237

Depression score [Mean (SD)]a 3.9 (3.8) 3.5 (3.0) 3.1 (2.2) 0.066a 0.967a

a: Kruskal-Wallis test; #: ―Others‖ refers to traditional Chinese anti-anginal medicines, such as the

Suxiaojiuxin pill (速效救心丸), the Shexiangbaoxin pill (麝香保心丸), and the Danshen pill (丹参滴

丸).

186

4.5.2 Exercise Stages of Change (ESC)

As shown in Tables 4.3 and 4.4, more patients in the ESMI group progressed in their

exercise stages of change than those in both the C and PE groups, and patients in the

PE group were more likely to progress in their exercise stages of change than those in

the C group, although no significant difference in changes in exercise stages of

change was detected among the three groups (Table 4.4).

Table 4.3 Distribution of the Exercise Stages of Change (ESC) in the Three Groups

ESC

C group

(n=8)

PE group

(n=8)

ESMI group

(n=9)

T0

n (%)

T1

n (%)

T0

n (%)

T1

n (%)

T0

n (%)

T1

n (%)

Precontemplation 1(12.5) 1(12.5) 0(0.0) 0(0.0) 2(22.2) 0(0.0)

Contemplation 1(12.5) 1(12.5) 0(0.0) 0(0.0) 1(11.1) 1(11.1)

Preparation 3(37.5) 3(37.5) 6(75.0) 2(25.0) 4(44.4) 1(11.1)

Action 1(12.5) 0(0.0) 0(0.0) 4(50.0) 0(0.0) 5(55.6)

Maintenance 2(25.0) 3(37.5) 2(25.0) 2(25.0) 2(22.2) 2(22.2)

T0: baseline data; T1: data immediately after the completion of the 8-week ESMI.

Table 4.4 Changes in the Exercise Stages of Change (ESC) in the Three Groups at T1

ESC

C group

(n=8)

n (%)

PE group

(n=8)

n (%)

ESMI group

(n=9)

n (%)

Chi-square test

χ2 p

Progressed 1 (12.5) 4 (50.0) 6 (67.7) 5.215 0.074

Stable 7 (87.5) 4 (50.0) 3 (33.3)

Progressed: patients moved forward by at least one stage as compared with the baseline; Stable:

patients did not move and there was no change as compared with the baseline.

187

4.5.3 Exercise Self-Efficacy (ESE)

After the interventions were implemented, the mean scores of ESE decreased in both

the C and PE groups, while they increased substantially in the ESMI group (Table

4.5). When the mean change scores of ESE were compared, a significant difference

was found among the three groups (mean rank: ESMI group = 16.4, PE group = 13.3,

C group = 8.9, p = 0.013). Patients in the ESMI group were more confident about

their ability to perform exercise than those in the C and PE groups.

Table 4.5 Changes in the Mean Scores of Exercise Self-Efficacy (ESE) in the Three

Groups

T0 T1 T1 - T0

pa

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

ESE 1127.5

(322.3)

1075.0

(471.5)

843.3

(208.8)

1058.8

(356.2)

1068.8

(406.8)

1319.4

(319.5)

-68.8

(468.1)

-6.3

(243.0)

476.1

(338.6)

0.013*

a: Kruskal-Wallis Test; T0: baseline data; T1: data immediately after the completion of the 8-week

ESMI; The ESE scores range from 0 to 1,800, with the higher scores indicating greater confidence in

engaging in exercise; * p < 0.05.

4.5.4 Exercise Decisional Balance

There were two scales to determine the exercise decisional balance of the patients: the

Exercise Benefits Scale (EBS) and the Exercise Barriers Scale (EBBS). The higher

the scores of the EBS were, the greater the perception of the benefits of engaging in

exercise. However, when the scores were higher, patients would also have the

188

perception that the barriers to engaging in exercise were greater, in accordance with

the EBBS.

Table 4.6 shows the changes in exercise decisional balance among the three groups.

An increase in the mean scores of EBS at T1 was seen for all of the groups. The

participants perceived exercise to be beneficial to them regardless of any interventions

that were being implemented. No significant differences in the mean change scores of

EBS were detected among the three groups (Table 4.6). All of the groups saw a

decrease in the mean scores of EBBS at T1. They perceived fewer barriers to engaging

in exercise, regardless of any interventions that were being implemented. Significant

differences in the mean change scores of EBBS were identified among the three

groups (mean rank: ESMI group = 9.3, PE group = 18.6, C group = 11.6, p = 0.027),

with the ESMI group demonstrating the greatest reduction in the mean change score

for EBBS, followed by the C group, and the PE group.

Table 4.6 Changes in the Mean Scores of the Exercise Benefits Scale (EBS) and Exercise

Barriers Scale (EBBS) in the three groups

T0 T1 T1 - T0

pa

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

EBS 81.6

(11.8)

84.3

(8.1)

87.7

(9.0)

87.3

(13.5)

89.9

(9.5)

90.0

(8.6)

5.6

(7.5)

5.6

(6.1)

2.3

(5.3)

0.512

EBBS 29.6

(7.5)

23.3

(6.1)

28.9

(4.5)

24.0

(8.0)

22.8

(5.3)

20.8

(6.2)

-5.6

(5.4)

-0.5

(2.8)

-8.1

(6.2)

0.027*


ESMI; The EBS scores range from 29 to 116, with the higher scores indicating greater benefits from

engaging in exercise; The EBBS scores range from 14 to 56, with the lower scores indicating fewer

barriers to engaging in exercise; * p < 0.05.

189

4.5.5 Exercise

Changes in the exercise duration (minutes/week) were investigated. As shown in

Table 4.7, the duration of both total and moderate exercise (minutes/week) increased

among all three groups after the intervention was implemented. The ESMI group

showed the greatest increase in both total and moderate exercise duration per week

among the three groups after the interventions were implemented, while the C group

demonstrated the least improvement in exercise duration. Significant differences in

the mean change of the total exercise duration (minutes/week) were found among the

three groups (mean rank: ESMI group = 17.1, PE group = 13.5, C group = 7.9, p =

0.037) (Table 4.7).

Table 4.7 Changes in the Mean Minutes of the Total Exercise Duration (TED) and

Moderate Exercise Duration (MED) per week in the Three Groups

T0 T1 T1 - T0

pa

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

TED 421.4

(318.2)

203.8

(276.3)

176.7

(202.0)

423.8

(200.5)

441.3

(252.6)

571.1

(346.4)

2.5

(196.7)

237.5

(274.0)

394.4

(383.5)

0.037*

MED 245.0

(272.6)

136.3

(144.2)

158.3

(198.7)

246.3

(251.1)

271.3

(185.7)

423.3

(280.2)

1.3

(86.6)

135.0

(211.0)

265.0

(265.5)

0.114


ESMI.

190

4.5.6 Angina

As shown in Table 4.8, no significant differences in the mean change of angina

frequency (episodes/week), angina severity, and angina duration (minutes/week) were

found among the three groups. Due to the fact that most patients prefer to take

traditional Chinese anti-anginal medications, such as the heart-protecting musk pill

(Shexiangbaoxin pill), the Danshen pill, and the Suxiaojiuxin pill instead of nitrates,

the number of sublingual glyceryl trinitrate (GTN) used per week was not calculated.

Table 4.8 Changes in Angina Frequency (AF), Angina Severity (AS), and Angina

Duration (AD) in the Three Groups

T0 T1 T1 - T0

pa

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

AF 0.6

(0.5)

0.8

(0.7)

1.8

(3.0)

0.6

(0.9)

0.6

(0.7)

1.1

(2.3)

0.0

(0.9)

-0.1

(0.4)

-0.6

(2.1)

0.909

AS 1.9

(1.8)

1.3

(1.3)

1.1

(1.5)

1.1

(2.4)

0.8

(1.0)

0.9

(1.3)

-0.8

(2.2)

-0.5

(1.1)

-0.2

(1.5)

0.690

AD 3.1

(3.5)

1.4

(1.7)

1.2

(1.6)

10.8

(20.8)

1.4

(1.8)

4.4

(9.8)

7.6

(21.7)

0.0

(0.5)

3.2

(9.5)

0.876

a: Kruskal-Wallis Test; AF: Angina Frequency (episodes/week); AS: Angina Severity (0-10), with the

higher scores indicating more serious angina; AD: Angina Duration (minutes/week); T0: baseline data;

T1: data immediately after the completion of the 8-week ESMI.

191

4.5.7 Quality of life

In this study, the patients‘ quality of life was measured using the Seattle Angina

Questionnaire (SAQ) and the Medical Outcomes Study 36-Item Short-Form (SF-36).

4.5.7.1 Seattle Angina Questionnaire (SAQ)

The SAQ consists of the following five subscales: physical limitation, angina stability,

angina frequency, treatment satisfaction, and disease perception. Table 4.9 shows that,

after the interventions were implemented, the mean scores of five subscales of SAQ

increased for both the PE and ESMI groups while the mean scores of angina stability,

treatment satisfaction, and disease perception decreased for the C group. Significant

differences in the mean change scores of angina stability were identified among the

three groups (mean rank: PE group = 17.2, ESMI group = 14.4, C group = 7.3, p =

0.014), with the C group having the lowest scores.

192

Table 4.9 Changes in the Mean Scores of the Five Subscales of SAQ in the Three Groups

T0 T1 T1 - T0

pa

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

Physical

limitations

75.7

(19.5)

72.9

(18.2)

73.8

(16.7)

82.1

(16.5)

81.3

(9.6)

83.6

(11.4)

6.4

(25.4)

8.3

(12.9)

9.9

(12.9)

0.511

Angina

stability

65.6

(18.6)

50.0

(18.9)

61.1

(22.1)

37.5

(13.4)

59.4

(12.9)

61.1

(13.2)

-28.1

(20.9)

9.4

(22.9)

0.0

(25.0)

0.014*

Angina

frequency

85.0

(14.1)

76.3

(21.3)

82.2

(26.8)

87.5

(14.9)

87.5

(14.9)

84.4

(17.4)

2.5

(19.8)

11.3

(21.0)

2.2

(17.2)

0.652

Treatment

satisfaction

78.1

(12.5)

79.7

(16.3)

62.5

(23.4)

76.6

(22.1)

82.0

(8.5)

74.3

(25.1)

-1.6

(22.8)

2.3

(13.7)

11.8

(23.9)

0.425

Disease

perception

64.6

(22.6)

61.5

(17.2)

66.7

(18.6)

61.5

(23.1)

66.7

(17.8)

72.2

(20.4)

-3.1

(24.8)

5.2

(12.5)

5.6

(22.8)

0.643


ESMI; The scores of each subscale of SAQ range from 0 to 100, with the higher scores indicating a

better quality of life.

4.5.7.2 SF-36

As shown in Table 4.10, after the interventions were implemented, for all three groups,

the mean scores of physical functioning, role-physical, social functioning, role-

emotional, physical component summary, and mental component summary increased,

and the mean score for reported health transition decreased. In addition, higher mean

change scores of vitality and mental health were seen for the ESMI group as

compared with those for the C and PE groups. When the mean change scores of the

eight domains, the physical component summary, mental component summary, and

193

reported health transition of SF-36 were compared among the three groups, no

significant differences were identified among them (Table 4.10).

194

Table 4.10 Changes in the Mean Scores of the Eight Domains of SF-36 in the Three

Groups

T0 T1 T1 - T0

pa

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

C

(n=8)

mean

(SD)

PE

(n=8)

mean

(SD)

ESMI

(n=9)

mean

(SD)

Physical

functioning

82.5

(9.3)

82.5

(11.0)

79.4

(13.8)

86.3

(11.9)

88.8

(6.4)

87.8

(6.7)

3.8

(12.5)

6.3

(8.3)

8.3

(16.4)

0.668

Role-

physical

50.0

(32.7)

84.4

(35.2)

61.1

(48.6)

75.0

(46.3)

90.6

(18.6)

75.0

(33.1)

25.0

(50.0)

6.3

(41.7)

13.9

(39.7)

0.789

Bodily pain 66.4

(21.9)

66.9

(5.5)

69.9

(23.6)

65.4

(16.4)

71.5

(21.7)

60.3

(17.3)

-1.0

(14.1)

4.6

(21.6)

-9.6

(19.6)

0.477

General

health

37.1

(28.8)

60.4

(18.6)

58.4

(22.5)

42.5

(29.6)

66.9

(13.2)

57.3

(18.1)

5.4

(9.3)

6.5

(13.7)

-1.1

(11.9)

0.425

Vitality

64.4

(20.1)

73.8

(20.7)

60.6

(21.4)

61.3

(23.9)

77.5

(13.1)

78.3

(13.9)

-3.1

(19.4)

3.8

(17.1)

17.8

(13.7)

0.056

Social

functioning

70.3

(25.8)

76.6

(15.6)

70.8

(16.5)

71.9

(26.5)

84.4

(18.6)

84.7

(13.7)

1.6

(35.6)

7.8

(13.3)

13.9

(17.1)

0.631

Role-

Emotional

50.0

(47.1)

70.8

(41.6)

74.1

(43.4)

79.2

(39.6)

83.3

(35.6)

88.9

(33.3)

29.2

(45.2)

12.5

(35.4)

14.8

(33.8)

0.610

Mental

health

56.5

(17.4)

67.5

(5.8)

57.3

(13.4)

55.0

(18.1)

65.5

(8.0)

65.8

(2.9)

-1.5

(7.7)

-2.0

(10.7)

8.4

(13.0)

0.316

PCS 236.0

(73.3)

294.1

(52.1)

268.9

(86.2)

269.1

(89.1)

317.8

(49.6)

280.4

(47.5)

33.1

(58.1)

23.6

(48.8)

11.6

(68.1)

0.772

MCS 241.2

(91.7)

288.7

(75.0)

262.8

(77.3)

267.3

(80.5)

310.7

(57.9)

317.7

(50.3)

26.1

(71.7)

22.1

(61.7)

54.9

(39.0)

0.281

HT 3.8

(0.9)

3.1

(1.3)

3.4

(0.7)

3.3

(0.5)

2.6

(1.4)

2.7

(0.5)

-0.5

(0.5)

-0.5

(0.9)

-0.8

(0.8)

0.628

a: Kruskal-Wallis Test; The scores of each domain range from 0 to 100, with the higher scores

indicating better health in each domain; PCS: Physical Component Summary (PF + RP + BP + GH);

MCS: Mental Component Summary (VT + SF + RE + MH); HT: Reported Health Transition, the

scores range from 1 to 5, with the lower scores indicating better health conditions; T0: baseline data; T1:

data immediately after the completion of the 8-week ESMI.

195

4.6 Implications for the main study

On the whole, the pilot study went smoothly. The main aims of the pilot study were to

test the feasibility of implementing the patient education programme in China and to

examine the preliminary effects of the TTM-based ESMI on patients with coronary

heart disease. These aims were achieved in the pilot study. The results from the pilot

study showed that the TTM-based ESMI had potentially positive effects on changing

exercise behaviour in terms of exercise stages of change, exercise self-efficacy,

exercise barriers, and exercise duration per week, and quality of life in terms of some

subscales of the SAQ and SF-36. Due to the small sample size, non-parametric tests

were conducted to analyze the data.

Based on the preliminary results, the proposed method and procedures can be

implemented for the main study with the following minor modifications:

4.6.1 Research Setting

Due to the special environment on Gulangyu Island, individuals living in this area are

expected to engage much more actively in physical activities than those living in other

communities in Xiamen City. Therefore, the effects of the TTM-based ESMI on one‘s

exercise behaviour may be minimized. In addition, according to the medical records

of the Medical Service Centre of Gulangyu Community, the mean age of all CHD

patients was 71.8 years old. Thus, it is suggested that the main study should be

conducted in other hospitals in Xiamen City in order to obtain more sedentary and

younger subjects.

196

4.6.2 Selection Criteria

One of the primary outcome variables in this study was the exercise stages of change.

The inclusion of individuals in the action and maintenance stages would result in a

ceiling effect in the exercise stages of change. The possible explanation for why the

TTM-based ESMI did not seem to demonstrate any significant effects on the exercise

stages of change in this pilot study is that patients in the action and maintenance

stages were also recruited in the pilot study, which resulted in a ceiling effect. In order

to avoid the ceiling effect with regard to the exercise stages of change, patients in the

action and maintenance stages will not be recruited in the main study because there is

no room for those who are in the maintenance stage to improve. In addition,

individuals in the action and maintenance stages are already exercising regularly. It is

more significant and meaningful to motivate sedentary CHD patients to change their

exercise behaviour than active ones. Thus, the actual study would only recruit

sedentary CHD patients who are in the precontemplation, contemplation, and

preparation stages according to the exercise stages of change scale. Those who are in

the action or maintenance stage will not be recruited in the main study.

4.6.3 Intervention

In this pilot study, patients in the PE group only received one 2-hour session of patient

education about CHD and the booklet, whereas patients in the ESMI group received

eight weekly sessions of ESMI through face-to-face or telephone contact in addition

to the one 2-hour session of patient education about CHD and the booklet. These

197

different frequencies of contact between the PE and ESMI groups may have

contributed to the better effects of the ESMI on exercise behaviour as compared with

the PE. To make the interventions of the ESMI and PE groups more comparable in

terms of contacts between the researcher and the patients, those in the PE group will

also receive eight weekly contacts face-to-face or over the telephone, the same as

designated for the ESMI group. They will receive at least two sessions of face-to-face

contacts over eight weeks. The contents of the eight weekly contacts will include

checking for compliance with the exercise regime and delivering information

regarding the importance and benefits of regular exercise.

4.6.4 Outcome measurements

Patients in the pilot study preferred to take traditional Chinese anti-anginal drugs,

such as the heart-protecting musk pill (Shexiangbaoxin pill), the Danshen pill, and the

Suxiaojiuxin pill, instead of nitrates when they experience anginal pain or chest

discomfort. Thus, in both the daily angina and daily physical activity records, patients

should record the type and number of any anti-anginalists taken, not only the number

of nitrates taken. In addition, the assessment of angina frequency regarding the taking

of nitrates in the SAQ (i.e., SAQ4: Over the past four week, on average, how many

times have you had to take nitros (nitroglycerin tablets) for your chest pain, chest

tightness, or angina) was changed to all anti-anginal drugs taken for chest pain, chest

tightness, or angina in the past four weeks.

198

4.7 Summary

This chapter presents the results of the pilot study and the implications for the main

study. The pilot study went smoothly, with no cardiac events or angina attacks

occurring during the time that the patients were engaged in exercise. The results

showed that the TTM-based ESMI had potentially positive effects on changing

exercise behaviour and on some domains of quality of life with respect to the SAQ

and SF-36. These findings suggest that it is feasible and effective to implement the

TTM-based ESMI in the patient education programme for CHD patients in Xiamen

City, China.

199

Chapter 5 Results

5.1 Introduction

This chapter presents the results of patient recruitment, the characteristics of the

patients, a comparison of patient characteristics between dropouts and completers of

the study, and the results, which address the research questions.

5.2 Recruitment of patients

A total of 1,140 patients were contacted for screening. Eight hundred and seventy-

seven patients were excluded according to the selection criteria and 67 patients

refused to participate in this study for the following three main reasons: (i) taking care

of grandchildren and have no time to participate in the programme (n = 27); (ii)

feeling that it takes too much time and so refuse to join the programme (n = 24); and

(iii) feel that my current health condition is good and that I do not need to join it (n =

16). Therefore, a total of 944 patients were not recruited in this study.

A total of 196 patients who met the selection criteria were recruited in this study.

They were classified according to the following three exercise stages of change:

precontemplation stage (n = 38), contemplation stage (n = 35), and preparation stage

(n = 123). They were then randomly allocated to one of the following three groups:

the C group (n = 67), the PE group (n = 64), and the ESMI group (n = 65). A total of

46 patients (23.5%) [17 patients in the C group (25.4%), 17 patients in the PE group

(26.6%), and 12 patients in the ESMI group (18.5%)] withdrew from the study during

200

the study period. In this study, dropouts were defined as: (i) patients who did not

attend one 2-hour patient education session about CHD; (ii) patients who did not

receive at least two face-to-face contacts over the eight weeks; (iii) patients who did

not attend at least four of the eight ESMI sessions (50%); or (iv) patients who did not

complete the data collection exercise at each time point. The reasons for the dropouts

are listed in Figure 5.1. The most common reasons were as follows: (i) the patient had

left Xiamen City (e.g., visiting children in another city, returning to the country side,

or going to a foreign country) during the study period; (ii) the patient refused to come

to the hospital due to the bad weather (e.g., too cold in winter or too hot in summer);

and (iii) the patient was busy with work or other tasks such as taking care of

grandchildren. In the end, a total of 150 patients completed the study. The overall

completion rate was 76.5%. The average participation rate of the eight ESMI sessions

was 85.2%. Intention-to-treat (ITT) analysis was employed in this study. Last

Observation Carried Forward (LOCF) was used to handle the missing data.

201

Screening (N=1140)

- Excluded by selection

criteria (n=877)

- Refusal (n=67)

T0: Baseline data collection (N=196)

Randomization with reference to the exercise stages of change


4 dropouts - Diagnosed with lung

cancer (1)

- Too busy to take care of

her husband who was

diagnosed with gastric

cancer (1)

- Left Xiamen City (1)

- Refusal (1)

11 dropouts - Diagnosed with lung

cancer (1)

- Too busy to take care of

grandchild (2)


- Refusal (6)

C group (n=63) T1 PE group (n=53) ESMI group (n=56)

1 dropout - Left Xiamen City (1)

1 dropout - Felt uncomfortable (1)

C group (n=55) PE group (n=52) ESMI group (n=55) T2

C group (n=50) T3 PE group (n=47)

ESMI group (n=53)

5 dropouts - Left Xiamen City (2)

- Not contactable (1)

- Refusal (2)

9 dropouts - Left Xiamen City (3)

- Hospitalized (1)

- Refusal (5)

8 dropouts - Got sick (1)


- Refusal (5)

5 dropouts - Hospitalized (1)


- Not contactable (1)

- Refusal (1)

2 dropouts - Refusal (2)

Figure 5.1 Flowchart of the recruitment process

202

5.3 Demographic and clinical characteristics of dropouts versus completers

This section compared the demographic and clinical characteristics of the dropouts

from the study and those who completed the study. Tables 5.1 and 5.2 show that

significant differences between the dropouts and completers were detected in gender,

marital status, type of medical payment, and anti-platelets taken. Dropouts were more

likely to be female, single or widowed, and have to pay for the entire amount of their

medical treatment themselves. Conversely, males, those were married, and those who

received partial reimbursement of their medical expenses (e.g., medical insurance)

were more likely to complete the study. The patients who completed the study were

more likely to take anti-platelets.

Table 5.1 Demographic Characteristics of Dropouts versus Completers

Dropouts

(n=46)

n (%)

Completers

(n=150)

n (%)

χ2 p

Age [mean (SD)] 64.4(11.0) 63.6(9.2) 0.522 a 0.603

Gender 6.198 0.013*

Male 27(58.7) 116(77.3)

Female 19(41.3) 34(22.7)

Marital status 4.866 0.027*

Single/widowed 7(15.2) 8(5.4)

Married 39(84.8) 142(94.7)

Living conditions 0.165 0.544

Living alone 1(2.2) 2(1.3)

Living with spouse and/or

children

45(97.8) 148(98.7)

a t-test;

b Fisher‘s exact test; * p < 0.05;

** p < 0.01.

203

Table 5.1 Continued

Dropouts

(n=46)

n (%)

Completers

(n=150)

n (%)

χ2 p

Education 3.310 0.346

No formal education 3(6.5) 6(4.0)

Elementary school 11(23.9) 21(14.0)

High school 22(47.8) 86(57.3)

College or above 10(21.7) 37(24.7)

Current employment status 3.382 0.184

Not working 41(89.1) 115(76.7)

Part-time work 1(2.2) 6(4.0)

Full-time work 4(8.7) 29(19.3)

Occupation before retirement 4.758 0.446

Manual labour 18(39.1) 40(26.7)

Technical 4(8.7) 21(14.0)

Clerical 6(13.0) 32(21.3)

Managerial 8(17.4) 31(20.7)

Professional 4(8.7) 13(8.7)

Business/Commercial 6(13.0) 13(8.7)

Religious beliefs 2.566 0.277

No belief 28(60.9) 103(68.7)

Buddhism 13(28.3) 40(26.7)

Christianity 5(10.9) 7(4.7)

Family income per month 8.906 0.113

≤ $1,000 RMB 5(10.9) 11(7.3)

$1,001-3,000 RMB 18(39.1) 31(20.7)

$3,001-5,000 RMB 11(23.9) 57(38.0)

$5,001-7,000 RMB 4(8.7) 16(10.7)

$7,001-10,000 RMB 3(6.5) 20(13.3)

≥ $10,001 RMB 5(10.9) 15(10.0)

Type of medical payment 15.079 0.001**

Totally reimbursed 1(2.2) 2(1.3) 0.165 b 0.554

Partially reimbursed 35(76.1) 142(94.7) 13.882 b 0.001**

Totally self-paid 10(21.7) 6(4.0) 14.777 b 0.001**

a t-test;

b Fisher‘s exact test; * p < 0.05;

** p < 0.01.

204

Table 5.2 Clinical Characteristics of dropouts versus completers

Dropouts

(n=46)

n (%)

Completers

(n=150)

n (%)

χ2 p


Angina pectoris 27(58.7) 88(58.7)

MI 19(41.3) 62(41.3)

PCI/stent 3.186 0.074

Yes 25(54.3) 103(68.7)

No 21(45.7) 47(31.3)


Yes 6(13.0) 29(19.3)

No 40(87.0) 121(80.7)


Yes 18(39.1) 44(29.3)

No 28(60.9) 106(70.7)

Diagnosed with hypertension 0.003 0.957

Yes 33(71.7) 107(71.3)

No 13(28.3) 43(28.7)


Never smoking 26(56.5) 70(46.7)

Quit smoking 13(28.3) 51(34.0)

Current smoking 7(15.2) 29(19.3)


Never drinking 38(82.6) 120(80.0)

Quit drinking 6(13.0) 16(10.7)

Current drinking 2(4.3) 14(9.3)

Current medications

Nitrates 8(17.4) 47(31.3) 3.390 0.066

ß-blockers 31(67.4) 112(74.7) 0.945 0.331

ACE inhibitors 13(28.3) 49(32.7) 0.316 0.574

Calcium antagonists 11(23.9) 55(36.7) 2.564 0.109

Anti-platelets 38(82.6) 139(92.7) 4.068 0.044*

Lipid-lowering drugs 32(69.6) 124(82.7) 3.720 0.054

HADS-D scores [mean (SD)] 2.3(2.3) 2.5(2.3) -0.435 a 0.664

a: t-test; HADS-D: Depression Subscale of the Hospital Anxiety and Depression Scale; * p < 0.05.

205

5.4 Demographic and clinical characteristics of the patients

This section describes and compares the demographic and clinical characteristics of

the three groups of patients to determine whether the random assignment produced

equivalent groups. Table 5.3 shows the demographic characteristics of the patients in

this study. The mean age of the patients was 63.8 years, with a range from 26 to 82

years. More than 70% of the patients were male. The overwhelming majority (92.3%)

of the patients were married and living with family members. More than 70% of the

patients had a high school level of education or above. Nearly 80% of the patients

were retired or not currently working. Before retirement, patients mainly worked as

manual labourers (29.6%) or in clerical (19.4%) and managerial (19.9%) jobs. More

than 60% of the patients had no religious beliefs. Regarding family income per month,

about 70% of the patients had a family income ranging from RMB 1,001- 5,000 per

month. About 80% of the patients had medical insurance. No statistically significant

differences in demographic data were identified among the C, PE, and ESMI groups

as confirmed by the Chi-square test, one-way ANOVA, or the Kruskal-Wallis test

(Table 5.3).

206

Table 5.3 Demographic Characteristics of the Subjects

Total

(N=196)

n (%)

C

(n=67)

n (%)

PE

(n=64)

n (%)

ESMI

(n=65)

n (%)

χ2 p

Age [mean (SD)] year 63.8(9.6) 65.8(10.1) 63.5(8.9) 61.9(9.5) 2.805 a 0.063

≤ 60 years 60(30.6) 14(20.9) 21(32.8) 25(38.5) 9.060 0.060

61-70 years 88(44.9) 29(43.3) 30(46.9) 29(44.6)

> 70 years 48(24.5) 24(35.8) 13(20.3) 11(16.9)

Gender 0.880 0.644

Male 143(73.0) 49(73.1) 49(76.6) 45(69.2)

Female 53(27.0) 18(26.9) 15(23.4) 20(30.8)

Marital status 2.746 0.253

Single/widowed 15(7.6) 8(11.9) 3(4.7) 4(6.2)

Married 181(92.3) 59(88.1) 61(95.3) 61(93.8)

Education 0.293b 0.864

No formal education 9(4.6) 5(7.5) 2(3.1) 2(3.1)

Elementary school 32(16.3) 7(10.4) 14(21.9) 11(16.9)

High school 108(55.1) 38(56.7) 31(48.4) 39(60.0)

College or above 47(24.0) 17(25.4) 17(26.6) 13(20.0)

Current employment

status

3.314 0.507

Not working 156(79.6) 56(83.6) 52(81.3) 48(73.8)

Part-time work 7(3.6) 3(4.5) 1(1.6) 3(4.6)

Full-time work 33(16.8) 8(11.9) 11(17.2) 14(21.5)

Occupation before

retirement

15.635 0.111

Manual labour 58(29.6) 21(31.3) 21(32.8) 16(24.6)

Technical 25(12.8) 9(13.4) 7(10.9) 9(13.8)

Clerical 38(19.4) 15(22.4) 12(18.8) 11(16.9)

Managerial 39(19.9) 17(25.4) 11(17.2) 11(16.9)

Professional 17(8.7) 2(3.0) 9(14.1) 6(9.2)

Business/Commercial 19(9.7) 3(4.5) 4(6.3) 12(18.5)

Religious beliefs 6.150 0.188

No belief 131(66.8) 50(74.6) 43(67.2) 38(58.5)

Buddhism 53(27.0) 12(17.9) 17(26.6) 24(36.9)

Christianity 12(6.1) 5(7.5) 4(6.3) 3(4.6)

a: one-way ANOVA; b: Kruskal-Wallis Test.

207

Table 5.3 Continued

Total

(N=196)

n (%)

C

(n=67)

n (%)

PE

(n=64)

n (%)

ESMI

(n=65)

n (%)

χ2 p

Family income per

month

12.912 0.229

≤ $1,000 RMB 16(8.2) 5(7.5) 7(10.9) 4(6.2)

$1,001-3,000 RMB 49(25.0) 19(28.4) 13(20.3) 17(26.2)

$3,001-5,000 RMB 68(34.7) 21(31.3) 23(35.9) 24(36.9)

$5,001-7,000 RMB 20(10.2) 3(4.5) 10(15.6) 7(10.8)

$7,001-10,000 RMB 23(11.7) 13(19.4) 6(9.4) 4(6.2)

≥ $10,001 RMB 20(10.2) 6(9.0) 5(7.8) 9(13.8)

Type of medical payment 2.938 0.568

Totally reimbursed 3(1.5) 2(4.5) 0(0.0) 1(1.5)

Partially reimbursed 177(90.3) 61(89.6) 57(89.0) 59(90.8)

Totally self-paid 16(8.2) 4(6.0) 7(10.9) 5(7.7)

Living conditions 1.951 0.377

Living alone 3(1.5) 2(3.0) 1(1.6) 0(0.0)

Living with spouse

and/or children

193(98.5) 65(97.0) 63(98.4) 65(100)

a: one-way ANOVA; b: Kruskal-Wallis Test.

Table 5.4 shows the clinical characteristics of the patients in this study. The patients

had either been diagnosed with myocardial infarction (MI) or angina pectoris. More

than 60% of the patients had undergone PCI/stent treatment. About 18% of the

patients had a family history of CHD. Around 30% of the patients had diabetes

mellitus. However, the condition of more than 70% of the patients was complicated

by the presence of hypertension. About one fifth of the patients were habitual

cigarette smokers. Less than 10% of the patients were habitual consumers of alcohol.

Over 70% of the patients had been prescribed ß-blockers, anti-platelets, and lipid-

lowering drugs. The Depression Subscale of the Hospital Anxiety and Depression

Scale (HADS-D) was used to assess the patients‘ mood. The mean score of HADS-D

208

was 2.5, which showed that the patients in this study were not suffering from

depression. The Kruskal-Wallis test was used to analyze the scores because the scores

were not normally distributed. When using the Chi-square test or the Kruskal-Wallis

test to analyze the clinical data of the C, PE, and ESMI groups, no statistically

significant differences among them were found (Table 5.4).

209

Table 5.4 Clinical Characteristics of the Subjects

Total

(N=196)

n (%)

C

(n=67)

n (%)

PE

(n=64)

n (%)

ESMI

(n=65)

n (%)

χ2 p


Angina pectoris 115(58.7) 34(50.7) 38(59.4) 43(66.2)

MI 81(41.3) 33(49.3) 26(40.6) 22(33.8)

PCI/stent 0.688 0.709

Yes 128(65.3) 42(62.7) 41(64.1) 45(69.2)

No 68(34.7) 25(37.3) 23(35.9) 20(30.8)


Yes 35(17.9) 8(11.9) 14(21.9) 13(20.0)

No 161(82.1) 59(88.1) 50(78.1) 52(80.0)


Yes 62(31.6) 20(29.9) 21(32.8) 21(32.3)

No 134(68.4) 47(70.1) 43(67.2) 44(67.7)

Diagnosed with

hypertension

3.650 0.161

Yes 140(71.4) 53(79.1) 41(64.1) 46(70.8)

No 56(28.6) 14(20.9) 23(35.9) 19(29.2)


Never smoking 96(49.0) 31(46.3) 30(46.9) 35(53.8)

Quit smoking 64(32.7) 23(34.3) 20(31.3) 21(32.3)

Current smoking 36(18.4) 13(19.4) 14(21.9) 9(13.8)


Never drinking 158(80.6) 55(82.1) 53(82.8) 50(76.9)

Quit drinking 22(11.2) 9(13.4) 6(9.4) 7(10.8)

Current drinking 16(8.2) 3(4.5) 5(7.8) 8(12.3)

Current medications

Nitrates 55(28.1) 20(29.9) 18(28.1) 17(26.2) 0.224 0.894

ß-blockers 143(73.0) 53(79.1) 46(71.9) 44(67.7) 2.235 0.327

ACE inhibitors 62(31.6) 20(29.9) 19(29.7) 23(35.4) 0.633 0.729

Calcium antagonists 66(33.7) 26(38.8) 15(23.4) 25(38.5) 4.460 0.108

Anti-platelets 177(90.3) 58(86.6) 59(92.2) 60(92.3) 1.626 0.443

Lipid-lowering drugs 156(79.6) 53(79.1) 49(76.6) 54(83.1) 0.857 0.651

HADS-D scores [mean (SD)]

2.5(2.3) 2.2(2.3) 2.8(2.4) 2.4(2.0) 3.420 a 0.181

a: Kruskal-Wallis test; HADS-D: Depression Subscale of the Hospital Anxiety and Depression Scale.

210

5.5 Effects of the Exercise Stage-Matched Intervention (ESMI)

Before the data analysis, skewness, kurtosis, the Kolmogorov-Smirnov test, and Q-Q

plot were employed to explore whether the data were normally distributed. The

Levene's test was used to explore the homogeneity of variance among the three

groups for each piece of data at each time point. The results showed that only the

scores of the exercise self-efficacy scale were normally distributed, and the related

homogeneity of variance was achieved at each time point (Appendix XV). Thus,

parametric tests were employed for the analyses of the data on exercise self-efficacy.

Non-parametric tests were applied for other data.

5.5.1 Exercise Stages of Change

Exercise stages of change is a core construct of the TTM. There are five stages,

namely, the precontemplation, contemplation, preparation, action, and maintenance

stages. The higher the stage, the better the exercise behaviour. In this section, the

effects of the TTM-based ESMI on exercise stages of change were presented as the

following research question:

Q1: Will the CHD patients who participated in the Exercise Stage-Matched

Intervention (ESMI) group demonstrate a more positive shift in exercise stages

of change than the patients in the Patient Education (PE) group and the

Conventional (C) group?

211

Table 5.5 and Figure 5.2 show the shifts in the exercise stages of change among the

three groups throughout the study. All of the CHD patients in the three groups were

motivated to engage in exercise after the intervention. More patients in the ESMI

group were in the action and maintenance stages than those in the PE and C groups

from T1 to T3. Slightly more than 60% (40/65) of the patients in the ESMI group were

in the action/maintenance stage immediately after the 8-week intervention (T1),

around 55% (36/65) at the 3-month follow up (T2), and over 40% (27/65) at the 6-

month follow up (T3). A trend of a reduction in the proportion of those in the

action/maintenance stage in the ESMI group was observed during the follow-up

period. In the PE group, around 17% (11/64) of the patients were in the

action/maintenance stage immediately after the 8-week intervention (T1), nearly 30%

(19/64) at the 3-month follow up (T2), and over 20% (14/64) at the 6-month follow up

(T3). For the C group, 4.5% (3/67) of the patients were in the action/maintenance

stage immediately after the 8-week intervention (T1), 7.5% (5/67) at the 3-month

follow up (T2), and 12% (8/67) at the 6-month follow up (T3).

212

Table 5.5 Exercise Stages of Change at Each Time Point

C group

(n=67)

n (%)

PE group

(n=64)

n (%)

ESMI group

(n=65)

n (%)

T0 Precontemplation 10(14.9) 17(26.6) 11(16.9)

Contemplation 9(13.4) 9(14.1) 17(26.2)

Preparation 48(71.6) 38(59.4) 37(56.9)


Contemplation 9(13.4) 5(7.8) 2(3.1)

Preparation 44(65.7) 39(60.9) 21(32.3)

Action 3(4.5) 11(17.2) 40(61.5)


Contemplation 3(4.5) 7(10.9) 3(4.6)

Preparation 46(68.7) 29(45.3) 24(36.9)

Action 5(7.5) 19(29.7) 36(55.4)


Contemplation 6(9.0) 5(7.8) 5(7.7)

Preparation 47(70.1) 37(57.8) 31(47.7)

Action 4(6.0) 6(9.4) 5(7.7)

Maintenance 4(6.0) 8(12.5) 22(33.8)

T0: baseline data; T1: data immediately after the completion of the 8-week intervention; T2: data at the

3-month follow up; T3: data at the 6-month follow up.

213

Figure 5.2 The Number of Patients in the Action and Maintenance

Stages at Each Time Point

03

58

0

11

19

14

0

40

36

27

0

5

10

15

20

25

30

35

40

45

T0 T1 T2 T3

Time

Nu

mb

er o

f P

ati

ents

in

th

e A

ctio

n a

nd

Ma

inte

na

nce

Sta

ges

C

PE

ESMI

Patients were divided into the categories of progressed, stable, and regressed after the

8-week intervention when compared to their baseline exercise stages of change. When

compared with the baseline, patients who progressed or moved forward at least one

stage higher were classified as progressed; patients who did not make any movement

in their exercise stages of change were classified as stable; and those who had

regressed or moved backward at least one stage lower were classified as regressed. As

shown in Table 5.6, in the ESMI group, more than 75% of the patients progressed in

their exercise stages of change immediately after the completion of the 8-week

intervention (T1) as compared with the baseline, slightly over 70% at the 3-month

follow up (T2), and more than 60% at the 6-month follow up (T3); in the PE group,

nearly 40% of the patients progressed in their exercise stages of change immediately

after the completion of the 8-week intervention (T1) as compared with the baseline,

214

and over 40% at both the 3- and 6-month follow up (T2 & T3); in the C group, slightly

over 10% of the patients progressed in their exercise stages of change immediately

after the completion of the 8-week intervention (T1), 18% at the 3-month follow up

(T2), and around 25% at the 6-month follow up (T3). No significant differences in

exercise stages of change among the three groups were detected at baseline (T0) (p =

0.199) (Appendix XVI). Significant differences in the movement of the exercise

stages of change were identified among the three groups at T1 (p < 0.01), T2 (p < 0.01)

and T3 (p < 0.01), when the Chi-square test was adopted to analyze the data (Table

5.6). These findings suggest that the patients in the ESMI group were more likely to

progress in their exercise stages of change after the completion of the 8-week

intervention and during the 6-month follow-up period as compared with those in the

PE and C groups.

The effect sizes (odd ratio, OR) of the ESMI on progression ranged from 5.2 to 24.6

immediately after the 8-week intervention as compared with the PE and C group,

respectively. This finding suggests that the patients in the ESMI group were 5.2 and

24.6 times more likely to progress in their exercise stages of change immediately after

the completion of the 8-week intervention as compared with those in the PE and C

group, respectively. The OR ranged from 2.1 to 3.1 and from 4.4 to 11.1 at the 3 - and

6-month follow-up, which suggests that the patients who participated in the ESMI

group were 2.1-3.1 and 4.4 -11.1 times more likely to progress their exercise stages of

change than those in the PE and C groups, respectively, during the 3- and 6-month

follow-up period. These findings reveal that the patients who participated in the ESMI

group demonstrated a more positive shift in exercise stages of change than those in

the PE and C groups.

215

Table 5.6 Comparisons of Movement of Exercise Stages of Change among Groups at

Each Time Point

C group

(n=67)

n (%)

PE group

(n=64)

n (%)

ESMI group

(n=65)

n (%)

χ2 p

Effect size

ORa OR

b

T1 Progressed 8(11.9) 25(39.1) 50(76.9) 59.151 0.000** 24.6 5.2

Stable 52(77.6) 36(56.3) 15(23.1)

Regressed 7(10.4) 3(4.7) 0(0)

T2 Progressed 12(17.9) 28(43.8) 46(70.8) 39.743 0.000** 11.1 3.1

Stable 47(70.1) 32(50.0) 19(29.2)

Regressed 8(11.9) 4(6.3) 0(0)

T3 Progressed 18(26.9) 28(43.8) 40(61.5) 16.787 0.002** 4.4 2.1

Stable 44(65.7) 34(53.1) 23(35.4)

Regressed 5(7.5) 2(3.1) 2(3.1)

Progressed: patients move forward at least one stage higher as compared to the baseline; Stable:

patients do not move any stage as compared to the baseline; Regressed: patients move backward at

least one stage lower as compared to the baseline; T1: data immediately after the completion of the 8-

week intervention; T2: data at the 3-month follow up; T3: data at the 6-month follow up; ** p < 0.01; a:

calculated OR as compared with the C group; b: calculated OR as compared with the PE group.

A recommended alternative approach to conceptualizing stage progression as a

trichotomous variable would be to count the number of stages progressed as the outcome

variable (Nigg, 2002). For example, an individual progressing a single stage (e.g.,

progress from the precontemplation to the contemplation stage, or progress from the

preparation to the action stage) would receive a score of 1, while an individual

progressing two stages would receive a score of 2 (e.g., progress from the contemplation

to the action stage), and so on. Regression to an earlier stage would be assigned negative

scores. For example, the subjects regressing a single stage (e.g., regress from the

216

contemplation to the precontemplation stage) would receive a negative score of 1; the

subjects regressing two stages would receive a negative score of 2, and so on. Then, the

mean scores of the exercise stages of change in each group were calculated at T1, T2, and

T3. As shown in Table 5.7, all of the three groups demonstrated an increase in the mean

scores of the exercise stages of change from T1 to T3, and the ESMI group demonstrated

higher mean scores of the exercise stages of change than did the PE and C groups.

Significant differences in the mean scores of the exercise stages of change were detected

among the three groups at T1 (mean rank: ESMI group = 134.0, PE group = 95.3, and

C group = 67.2, p < 0.01), T2 (mean rank: ESMI group = 127.0, PE group = 98.5, and

C group = 70.9, p < 0.01) and T3 (mean rank: ESMI group = 119.5, PE group = 96.6,

and C group = 80.0, p < 0.01), when the Kruskal-Wallis test was applied to analyze

the data (Table 5.7).

The effect size (r) of the TTM-based ESMI on the exercise stages of change ranged

from 0.3 to 0.5. According to Cohen (1988), this would be considered a medium (0.25)

to large effect (0.40) for an ANOVA analysis (Table 5.7). Clearly, the patients who

participated in the ESMI group demonstrated a more positive shift in the exercise

stages of change than those in the PE and C groups.

217

Table 5.7 Comparisons of the Mean Change Scores of the Exercise Stages of Change

among Groups at Each Time Point

C group

(n=67)

mean(SD)

PE group

(n=64)

mean(SD)

ESMI group

(n=65)

mean(SD)

Kruskal-Wallis test Effect

size

(r) χ

2 p

T1 - T0 0.0(0.7) 0.5(0.8) 1.1(0.9) 55.461 0.000** 0.5

T2 - T0 0.1(0.8) 0.6(0.9) 1.1(0.9) 37.992 0.000** 0.4

T3 - T0 0.3(0.9) 0.7(1.0) 1.2(1.3) 18.995 0.000** 0.3

** p < 0.01.

When the within-group comparisons were made using the Friedman test, significant

differences in the exercise stages of change were found among all of the three groups

from T0 to T3 (mean rank: C group: T0 = 2.4, T1 = 2.4, T2 = 2.5, T3 = 2.8, p < 0.01; PE

group: T0 = 1.9, T1 = 2.6, T2 = 2.7, T3 = 2.8, p < 0.01; ESMI group: T0 = 1.5, T1 = 2.9,

T2 = 2.7, T3 = 2.9, p < 0.01) (Table 5.8). This finding suggests that all of the three

groups progressed in their exercise stages of change over time.

218

Table 5.8 Comparisons of Exercise Stages of Change within Each Group across Time

Group Variable

T0

n (%)

T1

n (%)

T2

n (%)

T3

n (%)

Friedman test

χ2 p

C

group

Precontemplation 10(14.9) 11(16.4) 13(19.4) 6(9.0) 13.299 0.004**

Contemplation 9(13.4) 9(13.4) 3(4.5) 6(9.0)

Preparation 48(71.6) 44(65.7) 46(68.7) 47(70.1)

Action 0 3(4.5) 5(7.5) 4(6.0)

Maintenance 0 0 0 4(6.0)

PE

group


Contemplation 9(14.1) 5(7.8) 7(10.9) 5(7.8)

Preparation 38(59.4) 39(60.9) 29(45.3) 37(57.8)

Action 0 11(17.2) 19(29.7) 6(9.4)


ESMI

group


Contemplation 17(26.2) 2(3.1) 3(4.6) 5(7.7)

Preparation 37(56.9) 21(32.3) 24(36.9) 31(47.7)

Action 0 40(61.5) 36(55.4) 5(7.7)



3-month follow up; T3: data at the 6-month follow up; ** p < 0.01.

5.5.2 Exercise Self-Efficacy (ESE)

Exercise self-efficacy is one of the main constructs of the TTM. It predicts the change

in exercise behaviour with a linear increase from the precontemplation to the

maintenance stage. The higher scores of the exercise self-efficacy scale indicate more

confidence in engaging in exercise. This section examined the following research

question:

219


Intervention (ESMI) group demonstrate higher exercise self-efficacy than the

patients in the Patient Education (PE) group and the Conventional (C) group?

Referring to Table 5.9 and Figure 5.3, the mean scores of the exercise self-efficacy

scale in the ESMI group sharply increased during the period of the implementation of

the intervention (T0) and slowly decreased from T1 to T3, with the mean scores still

higher than the baseline; in the PE group, the mean scores rose steadily during the

period of the implementation of the intervention, and kept rising from T1 to T3; in the

case of the C group, the mean scores slightly declined during the period of the

implementation of the intervention (T1) and then rose from T1 to T3, with the mean

scores higher than the baseline. As a whole, the mean scores of the exercise self-

efficacy scale for the ESMI group were higher than those for the PE and C groups,

and those for the PE group were higher than those for the C group from T1 to T3.

Table 5.9 Mean and Standard Deviations of the Exercise Self-Efficacy (ESE) Scale

Scores at Each Time Point

ESE

C group

(n=67)

mean(SD)

PE group

(n=64)

mean(SD)

ESMI group

(n=65)

mean(SD)

T0 843.3(305.0) 809.5(307.6) 800.5(294.8)

T1 820.1(329.6) 936.9(345.3) 1183.8(360.3)

T2 869.6(344.7) 971.7(371.5) 1158.7(386.1)

T3 977.8(374.5) 1022.8(383.5) 1127.2(395.9)


3-month follow up; T3: data at the 6-month follow up; The scores range from 0 to 1,800 with the higher

scores indicating greater confidence in engaging in exercise.

220

Since the data on exercise self-efficacy were normally distributed and the related

homogeneity of variances among the three groups was achieved (Appendix XV), one-

way ANOVA was applied. At baseline, no significant differences in the mean scores

of the exercise self-efficacy scale were detected among the three groups (p = 0.692)

(Appendix XVI). After the completion of the 8-week intervention, the mean change

scores of the exercise self-efficacy scale were much higher for the ESMI group than

for the PE and C groups, and the mean change scores for the PE group were higher

than those for the C group at T1, T2, and T3 (Table 10). Significant differences in the

mean change scores of the exercise self-efficacy scale were found among the three

groups at T1 (F (2, 193) = 35.9, p < 0.01), T2 (F (2, 193) = 17.6, p < 0.01), and T3 (F (2,

193) = 4.8, p < 0.01) (Table 5.10).

221

The effect size (r) of the TTM-based ESMI on the exercise self-efficacy was 0.5

immediately after the completion of the 8-week intervention (T1) and ranged from 0.2

to 0.4 during the 6-month follow-up period (Table 5.10). This would be viewed as a

medium (0.25) to large effect (0.40) for an ANOVA analysis based on Cohen‘s (1988)

terms. These findings suggest that the patients who participated in the ESMI group

demonstrated higher exercise self-efficacy than those in the PE and C groups. In other

words, the patients who participated in the ESMI group showed greater confidence

about engaging in exercise than those in the PE and C groups.

Table 5.10 Comparisons of the Mean Change Scores of the Exercise Self-Efficacy (ESE)

Scale among Groups at Each Time Point

C group

(n=67)

mean(SD)

PE group

(n=64)

mean(SD)

ESMI group

(n=65)

mean(SD)

One-way ANOVA Effect

size

(r) F p

T1 - T0 -23.2(225.1) 127.3(271.1) 383.4(329.8) 35.936 0.000** 0.5

T2 - T0 26.3(286.9) 162.2(328.1) 358.2(351.2) 17.599 0.000** 0.4

T3 - T0 134.5(335.9) 213.3(372.3) 326.7(364.5) 4.808 0.009** 0.2

** p < 0.01.

For the within-group comparisons of the mean scores of the exercise self-efficacy

scale, the one-way repeated ANOVA was performed. Significant differences were

seen for all three groups in the mean scores of the exercise self-efficacy scale from T0

to T3 (C group: F(2.5, 66) = 7.6, p < 0.01; PE group: F(2.3, 63) = 11.8, p < 0.01;

ESMI group: F(2.3, 64) = 47.1, p < 0.01) (Table 5.11). This finding suggests that

over time the patients in all of the three groups became more confident about

engaging in exercise.

222

Table 5.11 Comparisons of Exercise Self-Efficacy Scale (ESE) Scores within Each

Group across Time

T0

mean (SD)

T1

mean (SD)

T2

mean (SD)

T3

mean (SD) df F p

C 843.3(305.0) 820.1(329.6) 869.6(344.7) 977.8(374.5) 2.5a 7.612

a 0.000**

PE 809.5(307.6) 936.9(345.3) 971.7(371.5) 1022.8(383.5) 2.3a 11.814

a 0.000**

ESMI 800.5(294.8) 1183.8(360.3) 1158.6(386.1) 1127.2(395.9) 2.3a 47.058

a 0.000**


3-month follow up; T3: data at the 6-month follow up; a: The degree of freedom of the F ratio is

evaluated by Greenhouse-Geisser (G-G) as estimates of adjustment (epsilon), if Mauchly‘s test of

sphericity is not assumed; ** p < 0.01.

5.5.3 Exercise Decisional Balance

Exercise decisional balance includes the Exercise Benefits Scale (EBS) and the

Exercise Barriers Scale (EBBS). The higher EBS scores indicate a greater

appreciation of the benefits of engaging in exercise, while the higher EBBS scores

show more barriers to exercising. In this section, we evaluated the effects of the TTM-

based ESMI on exercise decisional balance as addressing the following research

question:


Intervention (ESMI) group demonstrate better exercise decisional balance in

terms of greater exercise benefits and fewer exercise barriers than the patients in

the Patient Education (PE) group and the Conventional (C) group?

Table 5.12 and Figure 5.4 show the change in the mean scores of the EBS throughout

the study. The mean scores of the EBS in the ESMI group soared during the period of

223

the implementation of the intervention (T1), kept rising from T1 to T2, and then

dropped slightly from T2 to T3, with the mean scores much higher than the baseline.

For the PE group, the mean scores were stable during the period of the

implementation of the intervention (T1) and then increased steadily from T1 to T3. In

the C group, the mean scores decreased slightly during the period of the

implementation of the intervention (T1), and then increased steadily from T1 to T3,

with the mean scores much higher than the baseline. The mean scores of the EBS

were higher for the ESMI group than for the PE and C groups, and those for the PE

group were higher than those for the C group from T1 to T3.

Referring to Table 5.12 and Figure 5.5, in the ESMI group, the mean scores of the

EBBS plummeted during the period of the implementation of the intervention (T1),

and then increased steadily from T1 to T3, with the mean scores lower than the

baseline; the mean scores in the PE group slowly and steadily declined during the

period of the implementation of the intervention (T1), remained stable from T1 to T2,

and increased slightly again from T2 to T3, with the mean scores lower than the

baseline; for the C group, the mean scores dropped slightly during the period of the

implementation of the intervention (T1), remained stable from T1 to T2 , and decreased

slightly again from T2 to T3.

224

Table 5.12 Mean and Standard Deviations of the Exercise Benefits Scale (EBS) Scores

and the Exercise Barriers Scale (EBBS) Scores at Each Time Point

Variable C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)

EBS

T0 82.5(7.6) 83.7(8.0) 82.6(7.0)

T1 80.7(6.8) 83.6(8.4) 88.6(9.3)

T2 83.9(6.4) 88.7(10.5) 93.0(11.9)

T3 85.7(9.2) 90.6(12.2) 92.1(10.7)

EBBS

T0 29.1(2.8) 29.0(3.8) 29.5(2.8)

T1 28.4(2.3) 27.6(4.9) 23.2(6.0)

T2 28.4(2.2) 27.5(4.5) 24.6(5.4)

T3 27.8(3.2) 28.0(3.5) 25.8(4.7)


3-month follow up; T3: data at the 6-month follow up; The scores of the EBS range from 0 to 116, with

the higher scores indicating greater benefits from engaging in exercise; The scores of the EBBS range

from 0 to 56, with the lower scores indicating fewer barriers to engaging in exercise.

226

Because the data on both the EBS and EBBS were not normally distributed and the

related homogeneity of variance among the three groups was not achieved in the data

for both (Appendix XV), non-parametric tests were applied to analyze this data. At

baseline, there were no significant differences in the mean scores of the EBS (p =

0.984) and EBBS (p = 0.916) among the three groups as confirmed by the Kruskal-

Wallis test (Appendix XVI). After the completion of the 8-week intervention, higher

mean change scores of the EBS and lower mean change scores of the EBBS were

seen for the ESMI group than for the PE and C groups, and higher mean change

scores of the EBS and lower mean change scores of the EBBS were noted for the PE

group than for the C group. When the three groups were compared, significant

differences in both the mean change scores of the EBS and EBBS were revealed at T1

(mean rank: benefits: ESMI group = 129.7, PE group = 91.1, C group = 75.3, p < 0.01;

barriers: ESMI group = 67.8, PE group = 110.7, C group = 116.6, p < 0.01), T2 (mean

rank: benefits: ESMI group = 124.2, PE group = 96.4, C group = 75.6, p < 0.01;

barriers: ESMI group = 74.2, PE group = 109.5, C group = 111.6, p < 0.01), and T3

(mean rank: benefits: ESMI group = 116.4, PE group = 97.6, C group = 82.0, p < 0.01;

barriers: ESMI group = 81.0, PE group = 111.7, C group = 102.9, p < 0.01) (Table

5.13).

The effect size (r) of the TTM-based ESMI ranged from 0.3 to 0.4 on the EBS and

from 0.3 to 0.5 on the EBBS from T1 to T3, which in Cohen‘s (1988) terms, would be

considered between medium (0.25) and large effects (0.40) for an ANOVA analysis.

Thus, these findings suggest that the patients who participated in the ESMI group

experienced greater benefits from exercise and encountered lower barriers to exercise

than those in the PE and C groups. In other words, the patients who participated in the

227

ESMI group perceived there to be greater benefits and fewer barriers to engaging in

exercise than those in the PE and C groups.

Table 5.13 Comparisons of the Mean Change Scores of the Exercise Benefits Scale (EBS)

and the Exercise Barriers Scale (EBBS) among Groups at Each Time Point

Variable

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)


size (r) χ2 p

EBS

T1 - T0 -1.7(6.8) -0.1(7.5) 6.0(9.0) 32.156 0.000** 0.4

T2 - T0 1.5(7.5) 5.0(9.6) 10.4(10.0) 24.527 0.000** 0.4

T3 - T0 3.2(8.1) 7.0(12.0) 9.5(10.2) 12.264 0.002** 0.3

EBBS

T1 - T0 -0.8(2.8) -1.4(4.5) -6.2(6.0) 29.445 0.000** 0.5

T2 - T0 -0.8(2.8) -1.6(4.5) -4.8(5.6) 18.547 0.000** 0.4

T3 - T0 -1.4(3.3) -1.1(4.1) -3.7(5.0) 10.388 0.006** 0.3

** p < 0.01.

For the within-group comparisons of the mean scores of the EBS and the EBBS, the

Friedman test was performed. Significant differences in the mean scores of the EBS

were detected in all of the three groups from T0 to T3 (mean rank: C group: T0 = 2.5,

T1 = 1.8, T2 = 2.8, T3 = 2.9, p < 0.01; PE group: T0 = 2.1, T1 = 1.9, T2 = 2.9, T3 = 3.1,

p < 0.01; ESMI group: T0 = 1.6, T1 = 2.4, T2 = 3.1, T3 = 3.0, p < 0.01) (Table 5.14).

Both the C and ESMI groups revealed significant differences in the mean scores of

the EBBS from T0 to T3 (mean rank: C group: T0 = 2.9, T1 = 2.5, T2 = 2.4, T3 = 2.2, p

< 0.01; ESMI group: T0 = 3.3, T1 = 2.0, T2 = 2.3, T3 = 2.4, p < 0.01) (Table 5.14). No

significant difference in the mean scores of the EBBS was found in the PE group over

228

time (p = 0.051) (Table 5.14). These results suggest that all of the three groups

perceived there to be greater benefits to engaging in exercise, while only the C and

ESMI groups saw fewer barriers to engaging in exercise over time.

Table 5.14 Comparisons of the Exercise Benefits Scale (EBS) Scores and the Exercise

Barriers Scale (EBBS) Scores within Each Group across Time

Variable

T0

mean (SD)

T1

mean (SD)

T2

mean (SD)

T3

mean (SD)

Friedman test

χ2 p

EBS

C group 82.5(7.6) 80.7(6.8) 83.9(6.4) 85.7(9.2) 36.897 0.000**

PE group 83.7(8.0) 83.6(8.4) 88.7(10.5) 90.6(12.2) 48.760 0.000**

ESMI group 82.6(7.0) 88.6(9.3) 93.0(11.9) 92.1(10.7) 60.405 0.000**

EBBS

C group 29.1(2.8) 28.4(2.3) 28.4(2.2) 27.8(3.2) 14.336 0.002**

PE group 29.0(3.8) 27.6(4.9) 27.5(4.5) 28.0(3.5) 7.758 0.051

ESMI group 29.5(2.8) 23.2(6.0) 24.6(5.4) 25.8(4.7) 49.563 0.000**



5.5.4 Exercise

Total exercise duration refers to the duration of any planned and intentional exercise

(including mild and moderate exercise) in the past one week. Moderate exercise

duration refers to exercise that up to moderate intensity (3.0-6.0 METs and RPE 11-

13) such as those listed as examples of moderate activities in Appendix VIII

performed in the past one week (Ainsworth, Haskel, Whitt et al., 1993). Since

exercise of moderate intensity is beneficial to CHD patients, the moderate exercise

229

duration was calculated according to the self-reports and log records of the patients.

This section examined the effects of the TTM-based ESMI on exercise duration

(minutes/week) as the following research question:


Intervention (ESMI) group demonstrate longer exercise duration (minutes/week)

than the patients in the Patient Education (PE) group and the Conventional (C)

group?

The changes in the total exercise duration (minutes/week) throughout the study were

shown in Table 5.15 and Figure 5.6. In the ESMI group, the mean minutes of the total

exercise duration per week increased sharply during the period of the implementation

of the intervention (T1) and decreased steadily from T1 to T3, with the mean length

still longer than the baseline; the mean minutes of the total exercise duration per week

in the PE group rose rapidly during the period of the implementation of the

intervention (T1), dropped slightly from T1 to T2, and rose steadily again from T2 to T3,

with the mean length slightly shorter than that in the ESMI group at T3; for the C

group, the mean minutes of the total exercise duration per week rose slowly and

steadily from T0 to T3, with the mean minutes about the same as in the ESMI group at

T3.

Table 5.15 and Figure 5.7 show the changes in the moderate exercise duration

(minutes/week) throughout the study. Regarding the ESMI group, the mean minutes

of the moderate exercise duration per week soared during the period of the

implementation of the intervention (T1), decreased slightly from T1 to T2, and dropped

230

steadily from T2 to T3, with the mean length much longer than the baseline; the mean

minutes of the moderate exercise duration per week in the PE group rose steadily

during the period of the implementation of the intervention (T1), continued rising

from T1 to T2, and declined slightly from T2 to T3, with the mean length longer than

the baseline; for the C group, the mean minutes slowly and steadily increased from T0

to T3. As a whole, the moderate exercise duration per week in terms of mean minutes

was longer in the ESMI group than in the PE and C groups, and longer also in the PE

group than in the C group from T1 to T3.

Table 5.15 Mean and Standard Deviations of Exercise Duration (minutes/week) at Each

Time Point

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)

TED

T0 184.2 (217.8) 143.1 (196.9) 112.2 (162.1)

T1 196.3 (221.6) 224.0 (227.5) 309.4 (221.6)

T2 218.7 (209.6) 219.3 (212.0) 284.6 (221.7)

T3 272.7 (237.7) 251.1 (284.2) 272.2 (232.4)

MED

T0 17.2 (62.9) 10.0 (40.9) 15.4 (36.2)

T1 34.4 (87.0) 109.1 (199.3) 246.6 (252.3)

T2 43.5 (122.7) 135.4 (207.4) 242.9 (244.9)

T3 73.7 (160.5) 104.2 (192.2) 201.0 (228.7)

TED: Total Exercise Duration (minutes/week); MED: Moderate Exercise Duration (minutes/week); T0:

baseline data; T1: data immediately after the completion of the 8-week intervention; T2: data at the 3-

month follow up; T3: data at the 6-month follow up.

232

As the data on the total exercise duration (minutes/week) and moderate exercise

duration (minutes/week) were not normally distributed and the related homogeneity of

variance among the three groups was violated in the data for both (Appendix XV),

non-parametric tests were performed to analyze them. At baseline, no significant

differences in the mean minutes of both the total (p = 0.145) and moderate exercise

duration (p = 0.314) (minutes/week) were found among the three groups when the

Kruskal-Wallis test was applied (Appendix XVI). After the completion of the 8-week

intervention, the mean minutes of both the total and moderate exercise duration

(minutes/week) for all three groups increased as compared with the baseline (Table

5.16). The mean change in minutes in both the total and moderate exercise duration

per week was longer for the ESMI group than for the PE and C groups, and longer for

the PE group than for the C group. When the three groups were compared, significant

differences in the mean change in minutes of the total exercise duration per week

were detected at T1 (mean rank: ESMI group = 128.0, PE group = 92.9, C group =

75.3, p < 0.01) and T2 (mean rank: ESMI group = 115.2, PE group = 92.8, C group =

87.7, p < 0.05), while significant differences in the mean change in minutes of the

moderate exercise duration per week were found at T1 (mean rank: ESMI group =

129.0, PE group = 93.5, C group = 73.7, p < 0.01), T2 (mean rank: ESMI group =

122.0, PE group = 100.9, C group = 73.5, p < 0.01), and T3 (mean rank: ESMI group

= 118.9, PE group = 93.4, C group = 83.6, p < 0.01) (Table 5.16).

The effect size (r) of the TTM-based ESMI varied from 0.1 to 0.4 on the total exercise

duration (minutes/week) and from 0.3 to 0.5 on the moderate exercise duration

(minutes/week) from T1 to T3 (Table 5.16), which would be viewed as a small (0.10)

to large effect (0.40) on the total exercise duration per week, and a medium (0.25) to

233

large effect (0.40) on the moderate exercise duration per week for an ANOVA

analysis according to Cohen‘s (1988) terms. Thus, these findings suggest that the

patients who participated in the ESMI group exercised for a longer duration

(minutes/week) than those in the PE and C groups.

Table 5.16 Comparisons of Mean Change in Minutes of Exercise Duration

(minutes/week) among Groups at Each Time Point

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)


size

(r) χ

2 p

TED

T1 - T0 12.2 (220.1) 80.9 (164.3) 197.2 (198.6) 30.411 0.000** 0.4

T2 - T0 34.6 (236.9) 76.2 (177.2) 172.5 (226.1) 8.928 0.012* 0.3

T3 - T0 88.5 (255.4) 108.0 (230.5) 160.0 (218.7) 3.363 0.186 0.1

MED

T1 - T0 17.2 (89.3) 99.1 (194.7) 231.2 (251.9) 41.043 0.000** 0.5

T2 - T0 26.3 (111.8) 125.4 (199.4) 227.5 (251.8) 29.677 0.000** 0.4

T3 - T0 56.5 (133.6) 94.2 (189.5) 185.6 (227.7) 17.515 0.000** 0.3

TED: Total Exercise Duration (minutes/week); MED: Moderate Exercise Duration (minutes/week).

*p < 0.05; **p < 0.01.

For the within-group comparisons of the mean minutes of the total exercise duration

per week and moderate exercise duration per week, the Friedman test was performed.

Significant differences were seen in all the three groups in the mean minutes of the

total exercise duration per week from T0 to T3 (mean rank: C group: T0 = 2.2, T1 = 2.4,

T2 = 2.5, T3 = 2.9, p < 0.01; PE group: T0 = 2.0, T1 = 2.6, T2 = 2.6, T3 = 2.8, p < 0.01;

ESMI group: T0 = 1.6, T1 = 3.1, T2 = 2.7, T3 = 2.6, p < 0.01) and moderate exercise

duration per week from T0 to T3 (mean rank: C group: T0 = 2.3, T1 = 2.5, T2 = 2.5, T3

234

= 2.7, p < 0.01; PE group: T0 = 2.0, T1 = 2.6, T2 = 2.8, T3 = 2.6, p < 0.01; ESMI group:

T0 = 1.6, T1 = 3.0, T2 = 2.8, T3 = 2.6, p < 0.01) (Table 5.17). These results suggest that

patients in all the three groups increased their exercise duration (minutes/week) over

time.

Table 5.17 Comparisons of Exercise Duration (minutes/week) within Each Group across

Time

T0

mean (SD)

T1

mean (SD)

T2

mean (SD)

T3

mean (SD)

Friedman test

χ2 p

TED

C group 184.2(217.8) 196.3(221.6) 218.7(209.6) 272.7(237.7) 13.356 0.004**

PE group 143.1(196.9) 224.0(227.5) 219.3(212.0) 251.1(284.2) 19.972 0.000**

ESMI group 112.2(162.1) 309.4(221.6) 284.6(221.7) 272.2(232.4) 57.956 0.000**

MED

C group 17.2(62.9) 34.4(87.0) 43.5(122.7) 73.7(160.5) 12.049 0.007**

PE group 10.0(40.9) 109.1(199.3) 135.4(207.4) 104.2(192.2) 27.914 0.000**

ESMI group 15.4(36.2) 246.6(252.3) 242.9(244.9) 201.0(228.7) 65.021 0.000**

TED: Total Exercise Duration (minutes/week); MED: Moderate Exercise Duration (minutes/week); T0:

baseline data; T1: data immediately after the completion of the 8-week intervention; T2: data at the 3-

month follow up; T3: data at the 6-month follow up; ** p < 0.01.

5.5.5 Angina

This section compared anginal pain in the three groups in terms of angina frequency

(episodes/week), angina severity, and angina duration (minutes/week), whether

anginal attacks occurred, and whether or not the patients took anti-anginal drugs, as

addressed in the following research question:

235


Intervention (ESMI) group demonstrate a greater reduction in angina in terms

of angina frequency, angina severity, angina duration (minutes/week), anginal

attacks, and anti-anginal drugs taken than the patients in the Patient Education

(PE) group and the Conventional (C) group?

As shown in Table 5.18, according to the self-reports and log records of patients, the

average angina frequency (episodes/week) is around 1.0 per week with very slight

pain (the average severity of an episode of angina is less than 1.0), and the average

duration of an anginal attack is mostly less than 10 minutes per week in all the three

groups. Referring to Table 5.18 and Figure 5.8, the mean episodes of angina per week

among patients in the ESMI group decreased substantially during the period of the

implementation of the intervention (T1), remained stable from T1 to T2, and rose

slightly from T2 to T3, with the mean episodes being fewer than the baseline; stability

in angina frequency, in terms of the mean episodes of angina per week, was seen

among patients in the PE group during the period of the implementation of the

intervention (T1), a slight decrease was noted from T1 to T2, and a slight increase from

T2 to T3, with the mean episodes slightly fewer than the baseline; a rapid drop in

angina frequency, in terms of the mean episodes of angina per week, was noted

among patients in the C group during the period of the implementation of the

intervention (T1), and a steady rise from T1 to T3, with the mean episodes slightly

fewer than the baseline. On the whole, episodes of angina were less frequent in the

ESMI group than in the PE and C groups, and less frequent in the PE group than in

the C group from T1 to T3.

236

As shown in Table 5.18 and Figure 5.9, in the ESMI group, the mean angina severity

obviously declined during the period of the implementation of the intervention (T1),

remained stable from T1 to T2, and slightly increased from T2 to T3, with the mean

angina severity lower than the baseline at T3; in the PE group, the mean angina

severity decreased steadily from T0 to T3, with the mean angina severity still higher

than in the ESMI group at T3; in the C group, the mean angina severity decreased

rapidly during the period of the implementation of the intervention (T1), rose slightly

from T1 to T2, and decreased steadily again from T2 to T3, with the mean angina

severity much lower than the baseline. On the whole, the mean angina severity in the

ESMI group is lower than that in the PE and C groups, and that in the PE group is

lower than that in the C group from T1 to T3.

As shown in Table 5.18 and Figure 5.10, the mean angina duration (minutes/week) in

the ESMI group decreased rapidly during the period of the implementation of the

intervention (T1) and increased slightly from T1 to T3, with the mean angina duration

shorter than the baseline at T3; the mean angina duration in the PE group obviously

decreased during the period of the implementation of the intervention (T1) and rose

slightly from T1 to T3, and was one minute shorter than the baseline at T3; the mean

angina duration in the C group decreased from T0 to T3, and was still longer than in

the ESMI group but shorter than in the PE group at T3. On the whole, the mean angina

duration in the ESMI group is shorter than that in the PE and C groups from T1 to T3,

and that in the PE group is shorter than that in the C group from T1 to T2.

237

Table 5.18 Mean and Standard Deviations of Angina Frequency (AF), Angina Severity

(AS), and Angina Duration (AD) at Each Time Point

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)

AF

T0 1.4 (3.1) 1.1 (2.8) 0.9 (1.4)

T1 1.0 (1.6) 1.1 (2.9) 0.4 (0.9)

T2 1.0 (2.0) 0.9 (2.9) 0.4 (0.9)

T3 1.2 (2.8) 1.0 (3.1) 0.6 (2.1)

AS

T0 0.7 (1.2) 0.7 (1.1) 0.5 (0.7)

T1 0.4 (0.7) 0.5 (1.0) 0.2 (0.5)

T2 0.5 (0.8) 0.4 (0.9) 0.2 (0.5)

T3 0.3 (0.5) 0.4 (0.9) 0.3 (0.7)

AD

T0 13.4 (33.0) 9.8 (23.0) 9.3 (29.4)

T1 10.6 (45.2) 6.3 (16.6) 2.0 (6.4)

T2 10.0 (24.9) 7.0 (21.2) 2.2 (6.9)

T3 6.3 (14.0) 8.8 (30.2) 3.5 (12.5)

AF: Angina Frequency (episodes/week); AS: Angina Severity (0-10); AD: Angina Duration

(minutes/week); T0: baseline data; T1: data immediately after the completion of the 8-week intervention;

T2: data at the 3-month follow up; T3: data at the 6-month follow up.

239

Because the data on angina frequency (episodes/week), angina severity (0-10), and

angina duration (minutes/week) were not normally distributed and the related

homogeneity of variance among the three groups was not achieved in each variable

(Appendix XV), non-parametric tests were applied. No significant differences were

found in the mean episodes of angina frequency per week (p = 0.887), mean angina

severity (p = 0.891), and mean minutes of angina duration (p = 0.829) among the

three groups at baseline (Appendix XVI). Reductions in angina frequency

(episodes/week), angina severity, and angina duration (minutes/week) were observed

in all three groups after the completion of the 8-week intervention as compared with

the baseline (Table 5.19). No significant differences in the mean change of angina

frequency (episodes/week), angina severity, and angina duration (minutes/week) were

240

detected among the three groups at each time point when the Kruskal-Wallis test was

applied to analyze the data (Table 5.19).

The effect sizes of the TTM-based ESMI on the angina frequency (episodes/week),

angina severity and angina duration (minutes/week) ranged from 0.0 to 0.1 (Table

5.19), which was a small effect (0.10) for an ANOVA analysis according to Cohen

(1988). Thus, these findings suggest that the patients who participated in the ESMI

group did not experience a greater reduction in angina frequency (episodes/week),

angina severity, and angina duration (minutes/week) than those in the PE and C

groups.

Table 5.19 Comparisons of Angina Frequency (AF), Angina Severity (AS), and Angina

Duration (AD) among Groups at Each Time Point

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)


size

(r) χ

2 p

AF

T1 - T0 -0.5(3.0) -0.0(1.1) -0.5(1.4) 2.149 0.341 0.1

T2 - T0 -0.4(2.4) -0.2(1.1) -0.5(1.4) 0.383 0.826 0.1

T3 - T0 -0.3(2.4) -0.1(1.4) -0.3(2.5) 2.015 0.365 0.0

AS

T1 - T0 -0.3(1.0) -0.2(1.0) -0.3(0.8) 0.906 0.636 0.1

T2 - T0 -0.2(1.2) -0.3(1.0) -0.3(0.8) 0.444 0.801 0.0

T3 - T0 -0.4(1.1) -0.3(0.8) -0.2(1.0) 0.388 0.824 0.1

AD

T1 - T0 -2.8(56.5) -3.5(20.6) -7.3(29.2) 1.794 0.408 0.1

T2 - T0 -3.3(40.3) -2.8(23.8) -7.1(29.0) 0.734 0.693 0.1

T3 - T0 -7.1(33.6) -0.9(31.8) -5.8(31.4) 1.160 0.560 0.1


(minutes/week).

241

The Friedman test was applied for within-group comparisons of angina frequency

(episodes/week), angina severity, and angina duration (minutes/week). No significant

differences in angina frequency (episodes/week), angina severity, and angina duration

(minutes/week) were identified in the C group over time (Table 5.20). Significant

differences in angina severity (mean rank: T0 = 2.7, T1 = 2.5, T2 = 2.4, T3 = 2.4, p <

0.05) and angina duration (minutes/week) (mean rank: T0 = 2.7, T1 = 2.6, T2 = 2.4, T3

= 2.4, p < 0.05) were detected in the PE group over time (Table 5.20). Significant

differences in angina frequency (episodes/week) (mean rank: T0 = 2.8, T1 = 2.5, T2 =

2.4, T3 = 2.4, p < 0.01), angina severity (mean rank: T0 = 2.8, T1 = 2.5, T2 = 2.4, T3 =

2.4, p < 0.01), and angina duration (minutes/week) (mean rank: T0 = 2.8, T1 = 2.4, T2

= 2.4, T3 = 2.3, p < 0.01) were found in the ESMI group over time (Table 5.20). These

findings suggest that the patients who participated in both the PE and ESMI groups

experienced a reduction in the severity and duration (minutes/week) of their anginal

attacks over time, with those in the ESMI group also experienced a decline in the

frequency (episodes/week) of angina over time.

242

Table 5.20 Comparisons of Angina Frequency (AF), Angina Severity (AS), and Angina

Duration (AD) within Each Group across Time

T0

mean (SD)

T1

mean (SD)

T2

mean (SD)

T3

mean (SD)

Friedman test

χ2 p

AF

C group 1.4(3.1) 1.0(1.6) 1.0(2.0) 1.2(2.7) 3.370 0.338

PE group 1.1(2.8) 1.1(2.9) 0.9(2.9) 1.0(3.1) 5.440 0.142

ESMI group 0.9(1.4) 0.4(0.9) 0.4(0.9) 0.6(2.1) 14.591 0.002**

AS

C group 0.7(1.2) 0.4(0.7) 0.5(0.8) 0.3(0.5) 6.759 0.080

PE group 0.7(1.1) 0.5(1.0) 0.4(0.9) 0.4(0.9) 9.232 0.026*

ESMI group 0.5(0.7) 0.2(0.5) 0.2(0.5) 0.3(0.7) 15.448 0.001**

AD

C group 13.4(33.0) 10.6(45.2) 10.0(24.9) 6.3(14.0) 3.140 0.370

PE group 9.8(23.0) 6.3(16.6) 7.0(21.2) 8.8(30.2) 8.903 0.031*

ESMI group 9.3(29.4) 2.0(6.4) 2.2(6.9) 3.5(12.5) 18.717 0.000**


(minutes/week); T0: baseline data; T1: data immediately after the completion of the 8-week intervention;

T2: data at the 3-month follow up; T3: data at the 6-month follow up; *p < 0.05; ** p < 0.01.

Table 5.21 shows changes in the occurrence of anginal attacks and in the taking of

anti-anginal drugs in the past one week throughout the study. Since the data on the

anginal attacks and anti-anginal drugs are binary data, a Chi-square test was

performed. A trend towards a reduction in the occurrence of anginal attacks was

observed in both the PE and ESMI group from T0 to T3. However, no significant

differences in the occurrence of anginal attacks and taking of anti-anginal drugs were

detected among the three groups at each time point (Table 5.21). These results suggest

that the patients who participated in the ESMI group did not experience a greater

243

reduction in the occurrence of anginal attacks and in the amount of anti-anginal drugs

taken per week.

Table 5.21 Comparisons of Items on the Occurrence of Anginal Attacks and Anti-

Anginal Drugs taken in the Past One Week among Groups at Each Time Point

Variable

C group

(n=67)

n (%)

PE group

(n=64)

n (%)

ESMI group

(n=65)

n (%)

χ2 p

T0 Anginal attack 0.049 0.976

Yes 27(40.3) 25(39.1) 25(38.5)

No 40(59.7) 39(60.9) 40(61.5)

Anti-anginal

drugs taken

1.223 0.543

Yes 17(25.4) 12(18.8) 12(18.5)

No 50(74.6) 52(81.2) 53(81.5)


Yes 23(34.3) 19(29.7) 15(23.1)

No 44(65.7) 45(70.3) 50(76.9)

Anti-anginal

drugs taken

1.878 0.391

Yes 12(17.9) 12(18.8) 7(10.8)

No 55(82.1) 52(81.2) 58(89.2)


Yes 25(37.3) 15(23.4) 13(20.0)

No 42(62.7) 49(76.6) 52(80.0)

Anti-anginal

drugs taken

3.352 0.187

Yes 14(20.9) 6(9.4) 10(15.4)

No 53(79.1) 58(90.6) 55(84.6)


Yes 21(31.3) 14(21.9) 9(13.8)

No 46(68.7) 50(78.1) 56(86.2)

Anti-anginal

drugs taken

1.516 0.469

Yes 12(17.9) 7(10.9) 8(12.3)

No 55(82.1) 57(89.1) 57(87.7)


3-month follow up; T3: data at the 6-month follow up.

244

For the within-group comparisons of the occurrence of anginal attacks and anti-

anginal drugs taken in the past one week, Cochran‘s Q was performed because the

data was binary. As shown in Table 5.22, no significant differences in the occurrence

of angina attacks and anti-anginal drugs taken were identified in the C group over

time; significant differences in both the occurrence of anginal attacks (p < 0.05) and

anti-anginal drugs taken (p < 0.05) were found in the PE group over time; and a

significant difference in the occurrence of anginal attacks (p < 0.01) was detected in

the ESMI group over time. These results suggest that, over time, the patients in both

the PE and ESMI groups experienced a reduction in the occurrence of anginal attacks,

with those in the PE group also decreasing the amount of the anti-anginal drugs that

they were taking.

245

Table 5.22 Comparisons of the Occurrence of Angina Attacks and Anti-Anginal Drugs

taken within Each Group across Time

Group T0

n (%)

T1

n (%)

T2

n (%)

T3

n (%)

Cochran’s

Q p

Anginal attack

C group Yes 27(40.3) 23(34.3) 25(37.3) 21(31.3) 2.353 0.502

No 40(59.7) 44(65.7) 42(62.7) 46(68.7)

PE group Yes 25(39.1) 19(29.7) 15(23.4) 14(21.9) 9.857 0.020*

No 39(60.9) 45(70.3) 49(76.6) 50(78.1)

ESMI group Yes 25(38.5) 15(23.1) 13(20.0) 9(13.8) 18.130 0.000**

No 40(61.5) 50(76.9) 52(80.0) 56(86.2)

Anti-anginal

drugs taken

C group Yes 17(25.4) 12(17.9) 14(20.9) 12(17.9) 2.680 0.444

No 50(74.6) 55(82.1) 53(79.1) 55(82.1)

PE group Yes 12(18.8) 12(18.8) 6(9.4) 7(10.9) 7.851 0.049*

No 52(81.3) 52(81.3) 58(90.6) 57(89.1)

ESMI group Yes 12(18.5) 7(10.8) 10(15.4) 8(12.3) 3.612 0.306

No 53(81.5) 58(89.2) 55(84.6) 57(87.7)


3-month follow up; T3: data at the 6-month follow up; *p < 0.05; ** p < 0.01.

5.4.6 Quality of life

In this study, quality of life was assessed using both the Seattle Angina Questionnaire

(SAQ) and the Medical Outcomes Study 36-Item Short-Form (SF-36). This section

tested the effects of the TTM-based ESMI on quality of life in terms of the SAQ and

SF-36 to address the following research question:

246


Intervention (ESMI) group demonstrate greater improvement in quality of life

than the patients in the Patient Education (PE) group and the Conventional (C)

group?

5.6.1 Seattle Angina Questionnaire (SAQ)

The SAQ consists of the following five subscales: physical limitations, angina

stability, angina frequency, treatment satisfaction, and disease perception. The scores

of each subscale range from 0 to 100, with the higher scores indicating better health

conditions or quality of life.

Table 5.23 and Figures 5.11 to 5.15 show the change in the mean scores of the five

subscales of SAQ in each group from the baseline (T0) to the 6-month follow-up

period (T3). In the ESMI group, the mean scores for physical limitations, angina

frequency, treatment satisfaction, and disease perception increased sharply during the

period of the implementation of the intervention (T1) and remained stable from T1 to

T3, with the mean scores of these four subscales being much higher than the baseline,

while the mean scores for angina stability increased steadily during the period of the

implementation of the intervention (T1), continued to rise from T1 to T2, and then

dropped sharply from T2 to T3, with the mean scores lower than the baseline (T0). In

the PE group, the mean scores for angina stability, angina frequency, treatment

satisfaction, and disease perception climbed steadily from the baseline (T0) to the 3-

month follow up (T2), then fell from T2 to T3, with the exception of the mean scores

for treatment satisfaction, which kept rising from T2 to T3. The rising slope of these

247

subscales in the PE group was much smaller than in the ESMI group. The mean

scores for angina frequency, treatment satisfaction, and disease perception in the PE

group at the 6-month follow-up (T3) were higher than the baseline, while the mean

scores for angina stability at the 6-month follow-up (T3) were lower than the baseline.

The mean scores for physical limitations in the PE group declined slightly during the

period of the implementation of the intervention (T1), went up to a little higher than

the baseline from T1 to T2, and then decreased slightly again from T2 to T3, with the

mean scores slightly higher than the baseline (T0). In the C group, the mean scores for

physical limitations and treatment satisfaction plunged during the period of the

implementation of the intervention (T1) while the mean scores for physical limitations

remained stable from T1 to T3, and those for treatment satisfaction continued to

decline from T1 to T2, before rising again from T2 to T3, with the mean scores higher

than the baseline. The mean scores for angina stability, angina frequency, and disease

perception in the C group increased slightly or remained stable from T0 to T2 and

continued to rise from T2 to T3, with the exception of the mean scores for angina

stability, which decreased from T2 to T3. Higher mean scores for all five subscales of

SAQ from T1 to T3 were observed in the ESMI group than in the C and PE groups,

while higher mean scores for all five subscales of SAQ from T1 to T3 were seen in the

PE group than in the C group.

248

Table 5.23 Mean and Standard Deviations of the Subscales of SAQ at Each Time Point

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)

Physical limitations

T0 85.5(13.1) 85.9(13.0) 82.0(12.9)

T1 80.3(15.0) 83.8(12.5) 90.3(10.7)

T2 81.2(14.7) 87.2(12.6) 89.4(11.2)

T3 80.8(14.3) 86.3(11.1) 90.2(10.2)

Angina stability

T0 47.0(20.7) 50.8(20.4) 51.5(20.7)

T1 47.4(17.5) 51.6(19.4) 55.0(19.9)

T2 49.3(16.8) 52.0(16.2) 56.2(20.7)

T3 47.8(12.1) 46.9(14.4) 49.6(16.2)

Angina frequency

T0 83.3(18.1) 84.1(19.7) 83.5(17.6)

T1 84.8(18.6) 85.9(18.7) 91.4(12.9)

T2 84.6(19.3) 89.8(15.6) 91.8(13.2)

T3 86.4(20.6) 88.1(19.3) 91.2(18.8)

Treatment satisfaction

T0 69.9(20.1) 68.8(18.5) 66.9(17.5)

T1 67.5(18.4) 73.5(16.5) 84.7(15.1)

T2 66.0(16.7) 76.1(16.2) 84.3(16.4)

T3 73.5(17.4) 77.2(17.1) 84.3(18.0)

Disease perception

T0 71.1(21.9) 69.8(21.8) 68.1(17.7)

T1 71.4(20.0) 75.8(17.9) 84.2(17.7)

T2 71.0(20.8) 80.1(17.5) 85.0(18.2)

T3 76.6(19.4) 79.7(18.3) 84.5(20.3)

The scores of each subscale of SAQ range from 0 to 100, with the higher scores indicating better health

conditions; T0: baseline data; T1: data immediately after the completion of the 8-week intervention; T2:

data at the 3-month follow up; T3: data at the 6-month follow up.

251

Since the data of each subscale of SAQ were not normally distributed and the related

homogeneity of variance among the three groups was not achieved in most data

(Appendix XV), non-parametric tests were employed to analyze them. At baseline, no

significant differences were detected in the mean scores of the five subscales of SAQ

among the three groups when the Kruskal-Wallis test was performed (p > 0.05)

(Appendix XVI). Higher mean change scores for each subscale of SAQ were

observed in the ESMI group than in the C and PE groups from T1 to T3 (Table 5.24).

Significant differences were found among the C, PE, and ESMI groups in the mean

change scores for physical limitations (mean rank: T1 - T0: ESMI group = 131.0, PE

group = 88.0, and C group = 76.9, p = 0.000; T2 - T0: ESMI group = 123.0, PE group

= 95.6, and C group = 77.6, p = 0.000; T3 - T0: ESMI group = 125.1, PE group = 93.0,

and C group = 78.1, p = 0.000), treatment satisfaction (mean rank: T1 - T0: ESMI

252

group = 130.2, PE group = 93.1, and C group = 72.9, p = 0.000; T2 - T0: ESMI group

= 126.7, PE group = 98.2, and C group = 71.4, p = 0.000; T3 - T0: ESMI group =

121.0, PE group = 93.2, and C group = 81.7, p = 0.000), and disease perception (mean

rank: T1 - T0: ESMI group = 125.9, PE group = 95.8, and C group = 74.5, p = 0.000;

T2 - T0: ESMI group = 122.4, PE group = 99.8, and C group = 74.1, p = 0.000; T3 - T0:

ESMI group = 118.0, PE group = 95.0, and C group = 83.0, p = 0.001) of SAQ at T1,

T2, and T3 (Table 5.24). No significant differences in the mean change scores for

angina stability and angina frequency were identified among the three groups at each

time point.

The effect size (r) of the TTM-based ESMI on the five subscales of the SAQ varied

from 0.1 to 0.4 (Table 24), which in Cohen‘s (1988) terms would be considered a

small (0.10) to large effect (0.40) for an ANOVA analysis. Clearly, the patients who

participated in the ESMI group demonstrated greater improvement in quality of life in

terms of the SAQ, especially with regard to physical limitations, treatment satisfaction,

and disease perception than those in the PE and C groups.

253

Table 5.24 Comparisons of the Mean Change Scores of the Subscales of SAQ among

Groups at Each Time Point

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)


size

(r) χ

2 p

Physical

limitations

T1 - T0 -5.2(13.6) -2.2(13.6) 8.2(11.9) 33.473 0.000** 0.4

T2 - T0 -4.3(15.5) 1.3(11.5) 7.4(11.5) 21.553 0.000** 0.4

T3 - T0 -4.7(14.7) 0.3(11.8) 8.2(11.9) 23.765 0.000** 0.4

Angina

stability

T1 - T0 0.4(23.2) 0.8(23.6) 3.5(24.2) 1.124 0.570 0.1

T2 - T0 2.2(26.0) 1.2(20.1) 4.6(25.0) 0.479 0.787 0.1

T3 - T0 0.7(22.6) -3.9(21.5) -1.9(22.2) 1.024 0.599 0.1

Angina

frequency

T1 - T0 1.5(16.0) 1.9(14.4) 7.8(17.8) 5.093 0.078 0.2

T2 - T0 1.3(15.9) 5.8(13.8) 8.3(18.1) 2.296 0.317 0.2

T3 - T0 3.1(18.5) 4.1(20.4) 7.7(21.3) 3.829 0.147 0.1

Treatment

satisfaction

T1 - T0 -2.3(18.7) 4.7(15.9) 17.8(17.9) 35.248 0.000** 0.4

T2 - T0 -3.9(21.5) 7.2(16.1) 17.4(17.5) 31.853 0.000** 0.4

T3 - T0 3.6(20.8) 8.4(16.9) 17.4(17.0) 16.858 0.000** 0.3

Disease

perception

T1 - T0 -0.0(21.1) 6.0(16.4) 16.2(18.7) 27.454 0.000** 0.3

T2 - T0 -0.1(22.0) 10.3(17.7) 16.9(18.9) 24.115 0.000** 0.3

T3 - T0 5.5(22.8) 9.9(20.3) 16.4(21.4) 13.046 0.001** 0.2



254

For within-group comparisons of each subscale of SAQ, the Friedman test was

performed. The C group showed significant differences in the mean scores for angina

frequency (mean rank: T0 = 2.3, T1 = 2.4, T2 = 2.6, T3 = 2.8, p < 0.05) and disease

perception (mean rank: T0 = 2.5, T1 = 2.3, T2 = 2.4, T3 = 2.9, p < 0.05) from T0 to T3.

The PE group revealed significant differences in the mean scores for angina frequency

(mean rank: T0 = 2.2, T1 = 2.5, T2 = 2.6, T3 = 2.7, p < 0.05), treatment satisfaction

(mean rank: T0 = 2.1, T1 = 2.4, T2 = 2.8, T3 = 2.8, p < 0.01), and disease perception

(mean rank: T0 = 2.0, T1 = 2.4, T2 = 2.7, T3 = 2.9, p < 0.01) from T0 to T3. The ESMI

group demonstrated significant differences in the mean scores for physical limitations

(mean rank: T0 = 1.9, T1 = 2.7, T2 = 2.7, T3 = 2.7, p < 0.01), angina frequency (mean

rank: T0 = 2.0, T1 = 2.6, T2 = 2.7, T3 = 2.8, p < 0.01), treatment satisfaction (mean

rank: T0 = 1.5, T1 = 2.8, T2 = 2.8, T3 = 2.9, p < 0.01), and disease perception (mean

rank: T0 = 1.6, T1 = 2.7, T2 = 2.9, T3 = 2.8, p < 0.01) from T0 to T3 (Table 5.25). No

significant differences in the mean scores for angina stability were detected in any of

the three groups over time (Table 5.25).

255

Table 5.25 Comparison of the Subscale Scores of SAQ within Each Group across Time

Group

T0

mean (SD)

T1

mean (SD)

T2

mean (SD)

T3

mean (SD)

Friedman test

χ2 p

Physical

limitations

C group 85.5(13.1) 80.3(15.0) 81.2(14.7) 80.8(14.3) 7.764 0.051

PE group 85.9(13.0) 83.8(12.5) 87.2(12.6) 86.3(11.1) 4.927 0.177

ESMI group 82.0(12.9) 90.3(10.7) 89.4(11.2) 90.2(10.2) 29.950 0.000**

Angina

stability

C group 47.0(20.7) 47.4(17.5) 49.3(16.8) 47.8(12.1) 0.095 0.992

PE group 50.8(20.4) 51.6(19.4) 52.0(16.2) 46.9(14.4) 5.527 0.137

ESMI group 51.5(20.7) 55.0(19.9) 56.2(20.7) 49.6(16.2) 7.092 0.069

Angina

frequency

C group 83.3(18.1) 84.8(18.6) 84.6(19.3) 86.4(20.6) 9.836 0.020*

PE group 84.1(19.7) 85.9(18.7) 89.8(15.6) 88.1(19.3) 9.539 0.023*

ESMI group 83.5(17.6) 91.4(12.9) 91.8(13.2) 91.2(18.8) 28.798 0.000**

Treatment

satisfaction

C group 69.9(20.1) 67.5(18.4) 66.0(16.7) 73.5(17.4) 7.469 0.058

PE group 68.8(18.5) 73.5(16.5) 76.1(16.2) 77.2(17.1) 17.790 0.000**

ESMI group 66.9(17.5) 84.7(15.1) 84.3(16.4) 84.3(18.0) 64.141 0.000**

Disease

perception

C group 71.1(21.9) 71.1(20.0) 71.0(20.8) 76.6(19.4) 10.606 0.014*

PE group 69.8(21.8) 75.8(17.9) 80.1(17.5) 79.7(18.3) 24.862 0.000**

ESMI group 68.1(17.7) 84.2(17.7) 85.0(18.2) 84.5(20.3) 61.018 0.000**

The scores of each subscale of SAQ range from 0 to 100, with the higher scores indicating better health

conditions; T0: baseline data; T1: data immediately after the completion of the 8-week intervention; T2:

data at the 3-month follow up; T3: data at the 6-month follow up; *p < 0.05; ** p < 0.01.

256

5.4.6.2 SF-36

The SF-36 includes the following eight domains: Physical Functioning (PF), Role-

Physical (RP), Bodily Pain (BP), General Health (GH), Vitality (VT), Social

Functioning (SF); Role-Emotional (RE), and Mental Health (MH). These eight

domains are classified into two components: Physical Component Summary (PCS, PF

+ RP + BP + GH), and Mental Component Summary (MCS, VT + SF + RE + MH).

The higher scores of these domains indicate better health functioning. In addition, SF-

36 has another item: Reported Health Transition (HT). The lower scores of this item

indicate better health conditions.

Table 5.26 and Figures 5.16-5.25 show the changes in the mean scores of the above

mentioned eight domains of the SF-36, the physical component summary, mental

component summary, and reported health transition throughout the study. For the

ESMI group, the mean scores of all eight domains, and the PCS and MCS of SF-36,

increased sharply during the period of the implementation of the intervention (T1),

and remained stable or kept rising from T1 to T3. However, the mean scores for role-

physical, role-emotional, and mental health declined from T1 to T2, then rose slightly

again from T2 to T3. Meanwhile, the mean scores for mental health continued to fall

from T2 to T3, with the mean scores still higher than the baseline (T0). All of the mean

scores at T1, T2, and T3 were higher than the baseline (T0).

In the PE group, the mean scores of all eight domains, and the PCS and MCS of SF-

36, went up slightly or remained stable during the period of the implementation of the

intervention (T1); the mean scores for physical functioning, vitality, social functioning,

257

and mental health continued to increase steadily from T1 to T3, while the mean scores

for role-physical, bodily pain, role-emotional, PCS and MCS, declined from T1 to T2,

and remained stable or declined from T2 to T3. However, the mean scores for bodily

pain and MCS rebounded slightly from T2 to T3. Meanwhile, the mean scores for

general health were stable from T1 to T2, before falling slightly from T2 to T3. All of

the mean scores at T1, T2, and T3 were higher than the baseline (T0), with the

exception of the mean scores for role-physical at T3 and role-emotional at T2 and T3,

which were lower than the baseline (T0).

For the C group, the mean scores for physical functioning, general health, vitality,

social functioning, and the MCS of SF-36 dropped slightly during the period of the

implementation of the intervention (T1) and rose steadily from T1 to T3. However, the

mean scores for vitality remained stable from T1 to T2, then rose from T2 to T3, with

the mean scores equalling the baseline (T0). The mean scores for role-physical, bodily

pain, and PCS rose rapidly during the period of the implementation of the intervention

(T1) and declined steadily from T1 to T3, except that the mean scores for PCS

increased slightly again from T2 to T3. The mean scores for role-emotional remained

stable during the period of the implementation of the intervention (T1), slowly went

up from T1 to T2, and fell from T2 to T3. The mean scores for role-physical, social

functioning, role-emotional, mental health, and MCS at T3 were lower than the

baseline (T0).

Figure 5.26 shows the changes in the mean scores for reported health transition

throughout the study. The mean scores for reported health transition in all three

groups declined substantially from T0 to T3. The decrease slope was largest in the

258

ESMI group, followed by the PE group, and last by the C group. As a whole, higher

mean scores for all eight domains, PCS, and MCS, and lower mean scores for

reported health transition were seen for the ESMI group than for the C and PE groups

from T0 to T3.

Table 5.26 Mean and Standard Deviations of Eight Domains of SF-36 at Each Time

Point

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)

Physical functioning (PF)

T0 81.4(13.6) 82.3(9.7) 78.8(16.2)

T1 80.6(12.6) 82.7(11.4) 86.4(13.7)

T2 83.3(11.3) 85.2(11.0) 87.5(13.8)

T3 84.8(12.8) 87.3(9.3) 88.7(13.4)

Role-physical (RP)

T0 72.0(40.0) 63.7(39.6) 67.3(39.3)

T1 79.9(35.9) 74.2(38.3) 86.2(26.5)

T2 72.0(40.7) 69.1(41.0) 80.0(33.7)

T3 69.0(43.8) 64.1(42.2) 81.5(35.4)

Bodily pain (BP)

T0 73.7(24.8) 75.4(22.1) 75.4(22.9)

T1 82.2(22.2) 79.9(22.4) 87.7(16.7)

T2 76.5(23.2) 76.2(23.5) 87.6(17.1)

T3 74.9(24.8) 79.5(21.7) 85.3(20.8)

General health (GH)

T0 57.4(22.8) 55.4(22.3) 57.9(23.4)

T1 56.0(23.7) 64.2(20.8) 71.8(21.0)

T2 57.3(25.7) 64.6(21.3) 73.5(20.0)

T3 63.8(25.5) 62.7(23.0) 71.8(25.0)

Vitality (VT)

T0 72.5(17.6) 70.9(17.1) 68.8(18.8)

T1 68.3(19.2) 70.9(16.9) 80.2(15.1)

T2 68.4(18.0) 71.7(16.2) 79.8(14.1)

T3 72.5(17.0) 74.3(14.1) 82.0(13.0)

259

Table 5.26 Continued

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)

Social functioning (SF)

T0 84.5(22.1) 79.3(23.8) 80.6(21.7)

T1 82.8(22.4) 81.6(22.7) 90.0(17.6)

T2 83.6(22.3) 83.4(19.9) 91.9(16.5)

T3 84.1(22.1) 85.9(21.1) 91.2(17.5)

Role-emotional (RE)

T0 80.6(34.9) 84.9(27.8) 79.0(36.1)

T1 80.6(38.1) 87.0(28.9) 92.3(24.8)

T2 83.1(35.0) 81.8(34.1) 86.2(33.3)

T3 79.6(37.6) 82.3(33.6) 89.2(31.2)

Mental health (MH)

T0 83.0(13.9) 80.4(10.4) 80.4(12.8)

T1 80.6(14.5) 80.9(11.7) 88.9(10.3)

T2 81.6(13.9) 82.8(9.7) 87.3(10.8)

T3 82.3(14.1) 82.9(10.1) 85.8(13.3)

Physical component

summary (PCS)

T0 284.5(76.9) 276.8(65.1) 279.5(75.8)

T1 298.7(77.7) 301.1(64.5) 332.1(57.9)

T2 289.1(79.2) 295.2(70.2) 328.5(65.5)

T3 292.5(90.1) 293.6(69.8) 327.3(77.2)

Mental component

summary (MCS)

T0 320.6(67.6) 315.6(59.0) 308.8(72.2)

T1 312.3(79.9) 320.5(60.7) 351.4(58.6)

T2 316.7(76.8) 319.6(60.1) 345.1(62.4)

T3 318.5(76.8) 325.5(60.0) 348.2(64.6)

Reported health transition

(HT)

T0 3.3(1.1) 3.1(1.3) 3.3(1.1)

T1 3.3(1.0) 2.8(1.1) 2.7(1.1)

T2 3.1(0.9) 2.7(1.1) 2.6(1.2)

T3 2.9(1.0) 2.5(1.1) 2.5(1.2)

The scores of each domain range from 0 to 100, with the higher scores indicating better health

functioning; The scores of HT range from 1 to 5, with the lower scores indicating better health

conditions; PCS = PF + RP + BP + GH; MCS = VT + SF + RE + MH.

265

Since the data on the eight domains of SF-36, physical component summary, mental

component summary, and reported health transition were not normally distributed and

the related homogeneity of variance among the three groups was not achieved in most

data (Appendix XV), non-parametric tests were used to analyze them. At baseline, no

significant differences were found in the mean scores of the eight domains, the

physical component summary, mental component summary, and reported health

transition among the three groups, as confirmed by the Kruskal-Wallis test (Appendix

XVI). After the completion of the 8-week intervention, higher mean change scores for

all eight domains, the physical component summary and mental component summary,

and a larger reduction in the mean scores for reported health transition were observed

in the ESMI than in the PE and C groups at T1, T2, and T3 (Table 5.27). Significant

differences were identified in the mean change scores for physical functioning (mean

266

rank: T1 - T0: ESMI group = 125.0, PE group = 88.3, C group = 82.6, p < 0.01; T2 - T0:

ESMI group = 121.2, PE group = 93.4, C group = 81.4, p < 0.01; T3 - T0: ESMI group

= 117.4, PE group = 94.1, C group = 84.4, p < 0.01), vitality (mean rank: T1 - T0:

ESMI group = 128.6, PE group = 88.9, C group = 78.5, p < 0.01; T2 - T0: ESMI group

= 127.2, PE group = 90.8, C group = 78.1, p < 0.01; T3 - T0: ESMI group = 127.8, PE

group = 88.1, C group = 80.0, p < 0.01), social functioning (mean rank: T1 - T0: ESMI

group = 113.0, PE group = 97.7, C group = 85.2, p < 0.05; T2 - T0: ESMI group =

112.9, PE group = 97.1, C group = 85.9, p < 0.05; T3 - T0: ESMI group = 109.8, PE

group = 102.4, C group = 83.8, p < 0.05), mental health (mean rank: T1 - T0: ESMI


119.1, PE group = 100.5, C group = 76.6, p < 0.01; T3 - T0: ESMI group = 117.3, PE

group = 98.6, C group = 80.2, p < 0.01), physical component summary (mean rank: T1

- T0: ESMI group = 118.0, PE group = 93.3, C group = 84.6, p < 0.01; T2 - T0: ESMI


114.1, PE group = 92.7, C group = 88.9, p < 0.05), and mental component summary

(mean rank: T1 - T0: ESMI group = 127.0, PE group = 92.2, C group = 76.9, p < 0.01;

T2 - T0: ESMI group = 121.7, PE group = 89.9, C group = 84.2, p < 0.01; T3 - T0:

ESMI group = 117.4, PE group = 95.5, C group = 83.1, p < 0.01) among the three

groups at T1, T2, and T3 (Table 5.27). Significant differences in the mean change

scores for general health (mean rank: T1 - T0: ESMI group = 128.6, PE group = 88.9,

C group = 78.5, p < 0.01; T2 - T0: ESMI group = 119.3, PE group = 98.8, C group =

78.0, p < 0.01) and reported health transition (mean rank: T1 - T0: ESMI group = 84.6,

PE group = 100.2, C group = 110.3, p < 0.05; T2 - T0: ESMI group = 85.4, PE group =

100.6, C group = 109.2, p < 0.05) were also found among the three groups at T1 and

T2, but the effects disappeared at T3 (Table 5.27). In addition, significant differences

267

in the mean change scores for bodily pain (mean rank: T2 - T0: ESMI group = 113.4,

PE group = 90.6, C group = 91.7, p < 0.05) were detected among the three groups at

T2, while no significant differences were found at T1 and T3 (Table 5.27).

The effect sizes of the TTM-based ESMI on the eight domains, PCS, MCS, and

reported health transition of the SF-36 ranged from 0.1 to 0.4 (Table 5.27), which

would be between a small (0.10) and large (0.40) effect for an ANOVA analysis

based on Cohen‘s (1988) terms. These findings suggest that the patients who

participated in the ESMI group experienced a better quality of life in terms of the SF-

36, especially with regard to physical functioning, vitality, social functioning, mental

health, PCS, and MCS than those in the PE and C groups.

268

Table 5.27 Comparisons of the Mean Change Scores of Eight Domains of SF-36 among

Groups at Each Time Point

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)


size

(r) χ

2 p

PF

T1 - T0 -0.8(11.5) 0.4(9.1) 7.5(10.8) 22.983 0.000** 0.3

T2 - T0 1.9(11.4) 2.9(8.7) 8.6(11.3) 17.855 0.000** 0.3

T3 - T0 3.4(12.2) 5.0(9.5) 9.8(11.8) 12.288 0.002** 0.2

RP

T1 - T0 7.8(37.5) 10.5(40.3) 18.8(38.8) 3.075 0.215 0.1

T2 - T0 0.0(47.9) 5.5(42.4) 12.7(41.7) 2.226 0.329 0.1

T3 - T0 -3.0(53.9) 0.4(43.5) 14.2(39.5) 4.495 0.106 0.2

BP

T1 - T0 8.5(23.4) 4.5(19.9) 12.3(24.7) 4.531 0.104 0.1

T2 - T0 2.8(25.6) 0.8(22.2) 12.1(25.8) 6.976 0.031* 0.2

T3 - T0 1.2(29.1) 4.1(22.7) 9.8(29.1) 4.016 0.134 0.1

GH

T1 - T0 -1.4(20.3) 8.8(20.7) 14.0(24.7) 19.907 0.000** 0.3

T2 - T0 -0.0(22.3) 9.2(23.5) 15.6(20.1) 17.683 0.000** 0.3

T3 - T0 6.4(23.8) 7.3(21.6) 14.0(24.9) 4.512 0.105 0.1

VT

T1 - T0 -4.2(15.7) 0.0(15.4) 11.3(17.8) 28.906 0.000** 0.4

T2 - T0 -4.0(18.8) 0.8(17.0) 10.9(15.0) 26.834 0.000** 0.4

T3 - T0 0.0(16.5) 3.4(13.4) 13.2(15.4) 27.130 0.000** 0.4

SF

T1 - T0 -1.7(25.0) 2.3(23.6) 9.4(22.1) 9.071 0.011** 0.2

T2 - T0 -0.9(22.9) 4.1(24.5) 11.3(22.1) 8.409 0.015* 0.2

T3 - T0 -0.4(24.1) 6.6(23.1) 10.6(21.7) 8.456 0.015* 0.2

269


C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)


size

(r) χ

2 p

RE

T1 - T0 -0.0(33.8) 2.1(33.5) 13.3(31.6) 5.217 0.074 0.2

T2 - T0 2.5(37.3) -3.1(29.5) 7.2(40.2) 1.215 0.545 0.1

T3 - T0 -1.0(44.6) -2.6(33.2) 10.3(35.8) 4.312 0.116 0.2

MH

T1 - T0 -2.4(13.3) 0.5(10.7) 8.5(12.6) 32.569 0.000** 0.4

T2 - T0 -1.5(14.0) 2.3(11.0) 6.8(10.8) 19.093 0.000** 0.3

T3 - T0 -0.7(14.2) 2.5(11.3) 5.4(10.3) 14.460 0.001** 0.2

PCS

T1 - T0 14.2(63.8) 24.3(60.7) 52.7(70.5) 12.311 0.002** 0.2

T2 - T0 4.6(71.8) 18.4(63.0) 49.0(69.5) 11.672 0.003** 0.3

T3 - T0 8.0(86.9) 16.8(67.0) 47.9(81.6) 7.554 0.023* 0.2

MCS

T1 - T0 -8.3(62.7) 4.9(56.9) 42.6(69.4) 26.947 0.000** 0.3

T2 - T0 -4.0(69.0) 4.1(53.1) 36.3(70.0) 16.667 0.000** 0.3

T3 - T0 -2.1(72.5) 9.9(56.1) 39.3(65.6) 12.392 0.002** 0.3

HT

T1 - T0 -0.0(1.1) -0.2(1.3) -0.6(1.3) 7.493 0.024* 0.2

T2 - T0 -0.2(1.2) -0.4(1.4) -0.8(1.3) 6.562 0.038* 0.2

T3 - T0 -0.4(1.2) -0.5(1.4) -0.9(1.3) 5.269 0.072 0.2

PF: Physical Functioning; RP: Role-Physical; BP: Bodily Pain; GH: General Health; VT: Vitality; SF:

Social Functioning; RE: Role-Emotional; MH: Mental Health; PCS: Physical Component Summary

(PF + RP + BP + GH); MCS: Mental Component Summary (VT + SF + RE + MH); HT: Reported

Health Transition; *p < 0.05; ** p < 0.01.

270

For within-group comparisons of eight domains, the physical component summary,

mental component summary, and reported health transition of SF-36, the Friedman

test was applied. The C group showed significant differences in the mean scores for

physical functioning (mean rank: T0 = 2.4, T1 = 2.3, T2 = 2.5, T3 = 2.9, p < 0.01) and

general health (mean rank: T0 = 2.5, T1 = 2.2, T2 = 2.4, T3 = 2.9, p < 0.01) over time

(Table 5.28). The PE group demonstrated significant differences in the mean scores

for physical functioning (mean rank: T0 = 2.2, T1 = 2.1, T2 = 2.8, T3 = 2.9, p < 0.01),

general health (mean rank: T0 = 2.1, T1 = 2.6, T2 = 2.7, T3 = 2.7, p < 0.01), social

functioning (mean rank: T0 = 2.3, T1 = 2.5, T2 = 2.5, T3 = 2.8, p < 0.05), physical

component summary (mean rank: T0 = 2.1, T1 = 2.6, T2 = 2.7, T3 = 2.6, p < 0.05), and

reported health transition (mean rank: T0 = 2.8, T1 = 2.5, T2 = 2.4, T3 = 2.3, p < 0.05)

over time (Table 5.28). The ESMI group revealed significant differences in all eight

domains, such as physical functioning (mean rank: T0 = 1.6, T1 = 2.5, T2 = 2.8, T3 =

3.1, p < 0.01), role-physical (mean rank: T0 = 2.2, T1 = 2.7, T2 = 2.5, T3 = 2.6, p <

0.01), bodily pain (mean rank: T0 = 2.1, T1 = 2.7, T2 = 2.6, T3 = 2.6, p < 0.01), general

health (mean rank: T0 = 1.7, T1 = 2.7, T2 = 2.8, T3 = 2.8, p < 0.01), vitality (mean rank:

T0 = 1.7, T1 = 2.8, T2 = 2.6, T3 = 2.9, p < 0.01), social functioning (mean rank: T0 =

2.1, T1 = 2.6, T2 = 2.7, T3 = 2.7, p < 0.01), role-emotional (mean rank: T0 = 2.3, T1 =

2.6, T2 = 2.5, T3 = 2.6, p < 0.01), mental health (mean rank: T0 = 1.7, T1 = 3.0, T2 =

2.6, T3 = 2.7, p < 0.01), physical component summary (mean rank: T0 = 1.7, T1 = 2.7,

T2 = 2.8, T3 = 2.8, p < 0.01), mental component summary (mean rank: T0 = 1.7, T1 =

2.9, T2 = 2.6, T3 = 2.8, p < 0.01), and reported health transition (mean rank: T0 = 3.1,

T1 = 2.4, T2 = 2.3, T3 = 2.2, p < 0.01) over time (Table 5.28).

271

Table 5.28 Comparisons of Eight Domains of SF-36 within Each Group across Time

T0

mean (SD)

T1

mean (SD)

T2

mean (SD)

T3

mean (SD)

Friedman test

χ2 p

PF

C group 81.4(13.6) 80.6(12.6) 83.3(11.3) 84.8(12.8) 14.487 0.002**

PE group 82.3(9.7) 82.7(11.4) 85.2(11.0) 87.3(9.3) 31.233 0.000**

ESMI group 78.8(16.2) 86.4(13.7) 87.5(13.8) 88.7(13.4) 76.073 0.000**

RP

C group 72.0(40.0) 79.9(35.9) 72.0(40.7) 69.0(43.8) 2.991 0.393

PE group 63.7(39.6) 74.2(38.3) 69.1(41.0) 64.1(42.2) 5.283 0.152

ESMI group 67.3(39.3) 86.2(26.5) 80.0(33.7) 81.5(35.4) 13.627 0.003**

BP

C group 73.7(24.8) 82.2(22.2) 76.5(23.2) 74.9(24.8) 6.894 0.075

PE group 75.4(22.1) 79.9(22.4) 76.2(23.5) 79.5(21.7) 4.363 0.225

ESMI group 75.4(22.9) 87.7(16.7) 87.6(17.1) 85.3(20.8) 17.067 0.001**

GH

C group 57.4(22.8) 56.0(23.7) 57.3(25.7) 63.8(25.5) 13.297 0.004**

PE group 55.4(22.3) 64.2(20.8) 64.6(21.3) 62.7(23.0) 12.586 0.006**

ESMI group 57.9(23.4) 71.8(21.0) 73.5(20.0) 71.8(25.0) 41.915 0.000**

VT

C group 72.5(17.6) 68.3(19.2) 68.4(18.0) 72.5(17.0) 6.889 0.076

PE group 70.9(17.1) 70.9(16.9) 71.7(16.2) 74.3(14.1) 2.589 0.459

ESMI group 68.8(18.7) 80.15(15.1) 79.8(14.1) 82.0(13.0) 51.881 0.000**

SF

C group 84.5(22.1) 82.8(22.4) 83.6(22.3) 84.1(22.1) 1.492 0.684

PE group 79.3(23.8) 81.6(22.7) 83.4(19.9) 85.9(21.1) 8.339 0.040*

ESMI group 80.6(21.7) 90.0(17.6) 91.9(16.5) 91.2(17.5) 25.930 0.000**

272


T0

mean (SD)

T1

mean (SD)

T2

mean (SD)

T3

mean (SD)

Friedman test

χ2 p

RE

C group 80.6(34.9) 80.6(38.1) 83.1(35.0) 79.6(37.6) 1.301 0.729

PE group 84.9(27.8) 87.0(28.9) 81.8(34.1) 82.3(33.6) 0.682 0.877

ESMI group 79.0(36.1) 92.3(24.8) 86.2(33.3) 89.2(31.2) 14.255 0.003**

MH

C group 83.0(13.9) 80.6(14.5) 81.6(13.9) 82.3(14.1) 4.998 0.172

PE group 80.4(10.4) 80.9(11.7) 82.8(9.7) 82.9(10.1) 7.552 0.056

ESMI group 80.4(12.8) 88.9(10.3) 87.3(10.8) 85.8(13.3) 49.131 0.000**

PCS

C group 284.5(76.9) 298.7(77.7) 289.1(79.2) 292.5(90.1) 5.328 0.149

PE group 276.8(65.1) 301.1(64.5) 295.2(70.2) 293.6(69.8) 8.594 0.035*

ESMI group 279.4(75.8) 332.1(57.9) 328.5(65.5) 327.3(77.2) 38.777 0.000**

MCS

C group 320.6(67.6) 312.3(79.9) 316.7(76.8) 318.5(76.8) 2.720 0.437

PE group 315.6(59.0) 320.5(60.7) 319.6(60.1) 325.5(60.0) 5.138 0.162

ESMI group 308.8(72.2) 351.4(58.6) 345.1(62.4) 348.2(64.6) 43.222 0.000**

HT

C group 3.3(1.1) 3.3(1.0) 3.1(0.9) 2.9(1.0) 5.211 0.157

PE group 3.1(1.3) 2.8(1.1) 2.7(1.1) 2.5(1.1) 9.909 0.019*

ESMI group 3.3(1.1) 2.7(1.1) 2.6(1.2) 2.5(1.2) 30.051 0.000**



(PF + RP + BP + GH); MCS: Mental Component Summary (VT + SF + RE + MH); HT: Reported

Health Transition; *p < 0.05; ** p < 0.01.

273

5.7 Summary

This chapter presented the recruitment of the participants in this study, their

characteristics, a comparison of their exercise stages of change, exercise self-efficacy,

exercise benefits and barriers, exercise duration per week, angina, and quality of life

within and between the patients in the C, PE, and ESMI groups at each time point (T0,

T1, T2 and, T3). The findings showed a significantly more positive shift in the exercise

stages of change, higher exercise self-efficacy, greater exercise benefits, fewer

exercise barriers, longer exercise duration per week, and better quality of life in terms

of the SAQ and SF-36 in the ESMI group than in the C and PE groups immediately

after the 8-week intervention and at the 3- and 6-month follow-up period. These

findings suggest that the TTM-based ESMI has significantly positive effects on

changing exercise behaviour and improving quality of life in sedentary CHD patients

in China. However, in this study it was also observed during the follow-up period that

the effects on these variables tended to fade away.

274

Chapter 6 Discussion

6.1 Introduction

This chapter discusses the results of the study based on the research questions, in

order to determine whether the aims of the study had been achieved. It also compares

the findings with other related studies. This chapter includes a discussion of the high

participation/completion rate in this study; the effects of the TTM-based ESMI on

changing exercise behaviour and improving health outcomes in terms of reducing

anginal attacks and improving quality of life; and the tracking of the TTM-based

ESMI on exercise behaviour.

6.2 High Participation/Completion Rate

A total of 196 sedentary CHD patients were recruited in this study, of whom 150

completed the whole study. The completion rate in this study was 76.5% (150/196) –

much higher than that in previous studies of exercise-based cardiac rehabilitation

programmes, in which the participation/completion rate during the first six months

was about 50% (Dorn, Naughton, Imamura & Trevisan, 2001; Moore, Dolansky,

Ruland, Pashkow & Blackburn, 2003; Sanderson & Bittner, 2005; Sanderson, Phillips,

Gerald, DiLillo & Bittner, 2003; Sarrafzadegan, Rabiei, Shirani et al., 2007;

Worcester, Murphy, Mee, Roberts & Goble, 2004). Previous studies have shown that

the participation rate decreases over time, particularly six months into a programme

(Dorn, Naughton, Imamura & Trevisan, 2001; Touillet, Guesdon, Bosser, Beis &

Paysant, 2010). The finding from this study also showed that the average participation

275

rate in the eight weekly ESMI sessions was 85.2%. The high participation and

completion rates in this study substantiate the view that the implementation of the

TTM-based ESMI in cardiac rehabilitation programmes is suitable for sedentary CHD

patients in China.

The following two factors may have contributed to the high participation/completion

rate in this study. First, the delivery of a client-centred intervention may have been a

contributor. The characteristic of the TTM-based ESMI is the delivery of strategies or

techniques matched to the client's current stage of behavioural change (Burbank,

Padula & Nigg, 2000; Prochaska, DiClemente & Norcross, 1992), which may meet

the client's most needs (Prochaska & Velicer, 1997). Thus, a stage-specific

intervention can be delivered according to the TTM. Previous studies have

demonstrated that a TTM-based stage-matched intervention can increase the uptake of

programmes (Prochaska, DiClemente & Norcross, 1992; Prochaska & Velicer, 1997;

Rakowski, Ehrich, Goldstein et al., 1998) and reduce dropout rates (Beckie &

Beckstead, 2010; Schelling, Munsch, Meyer et al., 2009). In addition, in this study the

eight weekly ESMI sessions were delivered through either face-to-face or telephone

contacts. These modes of contact are the approaches most preferred by CHD patients

in China (Chen & Jing, 2008; Du, Chen, & Liu, 2005; Hu, 2006; Li & Liu, 2006; Li &

Wang, 2006; Liu, 2005; Wan & Wang, 2008) because these both forms of contact are

interactive in nature. Moreover, in this study the face-to-face or telephone contacts

between the researcher and the patients were scheduled according to the time that the

patients were available regardless of whether this was in the evenings or at weekends.

This kind of client-centred contact schedule may have contributed to the high

participation rate in the eight weekly ESMI sessions in this study (85.2%).

276

Second, the fact that there were no reports of exercise-induced adverse effects (e.g.,

heart attacks due to exercise) may have been another contributor to the high

participation/completion rate in this study. Previous studies have indicated that CHD

patients often lack the confidence to perform exercises because they worry about the

occurrence of angina or hold the misconception that physical activity may provoke an

anginal attack (Kristofferzon, Löfmark & Carlsson, 2007; Thompson & Lewin, 2000;

Zhu, Ho & Sit, 2012). Our previous interviews (Zhu, Ho & Sit, 2012) with 11 Chinese

CHD patients in mainland China also showed that the patients perceived CHD to be a

life-threatening illness mostly related to chest pain and worried about the recurrence

of heart attacks. Patients often hold the misconception that heart attacks cannot be

prevented and that physical activity provokes chest pain. The result of these

misconceptions is fewer changes in behaviour and even disengagement from physical

activity. During the whole study period, there were no reports of exercise-induced

adverse effects, which may have helped the patients to build up their confidence

(exercise self-efficacy) to engage in exercise and correct their misconception that

physical activity would provoke anginal attacks. Correcting their misconceptions may

have further enhanced their confidence to change exercise behaviour. Thus, the fact

that no exercise-induced adverse effects occurred during the study period may have

been a factor contributing to the high participation/completion rate in this study.

6.3 The Effects of the TTM-based ESMI on CHD Patients

In this randomized controlled trial, eligible patients were randomly allocated to one of

the following three groups: the Conventional (C) group, the Patient Education (PE)

277

group, and the Exercise Stage-Matched Intervention (ESMI) group. The aim of this

study was to evaluate whether sedentary CHD patients who participated in the ESMI

group had better results in exercise behaviour and health outcomes in terms of anginal

attacks and quality of life than those in the C and PE groups. Accordingly, in this

section, the effects of the TTM-based ESMI on these two areas are thoroughly

discussed.

6.3.1 Exercise Behaviour

This is the first study to examine the effects of the TTM-based ESMI on exercise

behaviour among sedentary CHD patients in China. In this study, exercise behaviour

was evaluated by exercise stages of change, exercise self-efficacy, exercise decisional

balance, and exercise duration per week. In this subsection, changes in the exercise

behaviour of each group were discussed thoroughly.

6.3.1.1 Exercise behaviour of the Conventional (C) Group

The findings from this study showed that the patients in all the three groups improved

their exercise behaviour after the interventions. This finding showed that patients in

the C group could also be motivated to change their exercise behaviour over time,

namely, they showed significant progress in exercise stages of change, exercise self-

efficacy, exercise benefits, and exercise duration per week, and a decrease in exercise

barriers over time. Possible explanations for the improvements noted in the C group

may be the content of conventional care, normal recovery, and measurement effects.

Patients in the C group only received conventional care, which is simple and

278

unstructured patient education on diet, exercise, and medications related to CHD.

Casually delivering information to them about the benefits of exercise and the risks of

physical inactivity may also have improved their knowledge of exercise and increased

their awareness of the importance of engaging in exercise, which resulted in a change

in their behaviour. Another possible reason for the progress in exercise behaviour

seen in the C group over time may be that it was due to the normal process of

recovery. Near half of the patients who participated in this study had been diagnosed

with coronary heart disease (myocardial infarction, angina pectoris, or had undergone

PTCA/PCI) for around three months. As they recovered from their illness, they may

have naturally increased the level of their physical activities or exercise. A previous

study has shown that self-efficacy increased over time, as patients had an opportunity

to gain confidence as they succeeded in adapting to lifestyle changes (Barnason,

Zimmerman, Nieween et al., 2003). With physical recovery over time, patients may

have accordingly become more confident about their ability to engage in exercise.

Finally, measurement effects may be another contributor to the changes in exercise

behaviour seen in the C group. A positive measurement effect has been observed in

randomized controlled trials promoting regular exercise (van Sluijs, van Poppel,

Twisk et al., 2005; van Sluijs, van Poppel, Twisk & van Mechelen, 2006). In these

studies, statistically significant measurement effects were found in self-reported

exercise, self-efficacy for resisting relapse, and knowledge and awareness, although

there were no significant differences in exercise stages of change and accelerometer

data (i.e., counts per minute). Van Sluijs et al. (2006) stated that measurements of

exercise or physical activity influence patients‘ exercise behaviour, possibly triggered

by a raised awareness, because awareness of one‘s own behaviour is an important

279

starting point for behavioural change. They explained that the content of the

measurements might have triggered this awareness because when patients were asked

about their level of exercise in detail, they were given the opportunity to create an

overview of their exercise pattern during a normal week. All of the patients in this

study underwent outcome measurements four times, which may have resulted in the

measurement effects that possibly contributed to the effects found in the C group.

However, all of the three groups were administered the same time-point outcome

measurements. The measurement effects were evenly distributed in all three groups.

Thus, measurement effects did not contribute to the findings from the comparisons

between the groups, which instead can be attributed to the effects of the intervention.

6.3.1.2 Exercise behaviour of the Patient Education (PE) Group

In this study, patients in the PE group demonstrated better effects on exercise

behaviour in terms of a more positive shift in exercise stages of change, higher

exercise self-efficacy, greater exercise benefits, fewer exercise barriers and longer

moderate exercise duration per week as compared with those in the C group. These

findings suggest that general patient education about CHD and exercise also has a

positive impact on changing exercise behaviour in sedentary CHD patients. The

finding of the positive effect on exercise behaviour is similar to the results from

previous systematic reviews of chronically ill patients (Conn, Hafdahl, Brown &

Brown, 2008) and heart disease patients (Zhu, Ho & Wong, unpublished), which

showed that patient education has a positive effect on changing exercise behaviour.

280

Patients in the PE group received conventional care, one 2-hour patient education

session and a booklet about cardiac rehabilitation, and eight weekly sessions of

general patient education about the importance and benefits of regular exercise. Thus,

one possible explanation for the finding in the PE group is that patient education

improved the patients‘ knowledge of CHD and exercise. Knowledge about the risk

factors for CHD is related to compliance with lifestyle changes (e.g., physical activity)

(Alm-Roijer, Stagmo, Udén & Erhardt, 2004). Previous studies have demonstrated

that patient education can increase the patients‘ knowledge and promote related

healthy behavioural changes (e.g., exercise) (Aldana, Greenlaw, Diehl et al., 2008;

Fuster, 2007; Hogan & Neill, 1982; Netto, McCloughan & Bhatnagar, 2007; Plach,

Wierenga & Heidrich, 1996). In addition, simply providing educational information

about CHD and exercise can also be viewed as a process of change according to

Prochaska and DiClemente (1983), who pointed out that consciousness raising (e.g.,

seeking new information and gaining understanding and feedback about exercise)

helps individuals to move from one motivational stage to another (Schelling, Munsch,

Meyer et al., 2009). Another possible explanation for this finding may be that most

patients (more than 60%) were at the preparation stage at baseline in this study, which

implies that most of the patients were ready to change their exercise behaviour at the

start of the study. The general patient education about the importance and benefits of

exercise was sufficient to motivate those who were already ready to begin to change

their exercise behaviour. The findings of this study suggest that general patient

education regarding CHD and the importance and benefits of exercise will also have a

positive impact on motivating sedentary CHD patients to engage in exercise.

281

Although few studies have evaluated the effect of generic patient education on

changing exercise behaviour with respect to exercise stages of change, exercise self-

efficacy, and exercise decisional balance, a number of studies have shown that patient

education may have a significantly positive effect on exercise adherence, with

participants who exercised regularly reaching the required guidelines (Allen,

Blumenthal, Margolis et al., 2002; Arrigo, Brunner-LaRocca, Lefkovits et al., 2008;

Cupples & McKnight, 1994; Giallauria, Lucci, D‘Agostino, Vitelli et al., 2009; Jeong,

Chae, Moon & Yoo, 2002; Johnson, Lim & Bowe, 2009; Murchie, Campbell, Ritchie

et al., 2003; Redfern, Briffa, Ellis & Freedman, 2008; The Vestfold Heartcare Group,

2003). These studies also indicate the importance of providing knowledge and giving

general information on cardiac rehabilitation and exercise for CHD patients to

motivate them to engage in exercise.

6.3.1.3 Exercise behaviour of the Exercise Stage-Matched Intervention (ESMI)

Group

Among the patients in the ESMI group, a significantly positive effect was observed

with regard to changes in exercise behaviour in terms of a more positive shift in the

exercise stages of change (p < 0.001), higher exercise self-efficacy (p < 0.001),

greater exercise benefits (p < 0.001), fewer exercise barriers (p < 0.001), and longer

moderate exercise duration per week (p < 0.001) than those in the C and PE groups.

These significantly positive effects persisted at the 3- and 6-month follow-up periods.

These findings suggest that using the 8-week TTM-based ESMI through face-to-face

and telephone contacts is effective at motivating sedentary CHD patients to engage in

exercise.

282

The positive effect of the TTM-based ESMI on changing exercise behaviour is

consistent with the results of previous studies that used the TTM to change exercise

behaviour among people in the community (Marcus, Banspach, Lefebvre et al., 1992)

and in worksite settings (Cardinal & Sachs, 1996; Faghri, Omokaro, Parker et al.,

2008; Ishii, Nakiri, Nagatomi et al., 2007; Peterson & Aldana, 1999; Purath, Miller,

McCabe & Wilbur, 2004), among adolescents (Nigg & Courneya, 1998), university

students (Huang, Hung, Chang & Chang, 2009; Kim, 2007 & 2008; Woods, Mutrie &

Scott, 2002), young to middle-aged women (Fahrenwald, Atwood, Walker, Johnson

& Berg, 2004; Shirazi, Wallace, Niknami et al., 2007), the elderly (Burbank, Reibe,

Padula & Nigg, 2002; Findorff, Stock, Gross & Wyman, 2007; Greaney, Riebe,

Garber et al., 2008; Märki, Bauer, Angst et al., 2006; Märki, Bauer, Nigg et al., 2006;

Resnick & Nigg, 2003), the general population (Bock, Marcus, Pinto & Forsyth, 2001;

Calfas, Long, Sallis et al., 1996; Lippke, Schwarzer, Ziegelmann et al., 2010),

physicians (Rogers, Gutin, Humphries et al., 2005), diabetes patients (Huang & Tang,

1996; Jackson, Asimakopoulou & Scammell, 2007; Kirk, Higgins, Hughes et al.,

2001; Kirk, MacIntyre, Mutrie & Fisher, 2003; Kirk, Mutrie, MacIntyre & Fisher,

2004; Zhu & Chen, 2007), breast cancer patients (Pinto, Frierson, Rabin et al., 2005),

patients with chronic disease (Shin, Yun, Jang & Lim, 2006), adults at increased risk

of developing coronary heart disease (Steptoe, Kerry, Rink & Hilton, 2001), and

patients with heart disease (Hughes, Gillies, Kirk et al., 2002; Hughes, Mutrie &

Maclntyre, 2007; Naser, Jafar, Kumar et al., 2008). These studies have shown that the

TTM-based ESMI is effective at motivating various populations to start exercising or

to maintain regular adherence to exercise. However, previous studies did not address

the issue of the effectiveness of the TTM-based ESMI on the exercise behaviour of

283

sedentary CHD patients. The findings from this study add evidence to support the

argument that the TTM-based ESMI is effective at changing the exercise behaviour of

sedentary CHD patients.

On the other hand, the findings in this study of the effect of the TTM-based ESMI on

changing exercise behaviour were inconsistent with those of other studies, which

found no significant effect on exercise behaviour from exercise consultations based

on the TTM as compared with generic patient education or the usual care (Dutton,

Provost, Tan & Smith, 2008; Goldstein, Pinto, Marcus et al., 1999; Jimmy & Martin,

2005; Kosma, Cardinal & Mccubbin, 2005; Pinto, Friedman, Marcus et al., 2002;

Taylor, Demoor, Smith et al., 2006; Wanner, Martin-Diener, Braun-Fahrländer et al.,

2009). The exception was one study that showed that the TTM-based exercise

intervention had a significant effect on exercise behaviour (increasing moderate

exercise duration per week) immediately after the intervention, although the effect

disappeared at the 6-month follow-up period (Pinto, Friedman, Marcus et al., 2002).

The discrepancies in the results on exercise behaviour between these studies and this

study may be attributed to the limited power reported by the authors of those studies

to detect the differences between the experimental and control groups (Goldstein,

Pinto, Marcus et al., 1999; Taylor, Demoor, Smith et al., 2006), the different research

designs (e.g., web-based intervention delivery) (Kosma, Cardinal & Mccubbin, 2005;

Wanner, Martin-Diener, Braun-Fahrländer et al., 2009), the involvement of

participants with physical disabilities (Kosma, Cardinal & Mccubbin, 2005), and the

recruitment of active participants at baseline (participants who performed around 130

minutes of moderate exercise per week at baseline), which resulted in little room for

further improvements (Dutton, Provost, Tan & Smith, 2008).

284

In this study, the patients in the ESMI group received conventional care, one 2-hour

session of patient education and a booklet regarding cardiac rehabilitation, and eight

weekly ESMI sessions and exercise stage-matched pamphlets. Three possible

explanations can be put forward for the positive effects of the TTM-based ESMI on

exercise behaviour. First, the characteristics of the TTM-based ESMI may be a main

contributor. The TTM-based ESMI is a client-centred and stage-specific intervention

for behavioural change, in which the strategies and techniques that are delivered are

matched to the individual's current stage of behavioural change. For patients in

different stages, different goals were set, and different processes of change or

strategies/techniques were used to motivate them to move to a more advanced stage.

This differed from the general patient education delivered to the PE group, in which

all of the participants received the same intervention on CHD and the same

information on the importance and benefits of exercise, without taking into

consideration their attitudes, intentions, and changes in their behaviour, namely, the

intervention was delivered without considering their exercise stages of change.

Previous studies have also demonstrated that a stage-matched intervention has a better

effect on behavioural change than a mismatched or non-matched one (Marcus,

Emmons, Simkin-Silverman et al., 1998; Prochaska, DiClemente, Velicer & Rossi,

1993). This is because a stage-specific and stage-matched intervention encourages

individuals to change their behaviour, since the delivery of the intervention occurs at a

time when the patients are most open to considering the particular changes suitable to

their condition at the time. For example, for those in the precontemplation or

contemplation stage, general patient education may not be effective at motivating

them to engage in exercise because such an intervention is typically designed for

285

people who are highly motivated and ready to begin to change their behaviour. It is

not effective enough to motivate a change in behaviour among those who have no

intention or interest in changing their behaviour (Marcus, Emmons, Simkin-Slverman

et al., 1998). In contrast, according to the TTM-based ESMI, only experiential

strategies or techniques, such as delivering information on the benefits of physical

activity (consciousness raising) and the personal risks of physical inactivity (dramatic

relief), uncovering the barriers to exercise, and encouraging thoughts about changing

one‘s sedentary lifestyle, were provided for those in the precontemplation or

contemplation stage and no action-oriented interventions were offered to them. On the

other hand, with respect to those in the action or maintenance stage, general patient

education may be not sufficient to help such participants overcome obstacles and

solve problems that they have encountered to maintain or adhere to regular exercise,

while the TTM-based ESMI providing problem-solving skills (e.g.,

counterconditioning, stimulus control, and reinforcement management) and the skills

to seek social support (e.g., helping relationships) may help them to overcome

obstacles, solve problems and resist relapsing into physical inactivity. Thus, providing

the TTM-based ESMI for patients could lead to better results in changing exercise

behaviour than general patient education and conventional care, as seen in this study.

This can explain why the patients in the ESMI group had better outcomes in exercise

behaviour than those in the C and PE groups in this study.

In addition, only sedentary CHD patients were recruited in this study. Thus, the

movement across the various stages of change, patients in the ESMI group not only

received information on the importance and benefits of exercise (e.g., consciousness

raising), but also received information about the risks of physical inactivity (e.g.,

286

dramatic relief), about self-reevaluation, environmental reevaluation, social liberation,

self-liberation to exercise, and about the skills of problem-solving (e.g.,

counterconditioning), overcoming barriers (e.g., stimulus control), and rewarding

oneself for physical activity (e.g., reinforcement management). The skills of problem-

solving, overcoming barriers, and rewarding oneself for physical activity were

provided especially for those in the action stage (starting to take action to engage in

regular exercise). In addition, all of the patients in the ESMI group were encouraged

to seek social support (e.g., helping relationships) as much as possible, which may

also have helped them to conquer barriers to engaging in exercise and to increase their

confidence in and perceptions of the benefits of exercise. Previous studies have

demonstrated that social support is a very important factor for attendance in a cardiac

rehabilitation programme (Hagan, Botti & Watts, 2007) and a predictor of a cardiac

patient‘s adherence to an exercise regime (Davies, Taylor, Beswick et al., 2010;

Moore, Dolansky, Ruland, Pashkow & Blackburn, 2003).

In this study, changes in exercise behaviour were measured using the exercise stages

of change scale (Marcus, Selby, Niaura & Rossi, 1992) and a log book. A log book

can facilitate accurate assessments of a patient‘s exercise behaviour, so that the most

appropriate and stage-specific intervention can be provided for that person. Keeping a

log book is also intended to motivate patients to engage in exercise.

Second, offering patients in this study a booklet and pamphlet may also have had a

positive effect on changing their exercise behaviour. The patients received a booklet

about cardiac rehabilitation immediately after completing the one 2-hour session of

patient education. The booklet is printed in colour, contains pictures, and is easy for

287

CHD patients to understand. Therefore, the information delivered in the patient

education session can be enhanced. A series of exercise stage-matched pamphlets in

simplified Chinese was also provided to patients in the ESMI group. Therefore, the

strategies and techniques employed to motivate changes in exercise behaviour can be

reinforced, namely by reinforcing participation at home. Thus, this multi-faceted

intervention (face-to-face and telephone contacts together with written materials) may

be credited for the positive results in exercise behaviour.

Third, home-based exercise may be another factor in the positive effect of the TTM-

based ESMI on exercise behaviour. In this study, the implementation of the TTM-

based ESMI was in a home-based mode. Patients in the ESMI group were encouraged

to start exercising at home and to incorporate exercise into their daily life, such as by

climbing the stairs instead of taking a lift, and by walking to the supermarket instead

of taking a bus. These skills would help them to start adopting exercise at home and to

develope the habit of exercising. Although patients in the PE group were also

encouraged to engage in exercise at home, they did not receive coaching on the

strategies or skills to incorporate exercise into their daily life. This may be one

possible explanation for why patients in the ESMI group demonstrated better results

in exercise behaviour than those in the PE group. The home-based exercise allowed

the patients to monitor themselves during the exercise session. Previous studies have

revealed that patients who attended home-based cardiac rehabilitation programmes

could significantly improve their exercise self-efficacy (Senuzun, Fadiloglu, Burke &

Payzin, 2006; Sinclair, Conroy, Davies & Bayer, 2005) because they needed to

monitor themselves at home during exercise. This training in self-monitoring their

exercise could help the patients build up their confidence (self-efficacy) in exercising

288

to a level sufficient to cause them to develop an exercise regime and to adhere to it

(Gary, 2006; Izawa, Watanabe, Omiya et al. 2005). In addition, patients who attended

a home-based cardiac rehabilitation programme perceived a higher level of social

support as compared with those in a hospital-based cardiac rehabilitation programme

(Gary, 2006). Social support is very important for attendance in or adherence to

cardiac rehabilitation programmes (Davies, Taylor, Beswick et al., 2010; Hagan, Botti

& Watts, 2007; Moore, Dolansky, Ruland, Pashkow & Blackburn, 2003). Obtaining

social support is itself also a process of change (e.g., helping relationships) for

behavioural change, which further enhances the individual's participation in exercise.

Thus, home-based exercise may have contributed to the positive effect of the TTM-

based ESMI on exercise behaviour that was observed in this study.

In this study, the most common reasons that the patients gave for dropping out of the

study were that they were leaving Xiamen City, busy with caring for grandchildren or

family members, and bad weather (e.g., too cold or hot). The findings suggest that it is

more appropriate to provide a home-based exercise programme for CHD patients in

Xiamen City than a centre-based one because of the former‘s convenience, cost-

effectiveness, high accessibility, and the much greater opportunity that patients have

to participate in it. Previous studies have also suggested that patients are more likely

to adhere to a home-based exercise programme than to a centre-based one (Arthur,

Smith, Kodis & McKelvie, 2002; Dalal, Zawada, Jolly et al., 2010; Leijon, Bendtsen,

Ståhle et al., 2010). Thus, the positive results on exercise behaviour in this study may

be attributed to the provision of support for home-based exercise. It may be a trend to

develop home-based exercise programmes for cardiac patients. This idea is consistent

289

with Thompson's (2007) hybrid mode of cardiac rehabilitation care – combining both

centre- and home-based rehabilitation cares.

Although the significant positive effects of the TTM-based ESMI on exercise

behaviour in terms of exercise stages of change, exercise self-efficacy, exercise

decisional balance, and exercise duration per week were sustained at the 6-month

follow-up period, a fading away of these effects was also found in the ESMI group

during the follow-up period. Due to time constraints, the longer follow-up effect of

the TTM-based ESMI on exercise behaviour was not evaluated in this study. Thus,

whether or not the positive effect of the TTM-based ESMI on exercise behaviour

would persist longer than six months remains unclear. Further studies over a longer

duration are needed to clarify this issue.

The trend of a reduction during the follow-up period may also suggest that the one 2-

hour session of patient education and a booklet, plus an 8-week TTM-based ESMI

and exercise stage-matched pamphlets, may not be enough to maintain the positive

impact on exercise behaviour in the long-term follow-up period (> 6 months). As

Adams and White (2005) argued, while the TTM-based stage-matched interventions

appear more likely to induce short-term changes in behaviour, they are not superior to

non-staged interventions in inducing long-term changes in behaviour. The effective

promotion of longer-term physical activity requires longer-lasting interventions that

may need to go beyond health education, incorporating environmental change

strategies to improve opportunities for physical activity and/or other strategies (e.g.,

social support) to maintain or adhere to regular physical activity (Brug, Conner, Harré,

Kremers, McKellar & Whitelaw, 2005). Thus, additional strategies or techniques

290

should be explored and added to improve the long-term effects of the intervention. A

booster intervention for the TTM-based ESMI may be a solution. A further study

featuring the addition of a booster intervention around the 6-month follow-up period

is suggested. Having a support group consisting of the patient‘s spouse or other family

members participating in the programme together with the patient may be another

way to encourage the patient to maintain long-term adherence to the exercise regime.

A further study focusing on this aspect is suggested.

6.3.2 Health Outcomes

This study focused on the effect of the TTM-based ESMI on health outcomes in terms

of anginal attacks and quality of life. A larger decline in angina frequency, angina

severity, angina duration, and anti-anginal drugs taken after the 8-week intervention

was found in the ESMI group than in the PE and C groups. However, no significant

differences in these variables were found among the three groups in this study. This

finding suggests that the TTM-based ESMI had no significant effect on anginal

attacks. The possible improvement in the ESMI group with regard to angina may be

due to the normal process of recovery from their illness. Nearly 50% of the patients in

this study were recruited immediately after the 3-month diagnosis of CHD (following

MI or PCI). Thus, they were still in the recovery stage. Another possible explanation

for the insignificant differences in angina variables among the three groups may be

due to the fact that the patients in this study experienced few episodes of angina

(around one episode/week), low angina severity (0-1, from no to slight pain), short

angina duration (about 10 minutes/week), and few anginal attacks and anti-anginal

drugs taken. Clearly, patients in this study only perceived mild angina. There may

291

have been little room for further improvements to begin with. In addition, the TTM is

targeted at motivating sedentary CHD patients to change their exercise behaviour.

Exercise-induced physiological changes may require some time to bring about.

Therefore, a longer intervention period is needed to achieve a significant reduction in

angina.

Regarding the quality of life, the results from this study showed that patients in the C

group improved in some domains of quality of life, especially in angina frequency and

disease perception of SAQ, and in physical functioning and general health of SF-36

over time. This improvement in the quality of life in the C group may have been due

to the normal recovery process and may have been a result of an increase in

engagement in exercise over time.

This study also showed that patients in the PE group had a better quality of life,

especially in angina frequency, treatment satisfaction, and disease perception of SAQ,

and in physical functioning, general health, social functioning, physical components

summary, and reported health transition of SF-36, than those in the C group. These

findings suggest that the structured patient education also had positive effects on the

quality of life of sedentary CHD patients. Several studies on controlling angina,

mainly through patient education, exercise training, and printed materials, have shown

that these approaches led to a significant improvement in quality of life with regard to

the SAQ (Burke, Williams & Lockyer, 2002; Lewin, Cay, Todd et al., 1995; Lewin,

Furze, Robinson et al., 2002), which is consistent with the findings of this study. A

number of randomized controlled trials also have revealed that cardiac rehabilitation

programmes or secondary prevention programmes, mainly including patient education

292

and exercise training, significantly improved the quality of life of CHD patients with

regard to SF-36 (Hanssen, Nordrehaug, Eide & Hanestad, 2007; Jiang, Sit, Wong,

Cheng & Li, 2004; McHugh, Lindsay, Hanlon et al., 2001; Murchie, Campbell,

Ritchie et al., 2004; Yu, Lau, Chau et al., 2004). A similar result was also reported in

several non-RCT studies (Izawa, Hirano, Yamada et al., 2004; Yonezawa, Masuda,

Matsunaga et al., 2009). These studies also suggest that the PE has a positive impact

on the quality of life of CHD patients with regard to both the SAQ and SF-36.

The greater improvement in quality of life in the PE group as compared with the C

group in this study may be a result of the increase in total and moderate exercise

duration per week and the contents of patient education. First, an increase in the

number of minutes of both total and moderate exercise duration per week may be a

factor. More patients in the action and maintenance stages (adopting regular exercise)

and a longer duration of moderate exercise were found in the PE group as compared

with the C group, which may explain why patients in the PE group showed a greater

improvement in quality of life than those in the C group. Second, patients in the PE

group received one 2-hour session of patient education related to CHD, including

information on the risk factors of CHD, healthy diets, and exercise, while those in the

C group only received conventional care. Health education can increase the patients‘

knowledge and promote related healthy changes in behavioiur or compliance with

lifestyle changes (Aldana, Greenlaw, Diehl et al., 2008; Alm-Roijer, Stagmo, Udén &

Erhardt, 2004; Fuster, 2007; Netto, McCloughan & Bhatnagar, 2007; Plach, Wierenga

& Heidrich, 1996). Such risk factor modifications and a healthy diet may also

contribute to an improvement in quality of life over time. This study focused on

changes in exercise behaviour and did not evaluate the results of diet and other risk

293

factor modifications. Thus, it is not clear whether patients modified these risk factors

and changed their diet after receiving one 2-hour session of patient education and the

booklet about cardiac rehabilitation. Further studies are recommended to clarify this

issue. Moreover, as with the ESMI group, the eight weekly sessions of general patient

education through face-to-face or telephone contacts, may have helped CHD patients

to learn more about angina and CHD, which may also have contributed to the

improvements seen in their treatment satisfaction and quality of life.

The findings from this study showed that patients in the ESMI group demonstrated

significantly greater improvements in three of the five subscales (namely, physical

limitations, treatment satisfaction, and disease perception) of SAQ, in five of the eight

domains of SF-36 (namely, physical functioning, general health, vitality, social

functioning, and mental health), the physical components summary, mental

components summary, and reported health transition of SF-36 as compared with those

in the C and PE groups. These significantly positive effects were maintained at the 3-

and 6-month follow-up periods, with the exception of those for general health and

reported health transition, which had disappeared by the 6-month follow-up period.

These findings suggest that the TTM-based ESMI could significantly improve the

quality of life of CHD patients, as measured using both disease-specific and generic

instruments.

This is the first study to use both the SAQ and SF-36 to evaluate the effect of the

TTM-based ESMI on quality of life. The limited number of studies on the effects of

the TTM-based stage-matched intervention on quality of life usually used the SF-36

to measure such effects. The positive findings on quality of life with regard to the SF-

294

36 are similar to the results of other studies, which found that a stage-matched

intervention resulted in significantly greater improvements in quality of life

immediately after the intervention according to the SF-36 (Beckie & Beckstead, 2011;

Kirk, Higgins, Hughes et al., 2001). However, these studies did not evaluate the

effects of the intervention during the follow-up period. On the other hand, the findings

of this study are inconsistent with those of Taylor and colleagues (2006), who found

that a lifestyle physical activity programme based on the TTM and social cognitive

theory resulted in no significant improvements in quality of life with respect to the

SF-36 six months after the intervention for patients with prostate cancer. The authors

explained that the lack of significant differences could have been due to the limited

power of the study, because they did not attain their projected sample size. Another

study conducted by Hughes, Mutrie, and Maclntyre (2007) also revealed that an

exercise consultation programme based on the TTM indicated no significant change

in all domains of SF-36 after the 6-month intervention. The authors explained that this

result was due to the high scores in all domains of SF-36 at baseline.

One possible reason for the observed improvements in quality of life in this study may

be that the TTM-based ESMI motivated sedentary CHD patients to change their

exercise behaviour and significantly increased their moderate exercise duration per

week, which subsequently improved their quality of life. In this study, 61.5% of the

patients in the ESMI group were in the action and maintenance stages (regularly

engaging in moderate exercise) immediately after the 8-week intervention, 55.4% at

the 3-month follow-up period, and 41.5% at the 6-month follow-up period as

compared with 4.5%, 7.5%, and 12.0% in the C group, and 17.2%, 29.7%, and 21.9%

in the PE group, respectively. The findings also showed that patients in the ESMI

295

group increased their moderate exercise per week to 231.2 minutes immediately after

the 8-week intervention, 227.5 minutes at the 3-month follow-up period, and 185.6

minutes at the 6-month follow-up period; while the figures were only 17.2, 26.3, and

56.5 minutes for the C group, and 99.1, 125.4, and 94.2 minutes for the PE group. The

significantly more patients in the action and maintenance stages and with a longer

moderate exercise duration per week in the ESMI group as compared with the C and

PE groups may explain why patients in the ESMI group demonstrated better quality

of life with regard to both the SAQ and SF-36, especially in the areas of physical

limitations, treatment satisfaction, disease perception, physical components summary,

and mental components summary, than those in the C and PE groups.

Increasing the duration of exercise per week has been shown to be beneficial to

reducing angina in CHD patients and improving their quality of life with respect to

the SAQ (Burke, Williams & Lockyer, 2002; Franklin, Bonzheim, Warren, Sue, Byl

& Gordon, 2002; Lewin, Furze, Robinson et al., 2002; Senuzun, Fadiloglu, Burke &

Payzin, 2006). Previous studies have demonstrated that regular exercise or physical

activity could increase the ischemic threshold and exercise tolerance of CHD patients

(Cui, Ren, Wang et al., 2006; Hambrecht, Walther, Mobius-Winkler et al., 2004), and

reduce exercise-induced angina (Cui, Ren, Wang et al., 2006), which may explain

why patients in the ESMI group demonstrated greater improvement in physical

limitations as compared with those in the C and PE groups. Previous studies have

shown an inverse relationship between the manifestation of symptoms of angina in

patients and treatment satisfaction and quality of life (Longmore, Spertus, Alexander

et al., 2011; Plomondon, Magid, Masoudi et al., 2007; Scirica, 2009).

296

A number of studies have also demonstrated that regular exercise or exercise-based

cardiac rehabilitation improved the exercise capacity, physical performance, and

quality of life of cardiac patients with respect to the SF-36 (Ades, Pashkow, Fletcher

et al., 2000; Bize, Johnson & Plotnikoff, 2007; Davies, Moxham, Rees et al., 2010;

Hwang & Marwick, 2009; Jeger, Jörg, Rickenbacher et al., 2007; Jiang, Sit, Wong et

al., 2004; Salvetti, Oliveira, Servantes & de Paola, 2008; van Tol, Huijsmans, Kroon

et al., 2006; Willmer & Waite, 2009). This may explain the positive findings for the

ESMI group in the present study, especially with regard to the physical components

summary.

The significantly positive effect on the mental components summary in the ESMI

group suggests that the TTM-based ESMI can improve the psychological well-being

of CHD patients. A previous study has shown that there is a link between exercise

capacity and the mental well-being of CHD patients (Milani & Lavie, 2007). Thus,

increased exercise can yield improvements in the mental well-being of CHD patients,

as has been shown in a number of systematic reviews (Netz, Wu, Becker &

Tenenbaum, 2005; Windle, Hughes, Linck et al., 2010). In this study, the TTM-based

ESMI motivated the sedentary CHD patients to engage in exercise and significantly

increased their exercise duration per week, which may have contributed to its positive

effect on the mental components summary as seen in this study.

However, no significant differences in angina stability and angina frequency were

found among the three groups at each time point. These results are similar to the

findings on angina conditions as mentioned in the patients‘ log records. No significant

differences in angina stability were also seen across time in all three groups. However,

297

a substantial reduction in angina stability was observed in all three groups at the 6-

month follow-up period, especially for the PE and ESMI groups. This phenomenon

was also in line with the angina conditions as reported in the patients‘ log records.

Possible explanations for this phenomenon are that the patients in both the PE and

ESMI groups were motivated and encouraged to engage in exercise. Thus, they may

have increased the intensity of their exercise after the intervention, while those in the

C group maintained their usual level of exercise intensity. The increase in exercise

intensity would result in a greater risk of suffering from angina, which may have

diluted the differences in angina stability and angina frequency between the groups.

However, that no significant differences in angina stability were noted in both the

between and within group comparisons suggests that the current exercise prescription

is safe for CHD patients.

No significant effects of the TTM-based ESMI on bodily pain, role-physical, and role

emotional aspects were found in this study. This finding was similar to the study of

Beckie and Beckstead (2011), who found that a TTM-based cardiac rehabilitation

programme significantly improved the general health, social functioning, vitality, and

mental health of women with CHD with regard to SF-36, while no significant effect

was detected on physical functioning, bodily pain, role-physical, and role-emotional

aspects. These findings suggest that it may be more difficult to bring about changes in

the domains of physiological and mental well-being than in other domains affecting

the functioning of CHD patients. Further research is needed to confirm this claim.

298

6.4 Tracking of the TTM-based ESMI on Exercise Behaviour

In order to determine changes in the trend of exercise behaviour during the 8-week

intervention period, the TTM-based ESMI was tracked with regard to exercise

behaviour. The results are presented and discussed in this section. As shown in Table

6.1, during the 8-week intervention period, the percentage of patients who progressed

to the action stage (engaging in regular exercise) increased over time. Delivering only

one session of the TTM-based ESMI could motivate CHD patients to at least,

consider to engaging in exercise (Contemplation stage) (Table 6.1). In fact, all of the

patients in the ESMI group started to exercise (Preparation and Action stages) at the

fifth week and over 50% of them were motivated to engage in regular exercise

(Action stage) (Table 6.1). The largest percentage of the patients who were motivated

to engage in regular exercise was by the eighth week, with over 70% of the patients in

the action stage (Table 6.1). This finding indicates that the TTM-based ESMI has a

dose-effect on changing exercise behaviour in sedentary CHD patients in China, i.e.,

an increase in the length of the intervention period will lead to an increase in the

number of patients who have progressed to the action stages (Table 6.1). The finding

also suggests that a longer intervention design or a booster intervention during the

follow-up period may improve on or maintain the positive effect on exercise

behaviour in the long-term follow-up period. The finding of the dose-effect on

exercise behaviour in this study is consistent with the results from a systematic review

(Thompson, Chair, Chan, Astin, Davidson & Ski, 2011), which also showed that

effectiveness improves with increased intensity (number and length of contacts).

299

In addition, the finding also showed the dynamic nature of exercise behaviour, in that

patients may move forward or backward in exercise stages of change during the

whole study period. This phenomenon echoes the TTM in that behavioural change is

dynamic and would move forward or backward during the whole process (Prochaska

& DiClemente, 1983; Prochaska & Velicer, 1997). The movement through five stages

does not always occur in a linear manner, but may also be cyclical, as many

individuals must make several attempts at changing their behaviour before they attain

their goals (Marcus, Banspach, Lefebvre, Rossi, Carleton & Abrams, 1992). Thus, it

is very important to assess an individual‘s exercise stages of change each time before

delivering the intervention. This will guarantee the delivery of the most appropriate

and stage-matched intervention for the patient. It is also very important to identify an

individual‘s barriers to exercise and explore ways of overcoming these obstacles so

that the patients will maintain their adherence to an exercise regime for as long as

possible.

Table 6.1 The changes in exercise stages of change in the ESMI group during the

intervention period

wk1

(n=57)

n(%)

wk2

(n=57)

n(%)

wk3

(n=56)

n(%)

wk4

(n=56)

n(%)

wk5

(n=55)

n(%)

wk6

(n=56)

n(%)

wk7

(n=55)

n(%)

wk8

(n=56)

n(%)

PC 6(10.5) 0 0 0 0 0 0 0

C 16(24.6) 4(7.0) 5(8.9) 2(3.6) 0 0 2(3.6) 1(1.8)

P 35(53.8) 39(68.4) 35(62.5) 29(51.8) 25(45.5) 26(46.4) 21(38.2) 15(26.8)

A 0 14(24.6) 16(28.6) 25(44.6) 30(54.5) 30(53.6) 32(58.2) 40(71.4)

PC: Precontemplation; C: Contemplation; P: Preparation; A: Action

300

6.5 Limitations and Controversies of the TTM

Although the Transtheoretical Model (TTM) of behavioural change has been widely

used to bring about changes in various behaviours, including exercise behaviour, and

has demonstrated promising results, it should also be noted that the TTM has a

number of limitations and that there are some controversies surrounding the TTM. In

this section, critiques of the TTM are discussed, and the strategies for dealing with

these critiques are explained. For example, the technique of motivational interviewing

is cited to enhance the validity of the categorisation of stages.

6.5.1 Validity of the categorisation of stages

The TTM emphasizes that behavioural change is a progression through a series of five

stages, namely precontemplation, contemplation, preparation, action, and maintenance

(Prochaska & DiClemente, 1983). The classification of these stages may violate the

assumptions of "qualitative transformations" (Bandura, 1997), especially with regard

to the action and maintenance stages because these two stages only differ in the

duration of behavioural adoption rather than in kind.

The specific problem associated with the categorisation of stages for exercise

behaviour may be due to the potential mismatch between a person's perceived and

actual exercise behaviour according to the TTM. A more specific kind of behaviour

and having a clearer goal or criterion for a specific change in behaviour would enable

people to evaluate their behaviour more accurately and reduce the discrepancy

between subjective assessment and actual exercise behaviour (Povey, Conner, Sparks,

301

James & Shepherd, 1999). It was suggested in a previous study (Reed, Velicer,

Prochaska, Rossi & Marcus, 1997) that clearly describing the stages of change and

using a complete definition of exercise that includes frequency, duration, and intensity,

would increase the validity and reliability of stage categorisation.

During our pilot study, we did encounter the problem of how to accurately categorize

individuals into different stages of change. Thus, after the pilot study, we set a clear

description of the five stages of change and a complete definition of regular exercise

with details on frequency, duration, and intensity, as follows: (i) precontemplation:

individuals are currently not doing exercise and have no intention to start exercising

in the next six months; (ii) contemplation: individuals are aware that a problem exists

with sedentary behaviour and they are seriously thinking about starting to exercise in

the next six months; (iii) preparation: individuals are currently engaging in some

exercise, but not regularly; (iv) action: individuals have been successfully exercising

regularly for less than six months; and (v) maintenance: individuals have been

exercising regularly for more than six months (Marcus, Eaton, Rossi & Harlow, 1994;

Prochaska & DiClemente, 1983). In this study, regular exercise is defined as

accumulating at least 30 minutes (at bouts of at least 10 minutes) of moderate

intensity of physical activity (3-6 METs, RPE 11-13, see examples of moderate

intensity of physical activity in Appendix XII) throughout the day for more than five

days of the week (American College of Sports Medicine, 2006; Marcus, Forsyth &

Blair, 2003).

According to the definition of five stages of change in the present study, the first two

stages are differences in degree of intention (precontemplators have no intention of

302

changing, and the contemplators have some intention of changing in the near future)

which is an important, though not sufficient, condition for behavioural change (Brug,

Conner, Harré, Kremers, McKellar & Whitelaw, 2005). The difference between the

stages of contemplation and preparation is that those in the stage of preparation have

taken some action to change their behaviour, such as engaging in some exercise, but

not regularly. The difference between the stages of preparation and action is that those

in the stage of action engage in regular exercise. The difference between the last two

stages is a difference in duration of behavioural adoption, with six months as a cut-off

point. Considering that the stage of maintenance may be viewed as an extension of the

action stage (Bandura, 1997; Povey et al., 1999), in our actual study we only focused

on the first three stages of the model. This was because, first, we could concentrate on

the motivational nature of the model; and, second, concerns about the validity of the

categorisation of stages could be minimized.

6.5.2 Behavioural change is "nonreversible"

According to the TTM, behavioural change is temporal and dynamic in nature

(Prochaska & DiClemente, 1983). Individuals move forward or backward during the

whole process. Relapse or regression is a common construct used to represent such

reversals (Prochaska & Velicer, 1997). In a genuine stage theory, a change in stage is

nonreversible (Bandura, 1997). However, behavioural change is different from

biological change. It includes relapse and recovery (Bandura, 1997). The findings

from this study showed that CHD patients progressed or regressed in their exercise

stages of change during the whole study period, which is consistent with the argument

that behavioural change is dynamic and will move forward or backward during the

303

whole process, as mentioned by Prochaska and DiClemente (1983) and Prochaska and

Velicer (1997). In a number of studies using the TTM as a framework to motivate

individuals to adopt exercise, this phenomenon was also observed during the process

of change in exercise behaviour (Bock, Marcus & Pinto, 2001; Dutton, Provost, Tan

& Smith, 2008; Kirk, Higgins, Hughes et al., 2001; Marcus, Emmons, Simkin-

Silverman et al., 1998; Purath, Miller, McCabe & Wilbur, 2004). The findings from

these studies also support the reversibility of behavioural change over time. The

phenomenon of the reversibility of behavioural change suggests that health care

professionals should assess an individual's stages of change in specific behaviour each

time before delivering a stage-matched intervention. This phenomenon also suggests

that health care professionals may need to provide support or a booster intervention

during the follow-up period to maintain the healthy change in behaviour over the long

term.

6.5.3 Complexity of physical activity

Physical activity is not a single behaviour, but a complex category of different

specific actions, such as transport behaviours, work-related physical activities, home-

making activities, gardening, and other leisure-time activities, including sports (Brug,

Conner, Harré, Kremers, McKellar & Whitelaw, 2005). Therefore, it is understood

that it is difficult to establish the validity of the TTM for complex health behaviours

(Brug et al., 2005). To deal with this inadequacy in the model, a clear definition of

physical activity was provided in this study. Physical activity refers to any planned

physical activity performed to increase physical fitness (Appendix XII). A complete

definition of regular exercise was also put forward in this study. As reported, using a

304

clear, commonly known, stable goal makes the process of applying the model of

behavioural change more concrete and certainly less difficult (Povey, Conner, Sparks,

James & Shepherd, 1999).

In this study, physical activity was defined as a planned behaviour, different from

addictive behaviours, that is the goal or end-point of behavioural change. In this study,

the goal was to motivate sedentary CHD patients to change their exercise behaviour.

This difference may cause problems for the model, which was originally based on

addictive behaviours (Povey, Conner, Sparks, James & Shepherd, 1999). There may

be many factors, such as environment, gender, age, and socioeconomic position, that

influence exercise behaviour, the motivation to participate in physical activity, and

exercise stages of change (Adams & White, 2005). These factors may be beyond the

scope of the TTM. As such, we once again acknowledge the inadequacy of the TTM

in this aspect. However, we would like to highlight the value of the TTM in

motivating changes in exercise behaviour in sedentary CHD patients. It has ignited a

spark in changing exercise behaviour, which is a critical step in promoting health.

6.5.4 Clinical application of the TTM

The findings from this study indicate that the 8-week TTM-based exercise stage-

matched intervention could set off a spark in sedentary CHD patients to change their

exercise behaviour. We believe that the TTM should play a role in changing health

behaviour. However, we agree that the model takes time to understand. As mentioned,

we experienced difficulties in applying it in the pilot study. To strengthen the clinical

applicability of the TTM, we have used a clear description of the five stages and a

305

complete definition of specific behaviour (e.g., exercise), and set a clear goal and

―end-point‖ of behavioural change in our actual study. These measures can enhance

the validity of stage categorisation and reduce the difficulty of using the model in

clinical practice (Povey, Conner, Sparks, James & Shepherd, 1999; Reed, Velicer,

Prochaska, Rossi & Marcus, 1997).

In addition, we suggest exploring the inclusion of motivational interviewing in future

clinical applications of TTM. Motivational interviewing (Miller & Rollnick, 2002;

Rollnick & Miller, 1995) is a client-centred method of communication that is focused

on enhancing the intrinsic motivation for change. A systematic review was conducted

to examine the related research findings, with specific comments on cardiovascular

health (Thompson, Chair, Chan, Astin, Davidson & Ski, 2011). The conclusion of this

review is that motivational interviewing is a practical front-line approach to

behavioural change. We wonder whether the inclusion of motivational interviewing

will augment the effects of TTM-based exercise stage-matched interventions. Further

studies focusing on this aspect are suggested.

In summary, while the TTM has a couple of limitations and controversies, especially

regarding the validity of stage categorisation and the complexity of physical activity,

the TTM-based ESMI is an effective approach to motivating sedentary CHD patients

to change their exercise behaviour and it is useful for clinical practice. Using a clear

description of five stages and a complete definition of specific behaviour (e.g.,

exercise) could increase the validity of stage categorisation and reduce the difficulty

of using the model in clinical practice. It is suggested that motivational interviewing

306

be included in the clinical application of the TTM. Further studies are recommended

to explore the related effects.

6.6 Role of Nurses in Cardiac Rehabilitation in Mainland China

Cardiac rehabilitation is defined as "the sum of activities required to influence

favourably the underlying causes of cardiac disease, as well as to ensure patients the

best possible physical, mental and social conditions so that they may, by their own

efforts, preserve or resume when lost, as normal a place as possible in the life of the

community" (p. 5) (WHO, 1993). Cardiac rehabilitation consists mainly of patient

education, exercise training, risk factor management, and behavioural change. Cardiac

rehabilitation is usually provided by a multidisciplinary team that includes nurses,

physiotherapists, medical staff, dietitians, psychologists, pharmacists, occupational

therapists, and social workers (Brown, 2009). Thus, cardiac rehabilitation is a

multifactorial, multidisciplinary activity, in which nurses should play a pivotal role in

prevention, education, and the delivery of health care (Stokes, 2000). In the UK, over

80.0% of cardiac rehabilitation programmes are coordinated by nurses (Stokes, 2000).

Nurses are members of the team, but the role of nurses in cardiac rehabilitation has

not been clearly defined both internationally and nationally (Pellatt, 2003). Fridlund

(2002) stated that the role of nurses in cardiac rehabilitation is to act as a container, a

counsellor, a coach, and an educator. As identified by Burton (2000), the nature of a

nurse‘s role in rehabilitation is to be a caregiver, a facilitator of personal recovery, and

a case manager. Smith (1999) found six key roles for nurses in the rehabilitation of an

adult, namely, to act as a technical expert and provider of care, to provide

307

psychological support, and to be an educator, coordinator, team worker, and evaluator.

Another report indicated the following eight categories of roles in rehabilitation

nursing: essential nursing skills, therapeutic practice, coordination, education,

empowerment and advocacy, political awareness, advice and counselling, and clinical

governance (Hawkey & Williams, 2007). A large part of the role of nurses in cardiac

rehabilitation is to provide opportune education in relation to cardiac disease,

cardiovascular risk factors, cardiac misconceptions, vocational and psychosocial

issues, and the secondary prevention of CHD (Brown, 2009).

Although cardiac rehabilitation programmes are well developed in Western countries,

such programmes are new and still underdeveloped in mainland China (Thompson &

Yu, 2007; Wang, Chair, Thompson & Twinn, 2009). Therefore, the role of nurses in

cardiac rehabilitation is also not well developed in mainland China. There is no

―blueprint‖ for nursing education, nor for the quality of nursing education with regard

to cardiac rehabilitation in China. Thus, a clear definition of the role of nurses and

regulations/guidelines regarding their role in cardiac rehabilitation are required to

standardize the role, as well as education requirements, competency standards, and

outcome measurements (Lowe, Plummer, O'Brien & Boyd, 2012; Wang & Xu, 2010).

The development of the field of cardiac rehabilitation requires that a greater emphasis

be placed on training and education for nurses in mainland China. Thus, providing

adequate education and training programmes is essential to strengthening their role in

cardiac rehabilitation (Stokes, 2000). For example, it is recommended that post-

registration training in cardiac rehabilitation be provided for nurses to enhance their

knowledge related to cardiac rehabilitation, their skills on how to provide patient

308

education programmes for CHD patients, and their skills on assessing exercise

behaviour.

The present study showed better changes in exercise behaviour and greater

improvements in the quality of life of CHD patients in both the PE and ESMI groups

as compared with those in the C group. These findings suggest that providing a

patient education programme guided by the TTM or a generic patient education

programme could have positive effects on Chinese CHD patients. Health care

professionals in mainland China could provide this kind of patient education

programme for CHD patients. The role of nurses in this study was to provide patient

education for CHD patients, assess their exercise stages of change, and deliver ESMI

or generic PE through either face-to-face or telephone contacts. The patient education

programme in this study is very simple and easy for nurses to perform. It is estimated

that a nurse with a bachelor‘s degree in nursing education and at least two years of

working experience in cardiovascular disease can provide such a patient education

programme from assessment to evaluation for CHD patients in mainland China.

6.7 Summary

This chapter thoroughly discussed and compared the high participation/completion

rate in this study with that of other studies, the effects of the TTM-based ESMI on the

exercise behaviour and health outcomes of patients with coronary heart disease, and

also discussed the tracking of the TTM-based ESMI on exercise behaviour. The

findings showed that the 8-week TTM-based ESMI was effective at changing exercise

behaviour and improving the quality of life of sedentary patients with CHD. These

309

positive effects of the TTM-based ESMI were maintained nearly to the point of the 6-

month follow-up period, while fading away effects on exercise behaviour were also

observed in this study. The findings suggest that introducing a booster intervention at

around the 6-month follow-up period or adding a support group (e.g., the spouse) to

maintain these positive effects may be considered. Better effects on exercise

behaviour and some domains of quality of life with regard to the SAQ and SF-36 after

the 8-week interventions were observed in the PE group as compared with the C

group, but these results lagged behind those for the ESMI group. These findings

suggest that the structured patient education on cardiac knowledge and exercise is

very important in motivating sedentary CHD patients to change their exercise

behaviour, while general patient education alone may be insufficient to do so. In order

to achieve desirable outcomes in exercise behaviour, the TTM-based ESMI may be a

solution. However, it should also be noted that the TTM has several limitations and

controversies. The findings of this study support the view that nurses have a role to

play in cardiac rehabilitation. Suggestions were made on the development of this role

in cardiac rehabilitation.

310

Chapter 7 Conclusions and Implications

7.1 Introduction

The aim of this study was to examine the effects of the TTM-based ESMI on

sedentary patients with CHD. This chapter contains a discussion of the conclusions

that can be drawn from the findings in this study, an examination of the limitations of

this study, and recommendations for future research. The implications of this study in

relation to clinical practice, nursing education, and the development of health care

policies are also presented.

7.2 Conclusions from the Findings

The TTM-based ESMI has shown itself to be an effective method for bringing about

changes in exercise behaviour in sedentary CHD patients and, consequently,

improving their quality of life. Below are the conclusions that can be drawn from this

study.

7.2.1 Changing Exercise Behaviour

In this study, the ESMI group showed a more positive shift in exercise stages of

change (p < 0.001) and higher exercise self-efficacy (p < 0.001) when compared with

the C and PE groups. The ESMI group also showed better decisional balance in terms

of higher exercise benefits scores (p < 0.001) and lower exercise barriers scores (p <

0.001) than the C and PE groups. Patients in the ESMI group engaged in exercise for

311

a longer duration (minutes/week) (p < 0.001) than the other two groups. To sum up,

the TTM-based ESMI could motivate sedentary CHD patients to engage in exercise.

7.2.5 Reducing Angina

After the TTM-based ESMI was implemented, there was an improvement in anginal

attacks in terms of a significant reduction in frequency (episodes/week) (p < 0.01),

severity (p < 0.01), and duration (minutes/week) (p < 0.001) as compared with the

baseline. No significant differences in these variables were detected among the three

groups at each time point. These findings suggest that the TTM-based ESMI has no

significantly positive effects on reducing anginal attacks in sedentary patients with

CHD.

7.2.6 Improving Quality of Life

The findings from this study have revealed that the ESMI group demonstrated

significantly better quality of life, in terms of improvements in physical limitations (p

< 0.01), treatment satisfaction (p < 0.001), and disease perception (p < 0.001) of SAQ,

and in physical component summary (p < 0.01), mental component summary (p <

0.001), and reported health transition (p < 0.05) of SF-36 in sedentary CHD patients

when compared with the C and PE groups. These findings suggest that the TTM-

based ESMI is an effective method for improving the quality of life of CHD patients,

as seen when both specific and general measurements were used to measure quality of

life.

312

7.3 Limitations of This Study and Recommendations for Future Research

Although this study was conducted based on the evidence of the systematic review,

and employed a high-quality study design, a pilot study, and main study, there were

still several limitations to the study. The findings from this study should be interpreted

with caution due to the following limitations, which future studies should strive to

overcome.

7.3.1 Self-reported Outcome Measurements

In this study, outcome variables were measured based on self-reports. This kind of

outcome measurement may have been affected by social desirability or poor recall,

especially with regard to levels of exercise (Davies, Taylor, Beswick et al., 2010).

Thus, the use of objective measurements, such as pedometers and heart monitors, to

validate self-reported exercise behaviour in such research would be desirable (Davies,

Taylor, Beswick et al., 2010) and is recommended in future studies. In this study, a

log book was used to record the patients‘ engagement in exercise in the past one week.

This could verify the results of self-reported exercise and minimize the possibility of

bias.

7.3.2 Exclusion of Depressive Patients

Patients with depression were not recruited in this study. In this study, the primary

outcome measurement is exercise behaviour. Previous studies have shown that

individuals with depression were less likely to participate in and more likely to

313

withdraw from cardiac rehabilitation programmes than those without depression

(Dorn, Naughton, Imamura & Trevisan, 2001; Taylor, Wilson & Sharp, 2011) and

had poor medical compliance (Lauzon, Beck, Huynh et al., 2003; Thompson & Lewin,

2000; Ziegelstein, Fauerbach, Stevens et al., 2000). In order to avoid bias in the

outcome measurements for changing exercise behaviour, patients with depression

were excluded from this study. This study focused on motivating sedentary CHD

patients to engage in exercise and was not particularly designed for those with

depression. Thus, coming up with an intervention to motivate those with depression to

engage in exercise is another area of future research interest.

7.3.3 No Long-term Follow up

In this study, the effects of the TTM-based ESMI on CHD patients were evaluated

immediately after the completion of the 8-week interventions and at the 3- and 6-

month follow-up periods. Since the long-term (> 6 months) effects of the TTM-based

ESMI could not be confirmed and there was fade away trend, the introduction of a

support group - inviting the patient's spouse or other family members to participating

in the programme together, as a method of maintaining exercise behaviour could be

considered. Adding a booster intervention around the 6-month follow-up period, or

additional strategies or techniques could be adopted for CHD patients to maintain the

positive effects of the intervention in long-term follow-up period. A further study

focusing on these aspects would be of value.

314

7.4 Implications

This discussion on the implications of this study focuses specifically on clinical

practice, nursing education, and policy development.

7.4.1 Implications for Clinical Practice

7.4.1.1 Patient education is an essential part of rehabilitation care

Patient education is an essential part of cardiac rehabilitation. Patients in China lack

knowledge on cardiac rehabilitation (Wong, Chair, Thompson & Twinn, 2009). They

seek information about cardiac rehabilitation and about preventing the recurrence of

MI, especially information about diet and physical activity (Zhu, Ho & Sit, 2012).

Patients in both the PE and ESMI groups received one 2-hour session of patient

education about coronary heart disease. This study showed that patients in both the PE

and ESMI groups were more ready to engage in exercise when compared with the C

group. This finding suggests a need to provide a structured or formal patient education

programme for CHD patients in China.

7.4.1.2 The TTM-based ESMI is an effective way to change exercise behaviour in

CHD patients

The aim of this study was to examine the effects of the TTM-based ESMI on patients

with CHD. The effects on patients with regard to exercise stages of change, exercise

self-efficacy, exercise decisional balance, and exercise duration per week were

315

significantly more positive for those in the ESMI group than for those in the PE and C

groups. This result suggests that the TTM-based ESMI is useful and effective for

encouraging sedentary CHD patients to change their exercise behaviour.

The number of people with CHD in China is growing (Health Statistics Information

Centre of Ministry of Health, 2010; Zhang, Lu & Liu, 2008) and there are multiple

obstacles to developing cardiac rehabilitation programmes in China, including limited

medical resources, the low administrative priority accorded to such programmes,

staffing and time pressures, insufficient knowledge and competence to run such

programmes, and an underdeveloped reimbursement system (Thompson & Yu, 2007;

Wang, Chair, Thompson & Twinn, 2009). An innovative and cost-effective

programme is needed to meet the requirements of the increasing number of people

with CHD. The TTM-based ESMI is a simple, economical, and effective way of

motivating CHD patients to begin exercising and improving their quality of life. The

positive findings in this study can facilitate the introduction of the TTM-based ESMI

to China.

A series of pamphlets for different exercise stages of change was developed in this

study. These exercise stage-matched pamphlets, which motivate patients to engage in

exercise, were tailor-made for Xiamen patients. The strategies and techniques to

motivate Xiamen‘s CHD patients to change their exercise behaviour were identified

in this study. They will play an important role in the development of TTM-based

cardiac rehabilitation programmes for CHD patients in that city. This study also sets

an excellent example for health professionals in the other parts of China to develop

their own set of TTM-based ESMI pamphlets and cardiac rehabilitation programmes.

316

7.4.1.3 Home-based exercise programmes are suitable for Chinese CHD patients

Due to the limited medical resources and underdeveloped reimbursement system in

mainland China, researchers have tried to come up with a cost-effective cardiac

rehabilitation programme for CHD patients. In this study, the TTM-based ESMI,

which can facilitate home-based cardiac rehabilitation, has been shown to be an

effective intervention for motivating sedentary CHD patient to adopt exercise and

improve their quality of life. This kind of home-based exercise programme meets the

rehabilitation care needs of CHD patients through education, face-to-face and

telephone contacts, and an emphasis on patient self-monitoring of an exercise regime

prescribed by a cardiologist. Home-based rehabilitation is well known for its

convenience, cost-effectiveness, high accessibility, and great opportunity for patients

to participate in cardiac rehabilitation. Taking into account the current conditions in

China, the approach of home-based cardiac rehabilitation should be most suitable for

Chinese CHD patients, as well as for those suffering from chronic illnesses.

In addition, Thompson (2007) has pointed out that the trend of the cardiac

rehabilitation development would be a ―hybrid‖ mode, that is, combining both centre-

and home-based rehabilitation care. In this study, patients in the ESMI group received

general patient education at a hospital and were instructed to engage in exercise at

home through face-to-face or telephone contacts. The findings from this study echo

Thompson‘s argument by showing the feasibility of implementing this hybrid mode

of rehabilitation.

317

7.4.2 Implications for nursing education

Nurses form the bulk of the health care workforce in China. Because nurses have the

most contact, and most continuous contact, with patients at all stages of recovery, they

are in a good position to take on responsibilities relating to rehabilitation care (Jiang,

2005). Education is a key strategy for nursing development. A multifaceted and

comprehensive cardiac rehabilitation requires nurses equipped with a wide range of

knowledge and skills. However, little formal education or training is offered to nurses

in China. Several reports have also stated that Chinese health professionals have

insufficient knowledge and competence to run cardiac rehabilitation programmes

(Thompson & Yu, 2007; Wang, Chair, Thompson & Twinn, 2009). Therefore, to

promote the development of cardiac rehabilitation, efforts should be devoted to

educating or training nurses. As Jiang (2005) stated, hospitals can offer rehabilitation

services for cardiac patients by equipping more nurses with knowledge and practical

skills on cardiac rehabilitation.

7.4.3 Implications for health care policy

Most studies on exercise-based cardiac rehabilitation or exercise behaviour have been

conducted in high-income countries. As a result, many of the related clinical and

public health policies being applied in lower-income countries (e.g., China) arise from

studies carried out in high-income regions. There are no existing policies developed

by professional nursing organizations about the roles and responsibilities of nurses in

cardiac rehabilitation in China. This study has shown that patient education plus the

TTM-based ESMI delivered by nurses through face-to-face and telephone contacts is

318

effective at motivating CHD patients to engage in exercise, consequently improving

their quality of life. Policies and guidelines on the role and responsibilities of nurses

in cardiac rehabilitation programmes should be established to guide professional

practice in the domain of cardiac rehabilitation and secondary prevention.

7.5 Summary

The TTM-based ESMI is effective at motivating sedentary CHD patients to engage in

exercise and improve their quality of life. Despite its limitations, this study has

important implications for the field of heath care and health care policy in China, and

has provided numerous useful suggestions for discussion and implementation.

319

References

Aben, I., Verhey, F., Strik, J., Lousberg, R., Lodder, J. & Honig, A. (2003). A

comparative study into the one year cumulative incidence of depression after

stroke and myocardial infarction. Journal of Neurology Neurosurgery and

Psychiatry, 74, 581-585.

Adams, J. & White, M. (2003). Are activity promotion interventions based on the

transtheoretical model effective? A critical review. British Journal of Sports

Medicine, 37, 106-114.

Adams, J. & White, M. (2005). Why don‘t stage-based activity promotion

interventions work? Health Education Research, 20(2), 237-243.

Adamson, J., Lawlor, D.A. & Ebrahim, S. (2004). Chronic diseases, locomotor

activity limitation and social participation in older women: cross sectional survey

of British women‘s heart and health study. Age and Ageing, 33, 293-298.

Ades, P.A., Pashkow, F.J., Fletcher, G., Pina, I.L., Zohman, L.R. & Nestor, J.R.

(2000). A controlled trial of cardiac rehabilitation in the home setting using

electrocardiographic and voice transtelephonic monitoring. American Heart

Journal, 139, 543-548.

Ainsworth, B.E., Haskell, W.L., Whitt, M.C., Irwin M.L., Swartz A.M., Strath S.J. et

al. (1993). Compendium of physical activities: an update of activity codes and

MET intensities. Medicine and Science in Sports and Exercise, 32(9), s498-s516.

Albarran, J.W., Clarke, B.A. & Crawford, J. (2007). Women‘s experiences of

myocardial infarction were described in terms of gradual onset, not having chest

pain, and responding to symptoms. Journal of Clinical Nursing, 16, 1292-1301.

Albert, C.M., Chae, C.U., Rexrode, K.M., Manson, J.E. & Kawachi, I. (2005).

Phobic anxiety and risk of coronary heart disease and sudden cardiac death

among women. Circulation, 111, 480-487.

Aldana, S.G., Greenlaw, R.L., Diehl, H.A., Merrill, R.M., Salberg, A. & Englert, H.

(2008). A video-based lifestyle intervention and changes in coronary risk. Health

Education Research, 23(1), 115-124.

Allen, J. K., Blumenthal, R. S., Margolis, S., Young, D. R., Miller, E. R. & Kelly, K.

(2002). Nurse case management of hypercholesterolemia in patients with

coronary heart disease: results of a randomized clinical trial. American Heart

Journal, 144, 678-686.

Allison, M.J. & Keller, C. (2004). Self-efficacy intervention effect on physical

activity in older adults. Western Journal of Nursing Research, 26, 31-46.

Alm-Roijer, C., Stagmo, M., Udén, G. & Erhardt, L. (2004). Better knowledge

improves adherence to lifestyle changes and medication in patients with coronary

heart disease. European Journal of Cardiovascular Nursing, 3, 321-330.

320

Alsén, P., Brink, E., Persson, L.O., Brändström, Y. & Karlson, B.W. (2010). Illness

perceptions after myocardial infarction: Relations to fatigue, emotional distress,

and health-related quality of life. Journal of Cardiovascular Nursing, 25(2), E1-

E10.

American College of Sports Medicine. (2006). ACSM’s guidelines for exercise testing

and prescription. Philadelphia: Lippincott Williams & Wilkins.

American Heart Association. (2001). Statistics. Available at

http://www.americanheart.org/presenter.jhtml?identifier=1200026

An, L.J., Wu, AP., Du, Y.Y., Ba, J.P., Wang, M., Qi, Y.H., Zhang, Z. & Yuan, B.

(2005). The effects of health instruction and danger awareness‘s patient

education on lifestyle compliance in patients with coronary heart disease.

Chinese Journal of Practical Nursing, 21(11A), 51-52.

Ariyo, A.A., Haan, M., Tangen, C.M., Furberg, C.D., Rutledge, J.C., Cushman, M. &

Dobs, A. (2000). Depression symptoms and risks of coronary heart disease and

mortality in elderly Americans. Circulation, 102, 1773-1779.

Arnold, H.J, Sewell, L. & Singh, S.J. (2007). A comparison of once-versus twice-

weekly supervised phase III cardiac rehabilitation. British Journal of Cardiology,

14(1), 45-48.

Arnold, S.V., Spertus, J.A., Jones, P.G., Xiao, L. & Cohen, D.J. (2009). The impact of

dyspnea on health-related quality of life in patients with coronary artery disease:

Results from the PREMIER registry. American Heart Journal, 157, 1042-1049,

e1.

Arrigo, I., Brunner-LaRocca, H., Lefkovits, M., Pfisterer, M. & Hoffmann, A. (2008).

Comparative outcome one year after formal cardiac rehabilitation: the effects of

a randomized intervention to improve exercise adherence. European Journal of

Cardiovascular Prevention and Rehabilitation, 15, 306-311.

Arthur, H.M., Gunn, E., Thorpe, K.E., Ginis, K.M., Mataseje, L., McCartney, N. &

McKelvie, R.S. (2007). Effect of aerobic vs combined aerobic-strength training

on 1-year, post-cardiac rehabilitation outcomes in women after a cardiac event.

Journal of Rehabilitation Medicine, 39, 730-735.

Arthur, H.M., Smith, K.M., Kodis, J. & McKelvie, R. (2002). A controlled trial of

hospital versus home-based exercise in cardiac patients. Medicine and Science in

Sports and Exercise, 34(10), 1544-1550.

Arthur, H.M., Smith, K.M. & Natarajan, M.K. (2008). Quality of life at referral

predicts outcome of elective coronary artery angiogram. International Journal of

Cardiology, 126, 32-36.

321

Arving, C., Glimelius, B. & Brandberg, Y. (2008). Four weeks of daily assessments

of anxiety, depression and activity compared to a point assessment with the

hospital anxiety and depression scale. Quality Life Research, 17, 95-104.

Asbury, E.A, Slattery, C., Grant, A., Evans, L., Barbir, M. & Collins. P. (2008).

Cardiac rehabilitation for the treatment of women with chest pain and normal

coronary arteries. Journal of the North American Menopause Society, 15(3), 1-7.

Ashton, K.C. (1997). Perceived learning needs of men and women after myocardial

infarction. Journal Cardiovascular Nursing, 12(1), 93-100.

Audelin, M.C., Savage, P.D. & Ades, P.A. (2008). Exercise-based cardiac

rehabilitation for very old patients (≥ 75 years): Focus on physical function.

Journal of Cardiopulmonary Rehabilitation and Prevention, 28, 163-173.

Bandura, A. (1986). Social Foundations of Thought and Action: A Cognitive Social

Theory. Englewood Cliffs, NJ, Prentice Hall.

Bandura, A. (1997) Self-efficacy: The exercise of control. New York: Freeman & Co.

Bandura, A. (1997). The anatomy of stages of change. American Journal of Health

Promotion, 12(1), 8-10.

Barefoot, J.C., Helms, M.J., Mark, D.B., Blumenthal, J.A., Califf, R.M., Haney, T.L.

et al. (1996). Depression and long-term mortality risk in patients with coronary

artery disease. American Journal of Cardiology, 78, 613-617.

Barnason, S., Zimmerman, L., Nieveen, J., Schmaderer, M., Carranza, B. & Reilly, S.

(2003). Impact of a home communication intervention for coronary artery bypass

graft patients with ischemic heart failure on self-efficacy, coronary disease risk

factor modification, and functioning. Heart and Lung, 32, 147-158.

Barnes, S.A., Mallinckrodt, C.H., Lindborg, S.R. & Carter, M.K. (2008). The impact

of missing data and how it is handled on the rate of false-positive results in drug

development. Pharmaceutical Statistics, 7, 215-225.

Barth, J. & Martin, C.R. (2005). Factor structure of the hospital anxiety and

depression scale (HADS) in German coronary heart disease patients. Health and

Quality of Life Outcome, 3, 1-9.

Barth, J., Schumacher, M. & Herrmann-Lingen, C. (2004). Depression as a risk factor

for mortality in patients with coronary heart disease: a meta-analysis.

Psychosomatic Medicine, 66, 802-813.

Batty, G.D., Shipley, M.J., Kivimaki, M., Marmot, M. & Smith, G.D. (2010).

Walking pace, leisure time physical activity, and resting heart rate in relation to

disease-specific mortality in London: 40 years follow-up of the original

Whitehall study. An update of our work with Professor Jerry N. Morris (1910-

2009). Annals of Epidemiology, 20, 661-669.

322

Beckie, T.M. (1989). A supportive-educative telephone programme: impact on

knowledge and anxiety after coronary artery bypass graft surgery. Heart and

Lung, 18(1), 46-55.

Beckie, T.M. (2006). A behaviour change intervention for women in cardiac

rehabilitation. Journal of Cardiovascular Nursing, 21(2), 146-153.

Beckie, T.M. & Beckstead, J.W. (2010). Predicting cardiac rehabilitation attendance

in a gender-tailored randomized clinical trial. Journal of Cardiopulmonary

Rehabilitation and Prevention, 30, 147-156.

Beckie, T.M. & Beckstead, J.W. (2010). The effects of a cardiac rehabilitation

program tailored for women on global quality of life: A randomized clinical trial.

Journal of Women's Health, 19(11), 1977-1985.

Beckie, T.M. & Beckstead, J.W. (2011). The effects of a cardiac rehabilitation

program tailored for women on their perceptions of health: A randomized

clinical trial. Journal of Cardiopulmonary Rehabilitation and Prevention, 31, 25-

34.

Beckie, T.M., Beckstead, J.W. & Schocken, D.D. (2011). The effects of a tailored

cardiac rehabilitation program on depressive symptoms in women: A

randomized clinical trial. International Journal of Nursing Studies, 48, 3-12.

Beckie, T.M., Fletcher, G.F., Beckstead, J.W., Schocken, D.D. & Evans, M.E. (2008).

Adverse baseline physiological and psychosocial profiles of women enrolled in a

cardiac rehabilitation clinical trial. Journal of Cardiopulmonary Rehabilitation

and Prevention, 28, 52-60.

Beinart, S.C., Sales, A.E., Spertus, J.A., Plomondon, M.E., Every, N.R. & Rumsfeld,

J.S. (2003). Impact of angina burden and other factors on treatment satisfaction

after acute coronary syndromes. American Heart Journal, 146, 646-652.

Bengtson, A., Herlitz, J., Karlsson, T. & Hjalmarson, A. (1996). Distress correlates

with the degree of chest pain: a description of patients awaiting revascularisation.

Heart, 75, 257-260.

Bengtsson, I., Hagman, M., Währborg, P. & Wedel, H. (2004). Lasting impact on

health-related quality of life after a first myocardial infarction. International

Journal of Cardiology, 97, 509-516.

Benzer, W., Platter, M., Oldridge, N.B., Schwann, H., Machreich, K., Kullich, W.,

Mayr, K., Philippi, A., Dörler, J. & Höfer, S. (2007). Short-term patient-reported

outcomes after different exercise-based cardiac rehabilitation programmes.

European Journal of Cardiovascular Prevention and Rehabilitation, 14, 441-447.

Berecki-Gisolf, J., Humphreyes-Reid, L., Wilson, A. & Dobson, A. (2009). Angina

symptoms are associated with mortality in older women with ischemic heart

disease. Circulation, 120, 2330-2336.

323

Bergman, E. & Bertero, C. (2003). 'Grasp life again'. A qualitative study of the

motive power in myocardial infarction patients. European Journal of

Cardiovascular Nursing, 2, 303-310.

Bethell, H., Lewin, R., Evans, J., Turner, S., Allender, S. & Petersen, S. (2008).

Outpatient cardiac rehabilitation attendance in England: variability by region and

clinical characteristics. Journal of Cardiopulmonary Rehabilitation and

Prevention, 28, 386-391.

Bittner, V. & Sanderson, B. (2006). Cardiac rehabilitation as secondary prevention

center. Coronary Artery Disease, 17, 211-218.

Bize, R., Johnson, J.A. & Plotnikoff, R.C. (2007). Physical activity level and health-

related quality of life in the general adult population: a systematic review.

Preventive Medicine, 45, 401-415.

Bjelland, I., Dahl, A.A., Haug, T.T. & Neckelmann, D. (2002). The validity of the

Hospital Anxiety and Depression Scale: An updated literature review. Journal of

Psychosomatic Research. 52, 69-77.

Blissmer, B.J. (2000). Integrating the theory of planned behaviour and the

transtheoretical model: a prospective study of lifestyle activity. Dissertation:

University of Illinois at Urbana-Champaign.

Blissmer, B. & McAuley, E. (2002). Testing the requirements of stages of physical

activity among adults: the comparative effectiveness of stage-matched,

mismatched, standard care, and control interventions. Annals of Behavioral

Medicine, 24(3), 181-189.

Blumenthal, J.A., Sherwood, A., Babyak, M.A., Watkins, L.L., Waugh, R.,

Georgiades, A., Bacon, S.L., Hayano, J., Coleman, R.E. & Hinderliter, A. (2005).

Effects of exercise and stress management training on markers of cardiovascular

risk in patients with ischemic heart disease: a randomized controlled trial.

Journal of the American Medical Association, 293(13), 1626-1634.

Bock, B.C., Marcus, B.H., Pinto, B.M. & Forsyth, L.H. (2001). Maintenance of

physical activity following an individualized motivationally tailored intervention.

Annals of Behavioral Medicine, 23(2), 79-87.

Boers, M. (2008). Missing data in trials: Do we have to keep carrying the last

observation forward? Arthritis and Rheumatism (Arthritis Care and Research),

59(1), 2-3.

Boersma, S.N., Maes, S. & Joekes, K. (2005). Goal disturbance in relation to anxiety,

depression, and health-related quality of life after myocardial infarction. Quality

of Life Research, 14, 2265-2275.

Bono, D.D. (1999). Investigation and management of stable angina: revised

guidelines 1998. Heart, 81, 546-555.

324

Borresen, J. & Lambert, M.I. (2008). Quantifying training load: a comparison of

subjective and objective methods. International Journal of Sports Physiology

Performance, 3(1), 16-30.

Briffa, T.G., Maiorana, A., Sheerin, N.J., Stubbs, A.G., Oldenburg, B.F., Sammel,

N.L. & Allan, R.M. (2006). Physical activity for people with cardiovascular

disease: recommendations of the National Heart Foundation of Australia.

Medical Journal of Australia, 184(2), 71-75.

Brink, E., Grankvist, G., Karlson, B.W. & Hallberg, L.R.M. (2005). Health-related

quality of life in women and men one year after acute myocardial infarction.

Quality of Life Research, 14, 749-757.

Broadbent, E., Ellis, C.J., Thomas, J., Gamble, G. & Petrie, K.J. (2009). Further

development of an illness perception intervention for myocardial infarction

patients: A randomized controlled trial. Journal of Psychosomatic Research, 67,

17-23.

Brodie, D. A. & Inoue, A. (2005). Motivational interviewing to promote physical

activity for people with chronic heart failure. Journal of Advanced Nursing,

50(5), 518-527.

Brodie, D.A., Inoue, A. & Shaw, D.G. (2008). Motivational interviewing to change

quality of life for people with chronic heart failure: A randomised controlled trial.

International Journal of Nursing Studies, 45, 489-500.

Brown, A. (2009). The role of a cardiac rehabilitation specialist nurse. British Journal

of Cardiac Nursing, 4(5), 230-232.

Brown, N., Melville, M., Gray, D., Young, T., Munro, J., Skene, A.M. & Hampton,

J.R. (1999). Quality of life four years after acute myocardial infarction: short

form 36 scores compared with a normal population. Heart, 81(4), 352-358.

Brubaker, C., Witta, E.L. & Angelopoulos, T.J. (2003). Maintaining exercise

tolerance and quality of life by long-term participation in a hospital-based

wellness programme for individuals with congestive heart failure. Journal of

Cardiopulmonary Rehabilitation, 23, 352-356.

Brug, J., Conner, M., Harré, N., Kremers, S., McKellar, S. & Whitelaw, S. (2005).

The Transtheoretical model and stages of change: a critique observations by five

commentators on the paper by Adams, J. And White, M. (2004) Why don't stage-

based activity promotion interventions work? Health Education Research, 20(2),

244-258.

Buckworth, J. & Wallace, L.S. (2002). Application of the transtheoretical model to

physically active adults. Journal of Sports Medicine and Physical Fitness, 42,

360-367.

Burbank, P.M., Padula, C.A. & Nigg, C.R. (2000). Changing health behaviours of

older adults. Journal of Gerontological Nursing, 26(3), 26-33.

325

Burbank, P.M., Reibe, D., Padula, C.A. & Nigg, C. (2002). Exercise and older adults:

changing behaviour with the transtheoretical model. Orthopaedic Nursing, 21(4),

51-63.

Burke, D., Williams, A. & Lockyer, L. (2002). The development of a nurse-led angina

management programme. Professional Nurse, 18(2), 86-90.

Burkholder, G.J. & Nigg, C.C. (2002). Overview of the Transtheoretical Model. In P.

M. Burbank & D. Riebe (Eds). Promoting exercise and behaviour change in

older adults. Interventions with the Transtheoretical Model. New York: Springer

Publishing Company, Inc.

Burns, K.J., Camaione, D.N., Froman, R. & Clark III, B.A. (1998). Predictors of

referral to cardiac rehabilitation and cardiac exercise self-efficacy. Clinical

Nursing Research, 7(2), 147-163.

Burton, C.R. (2000). A description of the nursing role in stroke rehabilitation. Journal

of Advanced Nursing, 32(1), 174-181.

Butler, L., Furber, S., Phongsavan, P., Mark, A. & Bauman, A. (2009). Effects of a

pedometer-based intervention on physical activity levels after cardiac

rehabilitation: A randomized controlled trial. Journal of Cardiopulmonary

Rehabilitation and Prevention, 29, 105-114.

Calfas, K.J., Long, B.J., Sallis, J.F., Wooten, W.J., Pratt, M. & Patrick, K. (1996). A

controlled trial of physician counselling to promote the adoption of physical

activity. Preventive Medicine, 25, 225-233.

Cameron, L.D., Petrie, K.J., Ellis, C.J., Buick, D. & Weinman, J.A. (2005). Trait

negative affectivity and responses to a patient education intervention for

myocardial infarction patients. Psychology and Health, 20(1), 1-18.

Campbell, N. C., Ritchie, L. D., Thain, J., Deans, H. G., Rawles, J. M. & Squair, J. L.

(1998). Secondary prevention in coronary heart disease: a randomised trial of

nurse led clinics in primary care. Heart, 80, 447-452.

Cannistra, L.B., Balady, G.J., O‘Malley, C.J., Weiner, D.A. & Ryan, T.J. (1992).

Comparison of the clinical profile and outcome of women and men in cardiac

rehabilitation. American Journal of Cardiology, 69, 1274-1279.

Cardinal, B.J. (1997). Construct validity of stages of change for exercise behaviour.

American Journal of Health Promotion, 12(1), 68-74.

Cardinal, B.J. & Sachs, M.L. (1996). Effects of mail-mediated, stage-matched

exercise behavior change strategies on female adults ‗leisure-time‘ exercise

behavior. Journal of Sports Medicine and Physical Fitness, 36(2), 100-107.

Cardiovascular Outcomes Inc. Scoring instruction for Seattle Angina Questionnaire -

2010 update. Available at: http://cvoutcomes.org/licenses/4008.

Cardiovascular%20Outcomes%20Inc.%20Scoring%20instruction%20for%20Seattle%20Angina%20Questionnaire%20-%202010%20update.%20From%20http:/cvoutcomes.org/licenses/4008.

Cardiovascular%20Outcomes%20Inc.%20Scoring%20instruction%20for%20Seattle%20Angina%20Questionnaire%20-%202010%20update.%20From%20http:/cvoutcomes.org/licenses/4008.

326

Carvalho, V.O., Bocchi, E.A. & Guimarães, G.V. (2009). The Borg Scale as an

important tool of Self-monitoring and self-regulation of exercise prescription in

heart failure patients during hydrotherapy: A randomized blinded controlled trial.

Circulation Journal, 73, 1871-1876.

Cay, E.L., Vetter, N., Philip, A. & Dugard, P. (1973). Return to work after a heart

attack. Journal of Psychosomatic Research, 17, 231-243.

Census and Statistics Department. (2011). Hong Kong Annual Digest of Statistics.

Government Printer, Hong Kong.

Chan, D.S.K., Chau, J.P.C. & Chang, A.M. (2005). Acute coronary syndromes:

cardiac rehabilitation programmes and quality of life. Journal of Advanced

Nursing, 49(6), 591-599.

Chan, V. (1990). Content areas for cardiac teaching: patients‘ perceptions of the

importance of teaching content after myocardial infarction. Journal of Advanced

Nursing, 15, 1139-1145.

Chair, S.Y., Chan, S.W.C., Thompson, D.R., Leung, K.P., Ng, S.K.C. & Choi, K.C.

(2011). Short-term effect of motivational interviewing on clinical and

psychological outcomes and health-related quality of life in cardiac rehabilitation

patients with poor motivation in Hong Kong: a randomized controlled trial.

European Journal of Cardiovascular Prevention & Rehabilitation, 0(00), 1-10.

Chair, S.Y., Lee, S.F., Lopez, V. & Ling, E.M. (2007). Risk factors of Hong Kong

Chinese patients with coronary heart disease. Journal of Clinical Nursing, 16,

1278-1284.

Chair, S.Y., Thompson, D.R., Tang, S.W. & Leung, K.P. (2007). The effect of cardiac

rehabilitation on changing patients' clinical outcomes. British Journal of Cardiac

Nursing, 2(4), 198-202.

Chen, J.P., Gu, W.P., Lu, E.B. & Yang, L.C. (1997). A survey of emotional disorder

in patients with coronary heart disease. Chinese Journal of Mental Health, 11(3),

143-144.

Chen, N.Y., Meng, X.Y., Wei, B., Zhang, Y. & Feng, Q.M. (2007). Epidemiological

features of coronary heart disease in urban residents of Guangxi province.

Practical Preventive Medicine, 14(5), 1384-1386.

Chen, N.Y., Wei, B., Meng, X.Y., Wu, G.W., Wang, F., Xie, Y.H. & Zhang, Y.

(2005). Epidemiologycial survey and analysis of coronary heart disease from

urban residents in Gungxi. Guangxi Preventive Medicine, 11(2), 65-67.

Chen, W. & Jing, N.L. (2008). An investigation and analysis of educational needs of

patients with coronary heart disease. Family Nurse, 6(1A), 16.

327

Chen, Z.M. & Whitlock, G. (2009). Unveiling the causes of heart disease in China.

Heart, 95(22), 1818-1819.

Cohen, J. (1988). Statistical power analysis for the behavioural sciences. New Jersey:

Lawrence Erlbaum Associate, Inc.

Condon, C. & McCarthy, G. (2006). Lifestyle changes following acute myocardial

infarction: Patients perspectives. European Journal of Cardiovascular Nursing, 5,

37 - 44.

Conn, V.S. (2010). Anxiety outcomes after physical activity interventions: meta-

analysis findings. Nursing Research, 59(3), 224-231.

Conn, V.S., Hafdahl, A.R., Brown, S.A. & Brown, L.M. (2008). Meta-analysis of

patient education interventions to increase physical activity among chronically ill

adults. Patient Education and Counselling, 70(2), 157-172.

Conn, V.S., Hafdahl, A.R., Cooper, P.S., Brown, L.M. & Lusk, S.L. (2009). Meta-

analysis of workplace physical activity interventions. American Journal of

Preventive Medicine, 37(4), 330-339.

Conn VS, Valentine JC, Cooper HM. (2002). Interventions to increase physical

activity among aging adults: A meta-analysis. Annals of Behavioral Medicine,

24(3), 190-200.

Corcoran, W.E. & Durham, C.F. (2000). Quality of life as an outcome-based

evaluation of coronary artery bypass graft critical paths using the SF-36. Quality

Management in Health Care, 8(2), 72-81.

Cornelissen, V.A., Verheyden, B., Aubert, A.E. & Fagard, R.H. (2010). Effects of

aerobic training intensity on resting, exercise and post-exercise blood pressure,

heart rate and heart-rate variability. Journal of Human Hypertension, 24, 175-

182.

Coull, A. J., Taylor, V. H., Elton, R., Murdoch, P. S. & Hargreaves, A. D. (2004). A

randomised controlled trial of senior Lay Health Mentoring in older people with

ischaemic heart disease: The Braveheart Project. Age and Ageing, 33, 348-354.

Courneya, K.S. (1995). Understanding readiness for regular physical activity in older

individuals: an application of the Theory of Planned Behaviour. Health

Psychology, 14(1), 80-87.

Critchley, J., Liu, J., Zhao, D., Wei, W. & Capewell, S. (2004). Explaining the

increase in coronary heart disease mortality in Beijing between 1984 and 1999.

Circulation, 110, 1236-1244.

Cruz, L.N., Fleck, M.P.d.A. & Polanczyk, C.A. (2010). Depression as a determinant

of quality of life in patients with chronic disease: data from Brazil. Social

Psychiatry and Psychiatric Epidemiology, 45, 953-961.

328

Cui, F., Ren, Y.S., Wang, H.F., Li, L., Mu, X. & Ma, H. (2006). Effects of

rehabilitation training on exercise tolerance of patients with coronary heart

disease after percutaneous coronary intervention. Chinese Journal of Physical

Medical Rehabilitation, 28(3), 177-179.

Cupples, M.E. & McKnight, A. (1994). Randomised controlled trial of health

promotion in general practice for patients at high cardiovascular risk. British

Medical Journal, 309(6960), 993-996.

Czar, M.L., MlittNsg, E. & Engler, M.M. (1997). Perceived learning needs of patients

with coronary artery disease using a questionnaire assessment tool. Journal of

Acute and Critical Care, 26(2), 109-117.

Dalal, H.M. & Evans, P.H. (2003). Achieving national service framework standards

for cardiac rehabilitation and secondary prevention. British Medical Journal, 326,

481-484.

Dalal, H.M., Evans, P.H., Campbell, J.L., Taylor, R.S., Watt, A., Read, K.L.Q.,

Mourant, A.J., Wingham, J., Thompson, D.R. & Pereira Gray, D.J. (2007).

Home-based versus hospital-based rehabilitation after myocardial infarction: a

randomized trial with preference arms – Cornwall Heart Attack Rehabilitation

Management Study (CHARMS). International Journal of Cardiology, 119, 202-

211.

Dalal, H.M., Zawada, A., Jolly, K., Moxham, T. & Taylor, R.S. (2010). Home based

versus centre based cardiac rehabilitation: Cochrane systematic review and meta-

analysis. British Medical Journal, 340, bs631. doi:10.1136/bmj.b5631.

Davies, E.J., Moxham, T., Rees, K., Singh, S., Coats, A.J.S., Ebrahim, S., Lough, F.

& Taylor, R.S. (2010). Exercise based rehabilitation for heart failure. Cochrane

Database of Systematic Reviews, Issue 4. Art No.: CD003331. DOI:

10.1002/14651858. CD003331. pub3.

Davies, P., Taylor, F., Beswick, A., Wise, F., Moxham, T., Rees, K. & Ebrahim, S.

(2010). Promoting patient uptake and adherence in cardiac rehabilitation.

Cochrane Database of Systematic Reviews, Issue 7. Art. No.: CD007131. DOI:

10.1002/14651858.CD007131.pub2.

Day, M.L., McGuigan, M.R., Brice, G. & Foster, C. (2004). Monitoring exercise

intensity during resistance training using the session RPE scale. Journal of

Strength and Conditioning Research, 18(2), 353-358.

de Geus, B., van Hoof, E., Aerts, I. & Meeusen, R. (2008). Cycling to work: influence

on indexes of health in untrained men and women in Flanders. Coronary heart

disease and quality of life. Scandinavian Journal of Medicine and Science in

Sports, 18, 498-510.

De Meester, F., van Lenthe, F.J., Spittaels, H., Lien, N. & De Bourdeaudhuij, I.

(2009). Interventions for promoting physical activity among European teenagers:

329

a systematic review. International Journal of Behavioral Nutrition and Physical

Activity, 6, 82.

de Vet, E., de Nooijer, J., de Vries, N.K. & Brug, J. (2008). Testing the

transtheoretical model for fruit intake: comparing web-based tailored stage-

matched and stage-mismatched feedback. Health Education Research, 23(2),

218-227.

Deaton, C. & Namasivayam, S. (2004). Nursing outcomes in coronary heart disease.

Journal of Cardiovascular Nursing, 19(5), 308-315.

DeBusk, R.F., Stenestrand, U., Sheehan, M. & Haskell, W.L. (1990). Training effects

of long versus short bouts of exercise in healthy subjects. American Journal of

Cardiology, 65, 1010-1013.

Department of Health. (2011). Department of Health Annual Report 2010/2011.

Government Printer, Hong Kong.

Dempster, M. & Donnelly, M. (2000). Measuring the health related quality of life of

people with ischemic heart disease. Heart, 83, 641-644.

Dickens, C.M., McGowan, L., Percival, C., Tomenson, B., Cotter, L., Heagerty, A. &

Creed, F.H. (2006). Contribution of depression and anxiety to impaired health-

related quality of life following first myocardial infarction. British Journal of


Dolansky, M.A. & Moore, S.M. (2004). Effects of cardiac rehabilitation on the

recovery outcomes of older adults after coronary artery bypass surgery. Journal

of Cardiopulmonary rehabilitation, 24, 236-244.

Donovan, R.J., Jones, S., Holman, C.D.A. & Corti, B. (1998) Assessing the reliability

of a stage of change scale. Health Education Research, 13(2), 285-291.

Dorjgochoo, T., Shu, X.O., Zhang, X.G., Li, H.L., Yang, G., Gao, L.F., Cai, H., Gao,

Y.T. & Zheng, W. (2009). Relation of blood pressure components and categories

and all-cause, stroke and coronary heart disease mortality in urban Chinese

women: a population-based prospective study. Journal of Hypertension, 27, 468-

475.

Dorn, J., Naughton, J., Imamura, D. & Trevisan, M. (2001). Correlates of compliance

in a randomized exercise trial in myocardial infarction patients. Medicine and

Science in Sports and Exercise, 33(7), 1081-1089.

Dougherty, C.M, Dewhurst, T., Nichol, W.P. & Spertus, J. (1998). Comparison of

three quality of life instruments in stable angina pectoris: Seattle Angina

Questionnaire, Short Form Health Survey (SF-36), and Quality of Life Index-

Cardiac Version III. Journal of Clinical Epidemiology, 51(7), 569-575.

Dressendorfer, R.H., Franklin, B.A., Cameron, J.L., Trahan, K.J., Gordon, S. &

Timmis, G.C. (1995). Exercise training frequency in early post-infarction cardiac

330

rehabilitation: Influence on aerobic conditioning. Journal of Cardiopulmonary

Rehabilitation, 15, 269-276.

Du, C.L., Chen, Z.Y. & Liu, S.Q. (2005). Investigation and analysis of educational

needs and strategies in patients with coronary heart disease. Journal of North

China Coal Medical College, 7(1), 87-88.

Du, X.L., Jiang, Y.F., Yang, H.M., Ai, H. & Gu, X.F. (2003). Analysis of depression

mood and related factors of hospitalized patients with coronary heart disease.

Chinese Journal of Nursing, 38(10), 761-764.

Dumas, J.E., Lynch, A.M., Laughlin, J.E., Smith, E.P. & Prinz, R.J. (2001).

Promoting intervention fidelity: Conceptual issues, methods, and preliminary

results from the EARLY ALLIANCE prevention trial. American Journal of

Preventive Medicine, 20(1S), 38-47.

Duryée, R. (1992). The efficacy of inpatient education after myocardial infarction.

Heart and Lung, 21(3), 217-225.

Dusseldorp, E., van Elderen, T., Maes, S., Meulman, J. & Kraaij, V. (1999). A meta-

analysis of psychoeducational programmes for coronary heart disease patients.

Health Psychology, 18(5), 506-519.

Dutton, G.R., Provost, B.C., Tan, F. & Smith, D. (2008). A tailored print-based

physical activity intervention for patients with type 2 diabetes. Preventive

Medicine, 47, 409-411.

Dwyer, T., Emmanuel, S.C., Janus, E.D., Wu, Z., Hynes, K.L. & Zhang, C. (2003).

The emergence of coronary heart disease in populations of Chinese descent.

Atherosclerosis, 67, 303-310.

Earle, A., Ayanian, J.Z. & Heymann, J. (2006). Work resumption after newly

diagnosed coronary heart disease: findings on the importance of paid leave.

Journal of Women’s Health, 15(4), 430-441.

Elderen, T.V., Maes, S. & Seegers, G. (1994). Effects of a post-hospitalization group

patient education programme for patients with coronary heart disease.

Psychology and Health, 9, 317-330.

Elley, C.R., Kerse, N., Arroll, B. & Robinson, E. (2003). Effectiveness of counselling

patients on physical activity in general practice: cluster randomised controlled

trial. British Medical Journal, 326, 1-6.

Elobeid, M.A., Padilla, M.A., McVie, T., Thomas, O., Brock, D.W., Musser, B., et al.

(2009). Missing data in randomized clinical trials for weight loss: scope of the

problem, state of the field, and performance of statistical methods. PloS ONE,

4(8), e6624. doi:10.1371/journal.pone.0006624.

Emaus, A., Degerstrøm, J., Wilsgaard, T., Hansen, B.H., Dieli-Conwright, C.M.,

Furberg, A.S., Pettersen, S.A., Andersen, L.B., Eggen, A.E., Bernstein, L. &

331

Thune, I. (2010). Does a variation in self-reported physical activity reflect

variation in objectively measured physical activity, resting heart rate, and

physical fitness? Results from the Tromsø study. Scandinavian Journal of Public

Health, 38, 105-118.

Eston, R.G. & Thompson M. (1997) Use of ratings of perceived exertion for

predicting maximal work rate and prescribing exercise intensity in patients

taking atenolol. British Journal of Sports Medicine, 31, 114-119.

Evenson, K.R., Johnson, A. & Aytur, S.A. (2006). Five-year changes in North

Carolina outpatient cardiac rehabilitation. Journal of Cardiopulmonary


Fagard, R.H. & Cornelissen, V.A. (2007). Effect of exercise on blood pressure control

in hypertensive patients. European Journal of Cardiovascular Prevention and

Rehabilitation, 14(1), 12-17.

Faghri, P.D., Omokaro, C., Parker, C., Nichols, E., Gustavesen, S. & Blozie, E.

(2008). E-technology and pedometer walking program to increase physical

activity at work. Journal of Primary Prevention, 29, 73-91.

Fahrenwald, N.L., Atwood, J.R., Walker, S.N., Johnson, D.R. & Berg, K. (2004). A

randomized pilot test of ―Moms on the Move‖: A physical activity intervention

for WIC mothers. Annals of Behavioral Medicine, 27(2), 82-90.

Failde, I. & Ramos, I. (2000). Validity and reliability of the SF-36 health survey

questionnaire in patients with coronary artery disease. Journal of Clinical

Epidemiology, 53, 359-365.

Failde, I.I. & Soto, M.M. (2006). Changes in health related quality of life 3 months

after an acute coronary syndrome. BMC Public Health, 6, 18.

Fang, J.Q. (2005). Short form 36 health survey questionnaire, SF-36. In Z.J. Zhang

(Ed). A handbook of behavioural medical scale. Beijing: Chinese Medical

Electronic Audio-Video Publishing House.

Fang, M., Sun, Y. & Zhao, J.H. (2006). Research on stage of changes model of

exercise behaviour among adolescents. Chinese Journal of Public Health, 22(8),

209-210.

Fei, X., You, G.Y. & Huang, Y. (2007). The effects of patient education through

nursing process on compliance in patients with coronary heart disease. Modern


Findorff, M.J., Stock, H.H., Gross, C.R. & Wyman, J.F. (2007). Does the

transtheoretical mode (TTM) explain exercise behaviour in a community-based

sample of older women? Journal of Aging Health, 19, 985-1003.

332

Fitzsimons, D., Parahoo, K. & Stringer, M. (2000). Waiting for coronary artery

bypass surgery: a qualitative analysis. Journal of Advanced Nursing, 32(5),

1243-1252.

Fletcher, B. & Braun, L.T. (2008). Sedentary Lifestyle. In Moser, D.K. & Riegel, B.

(Ed). Cardiac Nursing: A Companion to Braunwald’s Heart Disease. USA:

Saunders Elserier Inc. 2008. p485.

Foot, D.K., Lewis, R.P., Pearson, T.A. & Beller, G.A. (2000). Demographics and

cardiology, 1950-2050. Journal of the American College of Cardiology, 35(5,

suppl B), 66B-80B

Fortmann, S.P., Taylor, C.B., Folra, J.A. & Winkleby, M.A. (1992). Effect of

community patient education on plasma cholesterol levels and diet: the Stanford

Five-City Project. American Journal of Epidemiology, 137, 1039-1055.

Fortmann, S.P., Williams, P.T., Hulley, S.B., Maccoby, N. & Farquhar, J.W. (1982).

Does dietary patient education reach only the privileged? The Stanford Three

Community Study. Circulation, 66(1), 77-82.

Franklin, B.A., Bonzheim, K., Warren, J., Sue, H., Byl, N. & Gordon, N. (2002).

Effects of a contemporary, exercise-based rehabilitation and cardiovascular risk-

reduction programme on coronary patients with abnormal baseline risk factors.

Chest, 122(1), 338-343.

Frasure-smith, N., Lesperance, F. & Talajic, M. (1995). The impact of negative

emotions on prognosis following myocardial infarction: is it more than

depression? Health Psychology, 14(5), 388-398.

Fridlund, B. (2002). The role of the nurse in cardiac rehabilitation programmes.

European Journal of Cardiovascular Nursing, 1(1), 15-18.

Furze, G., Bull, P., Lewin, R.J., & Thompson, D.R. (2003). Development of the york

angina beliefs questionnaire. Journal of Health Psychology, 8, 307-314.

Fuster, V. (2007). A new perspective on non-prescription statins: an opportunity for

patient education and involvement. American Journal of Cardiology, 100, 907-

910.

Gary, R. (2006). Exercise self-efficacy in older women with diastolic heart failure.

Journal of Gerontological Nursing, 31-39.

Giallauria, F., Lucci, R., D‘Agostino, M., Vitelli, A., Maresca, L., Mancini, M., et al.

(2009). Two-year multicomprehensive secondary prevention program: favorable

effects on cardiovascular functional capacity and coronary risk profile after acute

myocardial infarction. Journal of Cardiovascular Medicine, 10, 772-780.

Giannuzzi, P., Temporelli, P.L., Marchioli, R., Maggioni, A.P., Balestroni, G., Ceci,

V., Chieffo, C., Gattone, M., Griffo, R., Schweiger, C., Tavazzi, L., Urbinati, S.,

Valagussa, F. & Vanuzzo, D. (2008). Global secondary prevention strategies to

333

limit event recurrence after myocardial infarction. Archives of Internal Medicine,

168(20), 2194-2204.

Glanz, K., Rimer, B.K. & Lewis, F.M. (Ed). (2002). Health behaviour and health

education: theory, research, and practice. San Francisco: Jossey-Bass, c2002.

Goel, K., Lennon, R.J., Tilbury, T., Squires, R.W. & Thomas, R.J. (2011). Impact of

cardiac rehabilitation on mortality and cardiovascular events after percutanesous

coronary intervention in the community. Circulation, 123, 2344-2352.

Goldman, L. & Cook, E.F. (1984). The decline in ischemic heart disease mortality

rates: An analysis of the comparative effects of medical interventions and

changes in lifestyle. Annals of Internal Medicine, 101, 825-836.

Goldstein, M.G., Pinto, B.M., Marcus, B.H., Lynn, H., Jette, A.M., Rakowski, W.,

McDermott, S., DePue, J.D., Milan, F.B., Dubé, C. & Tennstedt, S. (1999).

Physician-based physical activity counselling for middle-aged and older adults:

A randomized trial. Annals of Behavioral Medicine, 21(1), 40-47.

Goto, Y., Saito, M., Iwasaka, T., Daida, H., Kohzuki, M., Ueshima, K., Makita, S.,

Adachi, H., Yokoi, H., Omiya, K., Mikouchi, H. & Yokoyama, H. (2007). Poor

implementation of cardiac rehabilitation despite broad dissemination of coronary

interventions for acute myocardial infarction in Japan: a nationwide survey.

Circulation Journal, 71(2), 173-179.

Greaney, M.L., Riebe, D., Garber, C.E., Rossi, J.S., Lees, F.D., Burbank, P.A., Nigg,

C.R., Ferrone, C.L. & Clark, P.G. (2008). Long-term effects of a stage-based

intervention for changing exercise intentions and behaviour in older adults. The

Gerontologist, 48(3), 358-367.

Griffin-Blake, C.S. & DeJoy, D.M. (2006). Evaluation of social-cognitive versus

stage-matched, self-help physical activity interventions at the workplace.


Gulanick, M. (1991). Is phase 2 cardiac rehabilitation necessary for early recovery of

patients with cardiac disease? A randomized, controlled study. Heart and Lung,

20, 9-15.

Gump, B.B., Matthews, K.A., Eberly, L.E. & Chang, Y. (2004). Depression

symptoms and mortality in men: results from the multiple risk factor intervention

trial. Stroke, 36, 98-102.

Hagan, N.A., Botti, M.A. & Watts, R.J. (2007). Financial, family, and social factors

impacting on cardiac rehabilitation attendance. Heart and Lung, 36, 105-113.

Halm, M., Penque, S., Doll, N. & Beahrs, M. (1999). Women and cardiac

rehabilitation: referral and compliance patters. Journal of Cardiovascular

Nursing, 13(3), 83-92.

334

Hambrecht, R., Walther, C., Möbius-Winkler, S., Gielen, S., Linke, A., Conradi, K.,

Erbs, S., Kluge, R., Kendziorra, K., Sabri, O., Sick, P. & Schuler, G. (2004).

Percutaneous coronary angioplasty compared with exercise training in patients

with stable coronary artery disease: A randomized trial. Circulation, 109, 1371-

1378.

Hanssen, T.A., Nordrehaug, J.E., Eide, G.E. & Hanestad, B.R. (2007). Improving

outcomes after myocardial infarction: a randomized controlled trial evaluating

effects of a telephone follow-up intervention. European Journal of

Cardiovascular Prevention and Rehabilitation, 14(3), 429-437.

Hanssen, T.A., Nordrehaug, J.E., Eide, G.E. & Hanestad, B.R. (2009). Does a

telephone follow-up intervention for patients discharged with acute myocardial

infarction have long-term effects on health-related quality of life? A randomised

controlled trial. Journal of Clinical Nursing, 18, 1334-1345.

Hanssen, T.A., Nordrehaug, J.E. & Hanestad, B.R. (2005). A qualitative study of the

information needs of acute myocardial infarction patients, and their preferences

for follow-up contact after discharge. European Journal of Cardiovascular

Nursing, 4, 37- 44.

Haskell, W.L. (1994). The efficacy and safety of exercise programmes in cardiac

rehabilitation. Medicine and Science in Sports and Exercise, 26(7), 815-823.

Hawkey, B. & Williams, J. (2007). Role of the rehabilitation nurse. London: the

Royal College of Nursing, 20 Cavendish Square, London, W1G0RN.

He, X.L., Guo, C.X. & Guo, Y.Y. (2007). Investigation of demands of coronary heart

disease patients at different phases for patient education. Journal of Nursing,

14(3), 23-25.

Health Statistics Information Centre of the Ministry of Health, P.R.China. (2007). An

Annual Report of Chinese Health Statistic - 2007. Available at:

http://www.moh.gov.cn/publicfiles (accessed 1 October, 2007)

Health Statistics Information Centre of the Ministry of Health, P.R.China. (2010). An

Annual Report of Chinese Health Statistic - 2010. Available at:

http://www.moh.gov.cn/publicfiles (accessed 12 April 2011).

Hellman, E.A. (1997). Use of the stages of change in exercise adherence model

among older adults with a cardiac diagnosis. Journal of Cardiopulmonary


Hellsten, L., Nigg, C., Norman, G., Burbank, P., Braun, L., Breger, R., Coday, M.,

Elliot, D., Garber, C., Greaney, M., Lees, F., Matthews, C., Moe, E., Resnick, B.,

Riebe, D., Rossi, J., Toobert, D. & Wang, T. (2008). Accumulation of

behavioural validation evidence for physical activity stage of change. Health

Psychology, 27(Supple. 1), s43-s53.

http://www.moh.gov.cn/publicfiles

Health%20Statistics%20Information%20Centre%20of%20the%20Ministry%20of%20Health,%20P.R.China.%20(2010).%20An%20Annual%20Report%20of%20Chinese%20Health%20Statistic%20-%202010.%20Available%20at:%20http:/www.moh.gov.cn/publicfiles%20(accessed%2012%20April%202011).



335

Hemingway, H. & Marmot, M. (1999). Evidence based cardiology: psychosocial

factors in the aetiology and prognosis of coronary heart disease: systematic

review of prospective cohort studies. British Medical Journal. 318, 1460-1467.

Herman, A., Botser, I.B., Tenenbaum, S. & Chechick, A. (2009) Intention-to-treat

analysis and accounting for missing data in orthopaedic randomized clinical

trials. Journal of Bone and Joint Surgery, 91, 2137-2143.

Herry N, H.R.K., Suryadipradja, H.R.M., Shatri, H. & Prodjosudjadi, W. (2005). The

influence of depression on the quality of life of male patients post acute

myocardial infarct. Acta Medicine Indones – Indones Journal of Internal

Medicine, 37(2), 71-78.

Higgins, R.O., Murphy, B.M., Le Grande, M.R., Parkinson, A., Worcester, M.U.C., &

Goble, A.J. (2005). Expressed preferences for patient education of patients after

percutaneous coronary intervention. European Journal of Cardiovascular

Prevention and Rehabilitation, 12, 572-579.

Ho, J.E., Bittner, V., DeMicco, D.A., Breazna, A., Deedwania, P.C. & Waters, D.D.

(2010). Usefulness of heart rate at rest as a predictor of mortality, hospitalization

for heart failure, myocardial infarction, and stroke in patients with stable

coronary heart disease (data from the Treating to New Targets [TNT] Trial).

American Journal of Cardiology, 105, 905-911.

Hofman-Bang, C., Lisspers, J., Nordlander, R., Nygren, A., Sundin, O., Öhman, A. &

Rydén, L. (1999). Two-year results of a controlled study of residential

rehabilitation for patients treated with percutaneous transluminal coronary

angioplasty. A randomized study of a multifactorial programme. European Heart

Journal, 20, 1465-1474.

Hogan, C.A. & Neill, W.A. (1982). Effects of a teaching program on knowledge,

physical activity, and socialization in patients disabled by stable angina pectoris.

Journal of Cardiac Rehabilitation, 2(5), 379-385.

Hospital Authority. (2009/2010). Hospital Authority Statistical Report: Hong Kong,

China: Hong Kong Hospital Authority.

Hou, D.X. (2005). An investigation on psycho-problems of middle-aged in-patients

with coronary heart disease. Journal of Clinical Psychosomatic Disease, 11(1),

48-49.

Hou, Y.F., Zhou, F.C. & Zhang, X.H. (2003). The effects of patient education on

patients‘ early post-operative complication following percutaneous coronary

intervention. Shandong Medical Journal, 43(8), 57.

Hravnak, M., Whittle, J., Kellwy, M.E., Sereika, S., Good, C.B., Lbraim, S.A. &

Conigliaro, J. (2007). Symptom expression in coronary heart disease and

revascularization recommendations for Black and White patients. American

Journal of Public Health. 97(9), 1701-1708.

336

Hu, L.Q. (2006). Investigation of educational needs and strategies in patients with

coronary heart disease. Journal of Nurses Training, 21(1), 74-75.

Huang, F.G., Wang, Q.P., Xu, F. & Yin, X.M. (2002). The epidemiological

distributing character and hazards analysis of coronary heart disease from Jiaoou

district in Nanjing. Theory and Practice of Chinese Medicine, 2002(9), 1277.

Huang, F.L. & Zhang, W. (2004). Investigation and analysis of mental health level

and correlative factors of patients with coronary heart disease. Health

Psychology Journal, 12(3), 188-190.

Huang, K.M., Li, M.H., Mao, C.H., Deng, M., Zhang, G.X., Li, Y.X. & Chen, Y.Y.

(2006). Effect of rehabilitation nursing on the quality of life and complications in

patients with coronary heart disease undergoing PTCA and stent. Chinese

Journal of Rehabilitation Medicine, 21(5), 451-453.

Huang, K.M., Mao, C.H., Deng, M., Li, M.H., Zhang, G.X., Liang, J.Q. & Liu, H.C.

(2004). Effect of rehabilitation nursing on the recovery and restenosis of patients

with coronary heart disease undergoing PTCA and stent. Chinese Journal of

Cardiovascular Rehabilitation, 14(2), 101-103.

Huang, Q.L. & Tang, S.M. (1996). An experience using the transtheoretical model of

health behaviour change to promote exercise in a type 2 diabetes patient. Journal

of Nursing, 54(5), 99-103.

Huang, S.J., Hung, W.C., Chang, M. & Chang, J. (2009). The effect of an internet-

based, stage-matched message intervention on young Taiwanese women‘s

physical activity. Journal of Health Communication, 14(3), 210-227.

Hughes, A.R., Gillies, F., Kirk, A.F., Mutrie, N., Hillis, W.S. & Maclntyre, P.D.

(2002). Exercise consultation improves short-term adherence to exercise during

phase IV cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation, 22,

421-425.

Hughes, A.R., Mutrie, N. & Maclntyre, P.D. (2007). Effect of an exercise consultation

on maintenance of physical activity after completion of phase III exercise-based

cardiac rehabilitation. European Journal of Cardiovascular Prevention and


Hung, C., Daub, B., Black, B., Welsh, R., Quinney, A. & Haykowsky M. (2004).

Exercise training improves overall physical fitness and quality of life in older

women with coronary artery disease. Chest, 126, 1026-1031.

Hutchison, A.J., Breckon, J.D. & Johnston, L.H. (2009). Physical activity behaviour

change interventions based on the Transtheoretical Model: A systematic review.

Health Education and Behavior, 36, 829-845.

Hwang, R. & Marwick, T. (2009). Efficacy of home-based exercise programmes for

people with chronic heart failure: a meta-analysis. European Journal of


337

Ishii, A., Nakiri, M., Nagatomi, K., Tsuji, Y., Hoshiko, M., Yamaguchi, Y.,

Muramoto, J. & Ishitake, T. (2007). Effect of a physical activity improvement

program using the Transtheoretical Model at a small-scale company. Kurume

Medical Journal, 54, 1-8.

Ishikawa-Takata, K., Tanaka, H., Nanbu, K. & Ohta, T. (2010). Beneficial effect of

physical activity on blood pressure and blood glucose among Japanese male

workers. Diabetes Research and Clinical Practice, 87, 394-400.

Izawa, K., Hirano, Y., Yamada, S., Oka, K., Omiya, K. & Iijima, S. (2004).

Improvement in physiological outcomes and health-related quality of life

following cardiac rehabilitation in patients with acute myocardial infarction.

Circulation Journal, 68, 315-320.

Izawa, K.P., Watanabe, S., Omiya, K., Hirano, Y., Oka, K., Osada, N., et al. (2005).

Effect of the self-monitoring approach on exercise maintenance during cardiac

rehabilitation: A randomized, controlled trial. American Journal of Physical

Medicine and Rehabilitation, 84, 313-321.

Jackson, R., Asimakopoulou, K. & Scammell, A. (2007). Assessment of the

transtheoretical model as used by dietitians in promoting physical activity in

people with type 2 diabetes. Journal of Human Nutrition and Dietetics, 20, 27-36.

Jeger, R.V., Jörg, L., Rickenbacher, P., Pfisterer, M.E. & Hoffmann, A. (2007).

Benefit of outpatient cardiac rehabilitation in under-represended patient

subgroup. Journal of Rehabilitation Medicine, 39, 246-251.

Jensen, B.O. & Petersson, K. (2003). The illness experiences of patients after a first

time myocardial infarction. Patient Education and Counselling, 51, 123-131.

Jeong, H.S., Chae, J.S., Moon, J.S. & Yoo, Y.S. (2002). An individualized teaching

program for atherosclerotic risk factor reduction in patients with myocardial

infarction. Yonsei Medical Journal, 43(1), 93-100.

Jerlock, M., Gaston-Johansson, F. & Danielson, E. (2005). Living with unexplained

chest pain. Journal of Clinical Nursing, 14, 956-964.

Ji, W.Y., Huang, Z.H., Chen, S.R., Zheng, A.Y. & Wu, Y.D. (2005). Investigation of

community patient education and lifestyle change intervention in patients with

diabetes mellitus. Journal of Nurses Training, 20(8), 696-698.

Jia, Y. & Shao, X. (2005). A survey of mental status of coronary artery disease

inpatients and its influencing factors. Chinese Nursing Research, 19(9A), 1714-

1716.

Jiang, G.W. & Peng, F. (2005). Investigation of educational needs of patients with

coronary heart disease. Modern Medicine and Health, 21(18), 2530-2531.

338

Jiang, X.L. (2005). The effects of a nurse-led cardiac rehabilitation programme on

patients with coronary heart disease in Chengdu, China. Dissertation: The Hong

Kong Polytechnic University.

Jiang, X.L. Sit, J.W. & Wong, T.K.S. (2007). A nurse-led cardiac rehabilitation

programme improves health behaviours and cardiac physiological risk

parameters: evidence from Chengdu, China. Journal of Clinical Nursing, 16,

1886-1897.

Jiang, X.L. Sit, J.W. & Wong, T.K.S., Cheng, Y.J. & Li, J.P. (2004). Effect of a

cardiac rehabilitation programme on the quality of life of patients with coronary

heart disease. Chinese Journal of Evidence-Based Medicine, 4(12), 852-858.

Jimmy, G. & Martin, B.W. (2005). Implementation and effectiveness of a primary

care based physical activity counselling scheme. Patient Education and

Counseling, 56: 323-331.

Johansson, A., Dahlberg, K. & Ekebergh, M. (2003). Living with experiences

following a myocardial infarction. European Journal of Cardiovascular Nursing,

2, 229-236.

Johansson, I., Swahn, E. & Strömberg, A. (2007). Manageability, vulnerability and

interaction: A qualitative analysis of acute myocardial infarction patients'

conceptions of the event. European Journal of Cardiovascular Nursing, 6, 184–

191.

Johnson, N.A., Lim, L.L. & Bowe, S.J. (2009). Multicenter randomized controlled

trial of a home walking intervention after outpatient cardiac rehabilitation on

health-related quality of life in women. European Journal of Cardiovascular


Johnson, S.S. Paiva, A.L., Cummins, C.O., Johnson, J.L., Dyment, S.J., Wright, J.A.,

Prochaska, J.O., Prochaska, J.M. & Sherman, K. (2008). Transtheoretical model-

based multiple behaviour intervention for weight management: effectiveness on

a population basis. Preventive Medicine, 46, 238-246.

Jolliffe, J.A., Rees, K., Taylor, R.S., Thompson, D., Oldridge, N. & Ebrahim, S.

(2001). Exercise-based rehabilitation for coronary heart disease. Cochrane

Database of Systematic Review, Issue 1, Art. No.: CD001800. DOI:

10.1002/14651858. CD001800.

Jolly, K., Lip, G.Y.H., Sandercock, J., Greenfield, S.M., Raftery, J.P., Mant, J., Taylor,

R., Lane, D., Lee, K.W. & Stevens, A.J. (2003). Home-based versus hospital-

based cardiac rehabilitation after myocardial infarction or revascularisation:

design and rationale of the Birmingham Rehabilitation Uptake Maximisation

Study (BRUM): a randomised controlled trial. BMC Cardiovascular Disorders,

3, 10.

Jolly, K., Taylor, R., Lip, G.Y.H., Greenfield, S., Raftery, J., Mant, J., Lane, D., Jones,

M, Lee, K.W. & Stevens, A. (2007). The Birmingham Rehabilitation Uptake

339

Maximisation Study (BRUM). Home-based compared with hospital-based

cardiac rehabilitation in a multi-ethnic population: cost-effectiveness and patient

adherence. Health Technology Assessment, 11(35), 1-118.

Josephson, E.A., Casey, E.C., Waechter, D., Rosneck, J. & Hughes, J.W. (2006)

Gender and depression symptoms in cardiac rehabilitation. Journal of

Cardiopulmonary Rehabilitation, 26, 160-163.

Jue, N.H. & Cunningham, S.L. (1998). Stages of exercise behaviour change at two

time periods following coronary artery bypass graft surgery. Progress in

Cardiovascular Nursing, 13(1), 23-33.

Kang, X.F., Li, Z., Liang, T., Chen, Y.D., Zhang, X.M., Gao, R.X. & Zang, X.H.

(2006). The effect of exercise-base rehabilitation on patients underwent

percutaneous transluminal coronary intervention. Chinese Journal of Nursing,

41(4), 315-317.

Kannel, W.B., Schwartz, M.J. & McNamara, P.M. (1969). Blood pressure and risk of

coronary heart disease: The Framingham Study. Disease Chest, 56, 43-52.

Kanning, M. (2010). Physically active patients with coronary artery disease: a

longitudinal investigation of the processes of exercise behaviour change. British

Journal of Health Psychology, 15, 583-597.

Kao, Y.H., Lu, C.M. & Huang, Y.C. (2002). Impact of a transtheoretical model on the

psychosocial factors affecting exercise among workers. Journal of Nursing

Research, 10(4), 303-309.

Kelley, G.A., Kelley, K.S. & Franklin, B. (2006). Aerobic exercise and lipids and

lipoproteins in patients with cardiovascular disease. Journal of Cardiopulmonary


Kelley, G.A., Kelley, K.S. & Tran, Z.V. (2005). Exercise, lipids, and lipoproteins in

older adults: a meta-analysis. Preventive Cardiology, 8, 206-214.

Ketterer, M.W., Knysz, W., Keteyian, S.J., Schairer, J., Jafri, S., Alam, M., Farha, A.J.

& Deveshwar, S. (2008). Cardiovascular symptoms in coronary artery disease

patients are strongly correlated with emotional distress. Psychosomatics, 49, 230-

234.

Khaw, K.T. (2005). Epidemiology of coronary heart disease in women. In Wenger,

Nanette Kass & Collins, Peter (Ed). Women and Heart Disease. London and

New York: Taylor & Francis, 2005, 2nd

edition.

Kiebzak, G.M., Pierson, L.M., Campbell, M. & Cook, J.W. (2002). Use of the SF36

general health status survey to document health-related quality of life in patients

with coronary artery disease: effect of disease and response to coronary artery

bypass graft surgery. Heart and Lung, 31, 207-213.

340

Kiessling, A. & Henriksson, P. (2007). Time trends of chest pain symptoms and

health related quality of life in coronary artery disease. Health and Quality of

Life Outcomes, 5(13), 1-10.

Kim, Y.H. (2007). Application of the transtheoretical model to identify psychological

constructs influencing exercise behaviour: a questionnaire survey. International

Journal of Nursing Studies, 44, 936-944.

Kim, Y.H. (2008). A stage-matched intervention for exercise behaviour change based

on the transtheoretical model. Psychological Reports, 102, 939-950.

Kim, Y.H., Cardinal, B.J. & Lee, J.Y. (2006). Understanding exercise behaviour

among Korean adults: a test of the Transtheoretical model. International Journal

of Behavioural Medicine, 13(4), 295-303.

Kimble, L.P, Dunbar, S.B, Weintraub, W.S, McGuire, D.B, Fazio, S., De, A.K. &

Strickland, O. (2002). The seattle angina questionnaire: Reliability and validity

in women with chronic stable angina. Heart Disease, 4, 206-211.

Kirk, A.F., Higgins, L.A., Hughes, A.R., Fisher, B.M., Hillis, S. & MacIntyre, P.D.

(2001). A randomized, controlled trial to study the effect of exercise

counsultation on the promotion of physical activity in people with type 2

diabetes: a pilot study. Diabetic Medicine, 18, 877-882.

Kirk, A.F., MacIntyre, P., Mutrie, N. & Fisher, M. (2003). Increasing physical activity

in people with type 2 diabetes. Diabetes Care, 26, 1186-1192.

Kirk, A.F., Mutrie, N., MacIntyre, P.D. & Fisher, M.B. (2004). Promoting and

maintaining physical activity in people with type 2 diabetes. American Journal of


Kline, K.S., Scott, L.D. & Britton, A.S. (2007). The use of supportive-educative and

mutual goal-setting strategies to improve self-management for patients with heart

failure. Home Healthcare Nurse, 25(8), 502-510.

Kodama, S., Saito, K., Tanaka, S., Maki, M., Yachi, Y., Asumi, M., Sugawara, A.,

Totsuka, K., Shimano, H., Ohashi, Y., Yamada, N. & Sone, H. (2009).

Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and

cardiovascular events in healthy men and women. Journal of the American

Medical Association, 301, 2024-2035.

Kodama, S., Tanaka, S., Saito, K., Shu, M., Sone, Y., Onitake, F., Suzuki, E.,

Shimano, H., Yamamoto, S., Kondo, K., Ohashi, Y., Yamada, N. & Sone, H.

(2007). Effect of aerobic exercise training on serum levels of high-density

lipoprotein cholesterol: a meta-analysis. Archives of Internal Medicine, 167, 999-

1008.

Kosma, M., Cardinal, B.J. & Mccubbin, J.A. (2005). A pilot study of a web-based

physical activity motivational program for adults with physical disabilities.

Disability and Rehabilitation, 27(23), 1435-1442.

341

Koukouvou, G., Kouidi, E., Lacovides, A., Konstantinidou, E., Kaprinis, G., &

Deligiannis, A. (2004). Quality of life, psychological and physiological changes

following exercise training in patients with chronic heart failure. Journal

Rehabilitation Medicine, 36, 36-41.

Kreuter, M.W., Oswald, D.L., Bull, F.C. & Clark, E.M. (2000). Are tailored health

education materials always more effective than non-tailored materials? Health

Education Research, 15(3), 305-315.

Kristofferzon, M.L., Löfmark, R. & Carlsson, M. (2005). Coping, social support and

quality of life over time after myocardial infarction. Journal of Advanced

Nursing, 52(2), 113-124.

Kristofferzon, M.L., Löfmark, R. & Carlsson, M. (2007). Striving for balance in daily

life: experiences of Swedish women and men shortly after a myocardial

infarction. Journal of Clinical Nursing, 16, 391-401.

Lam, C.L.K., Chin, W.Y., Lee, P.W.H., Lo, Y.Y.C., Fong, D.Y.T. & Lam, T.P.

(2009). Unrecognised psychological problems impair quality of life and increase

consultation rates in Chinese elderly patients. International Journal of Geriatric


Lam, T.H., Chan, B., Ho, S.Y. & Chan, W.M. (2004). Stage of change for general

health promotion action and health-related lifestyle practices in Chinese adults.

Preventive Medicine, 38, 302-308.

Lampe, F.C., Morris, R.W. & Walker, M. (2005). Trends in rates of different forms of

diagnosed coronary heart disease, 1978 to 2000: prospective, population based

study of British men. British Medical Journal, 330, 1-5.

Larson, C.O., Nelson, E.C., Gustafson, D. & Batalden, P.B. (1996). The relationship

between meeting patients‘ information needs and their satisfaction with hospital

care and general health status outcomes. International Journal for Quality in

Health Care, 8(5), 447-456.

Lauzon, C., Beck, C.A., Huynh, T., Dion, D., Racine, N., Carignan, S., Diodati, J.G.,

Charbonneau, F., Dupuis, R. & Pilote, L. (2003). Depression and prognosis

following hospital admission because of acute myocardial infarction. Canadian

Medical Association Journal, 168, 547-552.

Lear, S. A., Ignaszewski, A., Laquer, E. A., Pritchard, P. H. & Frohlich, J. J. (2001).

Extensive lifestyle management intervention following cardiac rehabilitation:

pilot study. Rehabilitation Nursing, 26(6), 227-232.

Lear, S.A., Ignaszewski, A., Linden, W., Brozic, A., Kiess, M., Spinelli, J.J., Pritchard,

P.H. & Frohlich, J.J. (2002). A randomized controlled trial of an extensive

lifestyle management intervention (ELMI) following cardiac rehabilitation: study

design and baseline data. Current Controlled Trials in Cardiovascular Medicine,

3, 9.

342

Lear, S.A., Ignaszewski, A., Linden, W., Brozic, A., Kiess, M., Spinelli, J.J., Pritchard,

P.H. & Frohlich, J.J. (2003). The Extensive Lifestyle Management Intervention

(ELMI) following cardiac rehabilitation trial. European Heart Journal, 24, 1920-

1927.

Lear, S.A., Spinelli, J.J., Linden, W., Brozic, A., Kiess, M., Frohlich, J.J. &

Ignaszewski, A. (2006). The Extensive Lifestyle Management Intervention

(ELMI) after cardiac rehabilitation: a 4-year randomized controlled trial.

American Heart Journal, 152, 333-339.

Leijon, M.E., Bendtsen, P., Ståhle, A., Ekberg, K., Festin, K. & Nilsen, P. (2010).

Factors associated with patients self-reported adherence to prescribed physical

activity in routine primary health care. BMC Family Practice, 11, 38.

http://www.biomedcentral.com/1471-2296/11/38.

Leung, R.W., Leung, M.L. & Chung, P.K. (2004). Validity and reliability of a

Cantonese-translated rating of perceived exertion scale among Hong Kong adults.

Perceptual and Motor Skills, 98(2), 725-735.

Lewin, B., Cay, E.L., Todd, I., Soryal, I., Goodfield, N., Bloomfield, P. & Elton, R.

(1995). The angina management programme: a rehabilitation treatment. Journal

of British Cardiology, 1, 221-226.

Lewin, R.J., Furze, G., Robinson, J., Griffith, K., Wiseman, S., Pye, M. & Boyle, R.

(2002). A randomized controlled trial of a self-management plan for patients

with newly diagnosed angina. British Journal of General Practice, 52, 194-201.

Li, H. (2002). The application of aerobics in psychology recover of coronary heart

disease patients. Chinese Journal of Clinical Rehabilitation, 6(11), 1638.

Li, J. & Gao, Z.Y. (2007). The effect of exercise training on heart function in patients

with coronary heart disease. World Health Digest, 4(7), 162-163.

Li, S.B. & Wang, D. (2006). Investigation and analysis of educational needs on

patients with coronary heart disease. China Medical Herald, 3(30), 146.

Li, X.J., Sun, Z.Q., Zheng, L.Q., Feng, L., Zhang, X.Z., Zhang, X.G., et al. (2007)

Correlative risk factors and epidemic characteristics of coronary heart disease

among rural adult groups in North of China. Journal of Shanxi Medical

University, 38(2), 139-142.

Li, X.L. & Liu, C.L. (2006). An investigation of educational needs of patients with

coronary heart disease. International Journal of Nursing, 25(2), 126-127.

Liang, Q. & Ma, H. (2001). A status of quality of life on patients with coronary heart

disease. Chinese Journal of Internal Medicince, 40(3), 212-213.

Lie, I., Arnesen, H., Sandvik, L., Hamilton, G. & Bunch, E.H. (2009). Health-related

quality of life after coronary artery bypass grafting. The impact of a randomised

http://www.biomedcentral.com/1471-2296/11/38




343

controlled home-based intervention program. Quality of Life Research, 18, 201-

207.

Linde, B.J. & Janz, N.M. (1979). Effect of a teaching programme on knowledge and

compliance of cardiac patients. Nursing Research, 28(5), 282-286.

Lindgren, T.G., Fukuoka, Y., Rankin, S.H., Cooper, B.A., Carroll, D. & Munn, Y.

(2008). Cluster analysis of elderly cardiac patients‘ prehospital symptomatology.


Lippke, S., Schwarzer, R., Ziegelmann, J.P., Scholz, U. & Schüz, B. (2010). Testing

stage-specific effects of a stage-matched intervention: A randomized controlled

trial targeting physical exercise and its predictors. Health Education and

Behavior, 37, 533-546.

Lisspers, J., Sundin, Ö., Hofman-Bang, C., Nordlander, R., Nygren, A., Rydén, L. &

Öhman, A. (1998). Behavioral effects of a comprehensive, multifactorial

program for lifestyle change after percutaneous transluminal coronary

angioplasty: A prospective, randomized, controlled study. Journal of

Psychosomatic Research, 46(2), 143-154.

Lisspers, J., Sundin, Ö., Öhman, A., Hofman-Bang, C., Rydén, L. & Nygren, A.

(2005). Long-term effects of lifestyle behavior change in coronary artery disease:

effects on recurrent coronary events after percutaneous coronary intervention.


Liu, C.J., Li, N.X., Ren, X.H., Li, J., Zhang, J. & Sun, D. (2001). Feasibility of using

short form 36 in Chinese population. Journal of West China University Medical

Science, 32(1), 39-42.

Liu, J.Y.W., Chung, J.W.Y. & Wong, T.K.S. (2003). The psychometric properties of

Chinese pain intensity verbal rating scale. Acta Anaesthesiologica Scandinavica,

47, 1013-1019.

Liu, S.H. (2003). The Evaluation of the Reliability and Validity of SAQ Applied in a

Group of Chinese Patients with CHD. Thesis for Master Degree: Tianjin Medical

University.

Liu, X., Zhang, W., Yang, X.L., Yuan, X.J., Yang, F.Y. & Brodie, D.A. (2007).

Change of aerobic working capacity and myocardial oxygen supply of coronary

heart disease patients after cardiac rehabilitation. China Sport Science, 27(6), 35-

38.

Liu, Y. (2005). A survey of demands for patient education in patients with coronary

heart disease. Chinese Nursing Research, 19(1), 115-116.

Lloyd-Jones, D., Adams, R., Brown, T.M., Carnethon, M., Dai, S., De Simone, G.,

Ferguson, T.B., Ford, E., Furie, K., Gillespie, C., Go, A., Greenlund, K., Haase,

N., Hailpern, S., Ho, P.M., Howard, V., Kissela, B., Kittner, S., Lackland, D.,

Lisabeth, L., Marelli, A., McDermott, MM., Meigs, J., Mozaffarian, D.,

344

Mussolino, M., Nichol, G., Roger, V.L., Rosamond, W., Sacco, R., Sorlie, P.,

Stafford, R., Thom, T., Wasserthiel-Smoller, S., Wong, N. & Wylie-Rosett, J.

(2010). Heart Disease and Stroke Statistics— 2010 Update: a report from the

American Heart Association. Circulation, 121(7), 948-954.

Long, J.L., Wang, H.Y., Wang, Y.X. & Song, X.J. (2005). Comparisons of

psychosocial factors of patients with coronary heart disease. Journal of Clinical

Psychosomatic Disease, 11(2), 140-145.

Longmore, R.B., Spertus, J.A., Alexander, K.P., Gosch, K., Reid, K.J., Masoudi, F.A.,

Krumholz, H.M. & Rich, M.W. (2011). Angina frequency after myocardial

infarction and quality of life in older versus younger adults: the prospective

registry evaluating myocardial infarction: event and recovery study. American

Heart Journal, 16(3), 631-638.

Lowe, G., Plummer, V., O'Brien, A.P. & Boyd, L. (2012). Time to clarify - the value

of advanced practice nursing roles in health care. Journal of Advanced Nursing,

68(3), 677-685.

Lukkarinen, H. & Hentinen, M. (1997). Assessment of quality of life with the

Nottingham Health Profile among patients with coronary heart disease. Journal

of Advanced Nursing, 26(1), 73-84.

Luo, X.H., Chen, W.P., Meng, W.Y. & Ma, Y. (2007). The effects of patient

education on treatment attitude, medical compliance, and recurrence of

depression on coronary heart disease patients with depression. Chinese Journal

of Gerontology, 27, 1086-1087.

Luszczynska, A. (2006). An implementation intentions intervention, the use of a

planning strategy, and physical activity after myocardial infarction. Social

Science and Medicine, 62: 900-908.

Ma, S., Ma, Y.X. & Zhu, W. (2006). A dynamic observational study on effect of

intervention by stages on university students‘ exercise behaviour. Chinese

Journal of Behavioural Medical Science, 15(12), 1106-1108.

Ma, S., Wang, B.S. & Li, J.Z. (2008). The application of the transtheoretical model:

an intervention on exercise behaviour among University students. Chinese

Journal of Sports and Medicine, 27(2), 235-237.

Maddox, T.M., Reid, K.J., Spertus, J.A., Mittleman, M., Krumholz, H.M., Parashar,

S., Ho, M. & Rumsfeld, J.S. (2008). Angina at 1 year after myocardial infarction:

prevalence and associated findings. Archives of International Medicine, 168(12),

1310-1316.

Mahler, H.I.M., Kulik, J.A. & Tarazi, R.Y. (1999). Effects of a videotape information

intervention at discharge on diet and exercise compliance after coronary bypass

surgery. Journal of Cardiac Rehabilitation, 19(3), 170-177.

345

Marchionni, N., Fattirolli, F., Fumagalli, S., Oldridge, N., Lungo, F.D., Morosi, L.,

Burgisser, C. & Masotti, G. (2003). Improved exercise tolerance and quality of

life with cardiac rehabilitation of older patients after myocardial infarction:

Results of a randomized, controlled trial. Circulation, 107(17), 2201-2206.

Marcus, B.H., Banspach, S.W., Lefebvre, R.C., Rossi, J.S., Carleton, R.A. & Abrams,

D.B. (1992). Using the stages of change model to increase the adoption of

physical activity among community patients. American Journal of Health

Promotion, 6(6), 424-429.

Marcus, B.H., Eaton, C.A., Rossi, J.S. & Harlow, L.L. (1994). Self-efficacy, decision-

making, and stages of change: an integrative model of physical exercise. Journal

of Applied Social Psychology, 24(6), 489-508.

Marcus, B.H., Emmons, K.M., Simkin-Silverman, L.R., Linnan, L.A., Taylor, E.R.,

Bock, B.C., Roberts, M.B., Rossi, J.S. & Abrams, D.B. (1998). Evaluation of

motivationally tailored vs. standard self-help physical activity interventions at

the workplace. American Journal of Health Promotion, 12(4), 246-253.

Marcus, B.H., Forsyth, L.H. & Blair, S. (Ed). (2003). Motivating people to be

physically active. USA: Human Kinetics.

Marcus, B.H., Pinto, B.M., Simkin, L.R., Audrain, J.E. & Taylor, E.R. (1994).

Application of Theoretical models to exercise behavior among employed women.


Marcus, B.H., Rossi, J.S., Selby, V.C., Niaura, R.S. & Abrams, D.B. (1992). The

stages and processes of exercise adoption and maintenance in a worksite sample.


Marcus, B.H., Selby, V.C., Niaura, R.S. & Rossi, J.S. (1992). Self-efficacy and the

stages of exercise behaviour change. Research Quarterly for Exercise and Sport,

63(1), 60-66.

Marcus, B.H. & Simkin, L.R. (1993). The stages of exercise behaviour. Journal of

Sports Medicine and Physical Fitness, 33(1), 83-89.

Marcus, B.H. & Simkin, L.R. (1994). The transtheoretical model: applications to

exercise behaviour. Medicine and Science in Sports and Exercise, 26(11), 1400-

1404.

Märki, A., Bauer, B., Angst, F., Nigg, C.R., Gillmann, G. & Gebring, T.M. (2006).

Systematic counselling by general practitioners for promoting physical activity

in elderly patients: a feasibility study. Swiss Medical Weekly, 136, 482-488.

Märki, A., Bauer, G.F., Nigg, C.R., Conca-Zeller, A. & Gebring, T.M. (2006).

Transtheoretical model-based exercise counselling for older adults in

Switzerland: quantitative results over a 1-year period. Soz Preventive Medicine,

51, 273-280.

346

Marshall, J., Penckofer, S. & Llewellyn, J. (1986). Structured postoperative teaching

and knowledge and compliance of patients who had coronary artery bypass

surgery. Heart and Lung, 15(1), 76-82.

Marshall, S.J. & Biddle, S.J.H. (2001). The transtheoretical model of behaviour

change: a meta-analysis of applications to physical activity and exercise. Annals

of Behavioral Medecine, 23(4), 229-246.

Martin, C.R. & Thompson, D.R. (2000). A psychometric evaluation of the hospital

anxiety and depression scale in coronary care patients following acute

myocardial infarction. Psychology, Health and Medicine, 5(2), 193-201.

Mayoux-Benhamou, A., Giraudet-Le Quintrec, J.S., Ravaud, P., Champion, K.,

Dernis, E., Zerkak, D., Roy, C., Kahan, A., Revel, M. & Dougados, M. (2008).

Influence of patient education on exercise compliance in rheumatoid arthritis: a

prospective 12-month randomized controlled trial. Journal of Rheumatology,

35(2), 216-223.

McCarthy, M.M., Dickson, V.V. & Chyun, D. (2010). Barriers to cardiac

rehabilitation in women with cardiovascular disease: an integrative review.

Journal of Cardiovascular Nursing, 00(0), 1-10.

McCormick, K.M., Naimark, B.J. & Tate, R.B. (2002). Symptoms and distress in

patients awaiting coronary artery bypass surgery. Canadian Journal of Nursing

Research. 34(4), 95-105.

McGillion, M.H., Watt-Watson, J., Stevens, B., LeFort, S.M., Coyte, P. & Graham, A.

(2008). Randomized controlled trial of a psychoeducation program for the self-

management of chronic cardiac pain. Journal of Pain and Symptom Management,

36(2), 126-140.

McHorney, C.A., Ware, J.E. & Raczek, A.E. (1993). The MOS 36-item short form

health survey (SF-36): II. Psychometric and clinical tests of validity in measuring

physical and mental health constructs. Medical Care, 31(3), 247-263.

McHugh, F., Lindsay, G.M., Hanlon, P., Hutton, I., Brown, M.R., Morrison, C. &

Wheatley, D.J. (2001). Nurse led shared care for patients on the waiting list for

coronary artery bypass surgery: a randomised controlled trial. Heart, 86, 317-323.

McPherson, C.P., Swenson, K.K., Pine, D.A. & Leimer, L. (2002). A nurse-based

pilot programme to reduce cardiovascular risk factors in a primary care setting.

American Journal of Management Care, 8, 543-555.

Mendes de Leon, C.F., Krumholz, H.M., Vaccarino, V., Williams, C.S., Glass, T.A.,

Berkman, L.F. & Kas, S.V. (1998). A population-based perspective of changes in

health-related quality of life after myocardial infarction in older men and women.

Journal of Clinical Epidemiology, 51(7), 609-616.

http://csaweb116v.csa.com.ezproxy.lb.polyu.edu.hk/ids70/view_record.php?id=2&recnum=4&log=from_res&SID=s06dgk9sdsln6oo4ksgi9apad6





347

Meng, T.Y., Guo, H. & Guo, P. (2004). Correlative study of life quality and mental

health in senile patients with coronary heart disease. Journal of Clinical

Psychosomatic Disease, 10(2), 116-118.

Meyer, A.J., Nash, J.D., McAlister, A.L. & Maccoby, N. (1980). Skills training in a

cardiovascular patient education campaign. Journal of Consulting and Clinical

Psychology, 48(2), 129-142.

Milani, R.V. & Lavie, C.J. (2007). Impact of cardiac rehabilitation on depression and

its associated mortality. The American Journal of Medicine, 120, 799-806.

Milani, R.V., Lavie, C.J. & Cassidy, M.M. (1996). Effects of cardiac rehabilitation

and exercise training programmes on depression in patients after major coronary

events. American Heart Journal. 132, 726-732.

Mildestvedt, T., Meland, E. & Eide, G.E. (2008). How important are individual

counselling, expectancy beliefs and autonomy for the maintenance of exercise

after cardiac rehabilitation? Scandinavian Journal of Public Health, 36, 832-840.

Miller, W.R. & Rollnick, S. (2002). Motivational interviewing: Preparing people for

change. New York: Guilford Press.

Minganti, C., Capranica, L., Meeusen, R., Amici, S. & Piacentini, M.F. (2010). The

validity of session-rating of perceived exertion method for quantifying training

load in teamgym. Journal of Strength and Conditioning Research, 24(11), 3063-

3068.

Mital, A., Shrey, D.E., Govindaraju, M., Broderick, T.M., Colon-Brown, K. & Gustin,

B.W. (2000). Accelerating the return to work (RTW) chances of coronary heart

disease (CHD) patients: part 1 – development and validation of a training

programme. Disability and Rehabilitation, 22(13/14), 604-620.

Mochari, H., Lee, J.R., Kligfield, P. & Mosca, L. (2006). Ethnic differences in

barriers and referral to cardiac rehabilitation among women hospitalized with

coronary heart disease. Preventive Cardiology, 9, 8-13.

Moore, S.M. (1996). The effects of a discharge information intervention on recovery

outcomes following coronary artery bypass surgery. International Journal of

Nursing Studies, 33(2), 181-189.

Moore, S.M. & Charvat, J.M. (2002). Using the CHANGE intervention to enhance

long-term exercise. Nursing Clinics of North America, 37, 273-283.

Moore, S.M., Charvat, J.M., Gordon, N.H., Pashkow, F., Ribisl, P., Roberts, B.L. &

Rocco, M. (2006). Effects of a CHANGE intervention to increase exercise

maintenance following cardiac events. Annals of Behavioral Medicine, 31(1), 53-

62.

348

Moore, S.M., Dolansky, M.A., Ruland, C.M., Pashkow, F.J. & Blackburn, G.G.

(2003). Predictors of women‘s exercise maintenance after cardiac rehabilitation.

Journal of Cardiopulmonary Rehabilitation, 23, 40-49.

Mosca, L., Christian, A.H., Mochari-Greenberger, H., Kligfield, P. & Smith, S.C.Jr.

(2010). A randomized clinical trial of secondary prevention among women

hospitalized with coronary heart disease. Journal of Women’s Health, 19(2),

195-202.

Moser, D.K., Riegel, B., McKinley, S., Doering, L.V., An, K. & Sheahan, S. (2007).

Impact of anxiety and perceived control on in-hospital complications after acute

myocardial infarction. Psychosomatic Medicine, 69, 10-16.

Mozaffarian, D., Bryson, C.L., Spertus, J.A., McDonell, M.B. & Fihn, S.D. (2003).

Anginal symptoms consistently predict total mortality among outpatients with

coronary artery disease. American Heart Journal, 146, 1015-1022.

Murchie, P., Campbell, N. C., Ritchie L.D., Simpson, J.A. & Thain, J. (2003).

Secondary prevention clinics for coronary heart disease: four year follow up of a

randomised controlled trial in primary care. British Medical Journal, 326, 1-6.

Murchie, P., Campbell, N.C., Ritchie, L.D., Deans, H.G. & Thain, J. (2004). Effects

of secondary prevention clinics on health status in patients with coronary heart

disease: 4 year follow-up of a randomized trial in primary care. Family Practice,

21, 567-574.

Naser, A., Jafar, S., Kumar, G.V., Daga M.K., Hadi, H.S., Saeed, D., Mohamadreza, S.

& Hossein, M.A. (2008). Cardiac risk factor changes through an intensive

multifactorial life style modification program in CHD patients: Results from a

two year follow up. Journal of Biological Sciences, 8(2), 248-257.

National Service Framework. (2008). Coronary Heart Disease. From

http://www.dh.gov.uk/en/Healthcare/NationalServiceFramworks/Coronaryheartd

isease/index.htm

Naylor, P.J., Simmonds, G., Riddoch, C., Velleman, G. & Turton, P. (1999).

Comparison of stage-matched and unmatched interventions to promote exercise

behaviour in the primary care setting. Health Education Research, 14(5), 653-

666.

Nelson, M.S. (2000). A stage matched physical activity intervention in military

primary care. University of Maryland, Dissertation.

Netto, G., McCloughan, L. & Bhatnagar, A. (2007). Effective heart disease

prevention: Lessons from a qualitative study of user perspectives in Bangladeshi,

Indian and Pakistani communities. Public Health, 121, 177-186.

Netz, Y., Wu, M.J., Becker, B.J. & Tenenbaum, G. (2005). Physical activity and

psychological well-being in advanced age: a meta-analysis of intervention

studies. Psychology and Aging, 20(2), 272-284.

349

Neubeck, L., Freedman, S.B., Briffa, T. Bauman, A. & Redfern, J. (2010). Four-year

follow-up of the choice of health options in prevention of cardiovascular events

randomized controlled trial. European Journal of Cardiovascular Prevention

and Rehabilitation, 00(00), 1-8.

Nigg, C.R. (2001). Explaining adolescent exercise behaviour change: a longitudinal

application of the transtheoretical model. Annals Behavioral Medicine, 23(1), 11-

20.

Nigg, C.R. (2002). Physical Activity Assessment Issues in Population Based

Interventions: A Stage Approach. In: Welk GJ, eds. Physical Activity

Assessments for Health-Related Research. Champaign, IL: Human Kinetics.

Nigg, C.R. (2005). There is more to stages of exercise than just exercise. Exercise and

Sport Science Reviews, 33(1), 32-35.

Nigg, C.R. & Courneya, K.S. (1998). Transtheoretical model: examining adolescent

exercise behaviour. Journal of Adolescent Health, 22, 214-224.

Norekvål, T.M., Wahl, A.K., Fridlund, B., Nordrehaug, J.E. Wentzel-Larsen, T. &

Hanestad, B.R. (2007). Quality of life in female myocardial infarction survivors:

a comparative study with a randomly selected general female population cohort.

Health and Quality of Life Outcomes, 5, 58-68.

O‘Connor, G.T., Buring, J.E., Yusuf, S., Goldhaber, S.Z., Olmstead, E.M.,

Paffenbarger, R.S. & Hennekens, C.H. (1989). An overview of randomized trial

of rehabilitation with exercise after myocardial infarction. Circulation, 80, 234-

244.

Oerkild, B., Frederiksen, M., Hansen, J.F., Simonsen, L., Skowgaard, L.T. & Prescott,

E. (2011). Home-based cardiac rehabilitation is as effective as centre-based

cardiac rehabilitation among elderly with coronary heart disease: results from a

randomised clinical trial. Age and Aging, 40, 78-85.

Okura, T. & Tanaka, K. (2001). A unique method for predicting cardiorespiratory

fitness using rating of perceived exertion. Journal of Physiological Anthropology,

20(5), 255-261.

Ornish, D., Brown, S.E., Scherwitz, L.W., Billings, J.H., Armstrong, W.T., Ports,

T.A., McLanahan, S.M., Kirdeeide, R.L., Brand, R.J. & Gould, K.L. (1990). Can

lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial.

Lancet, 336(8708), 129-133.

Ornish, D., Scherwitz, L. W., Billings, J. H., et al. (1998). Intensive lifestyle changes

for reversal of coronary heart disease. Journal of the American Medical

Association, 280(23), 2001-2007.

350

Padberg, R.M. & Padberg, L.F. (1990). Strengthening the effectiveness of patient

education: applying principles of adult education. Oncology Nursing Forum,

17(1), 65-69.

Painter, J.E., Borba, C.P.C., Hynes, M., Mays, D. & Glanz, K. (2008). The use of

theory in health behaviour research from 2000 to 2005: a systematic review.

Annals of Behavioral Medicine, 35, 358-362.

Paradis, V., Cossette, S., Frasure-Smith, N., Heppell, S. & Guertin, M.C. (2010). The

efficacy of a motivational nursing intervention based on the stages of change on

self-care in heart failure patients. Journal of Cardiovascular Nursing, 25(2), 130-

141.

Parakh, K., Bhat, U., Thombs, B., Fauerbach, J.A., Bush, D.E. & Ziegelstein, R.C.

(2010). Self-assessed physical health predicts 10-year mortality after myocardial

infarction. Journal of Cardiopulmonary Rehabilitation and Prevention, 30, 35-

39.

Pavy, B., Iliou, M.C., Meurin, P., Tabet, J.Y. & Corone, S. (2006). Safety of exercise

training for cardiac patients. Results of the French registry of complications

during cardiac rehabilitation. Archives of Internal Medicine, 166, 2329-2334.

Pell, J., Pell, A., Morrison, C., Blatchford, O. & Dargie, H. (1996). Retrospective

study of influence of deprivation on uptake of cardiac rehabilitation. British

Medical Journal, 313, 267.

Pellatt, G.C. (2003). Perceptions of the nursing role in spinal cord injury rehabilitation.

British Journal of Nursing, 12(5), 292-299.

Peterson, T. & Aldana, S.G. (1999). Improving exercise behaviour: an application of

the stages of change model in a worksite setting. American Journal of Health

Promotion, 13(4), 229-232.

Pettersen, K.I., Reikvam, A., Rollag, A. & Stavem, K. (2008). Understanding sex

differences in health-related quality of life following myocardial infarction.

International Journal of Cardiology, 130, 449-456.

Pinsky, J.L., Jette, A.M., Branch, L.G., Kannel, W.B. & Feinleib, M. (1990). The

Framingham Disability Study: relationship of various coronary heart disease

manifestations to disability in older persons living in the community. American

Journal of Public Health, 80(11), 1363-1367.

Pinto, B.M., Friedman, R. Marcus, B.H., Kelley, H., Tennstedt, S. & Gillman, M.W.

(2002). Effects of a computer-based, telephone-counseling system on physical

activity. American Journal of Preventive Medicine, 23(2), 113-120.

Pinto, B.M., Frierson, G.M., Rabin, C., Trunzo, J.J. & Marcus, B.H. (2005). Home-

based physical activity intervention for breast cancer patients. Journal of Clinical

Oncology, 23(15), 3577-3587.

351

Pinto, B.M., Rabin, C. & Dunsiger, S. (2009). Home-based exercise among cancer

survivors: adherence and its predictors. Psycho-Oncology, 18, 369-376.

Plach, S., Wierenga, M.E. & Heidrich, S.M. (1996). Effect of a postdischarge

education class on coronary artery disease knowledge and self-reported health-

promoting behaviours. Heart and Lung, 25, 367-372.

Plomondon, M.E., Magid, D.J., Masoudi, F.A., Jones, P.G., Havranek, E., Peterson,

E.D., Krumholz, H.M., Spertus, J.A. & Rumsfeld, J.S. (2007). Association

between angina and treatment satisfaction after myocardial infarction. Journal of

General Internal Medicine, 23(11), 1-6.

Plotnikoff, R.C., Hotz, S.B., Birkett, N.J. & Courneya, K.S. (2001). Exercise and the

transtheoretical model: a longitudinal test of a population sample. Preventive

Medicine, 33, 441-452.

Povey, R., Conner, M., Sparks, P., James, R. & Shepherd, R. (1999). A critical

examination of the application of the Transtheoretical model's stages of change

to dietary behaviors. Health Education Research, 14(5), 641-651.

Prochaska, J.O. (2008). Decision making in the Transtheoretical model of behaviour

change. Medical Decision Making, 28, 845-849.

Prochaska, J.O. & DiClemente, C.C. (1983). Stages and processes of self-change of

smoking: toward an integrative model of change. Journal of Consulting and

Clinical Psychology, 51(3), 390-395.

Prochaska, J.O. & DiClemente, C.C. (1984). Self change processes, self efficacy and

decisional balance across five stages of smoking cessation. Progress in Clinical

Biochemistry and Medicine, 156, 131-140.

Prochaska, J.O. DiClemente, C.C. & Norcross, J.C. (1992). In search of how people

change: applications to addictive behaviours. American Psychologist, 47(9),

1102-1114.

Prochaska, J.O., DiClemente, C.C., Velicer, W.F. & Rossi, J.S. (1993). Standardized,

individualized, interactive, and personalized self-help programmes for smoking

cessation. Health Psychology, 12(5), 399-405.

Prochaska, J. O. & Marcus, B. H. (1995). The transtheoretical model: Applications to

exercise. Exercise Adherence II. R. Dishman. Illinois, Human Kinetics Press.

Prochaska, J.O. & Velicer, W.F. (1997). The transtheoretical model of health behavior

change. American Journal of Health Promotion, 12(1), 38-48.

Prochaska, J.O., Velicer, W.F., Rossi, J.S., Goldstein, M.G., Marcus, B.H., Rakowski,

W., Fiore, C., Harlow, L.L., Redding, C.A., Rosenbloom, D. & Rossi, S.R.

(1994). Stages of change and decisional balance for 12 problem behaviours.


352

Purath, J., Miller, A.M., McCabe, G. & Wilbur, J. (2004). A brief intervention to

increase physical activity in sedentary working women. Canadian Journal of


Rakowski, W., Ehrich, B., Goldstein, M.G., Rimer, B.K., Pearlman, D.N., Clark,

M.A., Velicer, W.F. & Woolverton, H. (1998). Increasing mammography among

women aged 40-74 by use of a stage-matched, tailored intervention. Preventive

Medicine, 27, 748-756.

Raleigh, E.H. & Odtohan, B.C. (1987). The effect of a cardiac teaching programme

on patient rehabilitation. Heart and Lung, 16(3), 311-317.

Ramm, C., Robinson, S. & Sharpe, N. (2001). Factors determining non-attendance at

a cardiac rehabilitation programme following myocardial infarction. New

Zealand Medical Journal, 114, 227-229.

Rao, Z.H. & Yuan, Z.M. (1996). An new questionnaire to evaluate physical functional

status on patients with coronary heart disease. International Journal of

Geriatrics, 17(1), 14-16.

Reboredo, M.M., Henrique, D.M.N., Faria, R.D.S., Chaoubah, A., Bastos, M.G. &

Paula, R.B.D. (2010). Exercise training during hemodialysis reduces blood

pressure and increases physical functioning and quality of life. Artificial Organs,

34(7), 586-593.

Redfern, J., Briffa, T., Ellis, E. & Freedman, S.B. (2008). Patient-centered modular

secondary prevention following acute coronary syndrom. Journal of

Cardiopulmonary Rehabilitation and Prevention, 28, 107-115.

Redfern, J., Briffa, T., Ellis, E. & Frredman, S.B. (2009). Choice of secondary

prevention improves risk factors after acute coronary syndrome: 1-year follow-

up of the CHOICE (Choice of Health Options In prevention of Cardiovascular

Events) randomized controlled trial. Heart, 95, 468-475.

Reed, G.R., Velicer, W.F., Prochaska, J.O., Rossi, J.S. & Marcus, B.H. (1997). What

makes a good staging algorithm: examples from regular exercise. American

Journal of Health Promotion, 12(1), 57-66.

Resnick, B. & Nigg, C. (2003). Testing a theoretical model of exercise behaviour for

older adults. Nursing Research, 52(2), 80-88.

Roebuck, A., Furze, G. & Thompson, D.R. (2001). Health-related quality of life after

myocardial infarction: an interview study. Journal of Advanced Nursing, 34(6),

787-794.

Rogers, L.Q., Gutin, B., Humphries, M.C., Lemmon, C.R., Waller, J.L., Baranowski,

T. & Saunders, R. (2005). A physician fitness program: enhancing the physician

as an ―exercise‖ role model for patients. Teaching and Learning in Medicine,

17(1), 27-35.

353

Rollnick, S. & Miller, W.R. (1995). What is motivational interviewing? Behavioural

and Cognitive Psychotherapy, 23, 325-334.

Rosamond, W., Flegal, K., Furie, K., Go, A., Greenlund, K., Haase, N., Hailpern,

S.M., Ho, M., Howard, V., Kissela, B., Kittner, S., Lloyd-Jones, D., McDermott,

M., Meigs, J., Moy, C., Nichol, G., O‘Donnell, C., Roger, V., Sorlie, P.,

Steinberger, J., Thom, T., Wilson, M., Hong, Y., American Heart Association

Statistics Committee & Stroke Statistics Subcommittee. (2008). Heart disease

and stroke statistics 2008 update: a report from the American Heart Association

statistics committee and stroke statistics subcommittee. Circulation, 117, e25-

e146.

Rosano, G.M.C., Vitale, C. & Volterrani, M. (2010). Heart rate in ischemic heart

disease. The innovation of ivabradine: more than pure heart rate reduction.

Advances in Therapy, 27(4), 202-210.

Rothenbacher, D., Hahmann, H., Wusten, B., Koenig, W. & Brenner, H. (2007).

Symptoms of anxiety and depression in patients with stable coronary heart

disease: prognostic value and consideration of pathogenetic links. European

Journal of Cardiovascular Prevention and Rehabilitation, 14, 547-554.

Sacker, A. Head, J. & Bartley, M. (2008). Impact of coronary heart disease on health

functioning in an aging population: are there differences according to

socioeconomic position? Psychosomatic Medicine, 70, 133-140.

Salminen, M., Isoaho, R., Vahlberg, T., Ojanlatva, A., Irjala, K. & Kivelä S.L. (2005).

Effects of health advocacy, counseling, and activation among older coronary

heart disease (CHD) patients. Aging Clinical and Experimental Research, 17,

472-478.

Salvetti, X.M., Oliveira, J.A., Servantes, D.M. & de Paola, A.A.V. (2008). How much

do the benefits cost? Effects of a home-based training programme on

cardiovascular fitness, quality of life, programme cost and adherence for patients

with coronary disease. Clinical Rehabilitation, 22, 987-996.

Sanderson, B.K. & Bittner, V. (2005). Women in cardiac rehabilitation: outcomes and

identifying risk for dropout. American Heart Journal, 150, 1052-1058.

Sanderson, B.K., Phillips, M.M., Gerald, L., DiLillo, V. & Bittner, V. (2003). Factors

associated with the failure of patients to complete cardiac rehabilitation for

medical and nonmedical reasons. Journal of Cardiopulmonary Rehabilitation, 23,

281-289.

Sarkar, U., Ali, S. & Whooley, M.A. (2007). Self-efficacy and health status in patients

with coronary heart disease: findings from the Heart and Soul study.


Sarrafzadegan, N., Rabiei, K., Shirani, S., Kabir, A., Mohammadifard, N. & Roohafza,

H. (2007). Drop-out predictors in cardiac rehabilitation programmes and the

354

impact of sex differences among coronary heart disease patients in Iranian

sample: a cohort study. Clinical Rehabilitation, 21, 362-372.

Scalzi, C.C., Burke, L.E. & Greenland, S. (1980). Evaluation of an inpatient

educational programme for coronary patients. Heart and Lung, 9, 846-853.

Schelling, S., Munsch, S., Meyer, A.H., Newark, P., Biedert, E. & Margraf, J. (2009).

Increasing the motivation for physical activity in obese patients. International

Journal of Eating Disorders, 42, 130-138.

Schroter, S. & Lamping, D.L. (2006). Responsiveness of the coronary

revascularization outcome questionnaire compared with the SF-36 and Seattle

Angina Questionnaire. Quality of Life Research, 15, 1069-1078.

Scirica, B.M. (2009). Chronic angina: definition, prevalence, and implications for

quality of life. Reviews in Cardiovascular Medicine, 10(Suppl 1), S3-S10.

Scott, J.T. & Thompson, D.R. (2003). Assessing the information needs of post-

myocardial infarction patients: a systematic review. Patient Education and

Counseling, 50, 167-177.

Scrutinio, D., Temporelli, P.L., Passantino, A. & Giannuzzi, P. (2009). Long-term

secondary prevention programs after cardiac rehabilitation for the reduction of

future cardiovascular events: focus on regular physical activity. Future

Cardiology, 5(3), 297-314.

Sechrist, K.R., Walker, S.N. & Pender, N.J. (1987) Development and psychometric

evaluation of the exercise benefits/barriers scale. Research in Nursing and

Health, 10, 357-365.

Senuzun, F., Fadiloglu, C., Burke, L. E. & Payzin, S. (2006). Effects of home-based

cardiac exercise program on the exercise tolerance, serum lipid values and self-

efficacy of coronary patients. European Journal of Cardiovascular Prevention

and Rehabilitation, 13, 640-645.

Shen, B.J., Avivi, Y.E., Todaro, J.F., Spiro III, A., Laurenceau, J.P., Ward, K.D. &

Niaura, R. (2008). Anxiety characteristics independently and prospectively

predict myocardial infarction in men. Journal of the American College of

Cardiology. 51, 113-119.

Shibeshi, W.A., Young-Xu, Y. & Blatt, C.M. (2007). Anxiety worsens prognosis in

patients with coronary artery disease. Journal of the American College of

Cardiology, 49(20), 2021-2027.

Shin, Y.H., Jang, H.J. & Pender, N.J. (2001). Psychometric evaluation of the exercise

self-efficacy scale among Korean adults with chronic disease. Research in

Nursing and Health, 24, 68-76.

355

Shin, Y.H., Yun, S.K., Jang, H.J. & Lim, J.H. (2006). A tailored program for the

promotion of physical exercise among Korean adults with chronic diseases.

Applied Nursing Research, 19, 88-94.

Shiotani, H., Umegaki, Y., Tanaka, M., Kimura, M. & Ando, H. (2009). Effects of

aerobic exercise on the circadian rhythm of heart rate and blood pressure.

Chronobiology International, 26(8), 1636-1646.

Shirazi, K.K., Wallace, L.M., Niknami, S., Hidarnia, A., Torkaman, G., Gilchrist, M.

& Faghihzadeh, S. (2007). A home-based, transtheoretical change model

designed strength training intervention to increase exercise to prevent

osteoporosis in Iranian women aged 40-65 years: a randomized controlled trial.

Health Education Research, 22(3), 305-317.

Sinclair, A.J., Conroy, S.P., Davies, M. & Bayer, A.J. (2005). Post-discharge home-

based support for older cardiac patients: a randomized controlled trial. Age and

Ageing, 34, 338-343.

Smeulders, E. S., van Haastregt, J. C., Ambergen, T., Janssen-Boyne, J. J., van Eijk, J.

T. & Kempen, G. I. (2009). The impact of a self-management group programme

on health behaviour and healthcare utilization among congestive heart failure

patients. European Journal of Heart Failure, 11, 609-616.

Smeulders, E. S., van Haastregt, J. C., van Hoef, E.F., van Eijk, J. T. & Kempen, G. I.

(2006). Evaluation of a self-management programme for congestive heart failure

patients: design of a randomised controlled trial. BMC Health Services Research,

6, 91.

Smith, K.M., Arthur, H.M., McKelvie, R.C. & Kodis, J. (2004). Differences in

sustainability of exercise and health-related quality of life outcomes following

home or hospital-based cardiac rehabilitation. European Journal of


Smith, L.K., Layton, K., Newmark, J.L. & Diethrich, E.B. (1987). An intensive

cardiovascular rehabilitation program for patients with disabling angina and

diffuse coronary artery disease. Journal of Cardiopulmonary Rehabilitation, 7,

425-429.

Smith, M. (1999). Nursing and rehabilitation. In: Smith, M. (ed). Rehabilitation in

Adult Nursing Practice. Edinburgh: Churchill Livingstone, 31-52.

So, H.K., Sung, R.Y.T., Li, A.M., Choi, K.C., Nelson, E.A.S., Yin, J., Ng, P.C. & Fok,

T.F. (2010). Higher exercise frequency associated with lower blood pressure in

Hong Kong adolescents: a population-based study. Journal of Human

Hypertension, 24, 646-651.

So.dermana, E., Lisspersa, J. & Sundinb, O. (2003). Depression as a predictor of

return to work in patients with coronary artery disease. Social Science and

Medicine, 56, 193–202.

356

Spertus, J.A., Dawson, J., Masoudi, F.A., Krumholz, H.M., Reid, K.J., Peterson, E.D.

& Rumsfeld, J.S. (2006). Prevalence and predictors of angina pectoris one month

after myocardial infarction. American Journal of Cardiology, 98, 282-288.

Spertus, J.A., Jones, P., McDonell, M., Fan, V. & Fihn, S.D. (2002). Health status

predicts long-term outcome in outpatients with coronary disease. Circulation,

106, 43-49.

Spertus, J.A., Winder, J.A., Dewhurst, T.A., Dewhurst, T.A., Prodzinski, J.,

McDonell, M. & Fihn, S.D. (1995). Development and evaluation of the Seattle

angina questionnaire: A new functional status measure for coronary artery

disease. Journal of the American College of Cardiology, 25(2), 333-341.

Spiraki, C., Kaitelidou, D., Papakonstantinou, V., Prezerakos, P. & Maniadakis, N.

(2008). Health-related quality of life measurement in patients admitted with

coronary heart disease and heart failure to a cardiology department of a

secondary urban hospital in Greece. Hellenic Journal of Cardiology, 49, 241-247.

Stafford, L., Berk, M. & Jackson, H.J. (2007). Validity of the hospital anxiety and

depression scale and patient health questionnaire-9 to screen for depression in

patients with coronary heart disease. General Hospital Psychiatry, 29, 417-424.

Stähle, A., Nordlander, N., Rydén, L. & Mattsson, E. (1999). Effects of organized

aerobic group training in elderly patients discharged after an acute coronary

syndrome. A randomized controlled study. Scandinavian Journal of


Steffen-Batey, L., Nichaman, M.Z., Goff, D.C., Frankowski, R.F., Hanis, C.L.,

Ramsey, D.J. & Labarthe, D.R. (2000). Change in level of physical activity and

risk of all-cause mortality or reinfarction: the Corpus Christi Heart Project.

Circulation, 102, 2204-2209.

Stenlund, T., Lindström, B., Granlund, M. & Burell, G. (2005). Cardiac rehabilitation

for the elderly: Qi Gong and group discussions. European Journal of


Steptoe, A., Doherty, S., Rink, E., Kerry, S., Kendrick, T. & Hilton, S. (1999).

Behavioural counselling in general practice for the promotion of healthy

behaviour among adults at increased risk of coronary heart disease: randomised

trial. British Medical Journal, 319, 943-948.

Steptoe, A., Kerry, S., Rink, E. & Hilton, S. (2001). The impact of behavioural

counselling on stage of change in fat intake, physical activity, and cigarette

smoking in adults at increased risk of coronary heart disease. American Journal

of Public Health, 91(2), 265-269.

Stern, M.P. & Farquhar, J.W., Maccoby, N. & Russell, S.H. (1976). Results of a two-

year patient education campaign on dietary behaviour: The Stanford Three

Community Study. Circulation, 54(5), 826-832.

357

Stewart, D.E., Abbey, S.E., Shnek, Z.M., Irvine, J. & Grace, S.L. (2004). Gender

differences in health information needs and decisional preferences in patients

recovering from an acute ischemic coronary event. Psychosomatic Medicine, 66,

42-48.

Stokes, H.C. (2000). Education and training towards competency for cardiac

rehabilitation nurses in the United Kingdom. Journal of Clinical Nursing, 9, 411-

419.

Suaya, J.A., Shepard, D.S., Normand, S.L.T., Ades, P.A., Prottas, J. & Stason, W.B.

(2007). Use of cardiac rehabilitation by medicare beneficiaries after myocardial

infarction or coronary bypass surgery. Circulation, 116, 1653-1662.

Suaya, J.A., Stason, W.B., Ades, P.A., Normand, S.L.T. & Shepard, D.S. (2009).

Cardiac rehabilitation and survival in older coronary patients. Journal of the

American College of Cardiology, 54, 25-33.

Sun, F.C., Zhang, X., Liu, X.L. & Wang, L.Q. (2008). Study on Guidance of TTM in

college students sports exercise after class. Journal of Nanjing Institute of

Physical Education, 22(4), 77-78, 88, 98.

Sundararajan, V., Bunker, S.J., Begg, S., Marshall, R. & McBurney, H. (2004).

Attendance rates and outcomes of cardiac rehabilitation in Victoria, 1998.

Medical Journal of Australia, 180, 268-271.

Szekely, A., Balog, P., Benko, E., Breuer, T., Szekely, J., Kertai, M.D., Horkay, F.,

Kopp, M.S. & Thayer, J.F. (2007). Anxiety predicts mortality and morbidity

after coronary artery and valve surgery – a 4-year follow-up study.


Taylor, C.C., Demoor, C., Smith, M.A., Dunn, A.L., Basen-Engquist, K., Nielsen, I.,

Pettaway, C., Sellin, R., Massey, P. & Gritz, E.R. (2006). Active for life after

cancer: a randomized trial examining a lifestyle physical activity program for

prostate cancer patients. Psycho-Oncology, 15, 847-862.

Taylor, G.H., Wilson, S.L. & Sharp, J. (2011). Medical, psychological, and

sociodemographic factors associated with adherence to cardiac rehabilitation

programs: A systematic review. Journal of Cardiovascular Nursing, 26(3), 202-

209.

Taylor, R.S., Brown, A., Ebrahim, S., Jolliffe, J., Noorani, H., Rees, K., Skidmore, B.,

Stone, J.A., Thompson, A.R. & Oldridge, N. (2004). Exercise-based

rehabilitation for patients with coronary heart disease: systematic review and

meta-analysis of randomized controlled trials. American Journal of Medicine,

116, 682-692.

Taylor, R.S., Dalal, H., Jolly, K., Moxham, T. & Zawada, A. (2010). Home-based

versus centre-based cardiac rehabilitation. Cochrane Database of Systematic

Reviews, Issue 1. Art. No.: CD007130. DOI: 10. 1002/14651858. CD007130.

pub2.

358

Teo, K.K, Liu, L., Chow, C.K., Wang, X., Islam, S., Jiang, L., Sanderson, J.E.,

Rangarajan, S. & Yusuf, S. (2009). Potentially modifiable risk factors associated

with myocardial infarction in China: the INTERHEART China study. Heart, 95,

1857-1864.

The Vestfold Heartcare Study Group. (2003). Influence on lifestyle measures and

five-year coronary risk by a comprehensive lifestyle intervention programme in

patients with coronary heart disease. European Journal of Cardiovascular


Thompson, D.R. (2007). Role of nurse-led, clinic and home-based intervention on

chronic heart failure patients. Journal of the Hong Kong College of Cardiology,

15 (Suppl 1), A66.

Thompson, D.R., Chair, S.Y., Chan, S.W., Astin, F., Davidson, P.M. & Ski, C.F.

(2011). Motivational interviewing: a useful approach to improving

cardiovascular health? Journal of Clinical Nursing, 20, 1236-1244.

Thompson, D.R. & Lewin, R.P. (2000). Management of the post-myocardial

infarction patient: rehabilitation and cardiac neurosis. Heart, 84, 101-105.

Thompson, D.R. & Roebuck, A. (2001). The measurement of health-related quality of

life in patients with coronary heart disease. Journal of Cardiological Nursing,

16(1), 28-33.

Thompson, D.R., Ersser, S.J., & Webster, R.A. (1995). The experiences of patients

and their partners 1 month after a heart attack. Journal of Advanced Nursing, 22,

707-714.

Thompson, D.R. & Yu, C.M. (2007). Cardiac rehabilitation: China. In J. Perk, P.

Mathes, H. Gohlke, C. Monpere, I. Hellemans, H. McGee, P. Sellier & H. Saner

(Ed). Cardiovascular prevention and rehabilitation. Lodon: Springer.com.

Tierney, A.J, Worth, A. & Watson, N. (2000). Meeting patients' information needs

before and after discharge from hospital. Journal of Clinical Nursing, 9, 859-860.

Todaro, J.F., Shen, B.J., Raffa, S.D., Tilkemeier, P.L. & Niaura, R. (2007).

Prevalence of anxiety disorders in men and women with established coronary

heart disease. Journal of Cardiopulmonary Rehabilitation and Prevention, 27,

86-91.

Todd, I.C. & Ballantyne, D. (1990). Antianginal efficacy of exercise training: a

comparison with β-blockade. Heart, 64, 14-19.

Touillet, A., Guesdon, H., Bosser, G., Beis, J.M. & Paysant, J. (2010). Assessment of

compliance with prescribed activity by hemiplegic stroke patients after an

exercise programme and physical activity education. Annals of Physical &


359

Tullmann, D.F., Haugh, K.H., Dracup, K.A. & Bourguignon, C. (2007). A

Randomized Controlled Trial to Reduce Delay in Older Adults Seeking Help for

Symptoms of Acute Myocardial Infarction. Research in Nursing and Health, 30,

485-497.

Tung, W.C. (2003). Examination of the transtheoretical model and physical activity

in family caregivers in Taiwan. Dissertation: The University of Utah.

Tung, W.C. & Gillett, P.A. (2005). Stages of change for physical activity among

family caregivers. Journal of Advanced Nursing, 49(5), 513-521.

Tung, W.C., Gillett, P.A. & Pattillo, R.E. (2005). Application the transtheoretical

model to physical activity in family caregivers in Taiwan. Public Health Nursing,

22(4), 299-310.

Tung, W.C. & Hsu, C.H. (2009). Assessing transcultural validity of the

transtheoretical model with Chinese Americans and physical activity. Journal of

Transcultural Nursing, 20, 286-295.

Turton, J. (1998). Importance of information following myocardial infarction: a study

of the self-perceived information needs of patients and their spouse/partner

compared with the perceptions of nursing staff. Journal of Advanced Nursing,

27,770-778.

Valkeinen, H., Aaltonen, S. & Kujala, M. (2010). Effects of exercise training on

oxygen uptake in coronary heart disease: a systematic review and meta-analysis.

Scandinavian Journal of Medicine and Science in Sports, 20, 545-555.

van Elderen-van Kemenade, T.E., Maes, S. & van den Broek, Y. (1994). Effects of a

health education programme with telephone follow-up during cardiac

rehabilitation. British Journal of Clinical Psychology, 33, 367-378.

van Sluijs, E.M.F., van Poppel, M.N.M., Twisk, J.W.R. & van Mechelen, W. (2006).

Physical activity measurements affected participants‘ behaviour in a randomized

controlled trial. Journal of Clinical Epidemiology, 59, 404-411.

van Sluijs, E.M.F., van Poppel, M.N.M., Twisk, J.W.R., Chin A Paw, M.J., Calfas,

K.J. & van Mechelen, W. (2005). Effect of a tailored physical activity

intervention delivered in general practice settings: results of a randomized

controlled trial. American Journal of Public Health, 95(10), 1825-1831.

van Sluijs, EMF., van Poppel MNM. & van Mechelen W. (2004). Stage-based

lifestyle interventions in primary care: are they effective? American Journal of


van Tol, B.A.F., Huijsmans, R.J., Kroon, D.W., Schothorst, M. & Kwakkel, G. (2006).

Effects of exercise training on cardiac performance, exercise capacity and quality

of life in patients with heart failure: a meta-analysis. European Journal of Heart

Failure, 8, 841-850.

360

Wallace, L.K., Slattery, K.M. & Coutts, A.J. (2009). The ecological validity ad

application of the seesion-RPE method for quantifying training loads in

swimming. International Journal of Nursing Studies, 23(1), 33-38.

Wan, G.S. & Wang, X.Y. (2008). Investigation and analysis of teaching needs on

patients with coronary heart disease. Chinese Journal of Modern Drug

Application, 2(5), 111-113.

Wang, X.L & Xu, L.H. (2010). Critical review of cardiac rehabilitation and nursing

research in patients with coronary heart disease. Shanghai Nursing, 10(2), 69-71.

Wang, W.R., Chair, S.Y., Thompson, D.R. & Twinn, S.F. (2009). Health care

professionals‘ perceptions of hospital-based cardiac rehabilitation in mainland

China: an exploratory study. Journal of Clinical Nursing, 18, 3401-3408.

Wannamethee, G.S., Shaper, A.G. & Walker, M. (2000). Physical activity and

mortality in older men with diagnosed coronary heart disease. Circulation, 102,

1358-1363.

Wanner, M., Martin-Diener, E., Braun-Fahrländer, C., Bauer, G. & Martin, B.W.

(2009). Effectiveness of active-online, an individually tailored physical activity

intervention, in a real-life setting: randomized controlled trial. Journal of

Medical Internet Research, 11(3), e23.

Warburton, D.E.R., Katzmarzyk, P.T., Rhodes, R.E. & Shephard, R.J. (2007).

Evidence-informed physical activity guidelines for Canadian adults. Applied

Physiology, Nutrition, and Metabolism, 32, s16-s68.

Ware, J.E. & Sherbourne, C.D. (1992). The MOS 36-item short-form health survey

(SF-36). I. Conceptual framework and item selection. Medical Care, 30(6), 473-

483.

Webster, R.A., Thompson, D.R. & Mayou, R.A. (2002). The experiences and needs

of Gujarati Hindu patients and partners in the first month after a myocardial

infarction. European Journal of Cardiovascular Nursing, 69-76.

Wenger, N.K., Smith, L.K., Froelicher, E.S., Comoss, P.M. (Ed). (1999). Cardiac

rehabilitation: a guide to practice in the 21st century. New York, NY: Marcel

Dekker. 70.

White, J., Hunter, M. & Holttum, S. (2007). How do women experience myocardial

infarction? A qualitative exploration of illness perceptions, adjustments and

coping. Psychology, Health and Medicine. 12(3), 278-288.

Wiklund, I., Sanne, H., Elmfeldt, D., Vedin, A. & Wilhelmsson, C. (1984). Emotional

reaction, health preoccupation and sexual activity two months after a myocardial

infarction. Scandinavian Journal of Rehabilitation Medicine. 16(2), 47-56.

361

Willmer, K.A. & Waite, M. (2009). Long-term benefits of cardiac rehabilitation: a

five-year follow-up of community-based phase 4 programmes. British Journal of

Cardiology, 16, 73-77.

Windle, G., Hughes, D., Linck, P., Russell, I. & Woods, B. (2010). Is exercise

effective in promoting mental well-being in older age? A systematic review.

Aging and Mental Health, 14(6), 652-669.

Witt, B.J., Jacobsen, S.J., Weston, S.A., Killian, J.M., Meverden, R.A., Allison, T.G.,

Reeder, G.S. & Roger, V.L. (2004). Cardiac rehabilitation after myocardial

infarction in the Community. Journal of the American College of Cardiology, 44,

988-996.

Wong, M.S. & Chair, S.Y. (2007). Changes in health-related quality of life following

percutaneous coronary intervention: a longitudinal study. International Journal

of Nursing Studies, 44, 1334-1342.

Wood, M.E. (2008). Theoretical framework to study exercise motivation for breast

cancer risk reduction. Oncology Nursing Forum, 35(1), 89-95.

Woods, C., Mutrie, N. & Scott, M. (2002). Physical activity intervention: a

transtheoretical model-based intervention designed to help sedentary young

adults become active. Health Education Research, 17(4), 451-460.

Worcester, M.U.C., Murphy, B.M., Elliott, P.C., Le Grande, M.R., Higgins, R.O.,

Goble, A.J. & Roberts, S.B. (2007). Trajectories of recovery of quality of life in

women after an acute cardiac event. British Journal of Health Psychology, 12, 1-

15.

Worcester, M.U.C., Murphy, B.M., Mee, V.K., Roberts, S.B. & Goble, A.J. (2004).

Cardiac rehabilitation programmes: predictors of non-attendance and drop-out.

European Journal of Cardiovascular Prevention and Rehabilitation, 11, 328-335.

World Health Organization. (1993). Needs and action priorities in cardiac

rehabilitation and secondary prevention in patients with coronary heart disease.

Copenhagen: WHO.

World Health Organization (WHO). (2004). Information database - 2004 (accessed

12 April 2011). Available at: https://apps.who.int/infobase/Mortality.

World Health Organization (WHO). (2005). The Impact of Chronic Disease in China

- 2005 (accessed 12 April 2011). Available at: http://

www.who.int/chp/chronic_disease_report/media/china.

World Health Organization (WHO). (2008). Cardiovascular Disease - 2008 (accessed

10 January 2009). Available at: http://www.who.int/cardiovascular_disease.

World Health Organization (WHO). (2011). Cardiovascular Disease - 2011 (accessed

12 April 2011). Available at: http:// www.who.int./cardiovascular_disease.

World%20Health%20Organization%20(WHO).%20(2004).%20Information%20database%20-%202004%20(accessed%2012%20April%202011).%20Available%20at:%20https:/apps.who.int/infobase/Mortality.

World%20Health%20Organization%20(WHO).%20(2004).%20Information%20database%20-%202004%20(accessed%2012%20April%202011).%20Available%20at:%20https:/apps.who.int/infobase/Mortality.

World%20Health%20Organization%20(WHO).%20(2005).%20The%20Impact%20of%20Chronic%20Disease%20in%20China%20-%202005%20(accessed%2012%20April%202011).%20Available%20at:%20http:/%20www.who.int/chp/chronic_disease_report/media/china.



World%20Health%20Organization%20(WHO).%20(2011).%20Cardiovascular%20Disease%20-%202011%20(accessed%2012%20April%202011).%20Available%20at:%20http:/%20www.who.int./cardiovascular_disease.

World%20Health%20Organization%20(WHO).%20(2011).%20Cardiovascular%20Disease%20-%202011%20(accessed%2012%20April%202011).%20Available%20at:%20http:/%20www.who.int./cardiovascular_disease.

362

Wu, S.K., Lin, Y.W., Chen, C.L. & Tsai, S.W. (2006). Cardiac rehabilitation vs.

home exercise after coronary artery bypass graft surgery. American Journal of

Physical Medicine and Rehabilitation, 85, 711-717.

Wu, X.G. (2003). An epidemiological status and trends of coronary heart disease in

Chinese population. Chinese Journal of Prevention and Control of Chronic Non-

communicable Disease, 11(4), 190-191.

Xia, Y.T. (2006). The analysis of reliability and validity of the hospital anxiety and

depression scale for pregnant women. Journal of Nursing (China), 13(11), 62-63.

Xu, L. (2004). Investigation and study of the personality, mentality and quality of life

in patients with coronary heart disease. Health Psychology Journal, 12(3), 178-

183.

Yan, X., Lee, S. & Li, N. (2009) Missing data handling methods in medical device

clinical trials. Journal of Biopharmaceutical Statistics, 19, 1085-1098.

Yan, Z.M., Zhang, M.R., Yang, Z., Li, Y.T. & Gong, H.Q. (2004). Epidemiological

survey and analysis of coronary heart disease from residents in Kunming. Soft

Science of Health, 18(6), 334-336

Yang, M., Yang, S. & Liu, X.H. (2007). A review of psychological assessment and

interventions on patient with coronary heart disease. Chinese Journal of

Practical Nursing, 23(8), 73-74.

Yates, B. C., Anderson, T., Hertzog, M., Ott, C. & Williams, J. (2005). Effectiveness

of follow-up booster sessions in improving physical status after cardiac

rehabilitation: health, behavioral, and clinical outcomes. Applied Nursing

Research, 18, 59-62.

Yates, B.C., Heeren, B.M., Keller, S.M., Agrawal, S., Stoner, J.A. & Ott, C. (2007).

Comparing two methods of rehabilitation for risk factor modification after a

cardiac event. Rehabilitation Nursing, 32(1), 15-22.

Ye, W.F. & Xu, J.M. (1993). The application and evaluation of hospital anxiety and

depression scale with patients in general hospital. Chinese Journal of Behaviour

Science, 2(3), 17-19.

Yohannes, A.M., Yalfani, A., Doherty, P. & Bundy, C. (2007). Predictors of drop-out

from an outpatient cardiac rehabilitation programme. Clinical Rehabilitation, 21,

222-229.

Yonezawa, R., Masuda, T., Matsunaga, A., Takahashi, Y., Saitoh, M., Ishii, A.,

Kutsuna, T., Matsumoto, T., Yamamoto, K., Aiba, N., Hara, M. & Izumi, T.

(2009). Effects of phase II cardiac rehabilitation on job stress and health-related

quality of life after return to work in middle-aged patients with acute myocardial

infarction. International Heart Journal, 50, 279-290.

363

Yu, C.M., Lau, C.P., Chau, J., McGhee, S., Kong, S.L., Cheung, B.M.Y. & Li, L.S.W.

(2004). A short course of cardiac rehabilitation program is highly cost effective

in improving long-term quality of life in patients with recent myocardial

infarction or percutaneous coronary intervention. Archives of Physical Medicine

& Rehabilitation, 85, 1915-1922.

Yue, L.P. (2004). Psychological analysis of 84 patients with coronary heart disease.

Chinese Journal of Health Psychology, 12(6), 429-430.

Yuval, R., Halon, D.A. & Lewis, B.S. (2007). Perceived disability and lifestyle

modification following hospitalization for non-ST elevation versus ST elevation

acute coronary symdromes: the patients‘ point of view. European Journal of

Cardiovascular Nursing, 6, 287-292.

Zboralski, K., Galecki, P., Wysokiński, A., Orzechowska, A. & Talarowska, M.

(2009). Quality of life and emotional functioning in selected cardiovascular

diseases. Kardiologia Polska, 67(11), 1228-1234.

Zhang, B.H., Li, X.W. & Wang, X.H. (1999). The effects of rehabilitation exercise on

the aerobic capacity of the patients with CHD post intervention therapy. Chinese

Journal of Cardiovascular Rehabilitation Medicine, 8(4), 3-5.

Zhang, H.S., Wang, X.M. & Zeng, D.Y. (2004). Clinical features of psychological

status in patients with coronary heart disease. Chinese Journal of Clinical


Zhang, J.P., Tang, Y. & Yu, X.P. (2005). Investigation on mental status in patients

with coronary heart disease. Journal of Nursing Science, 20(15), 43-45.

Zhang, L., Xu, D.Z., Huang, J.Y. & Li, L.S. (2004). Study on the application of the

Chinese version of SF-36 scales and selection of interceptive cents for its grade

range. Chinese Journal of Epidemiology, 25(1), 69-73.

Zhang, X.H., Lu, Z.L. & Liu, L. (2008). Coronary heart disease in China. Heart, 94,

1126-1131.

Zhang, Y.C., Huang, C.S., Han, L. & Li, S.M. (2004). Analysis of clinical characters

and psychosocial factors in patients with coronary heart disease. Nervous

Diseases and Mental Health, 4(5), 364-365.

Zhang, Z.J. (Ed). (2005). A handbook of behavioural medical scale. Beijing: Chinese

Medical Electronic Audio-Video Publishing House.

Zhao, Y. & Wong, F.K.Y. (2009). Effects of a postdischarge transitional care

programme for patients with coronary heart disease in China: A randomised

controlled trial. Journal of Clinical Nursing, 18, 2444-2455.

Zhong B., Lei Y., Qiao SB., Zhang WC., Liu YN. & Liu Y. (1999). Contrast study on

exercise rehabilitation in patients with angina of coronary heart disease. Chinese

Journal of Cardiovascular Rehabilitation Medicine, 8(4), 11-13.

364

Zhou, Y. & You, L.M. (2003). Psychological status and psychological care of the

patients with coronary heart disease. Chinese Journal of Nursing, 38(11), 836-

838.

Zhu, F. & Chen, Y.J. (2007). The effect of transtheoretical model for patient

education to the behavioural changes of diabetic patients. Zhejiang Preventive

Medicine, 19(8), 31, 41, 61.

Zhu, L.X., Ho, S.C. & Sit, W.H.J. (2012). The experiences of Chinese patients with

coronary heart disease. Journal of Clinical Nursing, 21(3-4), 476-484.

Zhu, L.X., Ho, S.C. & Wong, T.K.S. (unpublished). The effectiveness of health

education on exercise behaviour of patients with heart disease.

Zhu, L.X., Lin, B.L., Huang, L.P., Dai, X.Y., Chen, S.Z. & Song, M.Y. (2007).

Correlation about psychological condition and social supports for patients with

coronary heart disease. Chinese Journal of Practical Nursing, 23(12), 55-58.

Zhu, Y.J. (2004). Evaluation of 4-week exercise therapy on the amelioration of left

heart function and activities of daily living in patients with acute myocardial

infarction accompanied by left heart failure. Chinese Journal of Clinical


Ziegelstein, R.C., Fauerbach, J.A., Stevens, S.S., Romanelli, J., Richter, D.P. & Bush,

D.E. (2000). Patients with depression are less likely to follow recommendations

to reduce cardiac risk during recovery from a myocardial infarction. Archives of

Internal Medicine, 160, 1818-1823.

Zwisler, A.D., Soja, A. M., Rasmussen, S., Frederiksen, M., Abadini, S., Appel, J.,

Rasmussen, H., Gluud, C., Iversen, L., Sigurd, B., Madsen, M. & Fischer-

Hansen, J. (2008). Hospital-based comprehensive cardiac rehabilitation versus

usual care among patients with congestive heart failure, ischemic heart disease,

or high risk of ischemic heart disease: 12-month results of a randomized clinical

trial. American Heart Journal, 155, 1106-1113.

365

Appendices

366

Appendix I Contraindications for Exercise Training

Contraindications for Exercise Training

According to Wenger, Smith, Froelicher, Comoss (1999) and the expert work group

of the National Heart Foundation of Australia (Briffa, Maiorana, Sheerin, Stubbs &

Oldenburg et al., 2006), people with the following contraindications should not

engage in outpatient cardiac rehabilitation exercise training or physical activity:-

Table I Contraindications for exercise training

Wenger et al. (1999) Briffa et al. (2006)

Unstable angina;

Resting SBP > 200 mmHg or resting

DBP > 110 mmHg;

Orthostatic blood pressure drop of >

20mmHg with symptoms;

Critical aorthic stenosis (peak systolic

pressure gradient > 50 mmHg with

aortic valve orifice area < 0.75 cm2 in

average size adult);

Acute systematic illness or fever;

Uncontrolled atrial or ventricular

arrhythmias;

Uncontrolled sinus tachycardia (> 120

beats/min);

Uncompensated CHF;

Third degree AV block (without

pacemaker);

Active pericarditis or myocarditis;

Recent embolism;

Thrombophlebitis;

Unstable angina;

Uncontrolled hypertension or with

grade 3 (severe) hypertension e.g.,

SBP ≥ 180 and DBP ≥ 110

mmHg;

Symptomatic hypotension < 90/60

mmHg;

Severe aortic stenosis;

Symptoms such as chest

discomfort and shortness of breath

on low activity;

Resting tachycardia or

arrhythmias;

Acute infection or fever, or are

feeling unwell (including acute

myocarditis or pericarditis);

Uncontrolled cardiac failure;

Diabetes with poor blood glucose

control, e.g., blood glucose level

< 6 mmol/L or > 15 mmol/L

367

Table I Contraindications for exercise training (Continue)

Wenger et al. (1999) Briffa et al. (2006)

Resting ST segment displacement

(>2mm);

Uncontrolled diabetes (resting blood

glucose > 400 mg/dL);

Severe orthopaedic problems that

would prohibit exercise;

Other metabolic problems, such as

acute thyroiditis, hypo- or

hyperkalemia, hypovolemia, etc.

368

Appendix II Ethics Approval Letters

372

Appendix IV Screening Guidelines

Screening Guidelines

The following guidelines are provided for the cardiologists to screen each potential

patient and to decide whether the patient is suitable for participating in this study or

not, that is an exercise stage-matched intervention. According to the following

guidelines, if the patient does not meet any one item of the requirements, the patient

will not be invited to participate in the study.

1．Age__________years

Suitable：age ≥ 18 years old。

Unsuitable：age < 18 years old。

2. Is the patient living in Xiamen City?

Suitable：The patient is living in Xiamen City and can be contacted by telephone.

Living Address：____________________________________________

Telephone：______________________________________________

Unsuitable：The patient is not living in Xiamen City or cannot be contacted by

telephone.

3．Does patient be able to communicate in mandarin and read in Chinese?

Suitable：The patient is able to communicate in mandarin and read in Chinese.

Unsuitable：The patient has difficulties/obstacles in communicating in mandarin

or reading in Chinese.

Note：

(1) Communicate ability refers to the patient can understand the communication

contents and can communicate to each other using precise words.

(2) Communication difficulties / obstacles of communication refer to that the patient

is unable to understand the contents, can not convey the meaning of words, or

373

can not communicate to each other.

(3) Reading ability refers to the patient can read and understand Chinese

(4) Reading difficulties refer to the patient can not read in Chinese.

4．Disease diagnosis: angina pectoris, myocardial infarction, PCI

Suitable：The patient has been diagnosed with angina pectoris or myocardial

infarction or has undergone PCI for at least three months.

Unsuitable：The patient has been diagnosed with angina pectoris or myocardial

infarction or has undergone PCI for less than three months.

Note：

A.Angina pectoris ，date of diagnosis_________(month/year)

Diagnosis：According to the diagnostic criteria from the International Society of

Cardiology and the World Health Organization in 1979:

1）Medical history：Have a medical history of typical angina, that is the chest

discomfort is induced by the exertion or emotional excitement, usually lasting 1-

15 minutes, may radiate to the jaw, throat, shoulder, back, left arm or wrist, and

can be relieved by rest or sublingual nitroglycerin in a few minutes.

2）Men over the age of 40 years and women over the age of 45; the resting ECG

shows a significant myocardial ischemia; or the exercise test shows positive

results, without any other causes (e.g., a variety of heart disease, autonomic

dysfunction, significant anemia, COPD, taking digitalis, and electrolyte

imbalance), and has two of the following three items: hypertension, high blood

cholesterol and diabetes.

3）The patient was confirmed by the coronary angiography with the luminal

diameter stenosis 70% or more.

B. Myocardial infarction (___time), date of diagnosis_______(month/year)

Diagnosis：According to the revised diagnostic criteria from the National Integrative

control of coronary heart disease, angina, cardiac arrhythmia research symposium (in

Shanghai) in 1979.

I. Meet two of the following three items，the patient can be diagnosed with acute

myocardial infarction：

374

1）Typical clinical symptoms: A typical history of a serious and persistent chest

pain；

2）Abnormal Q spread or ST-T segment on ECG as the evolution of myocardial

infarction；

3）Increased serum enzyme as the process of myocardial infarction.

II. Certainly information (e.g., ECG or serum enzyme) confirmed that the patient had

suffered from myocardial infarction.

C. PCI (______time)，date of PCI_________(month/year)

Diagnosis ： PCI Includes percutaneous coronary angioplasty (PTCA), coronary

stenting, rotational atherectomy of coronary artery plaque, laser angioplasty

techniques.

5．Is patient medically stable?

Suitable：The patient is medically stable.

Unsuitable：The patient is not medically stable。

Note：

Whether the patient is medically stable or not is judged by the cardiologists.

References are as follows:

① Patients with stable vital signs, that is breathing, pulse, blood pressure and body

temperature within normal limits (see below for specific measurements); no fever

(oral temperature below 37.5 ℃ ); no manifestation of unstable angina or acute

myocardial infarction.

6．Does patient have unstable angina?

Suitable：Patient has no unstable angina.

Unsuitable：Patient has unstable angina.

Note：

（1）Stable angina: Patient has a stable condition. Stable angina is characterized by a

deep, poorly localized chest or arm discomfort that is reproducibly associated with

375

physical exertion or emotional stress and relieved within 5-15 minutes by rest

and/or sublingual nitroglycerin. Most patients can predict under what conditions

(such as how far, how fast, and how many steps to go, and so on) will occur angina

pain.

（2）Unstable angina：The unstable angina are classified as five types:

1）New angina: Individuals have never experienced angina before and suddenly

occurred frequent angina after physical exertion in the recent one month. It

can be deteriorated into myocardial infarction.

2）Worsening angina: Individuals have a history of angina, but the onset of

angina become more frequent and the pain become more serious recently,

which often last more than 15 minutes and can not be relieved by

nitroglycerin.

3）Resting angina: Angina occurs at rest or sleep with severe pain and individuals

are often forced to sit or stand.

4）Variant angina: The clinical manifestations are similar to the resting angina,

but ST-segment elevation on ECG during angina attack, which is due to the

sudden coronary artery spasm. The patient will suffer from myocardial

infarction sooner or later.

5）Post-infarction angina: Recurrent angina one month after the acute myocardial

infarction. This suggests that there may be a recurrence of myocardial

infarction.

7．Has patient participate in any cardiac rehabilitation programme?

Suitable：The patient has never participated in any cardiac rehabilitation

programme.

Unsuitable：The patient has participated in any related cardiac rehabilitation

programme.

Note：

（1） The related cardiac rehabilitation programme refers to structure patient

education regarding coronary heart disease, organized exercise training, or

instructions for cardiac rehabilitation and risk factor control.

376

8．Does patient have any cognitive impairment?

Suitable：The patient has no cognitive impairment.

Unsuitable：The patient has cognitive impairment.

Note：

（ 1 ） Meet any one following item, the patient is thought to have cognitive

impairment:

1）Has been diagnosed with psychosis.

2）Has been diagnosed with dementia.

3）Has been diagnosed with mental retardation.

4）Suffered from aphasia or agnosia after stroke or traumatic brain injury.

9．Does patient have depression?

Suitable：The patient has no depression.

Unsuitable：The patient has depression.

Note：

(1) In this study, the depression is diagnosed based on that the scores are equal to 11

or more on the Hospital Anxiety and Depression Scale – Depression Subscale.

10．Does patient have critical aortic stenosis?

Suitable：The patient has no critical aortic stenosis.

Unsuitable：The patient has been diagnosed with critical aortic stenosis.

Note：

（1） Aortic valve stenosis is narrowing of the orifice between the left ventricle and

the aorta. Normal aortic valve area is 3.0cm2 or more. When the valve area is

reduced to 1.5cm2, it is the mild stenosis; when the valve area becomes

1.0cm2, there is a significant pressure gradient and is classified as moderate

stenosis; when the valve area is < 0.75cm2, it can appear clinical symptoms

and is classified as severe stenosis.

377

（2） The common etiologies of the aortic valve stenosis are inflammatory

rheumatic valvular, congenital malformations and degenerative.

（3） The characteristic symptoms of critical aortic stenosis include chest pain,

syncope, heart failure or sudden death. Once the symptoms appeared, it often

has a progressive deterioration. If the patients do not receive treatment with

surgery, they will die within an average of 2-3 years. The typical signs of

aortic valve stenosis are a loud, rough systolic murmur which is most obvious

at the right edge of the second intercostals sternum and left sternal border of

the third and fourth intercostals, increased with the inhalation of amyl nitrite

or supine posture and weakened with the application of vasopressors or

standing. Generally, the more severe aortic stenosis, the stronger systolic

murmur. The intensity level of murmur is up to 3-4/6 grade and it is

accompanied with tremors and may radiate into the carotid arteries and to the

apex of the left ventricle.

（4） Laboratory tests: X-ray examination shows expansion after aortic stenosis and

calcification of aortic valve in most cases; ECG shows that around 85% of the

patients have left ventricular hypertrophy; echocardiography shows that the

aortic opening is smaller than 15 mm, the open speed slows down, and the

valve leaflets become thickening; Doppler ultrasound can measure blood

velocity in the heart and intravascular, calculate the maximum pressure

gradient across the valve by measuring aortic blood flow velocity, and also

can calculate the aortic valve area; cardiac catheterization is a golden method

for the diagnosis of aortic stenosis and the judgments of its severity. Since the

examination is invasive way, it is not use as a routine examination.

（5） According to the patient‘s medical history, typical symptoms and signs, and

laboratory tests (X-ray, electrocardiogram and echocardiography), it can be

generally made a diagnosis.

11．Heart function according to the New York Heart Functional Classification

(NYHA):

Suitable：According to the NYHA classification, the patient‘s heart function is

I/II grade.

378

Unsuitable：According to the NYHA classification, the patient‘s heart function

is III/IV grade.

Note：

① I：No limitation of physical activity. Ordinary physical activity does not cause

undue fatigue, palpitation, or dyspnea (shortness of breath).

② II：Slight limitation of physical activity. Comfortable at rest, but ordinary physical

activity results in fatigue, palpitation, or dyspnea.

③ III ：Marked limitation of physical activity. Comfortable at rest, but less than

ordinary activity causes fatigue, palpitation, or dyspnea.

④ IV：Unable to carry out any physical activity without discomfort. Symptoms of

cardiac insufficiency at rest. If any physical activity is undertaken, discomfort

is increased.

12．Diabetes mellitus (DM)

Suitable: The patient has no diabetes mellitus, or the patient has been diagnosed

with diabetes mellitus, but the blood glucose is controlled in the optical levels (fasting

blood glucose <15 mmol/L).

Unsuitable: If the patient uses hypoglycaemic drugs in the normal case, the

current blood glucose levels ≥ 15mmol/L.

Note：

（1） Diagnosis of diabetes: morning fasting blood glucose level ≥ 7.0mmol/L, or

the blood glucose in any time or the OGTT ≥ 11.1mmol/L.

（2） The blood glucose is measured using a blood glucose meter to measure the

blood at the end of the capillary blood on the left ring finger.

13．Hypertension

Suitable: The patient has no hypertension, or the patient has been diagnosed with

hypertension, but the blood pressure is well controlled, in the case of taking anti-

379

hypertensive drugs, the current systolic BP < 23.94kPa (180mmHg) or diastolic BP <

14.67 kPa (110mmHg).

Unsuitable: The patient has high blood pressure, taking anti-hypertensive drugs,

the current systolic BP ≥ 23.94kPa (180mmHg) or diastolic BP ≥ 14.67kPa

(110mmHg).

Note：

（1） Diagnosis of hypertension: Using the criteria published by the U.S. National

Joint Committee on Hypertension in 1997, that is the patient can be diagnosed

with hypertension if the resting systolic BP ≥ 18.6kPa (140mmHg) or resting

diastolic blood pressure ≥ 12.0 kPa (90mmHg).

（2） The guidelines for measuring blood pressure：

1）Using mercury sphygmomanometer to measure blood pressure on the right

brachial artery.

2）The patient should be emotionally stable, taking 15-minute break before the

measurement of blood pressure. If any following accidences occur, such as

smoking, exercise, mood changes, the patient should rest for 20-30 minutes

before the measurement.

3）The patient takes sitting position with the arm (brachial artery) at the same

level of the fourth rib.

4）The lower edge of the cuff is 2-3cm above the cubital fossa. An appropriate

tightness is able to insert a finger.

5）When a stethoscope appears the first pulse tone, the scale value of the mercury

column is the systolic BP; when the pulse sound suddenly become weak or

disappeared, the scale value of the mercury column is the diastolic BP.

14．Does patient has arrhythmias? Heart rate_________bpm.

Suitable：The patient‘s heart rhythm is regular with the pulse rate of 60-100

bpm.

Unsuitable：The patient has sinus tachycardia (pulse rate ≥ 120 bpm).

380

Note：

（1）Use pulse rate to show heart rate. The measurements of pulse rate are presented

as follows:

1）Measure the pulse rate on the right radial artery.

2）Patient preparation: Take sitting posture with stable mood and take 15-minute

break before the measurement. If the patient performs the following activities,

such as strenuous exercise, stress, fear, etc, he/she should rest for 20-30

minutes before the measurement.

3）The measurer uses the index, middle and ring fingers to press on the patient‘s

radial artery to measure it.

4）Use the second hand watch to measure the pulse for 30 seconds and multiply it

by 2.

15．Does patient have atrial fibrillation?

Suitable：The patient has no atrial fibrillation.

Unsuitable：The patient has atrial fibrillation.

Note：

（1）The clinical manifestations of the atrial fibrillation: Cardiac auscultation shows

that the intensity of the first heart sound is volatile and the heart rhythm is irregular.

When the ventricular rate is rapid, it will occur pulse shortage, that is the pulse rate is

less than heart rate.

16．Does patient have ventricular arrhythmias?

Suitable：The patient‘s heart rhythm is regular without ventricular arrhythmias.

Unsuitable ： The patient is suffering from frequent premature ventricular

contractions (≥ 5 bpm), paired premature ventricular contractions or ventricular

tachycardia (pulse rate ≥ 120 bpm), ventricular flutter or ventricular fibrillation.

381

Note：

（1） Ventricular arrhythmias: The most common one is the premature ventricular

contractions. The premature ventricular contractions often have no direct

related symptoms. Patients may feel palpitations, a sense of weightlessness

like rapid movements of the elevator, or a strong heart beat after compensatory

pause. Cardiac auscultation shows that there is a long stop after the premature

ventricular contraction, the intensity of the second heart sound of premature

ventricular contraction decreased, and only can hear the first heart sound.

Radial artery pulse is weakened or disappeared.

17．Does patient have third-degree AV block?

Suitable：The patient has no third-degree AV block.

Unsuitable：The patient has the third-degree AV block.

Note：The features of the third-degree AV block as follows:

（1） The activities of atrial and ventricular are separative and unrelated;

（2） The atrial rate is higher than the ventricular rate. The atrial impulse comes

from the sinus node or ectopic atrial rhythm (atrial tachycardia, flutter or

fibrillation);

（3） The ventricular pacemaker usually located at slightly below the block part.

18．Does patient have acute myocarditis?

Suitable：The patient has no acute myocarditis.

Unsuitable：The patient has acute myocarditis.

Note：

（1） Acute myocarditis refers to the recent onset of disease. The clinical

manifestations, such as chest discomfort, rapid heart rate, chest tightness,

palpitations, and tachycardia, are obvious and changeable. Laboratory tests

show elevated myocardial enzymes, ST segment elevation or depression, T

382

wave inversion and arrhythmia on the ECG, and the cardiac ultrasound shows

the reduction of diffuse or localized left ventricular wall contraction. The

disease history is within six months. The most common one is viral

myocarditis.

（2） Diagnosis of viral myocarditis: Currently, the method used to isolate virus for

the diagnosis of viral myocarditis is only conducted in few hospitals. Most

hospitals diagnose with the disease only based on the clinical manifestations,

ECG and the results of enzyme investigation.

19．Does patient have acute pericarditis?

Suitable：The patient has no acute pericarditis.

Unsuitable：The patient has acute pericarditis.

Note：

(1) Pericarditis refers to an inflammation of the pericardium, the membranous sac

enveloping the heart.

(2) Symptoms of acute pericarditis：

1) Chest pain: The most characteristic symptom of pericarditis is chest pain. The

pain may worsen with deep inspiration, coughing, swallowing and when lying

down or turning.

2) Symptoms of cardiac tamponade: It may appear dyspnea, paleness, irritability,

cyanosis, fatigue, upper abdominal pain, swelling or shock.

3) Symptoms of pericardial effusion pressure on adjacent organs: dyspnea,

coughing or hoarseness or swallowing difficulties.

4) Other symptoms: Chills, fever, palpitations, sweating and fatigue.

(3) Signs of acute pericarditis:

1）Pericardial friction rub: The most characteristic sign of pericarditis is a creaky

or scratchy friction rub heard most clearly at the left lower sternal border.

2）Signs of pericardial effusion:

• Cardiac signs: The heart beat becomes weakened or disappeared, or appears at

383

the inside left edge of the cardiac dullness. The cardiac dullness expands to

both sides of the heart and the relative dullness is disappeared. When the

patient change position from sitting to supine, the second and third intercostals

cardiac dullness becomes widened. Heart sound is light and distant.

• Signs of oppression left lung: When there is a large pericardial effusion, the

heart shifts backward which results in oppression of the left lung and can

cause the atelectasis of the left lung lower lobe. Under the left shoulder area,

there is a dullness area, the fremitus is enhanced and the bronchial breath

sounds can be heard (E wart sign).

• Signs of cardiac oppression: The tachycardia is obvious. Venous pressure is

increased seriously and can be expanded with heart beat and inspiration. It

also appears the manifestations of circulation congestion, such as

hepatomegaly with tenderness, ascites, subcutaneous edema and the positive

signs of liver-jugular reflux. The systolic blood pressure becomes lower, the

pulse pressure decreases, the pulse becomes thin and may appear paradoxical

pulse.

20．Does patient have embolism during the previous three months?

Suitable：The patient has no embolism during the previous three months。

Unsuitable：The patient has suffered from an embolism within the recent three

months.

Note：

（1） Thromboembolic disease includes myocardial infarction, cerebrovascular

disease, pulmonary thromboembolism, deep vein thrombosis, DIC and other

diseases.

21．Does patient have any acute noncardiac disorder that may affect exercise

performance or be aggravated by exercise (e.g., infection, renal failure,

thyrotoxicosis)?

384

Suitable：The patient has no acute noncardiac disorder that may affect exercise


thyrotoxicosis).

Unsuitable：The patient has acute noncardiac disorder that may affect exercise


thyrotoxicosis).

Note：

I．Acute infection

（1）Infection: When the on-site measurement of patients‘ oral temperature is ≥

37.5℃，the patients are viewed as infection ( body temperature______℃).

（2）The measurement of temperature：

1）Use mercury thermometer to measure the oral temperature.

2）The patients take a comfortable position and the mood is stable. If the patients

do any the following activities before measurement, such as exercise, eating,

hot or cold drink, cold or hot compress, bath, hip bath, enema, etc, they should

rest for 30 minutes before measurement.

3）The mercury thermometer is below 35℃.

4）Diagonally put the mercury side of the oral thermometer at the sublingual nest

and close moth for 3 minutes.

II．Acute and chronic renal failure

1) Acute renal failure (ARF) is a reversible clinical syndrome where there is a

sudden and almost complete loss of kidney function (decreased GFR) over a

period of hours to days with failure to excrete nitrogenous waste products and

to maintain fluid and electrolyte homestasis. The main manifestation of the

ARF is an increase in serum creatinine (Cr) and BUN. Urine volume is often

changed, including oliguria (less than 400 ml/day) and anuria (less than 50

ml/day).

2) Diagnosis of acute renal failure is based on the changes of the absolute or

relative value of serum creatinine (Cr), such as the absolute value of the Cr

increases average of 44.2umol/L or 88.4umol/L per day, or the relative value

385

of the Cr increases 25%~100% within 24~72 hours.

3) Chronic renal failure (CRF) is a progressive, irreversible deterioration in renal

function in which the body‘s ability to maintain metabolic and fluid and

electrolyte balance fails, resulting in uremia or azotemia.

4) Diagnosis of chronic renal failure is based on the medical history, signs and

laboratory tests.

III．Hyperthyroidism

（1）Diagnosis of hyperthyroidism: If the patient meets the following three items,

the diagnosis is confirmed.

1）High metabolic symptoms and signs

2）Goiter

3）Increase in serum TT4 and FT4 and decrease in TSH

386

Appendix V Information Sheet

INFORMATION SHEET

The effects of an exercise stage-matched intervention on patients with coronary

heart disease (CHD)

You are invited to participate in a study supervised by Dr Jacqueline Ho, Dr Janet Sit,

Dr. Guoqiang Ruan (a cardiologist) and Dr Qiang Xie (a cardiologist), and conducted

by Lixia Zhu, who is the student of the School of Nursing, The Hong Kong

Polytechnic University.

This study is aimed to evaluate the effects of an exercise stage-matched intervention

on patients with coronary heart disease (CHD). You will be randomly allocated to

different groups of interventions. The interventions include conventional service, one

2-hour health education session, and 8-week exercise stage-matched intervention

sessions. For the 8-week intervention sessions, they will be run weekly for 8 weeks

with 15-30 minutes per session. Regardless of which group you are, you have to

complete some questionnaires at four different time points: before you receive any

service/intervention from us, 8 weeks after the completion of the service/intervention,

3 and 6 months after the completion of the service/intervention.

The regular exercise/physical activity has been shown to be beneficial to patients with

heart disease. Thus, the exercise stage-matched intervention, which aims to motivate

CHD patients to do exercise, will benefit patients in this study. However, mild chest

discomfort may be found during exercise. To minimize the effects of chest discomfort

on you, a cardiologist will assess your physical, psychological and emotional status

before you are allowed to join this study. In addition, the cardiologist will prescribe

your dose of exercise and monitor the whole progress of the intervention. If you

experience any discomfort during the intervention, you can contact Lixia ZHU at any

time for help.

387

You have rights to withdraw from the study at any time during the study without any

penalty. All information related to you will be kept confidential by assigning a code

number for you. The raw data can only be accessed by the research team members.

If you have any complaints about the conduct of this research study, please do not

hesitate to contact Ms. Kath Lui, Secretary of the Human Subjects Ethics Sub-

Committee of The Hong Kong Polytechnic University in person or in writing (c/o

Research Office in Room M502 of the University). If you would like more

information about this study, please contact Lixia Zhu or her supervisor Dr Jacqueline

Ho.

Thank you for participating in this study.

Principal Investigator

Zhu Lixia

388

Appendix VI Consent Form

CONSENT TO PARTICIPATE IN RESEARCH

The effects of an exercise stage-matched intervention on patients

with coronary heart disease (CHD)

I _______________________ hereby consent to participate in the captioned research

supervised by Dr Jacqueline Ho, Dr Janet Sit, Dr Guoqiang Ruan (cardiologist) and

Dr Qiang Xie (cardiologist) and conducted by Lixia Zhu.

I understand that information obtained from this research may be used in future

research and published. However, my right to privacy will be retained, i.e., my

personal details will not be revealed.

The procedure as set out in the attached information sheet has been fully explained. I

understand the benefits and risks involved. My participation in the project is voluntary.

I acknowledge that I have the right to question any part of the procedure and can

withdraw at any time without penalty of any kind.

Name of participant

Signature of participant

Name of Parent or Guardian (if applicable)

Signature of Parent or Guardian (if applicable)

Name of researcher Zhu Lixia

Signature of researcher

Date

389

Appendix VII Protocol of Weekly Patient Education Session

Protocol for the Weekly Patient Education Informing Session

(I) Checking for Compliance

1. Did you perform exercise in the past one week?

2. What kind of exercise did you perform?

3. How many days did you perform it in the past one week?

4. How long did you perform it per day?

5. What was/were the RPE score(s) that you recorded on the exercise log sheet?

6. How did you feel during the exercise? Did you experience any increase in

respiratory rate? Any sweating?

7. Did you experience any discomfort during the exercise?

8. Did you take any anti-anginal medication because of exercise in the past one week?

If yes, how many pills did you take?

(II) Patient Education Informing

1. Inform the benefits and importance of regular exercise

390

Appendix VIII Guidelines for Exercise Prescription

Guidelines for Exercise Prescription

A. General rules when prescribing exercise to cardiac patients (Exercise

prescription website, 2009)

Recommendations

Exercise

mode

o Any form of physical activity which uses large muscle groups.

o Examples: walking (3.0-4.0 mph), cycling (8-11.9 mph), etc.

(see the examples of moderate intensity of physical activity)

Exercise

intensity

o Moderate intensity (activities equal to 3-6 METs).

o Initial exercise intensity is generally lower than that

recommended for healthy persons.

Exercise

duration

o Generally longer than that for healthy persons.

o 30-60 minutes of continuous or accumulated exercise for each

day (at least 10 minutes per bout).

Exercise

frequency

o Generally higher than that for healthy persons.

o At least 5 days per week is desirable, and preferably daily.

Progression o Generally slower than that for healthy persons.

o Depends on each person‘s specific abilities, goals and

preferences.

o A specific goal should be to increase aerobic capacity and

reduce submaximal myocardial oxygen demands.

(connect next page)

391

Recommendations

Special

considerations

o The prescribed activity should address the individual's goals.

o The activity should be enjoyable and easy to perform.

o Factors including medications, meal schedules, associated

complications/ disabilities/ impairments/ risk factors and

subclinical health problems which may be exaggerated by

exercise, etc should be carefully assessed and considered when

prescribing exercise.

o Monitor for abnormal signs and symptoms (e.g., chest pain, light

headedness, arrhythmias, etc) which can guide us to amend the

prescription.

o Increasing muscular strength is an important complement to an

aerobic training programme.

o Clients with low level of fitness are advised to start exercise

programme at lower intensities.

o Hypoglycaemia may occur several hours after exercise.

392

B. Exercise prescription for CHD patients (Exercise prescription website, 2009)

Function Improve heart function, reduce angina pain and MI recurrence,

improve quality of life

Exercise mode Aerobic activity such as walking (3.0-4.0 mph) (for detail see the

examples of moderate intensity of physical activity)

Select one or two interest exercises with examples of moderate

intensity of physical activity as reference and perform it.

Exercise

intensity

Moderate intensity (activities equal to 3-6 METs) (see Examples

of Moderate Intensity Level of Physical Activities).

Use Borg‘s scale (RPE) to monitor your exercise intensity. You

are recommended to exercise at 11-13 level on 6-20 Borg‘s scale.

Exercise

duration

30-60 minutes of continuous or accumulated exercise for each day

(at least 10 minutes per bout).

Exercise

frequency

At least 5 days per week is desirable, and preferably daily.

Termination Guidelines for termination of physical activity (Briffa, Maiorana,

Sheerin et al., 2006):

• Typical cardiac pain or discomfort in the chest and/or

radiation to the shoulders, neck, jaw or arms, or other

symptoms reminiscent of previous myocardial ischaemia;

• Dizziness, light headedness or feeling faint;

• Difficulty breathing or undue shortness of breath;

• Nausea;

• Uncharacteristic excessive sweating;

• Palpitations associated with feeling unwell;

• Undue fatigue;

• Leg ache that curtails function;

• Physical inability to continue.

Special

considerations

The prescribed activity should address the individual's goals,

characteristics, preference and medication.

Contact If you have any discomfort during exercise, you can contact the

researcher at any time.

393

Examples of moderate intensity level of physical activities

(adapted from Ainsworth, Haskell, Whitt et al., 1993)

Specific

activity

METs Moderate activities (3-6 METs)

Sports 3.3-5.0 Walking, 3.0-4.0mph or 4.8-6.4 km/h, level, firm surface

4.5 Badminton, social singles and doubles, general

6.0 Basketball, non-game, general

3.0 Bowling

4.0 Table tennis, ping pong

4.0 Tai chi

5.0 Tennis, doubles

3.0 Volleyball, non-competitive, 6-9 member team, general

5.0 Softball or baseball, fast or slow pitch, general

6.0 Swimming at lake, ocean or river, leisurely, not lap

swimming, general

4.0-6.0 Bicycling, 8-11.9mph, leisure, slow, light effort

3.0-5.5 Bicycling, stationary, 50-100 watts, light effort

6.0 Hiking, cross country

Dancing

and

conditioning

exercise

3.5 Callisthenics, home exercise, light or moderate effort,

general (example: back exercise)

4.0 Gymnastics, general

4.8 Twist , jazz, tap, jitterbug

3.0-4.5

fast (disco, folk, square), slow (e.g., waltz, slow dancing),

tango

4.0 Drums

Home

activities

3.5 Mopping

3.0-3.5 Downstairs, going up & down from floor

4.0-5.0 Walk/run – playing with child(ren) – only active periods

3.0-4.5 Walking, 2.5-3.5mph slowly and carrying objects less than

25 pounds

394

C. Physical Screening Item Form before Action

The following items were used to help the cardiologist to understand patients‘ health

status and to make sure whether they were suitable to start exercise or not before they

took action to exercise, action stage. If the patient was suitable to exercise, the

cardiologist would prescribe an exercise prescription to him/her according to the

guidelines for exercise prescription. In addition, it would help patients to monitor

themselves at home during exercise.

1. Blood pressure ________mmHg

2. Heart rate/pulse rate__________ bpm

3. Is patient medically stable? ① Yes ② No

4. Does patient have unstable angina? ① Yes ② No

5. Heart function according to the New York Heart Functional Classification:

① I: No limitation of physical activity. Ordinary physical activity does not cause


② II: Slight limitation of physical activity. Comfortable at rest, but ordinary

physical activity results in fatigue, palpitation, or dyspnea.

③ III: Marked limitation of physical activity. Comfortable at rest, but less than


③ VI: Unable to carry out any physical activity without discomfort. Symptoms of


is increased.

6. Does patient have resting heart rate > 120 bpm? ① Yes ② No

7. Does patient have atrial fibrillation? ① Yes ② No

8. Does patient have ventricular arrhythmias? ① Yes ② No

9. Does patient have third-degree AV block? ① Yes ② No

10. Does patient have critical aortic stenosis? ① Yes ② No

11. Does patient have acute myocarditis? ① Yes ② No

12. Does patient have acute pericarditis? ① Yes ② No

13. Has patient had embolism during the previous three months? ① Yes ② No

395

14. Does patient have any acute noncardiac disorder that may affect exercise


thyrotoxicosis)? ① Yes ② No

Result of screening:

Is patient suitable for exercise? ① Yes ② No

Signature of cardiologist: ___________________________________

Date: ___________________________________________________

References



MET intensities. Medicine & Science in Sports & Exercise, 32(9), s498-s516.

Exercise prescription website. (2009). Prescription guidelines. Available at:

http://exerciserx.cheu.gov.hk/html/eng/index.asp?n=sec2_Guidelines (accessed

April 2009).



disease: recommendations of the National Heart Foundation of Australia. Medical

Journal of Australia, 184(2), 71-75.

http://exerciserx.cheu.gov.hk/html/eng/index.asp?n=sec2_Guidelines

396

D. Form of Exercise Prescription

Recommended

mode of exercise

Exercise duration

(minutes/day)

Exercise intensity

(RPE)

Exercise frequency

(sessions/day)

Exercise progress

Rate of Perceived Exertion (RPE)

Signature of cardiologist: _______________ Date: ______________

Very

light

Fairly

light

Some-

what

hard

Hard Very

hard

Very,

very

hard

Very,

very

light

397

Appendix IX Exercise Stage-Matched Pamphlets

Pre-Contemplation Pamphlet

398

Lear more about:

Why Should I Exercise?

How Can I Become more Active?

Keys to an Active Lifestyle

Recall the successful experiences in behaviour change

The Saga of Lifestyle Linda

Physical Activity: What‟s in it for Me?

“… to gain the benefits of

regular activity you do not

have to go out and kill

yourself at the gym for hours”

399

The large number of reasons why you should exercise actually makes this a difficult

question to answer. All individuals exercise for their own reasons that can range from

how they feel when they exercise and look after a few months to the long-term health

and longevity benefits.

The long-term benefits of regular physical activity are probably pretty familiar to you

by now. Everyone knows that being physically active can help reduce your risk for

heart disease, diabetes, and even cancer. Not surprisingly given the many health

benefits, regular activity can even increase your life expectancy. There are also

numerous psychological benefits that you may experience with regular activity

including reductions in depression and stress and increased cognitive function, well-

being, and quality of life.

Although these long-term benefits are certainly important, you probably want to know

what being active can do for you right now. Being physically active can help you

improve heart and lung function and cardiovascular circulation, control your weight

and blood pressure, reduce chest discomfort and angina pain (see The Saga of

Lifestyle Linda), decrease your blood ―bad cholesterol‖ (low density lipoprotein

cholesterol) level and increase your blood ―good cholesterol‖ (high density

lipoprotein cholesterol) level. A number of studies have shown that being physically

active can delay or improve atherosclerosis or even reduce the atherosclerotic plaque

which results in reducing myocardial infarction rate, extending you life-span, and

improving your quality of life. In addition, being physically active can improve the

establishment of coronary collateral circulation and blood supply to the heart.

Consequently, it is beneficial for the recovery of coronary heart disease and the

reduction in the frequency of angina pain and re-infarction. Being physically active

can improve your flexibility, and your ability to perform everyday tasks with less

effort and pain. You can experience an afternoon of playing with your child without

the soreness you typically experience the next day. Being physically active also can

Why should I Exercise?

400

improve your sleep and appetite, and help you to establish healthy image and increase

your confidence.

These things may all sound great, but you still may lack confidence to perform

exercise/physical activity. You may think that people with coronary heart disease can

not exercise, and that exercise will add burden to heart which will provoke anginal

pain or hart attack. Actually, numerous studies have illustrated that low to moderate

intensity physical activity is not harmful to coronary heart disease, while it is

beneficial to the recovery of the disease, reduction in frequency of anginal pain or

heart attack. These things may all sound great, but you still may think that being

physically active will be boring and painful. Believe it or not, to gain the benefits of

regular activity you do not have to go out and kill yourself at the gym for hours. You

can incorporate activity into your everyday life at a moderate intensity (see Keys to a

Physically Active Lifestyle). After you have been active for a while you will find

yourself enjoying activity more and more and you will even begin to seek out more

demanding activities.

You must first realize that shifting from a sedentary to an active lifestyle is not going

to happen overnight. Below are just a couple of strategies that you can use to help you

get ready to begin your active lifestyle.

1) Learn More About Physical Activity

So you‘re not really ready to commit to a program of regular physical activity.

However, if you pay attention to the message all around you all day you may be

surprised at what you‘ll learn.

- Talk to friends, family members, and co-workers about why they exercise

- Talk to your physician to get his/her perspective on the link between your

health and physical activity

How Can I Become More Active?

401

- Watch for information in the newspaper about physical activity and its

benefits

- Look for positive examples of physical activity in the media

2) Focus on the Benefits of Activity

Often before we begin a new activity all we do is think about reasons for not changing

our behavior. I am sure you can list a number of reasons why you can‘t really begin a

more active lifestyle right now.

However, you should not focus on those negative aspects, instead think again about

all of the reasons you should be active.

To help you get started thinking about all of the benefits that you can get from being

active try completing the following list. To help you get started some of the common

benefits of activity have already been filled in, but remember, everyone has his or her

own goals and reasons for being active. Write down the benefits that being regularly

active will have for you.

Benefits of Regular Activity

Focus on why you should be more active rather than on reasons not to be active

1. I can control my weight

2. I can control my blood pressure

3. I can do more activities easier

4.___________________________________

5.___________________________________

6.___________________________________

7.___________________________________

8.___________________________________

9.___________________________________

10.__________________________________

402

Active Opportunities are All Around You - Just move!

Believe it or not, you have a number of chances to be active throughout your day. Try

to take advantage of those opportunities during your day to help make physical

activity a part of your everyday life. Recent research has indicated that even the

accumulation of activity over the course of your day can have significant health

benefits. You can divide 30-60 minutes physical activities into 2-3 times to complete

it, with more than 10 minutes per time. The accumulated 30-60 minutes‘ exercise in

one day has the same benefits as the continuous 30-60 minutes‘ exercise.

Use the Stairs

Using the stairs instead of the elevator can be an easy way to work some extra activity

into your day. You should be an ―Elevoider‖ that chooses to climb the flights of stairs.

If the floor you are going to is too high (generally not an issue in Champaign-Urbana)

take the stairs the first few flights and the elevator the rest of the way. For example,

Ms Ma, 41 years old, is working in a company. She had myocardial infarction half

year ago and underwent emergency PCI treatment. She doesn‘t dare to perform

exercise after discharging from the hospital. She perceives physical weakness and is

easy to get cold. After instructions from the health professionals, she knows that

exercise is very important for disease recovery. After that, Ms Ma decides to exercise

30 minutes per day. Due to the tight working schedule, she has no time to exercise in

a gym. She decides to use stairs instead of elevator everyday. Interestingly, her health

condition becomes better and feels much easier to walk.

Walk as much as Possible

Why not get off the bus a stop or two earlier and walk the rest of the way to your

building to get in a 5-10 minute walk?

Keys to a Physically Active Lifestyle

403

Take a 10-15 minute walk during your lunch break. This is a good way to gain a new

perspective on your day thus far and the day ahead. Walking with colleagues also

offers a way to socialize. If you had been retired, walking with your family members

after dinner can enhance family feelings.

Of course you feel great when you get that spot in the front of the parking lot, but if

you think about it you‘ll feel bad for circling the lot in your car when you could have

just parked in the back and walked a couple of minutes more. You may even save

some time!

Participate in Planned Physical Activities

Although there are a number of benefits associated with lifestyle activity that you

accumulate during the day, that doesn‘t mean you shouldn‘t try and schedule in some

regular, more strenuous activity, especially if you have weight loss or fitness goals.

Try to plan a visit to the gym or a more strenuous walk after dinner.

404

I believe that you can successfully change the sedentary behaviour. In order to let you

be confident to become an active exerciser, please spend a few minutes to fill in the

following form regarding your ―past successful record‖. Think about the behaviours

that you have successfully changed. This will help you to find back your confidence.

A. Behaviours that I have successfully changed

1. ___________________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

B. Factors that help to successfully change the behaviours

1. ___________________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

C. Factors that stop from change

1. ___________________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

Recall the successful experiences in behaviour change

405

Becoming more physically active is by no means an easy matter. Lifestyle Linda

thought that it would be impossible to ever become physically active. At the age of 45,

she weighed over 200 pounds, had high blood pressure, and had coronary heart

disease. She perceived chest tightness occasionally and the ECG manifestations show

ischemia myocardial.

While on a trip to Washington, D.C. with her family last summer Linda had trouble

walking up the steps of the Lincoln Memorial and huffed and puffed her way up to the

top. It was at that moment that Linda decided to begin incorporating more activity

into her lifestyle. Over one year later Linda has succeeded in becoming more active

on a regular basis and actually chooses to climb the stairs instead of using the elevator.

After talking to her doctor Linda had begun to take a 5-10 minute walk after dinner

every night. It wasn‘t easy, but she was determined to never feel embarrassed when

doing a simple physical activity.

After those first few weeks she began to take a walk after lunch at work and then

extended her after dinner walks to 20 minutes. She feels great and enjoys her walks.

She never thought she would get there, but she has succeeded in making physical

activity a part of her day. She enjoys various benefits from the regular physical

activity everyday, especially in physical fitness, walking much easier, and more

reduction in the frequency of anginal pain.

You are on your way to making

activity a part of your lifestyle!

You can do it!

The Saga of Lifestyle Linda

406


Contemplation Pamphlet

407

Learn More About:

I’m Ready to Commit!

Nix the Negatives

What Benefits can I Get from Exercise?

Why not Take Action?

“Active” Learning

Becoming an Active Person

What if I Stay Inactive?

Stepping to Success

“While you are wondering

if it can be done, someone

is already doing it.”

Physical Activity: I‟m Ready to Go!

408

As you seriously consider beginning to increase your level of physical activity, you

have taken a very important step on the path to successfully incorporating physical

activity into your everyday life.

There are several more important steps that you need to take before you will truly

experience an active lifestyle, but there are several proven strategies that you can

employ to help you on your way.

In this newsletter are several strategies you can use to help you solidify our

commitment to make regular activity a part of your life.

The changes that you are thinking about making are important and can have a number

of beneficial consequences in your health and life. Get ready to make the commitment

to a healthy active life!

The more you consider beginning a program of regular activity, the more likely you

are convinced of the benefits of regular activity. However, you probably still have

lingering doubts about our abilities and focus many of your thoughts on the

drawbacks of regular activity.

The negative aspects of exercise such as the time it takes to be active, the energy it

will require and use and the soreness you may feel afterwards probably all weigh

heavily on your mind. However, before you are ready to really commit to a program

of regular activity you need to get control over the negative aspects that you perceive

as the drawbacks of being physically active.

Nix the Negatives

I’m Ready to Commit!

409

One strategy is to think of the negative aspects such as a perceived lack of time

simply as a barrier that you have to overcome. You do not have to schedule an hour or

two block of time to go to the gym to work out, you may simply begin by

incorporating activity into your day by walking places, taking the stairs, etc.

Another strategy is to realize that although it may seem difficult first, incorporating

behaviors into your life can be accomplished without much difficulty. Think about

how habituated brushing your teeth has become. You were willing to incorporate that

activity into your daily life, can you not do the same for a habit that will have so many

physical and mental benefits?

Being regular active is very important for your disease recovery. It can bring you

many benefits as follows:

1. Improve your heart and lung function

2. Improve the establishment of coronary collateral circulation

3. Reduce anginal pain and dyspnea

4. Prevent stent restenosis or re-infarction

5. Control blood lipoprotein

6. Decrease stress

7. Control weight

8. Decrease blood pressure

9. Enhance physical function

10. Help sleep

11. Establish healthy image and increase your confidence

12. __________________________________________

Wow, there are so many benefits. Let‘s take action!

What Benefits can I Get from Exercise?

410

Although you know that there are many benefits of being regular active and you may

also want to perform physical activity, you still did not take action. What are barriers

that stop from your action? In order to help you better resolve the barriers of physical

activity, please write down the barriers of physical activity. To help you get started,

some of the common barriers of activity have already been filled in, but remember,

everyone has his or her own barriers for being active. Write down the barriers that

will stop you from activity.

1. Too many works

2. Worry about the heart attack

3. It is boring

4. ______________________________________

5. ______________________________________

6. ______________________________________

7. ______________________________________

8. ______________________________________

9. ______________________________________

10. _____________________________________

Based on the list of barriers for your activity, you should think about how to resolve

the barriers? If you have no time to exercise due to many works, you can think about

that being regular active does not mean that you should spent numerous hours to go

out and in the gym. You can simply incorporate activities into your daily life, such as

walking to supermarket to buy something or to somewhere to do business, or using

stairs instead of taking elevator. Accumulating activities have the same benefits.

Think about that a ten minutes episode is very quick. If you worry about the heart

attack provoking from physical activity, you can consult with a cardiologist to make

sure whether you could exercise? Talk about the benefits for exercise for you? I guess

that the doctor will tell you that appropriate regular active is beneficial for preventing

Why not Take Action?

-- Barriers of Physical Activity

411

heart attack. If you think that exercise is very boring, you can think about how

benefits of exercise for your recovery. If you….

As you begin to minimize what you think are the negative consequences or barriers

to activity, you should still be attempting to learn more about activity and adding to

your list of the benefits regular activity can have in your life.

In an effort t to learn more about physical activity you need to move from a passive

learner to an ―active‖ learner that is constantly seeking out new knowledge and

sources of information about physical activity. This type of learning involves you

asking questions about activity.

You may ask yourself, how much activity do I need to do? Some of this information

may be found in the newsletters you receive, but you can look for answers in

newspaper articles about activity. If you hear about a study on the news you can try

and locate the source and read it for yourself. You need to seek out your own answers.

You may also wonder about what activities are best for you. Your best source of

information may be asking others around you what they do and enjoy. Try out some

of these activities and decide for yourself. The ideal activity is the one that you enjoy

doing. Think about things you enjoy and try to figure out if you can be active while

doing that activity. If you enjoy nature, walk outside. If you like to ready, try reading

while riding a stationary bike. If you enjoy team activities, find a community league

that you can join.

You may also wonder about the psychological benefits of being regularly active. Ask

people you know that are active what they get out of it. Do they feel better after they

exercise? Does it help clear their heads? Does it relieve some of the stress in their

lives?

“Active” Learning for an Active Lifestyle

412

Develop your own set of questions that you want to answer and ―actively‖ seek out

those answers. You need to constantly learn more about physical activity and what it

will do for you in particular. As your list of positives grows and negatives shrink, you

will be on your way to committing to activity.

One of the biggest steps you can take towards making regular activity a part of your

life is to learn to identify yourself as an exerciser or active person. How you envision

yourself goes a long way towards determining your behaviors.

Imagine that you consider yourself to be a kind, compassionate person. You will go

out of your way to help others and listen to their problems. Now imagine that you are

an active person. Think about what behaviors should go along with such a label.

You will also need to spend some time thinking about how your current behaviors

help define you as an individual. Do you immediately come home and plop on the

couch and turn on the television? Think about why you do this. Ask yourself, what an

active person would do? Maybe instead of sitting at the table and discussing your day

with your spouse you can go for a walk together and talk about your day.

When you realize that you can help shape your identity by the behaviors you engage

in, you can start to do the behaviors that help make you into the person you want to be.

Think about how you would like to feel and look and then honestly ask yourself if

your current habits and behaviors are making you that person. If the answer is no then

you need to change your behaviors and remold your self-image.

Becoming an Active Person

413

Another important step you can take in affirming your desire and commitment to

being active is to imagine what your life might be like if you were to remain inactive.

Although these might not be pleasant thoughts, they should help motivate you to

make that change.

The consequences of inactivity are not very pleasant. Imagine how you would feel if

you were morbidly obese. Imagine how you would feel if you become weak day by

day. Imagine how you would feel if the blood lipoprotein and cholesterol is increasing.

Imagine the feelings of heart attack. Imagine the feelings of your family and friends if

you die young from a heart attack. Do you feel guilty about just sitting around ever

evening after work? Is a lifestyle of inactivity acting just life a bomb that is waiting to

explode its negative consequences throughout your life and the lives of those around

you?

All of these negative feelings that you imagine when you think about remaining

inactive can be a powerful tool in helping you realize why you need to be active.

These are all situations that you do not want to come to pass. Luckily the decision is

yours, you can be active and do everything in your power to prevent these negative

feelings, or you can be sedentary and passive and let them happen to you.

You are the only one that has the power to make these changes in your life. Others

can offer you help and guidance, but you need to commit to those behaviors.

What if I Stay Inactive?

--Toward healthy lifestyle

414

Making a significant change in your lifestyle is not an easy task. You need to begin by

taking some small steps in the right direction.

You could finish reading this and make a commitment to yourself to go for a brisk 5

minute walk today. Work you way up to your activity goals.

Current recommendations are that you walk approximately 10,000 steps a day, but as

cliché as it may be, you have to start the journey with a few small steps.

Today you just walk not jog. Only 5 minutes, no more. When you complete 5-minute

walk, how is your feelings? Does 5 minutes pass quickly?

Start from 5 minutes, then 10 minutes, and realize your activity goal step by step.

Let‘s start walk today1

Stepping to Success

415


Preparation Pamphlet

416

Learn More About:

Ready, Set, Let’s Go!

Formalize your Commitment

Everyone Needs a Hand

Realize Your Ideals

What Activities Should I Do?

What should I Pay Attention to during the Exercise?

Developing Your Activity Goals

My Activity Goal Worksheet

“Always remember that it

is you that is making this

commitment to yourself

and your health”

Physical Activity: I‟m On My Way!

417

You are ready to begin making physical activity a part of your life. You may have

already begun to increase your activity levels and look for ways to incorporate

physical activity into your lifestyle. Congratulations!

Now as you prepare to take you activity to the next level, there are several strategies

that you may employ to help you begin a lifestyle of regular activity. There are

several key strategies to help you formalize your commitment to activity, learn how to

set reasonable activity goals, find out how to get others to help you be active, and

further develop your self-image as an active individual.

You are well on your way to being regularly active. Using the strategies discussed in

this newsletter you can succeed in making activity a part of your life.

As you prepare to get, and stay, active on a regular basis, one approach that you can

take to strengthen your commitment is to make your goals and plans formal.

We all like to make up ―to do‖ lists and check off our accomplishments (at least we

hope to get to them all) at the end of each day. In much the same way, by making

your commitment to be regularly active known, you can enhance your pride as you

reach your exercise goals.

However, in order for this strategy to be successful you need to develop realistic

activity goals for yourself. Make sure to read the section on developing your activity

goals for more information about proper goal setting.

Formalize your Commitment

Ready, Set, Let’s Go!

418

After you have developed your own activity goals you need to formalize these goals.

When your goals are written down or you tell others about them you eliminate your

ability to ignore those goals. You no longer can say to yourself that you‘ll do them

next time or that is not what you really expected to do. You are responsible for your

own action or inaction.

In order to help you make your goals formal, we have provided you with a personal

activity goal sheet attached as the last page of this newsletter. Take the time to fill it

out and then place it somewhere you‘ll see it. Better yet, post it where others can see

it. Always remember that it is you that is making this commitment to yourself and

your health.

A great way to help you reach your activity goals is to find a friend or buddy that can

support your efforts. This person can either be a cheerleader who offers you

encouragement, a watchdog that reminds you when you are slipping, or someone

making the change with you. Ideally your buddy will be a combination each of these

three aspects.

Your buddy must be aware of your goals and told how they can best help you. The aid

that you receive should always be positive. Criticism and yelling will not help

motivate you to stick with your activity program.

Your buddy may be your spouse or co-worker. Even your children can act as buddies

to help support you on your way to becoming more active. The key is to get a

supportive buddy that wants to help you make the change. For example, Mr Chen, 57

years old, has been diagnosed with coronary heart disease for two years. He was

inactive after he got the disease, so he often feels chest discomfort. After he received

instructions from the health professional, he knows that being physical active is

beneficial for his disease recovery. In order to help himself start and maintain to

Everyone Needs a Hand

419

exercise, he committed to perform regular exercise to his family members and to

obtain their supports and help. After that, when the time is up, his daughter would

remind him ―It is time to exercise‖. His daughter also asked her son to accompany Mr

Chen to play basketball 2-3 times per week. Not surprising, Mr Chen successfully

changes exercise behaviour and maintains regular exercise. After being regular

exercise for four weeks, Mr Chen felt more and more comfortable, much easier to

walk, and less anginal pain. Since he experiences the benefits from the physical

activity, he becomes more and more like to exercise. After half year, regular exercise

becomes an interest of his life.

As you continue on your path to making physical activity a habit in your life, you

need to work on continuing to redefine yourself as an active individual. By this point

in your life you already have a well established sense of who you are and you now

need to think of yourself as someone that is active on a regular basis.

You are defined by the roles in your life, whether they be at your job or in your family.

The behaviors you engage in are often the best reflection of who you are. To help you

become the more active individual that you want to be you need to continue to let

your actions speak for themselves and be more active.

You need to let go of any behaviors from your past that may have been keeping you

from being active. It may be comforting to know that every evening you will go home,

eat dinner, and then sit down to ―Must See TV‖. However, the pleasure that you

receive from this may largely be the comfort you associate with that habituated

behavior. You defend the behavior by saying that it is just what you do everyday, it is

a part of who you are.

However, the only reason you feel such comfort in this behavior is because that it is

what you have been doing for so long. Changing your behaviors and habits may be

Realize Your Ideals

420

stressful, but realize that with a little time and effort, physical activity may be a good

habit in your life. Taking a walk after work will then be what you are comfortable

doing everyday. You need to be patient with yourself as you attempt to redefine what

you do. Keep in mind all that you are doing for yourself by being more active and

remember that you are worth the effort.

In order to receive the benefits of regular activity, recent scientific research has

recognized that you do not have to work out hard at the gym for over 30 minutes

nearly everyday as we used to believe. Health benefits can be found simply by

accumulating 30 minutes of moderate intensity activity on most days of the week.

This means that you can incorporate several bouts of activity into your day in order to

reach your activity goals. You now have several choices for meeting your exercise

goals that can range from getting in several 10 minutes at a greater level of intensity.

This flexibility in activity choices should make it easier for you to match your activity

desires to your own lifestyle and situational demands.

Moderate Activity – What is It?

You may very well wonder how hard you have to be working to do moderate activity.

A classic example is walking briskly. Wandering around the mall window shopping

will not qualify as brisk walking, you need to be walking ―with a purpose‖. The

notion of lifestyle activity is that it is activity that you can incorporate into your life.

However, it would be a mistake to simply assume that you are getting enough activity

in your life. Wandering around the office or puttering around in the garden will not be

enough, you need to get your heart rate up about its normal daily level. If the exercise

what you were performing can not make you feel mild asthma, it can not strength

your heart and lung. This is why a busy work can not reach the exercise effects.

What Activities Should I Do?

421

In reality no one can dictate a certain speed in miles per hour that you need to walk or

bike, the best judge of moderate activity is yourself. You need to learn to pay

attention to your body. You can tell when our heart rate is elevated and you are

breathing more heavily. These are the keys to understanding your moderate level of

activity. Depending on your initial fitness level you will need to do work at different

absolute loads to work at a relatively moderate intensity. Learn to take and monitor

your pulse to help get an idea of how what you feel translates into beats per minute.

An important thing to remember is that moderate intensity activity should not be

painful. If you are in pain or just cannot go on anymore, then you should stop because

you have over-stepped your abilities. You should be able to maintain this moderate

level of activity for a long period of time.

The signs of appropriate exercise load are: when you are exercising, you have a little

sweating and mild breathing but does not affect your speech, feel comfortable in the

morning after getting up, no sleepy or any discomfort; after the exercise, feel light,

good appetite and good sleep. If you feel dizziness, chest tightness, palpitations,

shortness of breath, loss of appetite, poor sleep and heavy fatigue indicating that the

exercise is over load.

Once you are comfortable being more active, you should still consider incorporating

some more intense activities into your life. This may mean you make a visit to the

gym, swim some laps at the pool, go to an aerobics class or begin to jog some while

you walk. These more intense activities will really begin to improve your fitness.

Common Examples of Moderate Activities

For patients with coronary heart disease, the best moderate exercise is brisk walk (80-

100 meters/minute). The following examples are equal to moderate intensity activities.

Home activities

o Mopping

o Downstairs, going up and down from floor

422

o Walk/run – playing with child(ren) – only active periods

o Walking, 2.5-3.5 mph slowly and carrying objects less than 25 pounds.

Sports

o Walking, 3.0-4.0 mph level, firm surface

o Badminton, social singles and doubles, general

o Basketball, non-game, general

o Bowling

o Table tennis, ping pong

o Tai chi

o Tennis, doubles

o Volleyball, non-competitive, 6-9 member team, general

o Softball or baseball, fast or slow pitch, general

o Swimming at lake, ocean or river, leisurely, not lap swimming, general

o Bicycling, 8.0-11.9 mph, leisure, slow, light effort

o Bicycling, stationary, 50-100 watts, light effort

o Hiking, cross country

Conditioning exercise

o Fitness club sports

o Calisthenics, home exercise, light or moderate effort, general (example: back

exercise)

o Gymnastics, general

o Weight loss calisthenics

Dancing

o Twist, jazz, tap, jitterbug

o Fast (disco, folk, square), slow (e.g., waltz, slow dancing), tango

o Drums

423

Exercise is safe for most patients with coronary heart disease. In order to avoid any

accidence, patients with coronary heart disease should pay attention to the following

issues when they are doing exercise:

o Before start regular exercise, take physical examination and have exercise

prescription from the cardiologist;

o Carry nitroglycerin pills or other anti-angina drugs when performing exercise,

such as shexiangbaoxin pills, suxiaojiuxin pills or danshendiwan, to prepare

for chest pain, which are placed under the tongue;

o Warm up before the exercise and cooling down after the exercise. Usually, use

walk or calisthenics for 5-10 minutes. Insufficient preparation of warm up and

cooling down is the most common reason caused accidence;

o Avoid to do exercise when you are too hungry or full, too cold or hot

environment, physical fatigue, and angry or poor emotion. Start exercise 2

hours after meal and avoid to entering places with too much different

temperature.

o Avoid hot shower immediately after exercise. It is better to take shower half

hour after exercise to reduce the impact on the heart and prevent suddenly die

after exercise.

o Avoid lifting heavy objects. If necessary, keep breathing smoothly and should

not hold your breath.

o Note that the air flows and pay attention to whether your heart rate is

excessive speed or irregular.

o Avoid competitive sport and accelerating movement too fast, e.g., race of

climbing stairs fast.

o Restart exercise 2 days after disappearing the symptoms and signs of cold or

fever.

o Low temperatures in early morning which is not suitable for patients with

heart disease to exercise, so it is best to exercise in the morning or evening.

What should I Pay Attention to during Exercise?

424

Indications to terminate exercise/activity

o Typical cardiac pain or discomfort in the chest and/or radiation to the

shoulders, neck, jaw or arms, or other symptoms reminiscent of previous

myocardial ischaemia;

o Dizziness, light headedness or feeling faint;

o Difficulty breathing or undue shortness of breath;

o Nausea;

o Uncharacteristic excessive sweating;

o Palpitations associated with feeling unwell;

o Undue fatigue;

o Leg ache that curtails function

o Physical inability to continue.

Other points should also be remembered

o If you are unable to breath and speech during exercise, you should take rest

until only a slight breather before continuing.

o If you feel chest pain, rest until the pain disappears. If the chest pain appeared

regularly, you should tell the cardiologist. If you have anginal pain, take

medicine and then continue to exercise.

o Doing exercise according to the plan. Do not do exercise too much in the short

term which will delay your recovery and even dangerous. Haste makes waste.

o If you feel discomfort one day during exercise, do not worry. Everyone may

encounter this condition. Ask yourself whether you have too large exercise

than the past few days, which may explain why you feel a bit tired.

425

In order to experience success in achieving your activity goals you need to learn to set

proper goals. This involves forming realistic expectations about changing your

behavior. The focus of your goals in the beginning should be on how short-term goals

or behaviors can help lead to the long-term benefits you are seeking.

Becoming active on a regular basis is not going to happen overnight. If you have been

inactive for a while you will need to ease into this new lifestyle. Before you know it,

being active will be second nature, but that can only come with time. You also cannot

expect a dramatic weight loss without engaging in more vigorous activity and

incorporating dietary modifications into your new, healthy lifestyle. For now, you

should just concentrate on developing some short-range goals to increase our activity

level.

The last page of this newsletter offers you a chance to develop some activity

commitments of your own. You can make an initial commitment to walk after lunch

and dinner everyday for 10 minutes, you can agree to use the stairs, and you can also

set your own specific goals. Remember that it is you who is making this change, what

do you hope to get out of it and how can you best help to make that happen? Write in

your own specific activity goals.

After filling in your goals, sign and date your commitment. Then place this sheet

somewhere you (and others) will see it on a daily basis. Whenever you look at this

sheet, you should check off those behaviors that you are doing, if you are not meeting

all your goals, don‘t despair. The average individual will make the same New Years

Resolution 3 times before they successfully change their behavior. Using the

strategies in the newsletters you receive should help you make the change, but expect

some setbacks. The key is to make sure that the goals are reasonable, focus on what

you have accomplished so far, and then redouble your efforts to meet the goals.

Developing Your Activity Goals

426

My Activity Goal Worksheet

I will walk _________ minutes a day.

I will climb stairs when possible.

I will __________________________

I will do my best to make activity a part of my life.

I can and will be an active individual

Signed ______________________

Date________________________

427


Action Pamphlet

428

Learn More About:

Moving Towards an Active Lifestyle

Make Healthy Substitutions

Reward Yourself – You’re Doing a Good Thing

Spice Up Your Activity Routine

Inactivity – Just Don’t Do it!

The art of Problem Solving

“Keep on „Moving‟

towards your activity

goals!”

Physical Activity: I‟m “Moving” Along!

429

You should be proud of yourself and all that you are doing to improve your life. As

you are well aware, regular physical activity can have numerous mental and physical

health benefits. The key for you is to continue to incorporate physical activity into

your life.

There may be minor setbacks along the way, but in the articles in this pamphlet you

will find a number of strategies designed to keep you moving towards your physical

activity goals.

As you strive to maintain a lifestyle that includes regular physical activity, you need

to learn how to avoid those situations that may foster inactivity, learn to refocus your

thoughts about your behavior, and develop your own reward structure. It will also be

important for you to continue to add some variety to your activity choices. Doing the

same activities day in and day out can lead to boredom and reduced motivation.

Congratulations, you are well on your way to an active lifestyle. Now just keep on

moving!

As you continue to make physical activity an everyday part of your life, you will be

tempted from time to time to slip back into your bad habit of being inactive. Think of

all the ―bad‖ things you let yourself get away with during the holiday season. You

need to recognize when you are slipping and attempt to refocus on your goals.

When you begin to revert back to a sedentary lifestyle you may begin to think of all

the reasons why you should not be active. This is when you need to have a dialogue

Make Healthy Substitutions

Moving Towards an Active Lifestyle

430

with yourself. If you think being active takes too much time remind yourself of how

quickly 10 minutes at a time can add up! If you are focusing on how activity makes

you sweaty, remind yourself about how good you feel after you exercise.

Think of all the opportunities that are available for you to incorporate physical

activity into your lifestyle to replace your old inactive habits. If you are someone that

needs to watch television, then find exercises that you can do in your home while

watching television such as walking on a treadmill or riding a stationary bike. If you

like to sit around and talk with your co-workers after you eat lunch, try to get them to

take a walk with you so that you can talk and get some activity at the same time.

You will be tempted to slip back into old habits, but you need to plan for those times

and find ways to continue to make activity a part of your life.

As you continue to reach your physical activity goals, you are probably feeling better

about yourself and your health. That in and of itself may be reward enough for many,

however, you really should take the time to congratulate yourself on a good job.

Being physically active is not necessarily an easy thing although the more you do it,

the more it becomes a part of your life.

There are several ways that you can ―reward‖ yourself for your efforts to help keep up

your motivation for physical activity. Assuming that you have a set of activity goals

written down (if you don‘t go ahead and write out how you intend to incorporate

activity into your day), a simple reward may be to check off those goals that you have

reached or are reaching. The simple act of checking off a ―to do‖ can often be a great

reward and boost to your confidence. If you aren‘t reaching some goals yet, think of

how good you‘ll feel when you can check those off as well.

Reward Yourself – You’re Doing a Good Thing

431

When you successfully avoid a situation that may lead to inactivity, reward yourself

with a verbal pat on the back. Positive words and thoughts such as ―Good going!‖ and

―I can do it‖ can act as great motivators. You can be your own cheering section. If

you are exhibiting good behaviors then you have every right to feel good about

yourself. Go ahead, ―keep it up‖!

If you don‘t want to act as your own cheerleader, you should enlist the aid of others

around you. They can help encourage you if they know your physical activity goals.

Having your family, friends, and co-workers offer you encouragement can make you

realize that your efforts are not going unnoticed.

A final reward strategy is to set up a behavioral contract with yourself. You can

choose a specific reward that you will receive if you are able to successfully meet a

particularly challenging goal.

However, do not reward your activity with inactivity. If you plan to take a special trip

or vacation, make sure that it is one that would allow you to continue to make activity

a part of your day. Let the new scenery at your vacation site be the reward for you as

you take a long walk.

A very important aspect to making physical activity an everyday part of your life is to

make sure that it does not become boring. Although this may seem at odds with the

suggestion that you make regular activity a habit, you need to include activities or

settings that you enjoy.

If you are meeting your activity goals by taking a walk, try a new route around that

campus or your neighborhood. New scenery or a more challenging route can add

some variety to your routine and give you something to look forward to in your next

Spice Up Your Activity Routine

432

walk. A habit does not have to become boring if you can keep adding different aspects.

Use new activities and settings to add some ―spice‖ to your activity goals.

Another great way of helping you continue to meet your activity goals is to try more

challenging tasks. If you have been walking for a mile every evening, try to make it a

mile and a half or set a goal to walk it faster than you did last week. As you become

more and more active you will find that what you did when you made the switch from

a sedentary lifestyle now seems rather easy. To keep your motivation high you need

to provide yourself with goals that are challenging enough that you feel a sense of

accomplishment when you reach them.

You may also want to try a totally different activity. As long as you are careful not to

over-exert yourself, you can try and get involved in some competitive sports. Try

playing racquetball or a get involved in a departmental game of basketball or softball.

You can also try a new piece of equipment at the gym. If you have been eyeing that

new cardiovascular machine, go ahead and give it a try. You may find it to be an

activity that you really enjoy.

The key is to make sure that your activity patterns are constantly changing so that you

are not stuck in a ―rut‖ of activity that you decide to break by revering to a sedentary

lifestyle. Keep it different, new and challenging and before long you‘ll be amazed at

the wide variety of physical activities in which you participate on a regular basis.

One of the major obstacles that you will face in your efforts to be an active individual

will occur when you face those situations that tempt you to be inactive. With poor

weather such as rain, snow, and cold it can be very tempting to stay inside and do

nothing. Unfortunately, you cannot afford to do nothing. To stay active you need to

start by understanding which situations will offer the most challenges to you meeting

your activity goals.

Inactivity – Just Don’t Do it!

433

The following list contains several common barriers that individuals encounter when

they attempt to be active on a regular basis. Review the list and add a few of your own

at the bottom.

IT’S HARD TO EXERCSIE…

1) During poor weather

2) When on vacation or holiday season

3) When a visitor at home

4) When there are too many things to do at home

5) When you face a deadline at work

6) When you feel tired

7) When your ―buddy‖ can not be active with you

8) ________________________________________

9) ________________________________________

10) _______________________________________

Looking at this list you may feel over-whelmed and wonder how you can even

continue to be active on a regular basis. However, by examining when you are

tempted to be sedentary you have taken an important first step to continuing your

active lifestyle.

Now that you have acknowledged situations that may lead to inactivity, one key is to

try and avoid those situations or create plans to help you deal with them when they

occur.

For example, when the weather prevents you from taking a walk outside, try going for

a walk in the Armory or around the local mall, or doing calisthenics or marking time

at home. Develop your own weather contingency plans so that when poor weather hits

you already know how you are going to continue with your planned activity.

Likewise, during the stressful time of the holiday season, rather than limit your

activity, you should take extra care to find the time to be active. The time you

434

spending being active may give you a chance to clear your head and do something

nice for yourself rather than focusing on others all the time.

When there is a visitor at home, you can try to take a walk with the visitor after the

dinner, so you can exercise while chatting, which serves two purposes, rather than sit

there and talk. If there are too many things to do at home, you can incorporate your

exercise in your daily life, or seek help from your family members to reach your

exercise goal.

For each of these situations, you need to be prepared to overcome the barrier and

continue to meet your exercise goals. Another way that you can help meet your goals

is to leave reminders around your home or office to encourage you to be active. You

can leave post-it notes around, mail yourself a postcard reminding you to be active,

send yourself a reminder through campus mail or even leave your work-out shoes in

front of your door. You can also set a clock in you mobile phone to remind you

exercise everyday. The key is to surround yourself with enough positive messages

that you are able to overcome those negative situations that encourage you to be

inactive.

A final way to combat the temptation to be sedentary is to continue to make and

revise ―activity to do‖ lists. By having a set of specific plans and goals for each day

you are able to foresee any obstacles or barriers and plan accordingly. Having a

number of activity options will allow you to choose the one best suited for meeting

your goals on that day depending on the weather or your time commitments.

You are well on your way to making physical activity a part of your life. The

continued effort that prevents you from reverting to a sedentary lifestyle is well worth

that effort. Think of all the positive benefits that being physically active is having in

your life. Keep on moving towards your goals!

435

Using IDEA form

I – Identify a barrier that keeps you from being active.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

D – Develop a few creative solutions (the more the merrier)

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

E – Evaluate your list of solutions. In the following space, write the solution you are

wiling to try. While you‘re at it, write down precisely when you will put it into action.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

A – Analyze how well your plan worked and revise it if necessary. If your plan

worked well, give it five stars. If it only deserves two stars, write down how it could

become a five-star plan. If your plan bombed completely, look back at your list of

solutions and try again. (remember, a plan that doesn‘t work isn‘t a complete failure.

It often points toward the solution that will work. The only failure is giving up.)

_____________________________________________________________________

_____________________________________________________________________

____________________________________________________________________

The Art of Problem Solving

436


Maintenance Pamphlet

437

Learn More About:

Maintaining an Active Lifestyle

How to Maintain Regular Exercise Habit?

It’s Not the End of the World

It’s Your Lifestyle – Take Charge

Help Make Change Happen

“You are doing a great job!

Physical activity is a part of

your lifestyle!”

Physical Activity: Doing it for a Lifetime!

438

You have managed to make physical activity a regular part of your life and should be

commended for your commitment. You are doing a great deal to help enhance your

physical and mental health. Admit it, you feel great that physical activity is a part of

your life.

Although you have succeeded in meeting the activity goals that you set for yourself,

now is not the time to relax. The physical activity ―habit‖ that you have acquired is

beneficial, but you still need to be wary of any setbacks that may land you right back

in your Lay-Z-Boy.

The best way to ensure that you can remain active is to learn how to effectively

manage the setbacks that you will eventually encounter, to continue to plan for times

when staying active becomes difficult, and to enhance your identity as an active

individual by serving as a role model for change.

You should select exercise as……

o Interesting……

It is very hard to maintain a sport if you don‘t like it. If you have done sports, such as

bicycling, walking, swimming, dancing, and playing bowling and badminton, you try

to start these sports.

How to Maintain Regular Exercise Habit?

Maintaining an Active Lifestyle

439

o Regular……

If you cannot properly adhere to exercise, you can participate in organized sports,

such as exercise classes. If the weather is bad, you can do some sports that you can.

Swimming is a special good exercise because you can do it the whole year. If you

cannot swim, you can participate a swimming training.

o Diversified……

Do several sports, so when you feel tired of a sport, you can make other activities.

o Nearby……

Travel is costly and time-consuming, you may give it up easily. If there are no places

that you can go in your area, you can use rowing machine or a bicycle stationary at

home, or marking walk/run at hall or balcony. These activities may be tedious, so you

can exercise while watching TV.

o Incorporating in your daily life……

Make exercise as part of your life. Try to walk or bike to work or shopping.

It is going to happen. It is inevitable. Eventually you will slip and fail to meet your

activity goals. It may be a run of terrible weather, excessive demands at your job, or

the pressures of the holiday season. No matter how it occurs, you need to be ready to

deal with the time when you must get back on the right track towards a healthy active

lifestyle.

It’s Not the End of the World

440

You need to realize that you are not failure, that this is not the end of the world.

Setbacks are a part of everything we do in our lives, what separates individuals is their

ability to successfully cope with these setbacks.

There a few strategies that you can use to get back into the activity habit. First, you

need to get back into your activity routine as quickly as possible. Don‘t waste your

time lamenting the missed opportunities, get back to being active. Your relapse is not

permanent and you are in charge of deciding how long it will last. Make sure your slip

back into your sedentary lifestyle a short stay.

You also need to stay positive and focused. All your work is not wasted when you fail

to meet your goals. Remember all that you have accomplished, it did not happen

overnight and neither will your transition to a sedentary lifestyle. With a positive

attitude you will be active again.

The challenges of a lifetime of activity mean that you will slop at one point. When

that occurs make sure you stay positive and get back into action as soon as possible.

You are an active individual!

Making physical activity a continuing part of your life may not be necessarily easy,

but is something that you can do. You should be congratulated for your efforts so far

and with some of these strategies you will be active for decades to come and enjoy the

benefits of activity the entire time.

You are at your greatest risk for relapse when you encounter unusual situations. If you

are unprepared you may be likely to revert to an old habit as a way of coping with a

novel or particularly stressing event. These urges to revert to your prior behaviors can

be surprisingly strong, however, with proper planning you can deal with these

situations as they arise.

It’s Your Lifestyle – Take Charge

441

You need to make sure that you plan ahead when unusual circumstances may keep

you from your typical activity routine. If you are on vacation, then make sure you

bring along your exercise clothes and investigate if where you are staying has fitness

facilities or a recommended route for a walk or run.

When events occur unexpectedly, you need to take a moment to two to re-examine

your activity goals and why you are committed to those goals. Reviewing your goals

will give you an opportunity to plan how you will continue your activity or deal with

your relapse if being inactive is inevitable.

You also need to make sure that you occasionally take the time to remind yourself

why you are active. Watch the television and news for reports on the benefits of

activity and congratulate yourself on your behavior. For every hassle or obstacle that

you can think of why you should not be active, challenge yourself to think of 4 or 5

reasons why you should be active.

Now that you are active, you may forget why you even began your activity in the first

place. Occasionally reminding yourself of the benefits you have received from your

active lifestyle can act as a great motivational tool for your continued good behavior.

Another tool for meeting the challenges of a lifetime of physical activity is to make it

a habituated part of your day. Just like showering in the morning, you may eventually

get to the point where you don‘t feel like yourself until you have gone for a 20 minute

walk.

This habituation of activity is an important step in ensuring that you are making a

lifetime commitment to activity that you will be able to maintain.

442

As someone that is physically active and enjoying the benefits of a program of regular

activity, you need to realize your potential to encourage change in those around you.

Serving as an example or role model can be a great way for you to continue to

develop your own identity as an active individual as well as serve as a motivational

tool against relapsing to a sedentary lifestyle.

What does it mean to be a role model? Acting as an ―Activity Cop‖ certainly will

offend more people than it will encourage to becoming active. People will simply

avoid you. What you can do is make sure that you take the stairs when they take the

elevators. If they ask why you are doing it, you can share your experiences with them

and they may choose to join you next time. You can also invite people along for your

daily walks. If someone wants to join you, you should share your knowledge with

them to help them begin to make activity a part of their life.

The benefits of regular activity in your life should be evident enough that individuals

seek you out on their own. You role is to help facilitate change in those individuals

that seek you out and to serve as an example of the positive efforts of regular physical

activity.

As an active individual you are the example that many people around you will use

when they consider making activity a part of their life. This responsibility should help

encourage you to minimize any relapses that occur as well as focus on the positive

aspects of activity. If someone that is regularly active is constantly complaining about

time constraints and fatigue, that will not encourage others.

You should be proud of your accomplishments, but with those accomplishments you

need to realize that you now have some responsibilities. The best way to meet those

responsibilities is to maintain your healthy, active lifestyle with a positive outlook.

Help Make Change Happen

443

References

Blair, S.N., Dunn, A.L., Marcus, B.H., Carpenter, R.A., & Jaret, P. (2001). Active

living every day. Champaign, IL: Human Kinetics.





N.L. & Allan, R.M. (2006). Physical activity for people with cardiovascular disease:

recommendations of the National Heart Foundation of Australia. Medical Journal of

Australia, 184(2), 71-75.

Marcus, B.H., Forsyth, L.H. & Blair S. (2003). Motivating people to be physically

active. United States: Human Kinetics.



Self-help cardiac rehabilitation handbook. (unpublish). School of Nursing, The Hong

Kong Polytechnic University, The Chinese University of Hong Kong, and Peking

Union Medical College (Ed), 2009.

444

Appendix X An Example of the TTM-based ESMI

An example of the TTM-based Exercise Stage-Matched Intervention (ESMI)

Mr Wang received one 2-hour session of patient education and a booklet about cardiac rehabilitation.

Immediately after receiving the education session, he was booked an appointment for face-to-face

consultation at the hospital next week.

week1 Face-to-face contact at hospital:

• Assessment of exercise stages of change (Appendix XIV): After receiving the one 2-hour session of

patient education, Mr Wang knew that exercise is beneficial to his illness recovery and started to

thinking about it, but he did not take any action yet. Thus, he was in the contemplation stage.

• Delivering ESMI (Table 3.2): The goal of increasing motivation and confidence in the ability to

change was set and the following strategies were provided: ① Delivering the information about the

benefits of physical activity (consciousness raising) and the risks of physical inactivity (dramatic

relief); ② Finding out his barriers to engaging in physical activity (The main barrier stopping him

from engaging in exercise was that he thought that exercise would increase his heart load which was harmful to heart because he had suffered from MI.) (Giving related information to correct his

misconception); ③ Pointing out people who included regular exercise in their lives and now are

obtaining benefits from exercise (social liberation); ④ Increasing awareness of opportunities that exist

to encourage regular exercise; ⑤ Encouraging him to think about change.

• ESMI pamphlet (Appendix IX): Contemplation pamphlet was given to him.

week2 Telephone follow-up:

• Compliance checking (Table 3.1): In the past one week, he took jogging 15 minutes per day on 7

days. During the exercise, he had mild sweating, felt a little fast breathing, perceived light exertion (RPE 12), and did not experience any discomfort or take any anti-angina drugs.

• Assessment of exercise stages of change (Appendix XIV): He exercised some, but not up to the

accumulated 30 minutes per day on at least five days per week. Thus, he was in the preparation stage.

• Delivering ESMI (Table 3.2): Congratulation to him because he had moved forward one stage. The

goal of negotiating a plan for exercising was set and the following strategies were provided: ① Further

providing information about the benefits of physical activity and the personal risks of physical

inactivity; ② Discussing the safety of exercise and attentions should be paid during exercise

(Introducing guidelines for termination of physical activity. Advise him to call the researcher at any

time if he experienced any discomfort due to exercise); ③ Finding out difficulties encountered in

exercising (He experienced no difficulty in exercising); ④ Encouraging him to obtain social support

from his family members to support his engagement in exercise (helping relationships); ⑤ Invite him

to come to the hospital for exercise prescription by the cardiologist next week.


• Compliance checking (Table 3.1): In the past one week, he continued to take jogging 15 minutes per

day on 7 days. During the exercise, he had mild sweating and a little fast breathing, perceived exertion

fairly light (RPE 11), and did not experience any discomfort or take any anti-angina drugs.

• Assessment of exercise stages of change (Appendix XIV): He was in the preparation stage.

• Exercise prescription (Appendix VIII): The cardiologist examined his physical conditions and prescribed exercise prescription for him (He is fit for exercise of moderate intensity). Show the

examples of moderate intensity of level of physical activity to him (He likes walking, jogging and

hiking). The exercise prescription was that he could take walking or jogging (5 km/h) 20 minutes/day

with the progression of 5 minutes/day per 2-4 weeks up to jogging (5-6 km/h) at least 30 minutes/day.

• Delivering ESMI (Table 3.2): The goal of negotiating a plan for exercising was set and the following

strategies were provided: ① Encouraging him to create a new self-image as an exerciser (self-

reevaluation); ② Encouraging him to make a public commitment to exercise (Encourage the patient to

inform his family members that exercise is beneficial to him and he start to engaging in exercise) (self-

liberation); ③ Making a plan for engaging in exercise; ④ Encouraging him to obtain social support to

participate in exercise.

• ESMI pamphlet (Appendix IX): Preparation pamphlet was given to him.


• Compliance checking (Table 3.1): In the past one week, he took jogging 20 minutes per day on 7

days. During the exercise, he had mild sweating, felt a little fast breathing and perceived exertion fairly

light (RPE 11), and did not experience any discomfort or take any anti-angina drugs.



strategies were provided: ① Further discussing the safety of exercise and attentions should be paid

during exercise; ② Finding out whether he encountered any difficulties in maintaining regular

exercise? (He experienced no difficulty in it); ③Telling him that accumulated exercise (e.g., three 10-

minute bouts) of moderate intensity in one day produced similar benefits to one longer exercise session

(e.g., one 30-minute bout); ④ Encouraging him to find exercise buddies (helping relationships).

445

An example of the TTM-based Exercise Stage-Matched Intervention (ESMI) (Continue)


• Compliance checking (Table 3.1): In the past one week, he took jogging 15 minutes per session, two

sessions per day on 7 days. During the exercise, he had mild sweating, felt a little fast breathing and

perceived fairly light (RPE 11), and did not experience any discomfort or take any anti-angina drugs.

• Assessment of exercise stages of change (Appendix XIV): He was in the action stage.

• Delivering ESMI (Table 3.2): Congratulation to him because he had moved forward one stage. The goal of reaffirming commitment and following up was set and the following strategies were provided:

① Encouraging him to reward himself for exercise regularly (reinforcement management); ② Finding

out whether he encountered any difficulties in maintaining regular exercise? (He experienced no

difficulty in it); ③ Introducing additional exercise alternatives, such as hiking on the weekend; ④

Encouraging him to find exercise buddies (helping relationships); ⑤ Encouraging him to check off

each time when he exercised (reinforcement management).


• Compliance checking (Table 3.1): In the past one week, he took jogging 15-20 minutes per session,

two sessions per day on 7 days. During the exercise, he had mild sweating, felt a little fast breathing and perceived fairly light (RPE 11), and did not experience any chest discomfort or take any anti-

angina drugs.


• Delivering ESMI (Table 3.2): The goal of reaffirming commitment and following up was set and the

following strategies were provided: ① Further encouraging him to reward himself for exercise

regularly (e.g., buy a special gift or a coat to reward himself) (reinforcement management); ② Finding

out whether he encountered any difficulties in maintaining regular exercise; ③ Introducing additional

exercise alternatives, such as bicycling; ④ Encouraging him to find exercise buddies (Invite his wife to

exercise together) (helping relationships); ⑤ Encouraging him to maintain regular exercise.


• Compliance checking (Table 3.1): In the past one week, he only took jogging 20 minutes per day on

2 days. During the exercise, he had mild sweating, felt a little fast breathing and perceived fairly light (RPE 11), and did not experience any discomfort or take any anti-angina drugs.



strategies were provided: ① Finding out why he cut down exercise in the past one week? (He said that

the main reason to cut down the exercise was due to the bad weather (raining in most days of the past one week)). (According to his situation, suggest him to do indoor exercise when it is raining.) (stimulus

control); ② Introducing additional exercise alternatives, such as calisthenics and/or marking run at

home (counterconditioning); ③ Encouraging him to think about the benefits of exercise and good

health conditions due to engaging in regular exercise recently; ④ Encouraging him to maintain regular

exercise.

• Make an appointment for face-to-face consultation at the hospital next week.


• Compliance checking (Table 3.1): In the past one week, he took jogging around 20 minutes per session, two sessions per days on 7 days. During the exercise, he had mild sweating, felt a little fast

breathing and perceived fairly light (RPE 11), and did not experience any discomfort or take any anti-

angina drugs.


• Delivering ESMI (Table 3.2): The goal of reaffirming commitment and following up was set and the

following strategies were provided: ① Further encouraging him to reward himself for exercise

regularly (e.g., buy a special gift to reward himself) (Reinforcement management); ② Finding out

whether he encountered any difficulties in maintaining regular exercise (He said that, usually, there were no difficulties in maintaining regular exercise, except that he travels on business). Encourage him

to bring exercise suits together when he is traveling on business and encourage him to do some

exercises inside of hotel or take walking around hotel (stimulus control); ③ Introducing additional

exercise alternatives, such as calisthenics, Taichi and home exercise (counterconditioning); ④

Encouraging him to find exercise buddies (Join a community fitness club sports) (helping

relationships); ⑤Encouraging him to obtain social support to participate in exercise or maintain

regular exercise; ⑥Planning for resisting the temptation to skip exercise, such as bad weather,

holidays/vocations (e.g., Lunar New Year), and traveling on business (stimulus control); ⑦Encouraging him to maintain regular exercise.

• ESMI pamphlet (Appendix IX): Action pamphlet was given to him.

446

Appendix XI Screening Form

Part I Demographic Data

1. Gender

① Male ② Female

2. Age __________years old

3. Marital status

① Single ② Married ③ Divorced ④ Separated ⑤ Widowed

4. Education level (circle the highest level that you have completed)

① No formal education ② Elementary school

③ Junior high school ④ Senior high school

⑤ Associate degree ⑥ Baccalaureate degree or above

5. Current employment status

① Not working

② Working on a part-time basis

③ Working on a full-time basis

6. Occupation before retirement

① Manual labour ② Technical ③ Clerical

④ Managenal ⑤ Professional ⑥ Business/Commercial

⑦ Other, please specify_________________________

7. Religious belief

① No belief ② Buddhism ③ Christianism

④ Islamism ⑤ Catholicism ⑥ Taoism

⑦ Other, please specify_________________________

447

8. Family income per month

① Less than ￥1,000 ②￥1,001-3,000 ③￥3,001-5,000

④￥5,001-7,000 ⑤￥7,001-10,000 ⑥￥More than 10,001

9. Type of medical payment

① Totally reimbursed ② Partially reimbursed

③ Medical insurance ④ Totally self-paid

10. Living condition

① Living alone ② Living with friend ③ Living with spouse

④ Living with children ⑤ Living with spouse and children

Part II Clinical Data

1. Diagnosis

① Angina pectoris ② Myocardial infarction

2. PCI/Stent intervention

① No ② Yes

3. CHD family history (occurring at age < 50)

① No ② Yes

4. Diagnosed with diabetes mellitus (DM)

① No ② Yes

5. Diagnosed with hypertension

① No ② Yes (________mmHg)

448

6. Smoking (use of cigarettes, cigars, cigarillos, pipe tobacco, or any other form of

tobacco)

① Never smoking

② Once smoking (average_____/day), now quit smoking.

③ Current smoking (average _____/day).

7. Alcohol drinking

① Never drinking

② Once drinking (average ___kg/week), now quit drinking.

③ Current drinking (average ____kg/week).

8. Current medication

8.1 Nitrates_______________________________________________________

8.2 Beta-blockers___________________________________________________

8.3 ACE inhibitors__________________________________________________

8.4 Calcium antagonists______________________________________________

8.5 Lipid-lowering drugs_____________________________________________

8.6 Antiplatelets____________________________________________________

8.7 Others_________________________________________________________

Part III Hospital Anxiety and Depression Scale – Depression

Subscale (HADS-D)

Doctors are aware that emotions play an important part in most illness. If your doctor

knows about these feelings he will be able to help you more. This questionnaire is

designed to help your doctor to know how you feel. Read each item and mark a

number in the right column opposite the reply which comes closest to how you have

been feeling in the past week. Don‘t take too long over your replies: your immediate

reaction to each item will probably be more accurate than a long thought-out response.

449

Sub-

scale

Items Answer Score

1 I still enjoy the things I used to

enjoy

Definitely as much

Not quite so much

Only a little

Hardly at all

0

1

2

3

2 I can laugh and see the funny

side of things

As much as I always could

Not quite so much now

Definitely not so much now

Not at all

0

1

2

3

3 I feel cheerful

Not at all

Not often

Sometimes

Most of the time

3

2

1

0

4 I feel as if I am slowed down Nearly all the time

Very often

Sometimes

Not at all

3

2

1

0

5 I have lost interest in my

appearance

Definitely

I don‘t take so much care as I should

I may not take quite as much care

I take just as much care as ever

3

2

1

0

6 I look forward with enjoyment

to things

As much as I ever did

Rather less than I used to

Definitely less than I used to

Hardly at all

0

1

2

3

7 I can enjoy a good book or TV

programme

Often

Sometimes

Not often

Very seldom

0

1

2

3

Total scores: _______________

450

Part IV Screening Item Form

The following items were used to help cardiologist to screen patients according to the

screening guidelines based on the selection criteria and to decide whether they were

suitable to participate in the project, the exercise stage-matched intervention. Patients

would not be recommended to participate in the project if they did not meet any one

of the following items.

1. Age ________years

① Less than 18 years old ② Equal to or more than 18 years old

2. Whether is patient living in Xiamen City?

① Yes, address______________________________________________

Contact telephone No.:______________________________________

② No

3. Patient‘s ability of communication in mandarin and reading in Chinese

(1) The ability of communication in mandarin ① Yes ② No

(2) The ability of reading in Chinese ① Yes ② No

4. Disease diagnosis

① Angina pectoris, date of diagnosis ____________month/year;

② Myocardial infarction, date of diagnosis________month/year;

③ PCI/Stent treatment, date of treatment__________month/year.

5. Is patient medically stable? ① Yes ② No

6. Does patient have unstable angina? ① Yes ② No

7. Has patient participate any cardiac rehabilitation programme?

① Yes ② No

8. Does patient have any cognitive impairment or diagnose with any psychiatric

illnesses such as psychosis and dementia? ① Yes ② No

9. Does patient have depression? ① Yes ② No

10. Has patient have critical aortic stenosis? ① Yes ② No

11. Heart function according to the New York Hear Functional Classification:

451

① I: No limitation of physical activity. Ordinary physical activity does not cause


② II: Slight limitation of physical activity. Comfortable at rest, but ordinary

physical activity results in fatigue, palpitation, or dyspnea.

③ III: Marked limitation of physical activity. Comfortable at rest, but less than


③ VI: Unable to carry out any physical activity without discomfort. Symptoms of


is increased.

12. Diabetes mellitus (DM)

① No ② Yes (resting blood glucose _______________)

13. Hypertension

① No ② Yes (blood pressure___________mmHg)

14. Hear rate/pulse rate _________bpm

15. Does patient have resting heart rate > 120 bpm? ① Yes ② No

16. Does patient have atrial fibrillation? ① Yes ② No

17. Does patient have ventricular arrhythmias? ① Yes ② No

18. Does patient have third-degree AV block? ① Yes ② No

19. Does patient have resting SBP > 180mmHg or resting DBP > 110mmHg?

① Yes ② No

20. Does patient have acute myocarditis? ① Yes ② No

21. Does patient have acute pericarditis? ① Yes ② No

22. Has patient have embolism during the previous three months?

① Yes ② No

23. Does patient have any acute noncardiac disorder that may affect exercise


thyrotoxicosis)? ① Yes ② No

Result of screening: ① Recommend ② Not recommend

Name of cardiologist: ______________________________________

Signature of cardiologist: ___________________________________

Date: ___________________________________________________

452

Appendix XII Questionnaires

Part I Exercise Stages of Change

DIRECTIONS: Regular physical activity is any planned physical activity (e.g., tai

chi, brisk walking, bicycling, swimming) performed to increase physical fitness. Such

activity should accumulate at least 30 minutes of moderate intensity physical activity

throughout the day for more than 5 days of the week (see EXAMPLES OF

MODERATE ACTIVITIES). It is not necessary to perform activity all in one

session. Several 10-min sessions can be just as effective. Moderate intensity physical

activity dose not have to be painful but to be effective. It should be done at a level that

increases your breathing rate and causes you to break a sweat.

Do you exercise regularly according to the definition above? Please mark only

ONE of five statements:

1._____ No, and I do NOT intend to in the next 6 months.

2._____ No, but I intend to in the next 6 months.

3._____ No, but I intend to in the next 30 days.

4._____ Yes, I have been for LESS than 6 months.

5._____ Yes, I have been for MORE than 6 months.

Scoring:

Item 1 = Precontemplation

Item 2 = Contemplation

Item 3 = Preparation

Item 4 = Action

Item 5 = Maintenance

453

Examples of moderate intensity level of physical activities

(adapted from Ainsworth, Haskell, Whitt et al., 1993)

Specific

activity

METs Moderate activities (3-6 METs)

Sports 3.3-5.0 Walking, 3.0-4.0mph or 4.8-6.4 km/h, level, firm surface

4.5 Badminton, social singles and doubles, general

6.0 Basketball, non-game, general

3.0 Bowling

4.0 Table tennis, ping pong

4.0 Tai chi

5.0 Tennis, doubles

3.0 Volleyball, non-competitive, 6-9 member team, general

5.0 Softball or baseball, fast or slow pitch, general

6.0 Swimming at lake, ocean or river, leisurely, not lap

swimming, general

4.0-6.0 Bicycling, 8-11.9mph, leisure, slow, light effort

3.0-5.5 Bicycling, stationary, 50-100 watts, light effort

6.0 Hiking, cross country

Dancing

and

conditioning

exercise

3.5 Callisthenics, home exercise, light or moderate effort,

general (example: back exercise)

4.0 Gymnastics, general

4.8 Twist , jazz, tap, jitterbug

3.0-4.5

fast (disco, folk, square), slow (e.g., waltz, slow dancing),

tango

4.0 Drums

Home

activities

3.5 Mopping

3.0-3.5 Downstairs, going up & down from floor

4.0-5.0 Walk/run – playing with child(ren) – only active periods

3.0-4.5 Walking, 2.5-3.5mph slowly and carrying objects less than

25 pounds

Others 3.0-6.0

454

Part II Exercise Self-Efficacy Scale (ESES)

DIRECTIONS: A number of situations are described below that can make it hard to

stick to physical activity regularly. On the items below, please rate your degree of

confidence that you can perform physical activity on a regular basis by recording in

each of the blank spaces a number from 0 to 100 using the scale below.

0 10 20 30 40 50 60 70 80 90 100

Cannot Moderately Certain

do at all certain can do can do

(0-100)

1. When I am feeling tired.

2. When I am feeling under pressure from work.

3. During bad weather

4. After recovering from an injury that caused me to stop exercising.

5. During or after experiencing personal problems.

6. When I am feeling depressed.

7. When I am feeling anxious.

8. After recovering from an illness that caused me to stop exercising.

9. When I feel physical discomfort when I exercise.

10. After a vacation.

11. When I have too much work to do at home.

12. When visitors are present.

13. When there are other interesting things to do.

14. If I don‘t reach my exercise goals.

15. Without support from my family or friends.

16. During a vacation

17. When I have other time commitments.

18. After experiencing family problems.

455

Part III Exercise Benefits and Barriers

Exercise Benefits Scale

INSTRUCTIONS: Below are statements that relate to ideas about exercise. Please

indicate the degree to which you agree or disagree with the statements by circling:

1=Strongly Disagree (SD)

2=Disagree (D)

3=Agree (A)

4=Strongly Agree (SA)

SD D A SA

1. I enjoy exercise. 1 2 3 4

2. Exercise decrease feelings of stress and tension for me. 1 2 3 4

3. Exercise improves my mental health. 1 2 3 4

4. I will prevent heart attacks by exercising. 1 2 3 4

5. Exercise increases my muscle strength. 1 2 3 4

6. Exercise gives a sense of personal accomplishment. 1 2 3 4

7. Exercising makes me feel relaxed. 1 2 3 4

8. Exercising lets me have contact with friends and

persons I enjoy.

1 2 3 4

9. Exercising will keep me from having high blood

pressure.

1 2 3 4

10. Exercising improves the level of my physical fitness. 1 2 3 4

11. Exercising improves functioning of my cardiovascular

system.

1 2 3 4

12. My muscle tone is improved with exercise. 1 2 3 4

13. I have improved feelings of well-being from exercise. 1 2 3 4

14. Exercising increases my stamina. 1 2 3 4

15. Exercising improves my flexibility. 1 2 3 4

16. My disposition is improved with exercise. 1 2 3 4

17. Exercising helps me sleep better at night. 1 2 3 4

18. I will live longer if I exercise. 1 2 3 4

456

19. Exercising helps me decrease fatigue. 1 2 3 4

20. Exercising is a good way for me to meet with new

people.

1 2 3 4

21. My physical endurance is improved by exercising. 1 2 3 4

22. Exercising improves my self-concept. 1 2 3 4

23. Exercising increases my mental alertness. 1 2 3 4

24. Exercise allows me to carry out normal activities

without tiredness.

1 2 3 4

25. Exercise improves the quality of my work. 1 2 3 4

26. Exercise is good entertainment. 1 2 3 4

27. Exercise increases my acceptance by others. 1 2 3 4

28. Exercise improves overall body functioning for me. 1 2 3 4

29. Exercise improves the way my body looks. 1 2 3 4

Copyright © Sechrist, K.R., Walker, S.N., & Pender, N.J. (1987)

457

Exercise Barriers Scale

INSTRUCTIONS: Below are statements that relate to ideas about exercise. Please

indicate the degree to which you agree or disagree with the statements by circling:

1=Strongly Disagree (SD)

2=Disagree (D)

3=Agree (A)

4=Strongly Agree (SA)

SD D A SA

1. Exercising takes too much of my time. 1 2 3 4

2. Exercise tires me. 1 2 3 4

3. Places for me to exercise are too far away. 1 2 3 4

4. I am too embarrassed to exercise. 1 2 3 4

5. It costs too much to exercise. 1 2 3 4

6. Exercise facilities do not have convenient schedules for me. 1 2 3 4

7. I am fatigued by exercise. 1 2 3 4

8. My spouse (or significant other) does not encourage

exercising.

1 2 3 4

9. Exercise takes too much time from family responsibilities. 1 2 3 4

10. I think people in exercise clothes look funny. 1 2 3 4

11. My family members do not encourage me to exercise. 1 2 3 4

12. Exercise takes too much time from family relationships. 1 2 3 4

13. Exercise is hard work for me. 1 2 3 4

14. There are too few places for me to exercise. 1 2 3 4

Copyright © Sechrist, K.R., Walker, S.N., & Pender, N.J. (1987)

458

Part IV Log Book for Patients’ Self-reporting and Self-evaluation of

Physical Activity

DIRECTIONS: This is a log book for recording the details of your daily physical

activity performed, including the mode (see the examples of moderate activities),

frequency, intensity and duration of each session of physical activity, whether it occur

angina and the additional number of short-acting sublingual trinitrate (GTN) or any

other anti-anginal drug tablets taken during the physical activity. The intensity of

physical activity was assessed by rating Borg‘s Rate of Perceived Exertion (RPE)

from 6 to 20, with 6 being very, very light (rest) and 20 being exhaustion. Level of

exercise, please rate the number from 6 to 20 to represent your perceived exertion.

Please also record the mode, frequency, and duration of each session of physical

activity, and the occurrence of anginal pain and the additional number of GTN tablets

or any other anti-anginal drugs taken when angina occurs due to the physical activity.


Very

light

Fairly

light

Some-

what

hard

Hard Very

hard

Very,

very

hard

Very,

very

light

459

Date

Physical activity

Total

Mon Tues Wed Thurs Fri Sat Sun

Mode

Frequency

Intensity (RPE: 6-20)

Duration (minute)

Angina occurs?

No

Yes

Take additional number

of GTN or any other

anti-anginal drugs

because of physical

activity (number)

460

Part V Log Book for Patients’ Self-reporting and Self-evaluation of

Angina

DIRECTIONS: This is a log book for recording the details of your daily angina,

including the frequency, severity and duration of each episode of angina, and the total

number of short-acting sublingual trinitrate (GTN) and any other anti-anginal drugs

tablets taken each day. Each episode of angina for severity was rated by a following

visual scale from 0 to 10, with 0 being no pain and 10 being ‗Crucifying pain‘, 5

being very painful. Please rate the number from 0 to 10 to represent your perceived

severity of angina and document the duration of each episode in minutes, and the total

number of GTN and any other anti-anginal drugs tablets taken each day.

10

Crucifying pain

9

Crushing the heart and lungs

8

Excruciating pain

7

Unbearable

6

Indescribable

5

Very painful

4

Painful

3

Bearable

2

Quite painful

1

Slight pain

0 No pain

461

Date

Angina

Total*

Mon Tues Wed Thu Fri Sat Sun

Frequency of angina

Severity of angina (0-10)

Duration of each episode of

angina (min)

Total number of GTN and any

other anti-anginal drugs taken

each day

*For the total of ―severity of angina‖, calculate its average value.

462

Part VI Quality of Life


1. The following is a list of activities that people often do during the week. Although

for some people with several medical problems it is difficult to determine what it is

that limits them, please go over the activities listed below and indicate how much

limitation you have had due to chest pain, chest tightness, or angina over the past 4

weeks. (Place an ―√ ‖ in one box on each line).

Activity Severely

limited

Moderately

limited

Somewhat

limited

A little

limited

Not

limited

Limited,

or did

not do

for other

reasons

Dressing

yourself □ □ □ □ □ □

Walking indoors

on level ground □ □ □ □ □ □

Showering □ □ □ □ □ □

Climbing a hill

or a flight of

stairs without

stopping

□ □ □ □ □ □

Gardening,

vaccuming, or

carrying

groceries

□ □ □ □ □ □

Walking more

than a block at a

brisk pace

□ □ □ □ □ □

463

Activity Severely

limited

Moderately

limited

Somewhat

limited

A little

limited

Not

limited

Limited,

or did

not do

for other

reasons

Running or

jogging □ □ □ □ □ □

Lifting or

moving heavy

objects (e.g.,

furniture,

children)

□ □ □ □ □ □

Participating in

strenuous sports

(e.g., swimming,

tennis)

□ □ □ □ □ □

2. Compared with 4 weeks ago, how often do you have chest pain, chest tightness, or

angina when doing your most strenuous level of activity?

I have had chest pain, chest tightness, or angina……

Much

more often

Slightly

more often

About the

same

Slightly

less often

Much less

often

I‘ve had no chest

pain over the last 4

weeks

□ □ □ □ □ □

3. Over the past 4 weeks, on average, how many times have you had chest pain, chest

tightness, or angina?

464

I get chest pain, chest tightness, or angina……

4 or more

times per

day

1-3 times

per day

3 or more

times per

week but not

every day

1-2 times

per week

Less than

once a

week

None over

the past 4

weeks

□ □ □ □ □ □

4. Over the past 4 weeks, on average, how many times have you had to take nitros

(nitroglycerin tablets) for your chest pain, chest tightness, or angina?

4 or more

times per

day

1-3 times

per day

3 or more times

per week but not

every day

1-2 times

per week

Less than

once a

week

None over

the past 4

weeks

□ □ □ □ □ □

5. How bothersome is it for you to take your pills for chest pain, chest tightness or

angina as prescribed?

Very

bothersome

Moderately

bothersome

Somewhat

bothersome

A little

bothersome

Not

bothersome

at all

My doctor

has not

prescribed

pills

□ □ □ □ □ □

465

6. How satisfied are you that everything possible is being done to treat your chest pain,

chest tightness, or angina?

Not satisfied

at all

Mostly

dissatisfied

Somewhat

satisfied

Mostly

satisfied

Highly

satisfied

□ □ □ □ □

7. How satisfied are you with the explanations your doctor has given you about your

chest pain, chest tightness, or angina?

Not satisfied

at all

Mostly

dissatisfied

Somewhat

satisfied

Mostly

satisfied

Highly

satisfied

□ □ □ □ □

8. Overall, how satisfied are you with the current treatment of your chest pain,


Not satisfied

at all

Mostly

dissatisfied

Somewhat

satisfied

Mostly

satisfied

Highly

satisfied

□ □ □ □ □

9. Over the past 4 weeks, how much has your chest pain, chest tightness, or angina

interfered with your enjoyment of life?

It has severely

limited my

enjoyment of

life

It has

moderately

limited my

enjoyment of

life

It has slightly

limited my

enjoyment of

life

It has barely

limited my

enjoyment of

life

It has not

limited my

enjoyment of

life

□ □ □ □ □

466

10. If you had to spend the rest of your life with your chest pain, chest tightness, or

angina the way it is right now, how would you feel about this?

Not satisfied

at all

Mostly

dissatisfied

Somewhat

satisfied

Mostly

satisfied

Highly

satisfied

□ □ □ □ □

11. How often do you worry that you may have a heart attack or die suddenly?

I can‘t stop

worrying

about it

I often think

or worry

about it

I

occasionally

worry about

it

I rarely

think or

worry

about it

I never

think or

worry

about it

□ □ □ □ □

467

Short Form 36 Health Survey Questionnaire (SF-36)

The following questions are to assess your opinion, feeling and ability to perform

daily activities. Please choose the answer that is closest to your condition for each

question.

1. In general, would you say your health is:

Excellent

Very good

Good

Fair

Poor

2. Compared to one year ago, how would you rate your health in general now?

Much better now than one year ago

Somewhat better now than one year ago

About the same as one year ago

Somewhat worse now than one year ago

Much worse now than one year ago

3. The following items about activities you might do during a typical day. Does your

health now limit you in these activities? If so, how much?

Limited a

lot

Limited a

little

Not

limited

Vigorous activities, such as running, lifting heavy

objects, participating in strenuous sports

Moderate activities, such as moving a table,

cleaning the floor

Lifting or carrying groceries

Climbing several flights of stairs

Climbing one flight of stairs

468

Bending, kneeling, or stooping

Walking 1500 meters

Walking 800 meters

Walking 100 meters

Bathing or dressing yourself

4. During the past four weeks, have you had any of the following problems with your

work or other regular activities as a result of your physical health?

Yes No

Cut down on the amount of time you spent on work or other

activities

Accomplished less than you would like

Were limited in the kind of work or other activities

Had difficulty performing the work or other activities (for

example, it took extra effort)


work or other regular daily activities as a result of any emotional problems (such as

feeling depressed or anxious)?

Yes No


activities


Did work or other activities less carefully than usual

6. During the past four weeks, to what extent has your physical health or emotional

problems interfered with your normal social activities with family, friends, neighbors,

or groups?

469

Not at all

Slightly

Moderately

Quite a bit

Extremely

7. How much bodily pain have you had during the past four weeks?

None

Very mild

Mild

Moderate

Severe

Very severe

8. During the past four weeks, how much did pain interfere with your normal work,

including work outside the home and housework?

Not at all

A little bit

Moderately

Quite a bit

Extremely

9. The next set of questions is about how you feel and how things have been with you

during the past four weeks. For each question, please give the one answer that comes

closest to the way you have been feeling.

How much of the time during the past

four weeks

All

the

time

Most

of

the

time

A

good

bit of

the

time

Some

of

the

time

A

little

of

the

time

None

of

time

Did you feel full of pep?

Have you been a very nervous person?

Have you felt so down in the dumps that

470

nothing could cheer you up?

Have you felt calm and peaceful?

Did you have a lot of energy?

Have you felt downhearted and blue?

Did you feel worn out?

Have you been a happy person?

Did you feel tired?

Has your physical health or emotional

problems interfered with your social

activities like visiting friends, relatives,

etc.

10. How true or false is each of the following statements for you?

Definitely

true

Mostly

true

Don‘t

know

Mostly

false

Definitely

false

I seem to get sick a little easier

than other people

I am as healthy as anybody I

know

I expect my health to get worse

My health is excellent

471

Appendix XIII Scoring Instructions

Part I Scoring instructions and data analyses of the exercise stages of

change

There are three ways to handle with data of exercise stages of change: ① At every

outcome measure point (e.g., T0, T1, T2 and T3), the count of distribution of each stage

and proportion could be employed to show data. The exercise stages of change

contain five stages, such as precontemplation, contemplation, preparation, action and

maintenance stages. Since these five stages are ordinal data and there are three groups

in this study, Kruskal-Wallis test could be used to compare the difference in the

exercise stages of change among the three groups at each time point and Friedman test

could be used for within group comparison from T0 to T3. ② An approach to

conceptualizing stage progression as a trichotomous variable (progression, stable and

regression) would be to count the number of stages progressed, stable or regressed as the

outcome variable. For example, compared to the baseline exercise stages of change, an

individual progresses at least one single stage (e.g., progress from precontemplation to

contemplation stage or to action stage) would be viewed as progression. An individual

regresses at least one earlier stage (e.g., regress from contemplation to precontemplation

stage) would be assigned as regression. An individual has no movement of exercise

stages of change before and after the intervention would be viewed as stable. The count

and proportion of each label could be employed to show data. Kruskal-Wallis test could

be used to compare the difference in the exercise stages of change among the three

groups at each time point and Friedman test could be used for within group

comparison from T0 to T3. ③ A recommended alternative approach to conceptualizing

stage progression as a trichotomous variable would be to count the number of stages

progressed as the outcome variable. For example, an individual progressing a single

stage (e.g., progress from precontemplation to contemplation stage, or progress from

contemplation to action stage) would receive a score of 1, while an individual

progressing two stages would receive a score of 2 (e.g., progress from precontemplation

to action stage), and so on. Regression to an earlier stage would be assigned negative

scores. For example, the subjects regressing a single stage (e.g., regress from

contemplation to precontemplation stage) would receive a negative score of 1; the

472

subjects regressing two stages would receive a negative score of 2, and so on. Then we

can calculate the mean scores of exercise stages change in each group. For the scores of

each point (e.g., T1, T2 and T3), one way ANOVA or Kruskal-Wallis test (if data is not

normally distributed and/or the related homogeneity of variance was not achieved) could

be used to analyze the data. Within each group, one-way repeated ANOVA or Friedman

test would be used to analyze the data. (Nigg, 2002, cited in G.J. Welk (Ed)).

Part II Scoring instructions and data analyses of the exercise self-

efficacy scale

The exercise self-efficacy scale consists of 18 items. The scores of each item ranges

from 0 (can not do at all) to 100 (certainly can do). The instrument may be scored and

used in its entirely. The total scores can be calculated to add scores of each item.

Scores on the total instrument can range from 0 to 1800. The higher scores mean the

higher degree of confidence to perform physical activity on a regular basis. The data

are scale data. We can calculate the mean scores of each group and then use two-way

repeated ANOVA to analyze the groups, time and interactive effects. For the scores of

each point (e.g., T0, T1, T2 and T3), one way ANOVA or Kruskal-Wallis test (if data is

not normally distributed and/or the related homogeneity of variance was not achieved)

could be used to analyze the data. Within each group, one-way repeated ANOVA or

Friedman test would be used to analyze the data.

Part III Scoring instructions and data analyses of the exercise

benefits and barriers scale

The instrument can be scored and used in its entirely or as two separate scales, such as

the exercise benefits scale and the exercise barriers scale. The instrument has a four-

response, force-choice Liker-type format with responses ranging from 4 (strongly

agree) to 1 (strongly disagree). Barrier Scale items are reverse-scored.

473

Missing data can be handled in one of the two ways. If more than five percent of the

items are unanswered, it is recommended that the response be discarded. If the

missing item response rate is less than five percent, median substitution prevents

falsely low scores.

Scores on the total instrument can range from 43 to 172. The higher the score, the

more positively the individual perceives exercise. When the Benefits Scale is used

alone, the score range is between 29 and 116. When the Barriers Scale is used alone,

scores range between 14 and 56. If used alone, the Barriers Scale does not need to be

reverse-scored. In this instance, the higher the score on the Exercise Barriers Scale,

the greater the perception of barriers to exercise.

In this study, we used the instrument as two separate scales. The scores of exercise

benefits scale and exercise barriers scale were calculated separately. The data are

scale data. We can calculate the mean scores of each group and then use two-way

repeated ANOVA to analyze the groups, time and interactive effects. For the scores of

each point (e.g., T0, T1, T2 and T3), one way ANOVA or Kruskal-Wallis test (if data is

not normally distributed and/or the related homogeneity of variance was not achieved)

could be used to analyze the data. Within each group, one-way repeated ANOVA or

Friedman test would be used to analyze the data.

Part IV Scoring instructions and data analyses of Patients’ Self-

reporting and Self-evaluation of Physical activity

1. Duration of physical activity: Calculate the duration of any planned and/or

intentional physical activities and moderate physical activities performed for

physical fitness in the past one week. The moderate physical activities duration

was calculated based on the moderate physical activities according to the form of

examples of moderate physical activities.The data are ratio data. We can calculate

the mean scores of each group and then use two-way repeated ANOVA to analyze

the groups, time and interactive effects. For the scores of each point (e.g., T0, T1, T2

and T3), one way ANOVA or Kruskal-Wallis test (if data is not normally distributed

474

and/or the related homogeneity of variance was not achieved) could be used to

analyze the data. Within each group, one-way repeated ANOVA or Friedman test

would be used to analyze the data.

2. The number of anti-anginal drugs taken: Calculate the number of any anti-anginal

drugs taken in the past one week due to the chest pain, chest tightness or angina

induced by physical activities. The anti-anginal drugs include short-acting

sublingual trinitrate, shexiangbaoxin pill, danshendiwan and suxiaojiuxin pill.

Thus, calculate the number of these anti-anginal drugs taken in the past one week.

Although these anti-anginal drugs have similar effect on anti-anginal pain, they

have different taking ways and doses. We cannot simply compare the number of

each anti-anginal drugs taken. Based on whether patient took the anti-anginal

drugs during exercise session in the past one week, the data were viewed as

nominal data. The count of and proportion of whether patient took anti-anginal

drug could be employed to show data. Chi-square test could be used to analyze

data at each time point among the three groups and Cochran‘s Q test could be

used to analyze data within each group from T0 to T3.

Part V Scoring instructions and data analyses of Patients’ Self-

reporting and Self-evaluation of Angina

1. Angina frequency (episodes/week): Calculate the total episodes of angina attack in

the past one week. The data are scale data. We can calculate the mean scores of

each group and then use two-way repeated ANOVA to analyze the groups, time

and interactive effects. For the scores of each point (e.g., T0, T1, T2 and T3), one

way ANOVA or Kruskal-Wallis test (if data is not normally distributed and/or the

related homogeneity of variance was not achieved) could be used to analyze the data.

Within each group, one-way repeated ANOVA or Friedman test would be used to

analyze the data.

2. Angina severity (0-10): The severity of each episode of angina was rated by a

visual scale ranged from 0 to 10, with 0 being no pain and 10 being ‗Crucifying

pain‘, 5 being very painful. Patients rate the number from 0 to 10 to represent their

perceived severity of angina. Calculate the average severity of angina in the past

475

one week. The data are ratio data. We can calculate the mean scores of each group

and then use two-way repeated ANOVA to analyze the groups, time and

interactive effects. For the scores of each point (e.g., T0, T1, T2 and T3), one way

ANOVA or Kruskal-Wallis test (if data is not normally distributed and/or the related

homogeneity of variance was not achieved) could be used to analyze the data. Within

each group, one-way repeated ANOVA or Friedman test would be used to analyze

the data.

3. Angina duration (minutes/week): Calculate the total minutes of angina duration in

the past one week. The data are ratio data. We can calculate the mean scores of

each group and then use two-way repeated ANOVA to analyze the groups, time

and interactive effects. For the scores of each point (e.g., T0, T1, T2 and T3), one

way ANOVA or Kruskal-Wallis test (if data is not normally distributed and/or the

related homogeneity of variance was not achieved) could be used to analyze the data.

Within each group, one-way repeated ANOVA or Friedman test would be used to

analyze the data.

4. Based on whether patient experienced angina in the past one week, the data was

viewed as a nominal data. The count of and proportion of whether patient

experienced angina could be employed to show data. Chi-square test could be

used to analyze data at each time point among the three groups and Cochran‘s Q

test could be used to analyze data within each group from T0 to T3.

5. Anti-anginal drugs taken: Calculate the number of any anti-anginal drugs taken in

the past one week, such as short-acting sublingual trinitrate, shexiangbaoxin pill,

danshendiwan and suxiaojiuxin pill. Thus, calculate the number of these anti-

anginal drugs taken in the past one week. Although these anti-anginal drugs have

similar effect on anti-anginal pain, they have different taking ways and doses. We

cannot simply compare the number of each anti-anginal drug taken. Based on

whether patient took the anti-anginal drugs in the past one week, the data were

viewed as nominal data. The count of and proportion of whether patient took anti-

anginal drugs could be employed to show data. Chi-square test could be used to

analyze data at each time point among the three groups and Cochran‘s Q test

could be used to analyze data within each group from T0 to T3.

476

Part VI Scoring and Interpreting the SAQ

There are 5 summary scores within the SAQ, which are calculated as follows:

A. The Physical Limitation scale

The Physical Limitation score corresponds to questions 1a through 1i. Responses to

questions 1a through 1i should be coded numerically as follows:

1 = Extremely Limited

2 = Quite a bit Limited

3 = Moderately Limited

4 = Slightly Limited

5 = Not at all Limited

6 = Limited for other reasons or did not do the activity

If the responses to questions 1a through 1i are not 1, 2, 3, 4 or 5 then the response is

set to missing. Note that a response of 6 is treated as a missing value. Missing values

are assigned the average score for that level of activity. Activities are grouped into 3

levels of exertional requirements. The lowest level includes dressing, walking and

showering (1a, 1b and 1c); the middle level is climbing, gardening, and walking more

than a block (1d, 1e and 1f); the highest level includes running, lifting, and sports (1g,

1h and 1i). If any one item in a group is missing, then assign the average value of the

other group items to the missing item. If all items in the lowest or the highest level are

missing, then assign each item the mean of the items in the middle level. If all items

in the middle level are missing, then assign each item the average of the means of the

lowest and highest levels. If more than 4 items are missing in this scale then no

reasonable score for this dimension can be calculated. After accounting for any

missing items the physical limitation score is computed by standardizing the mean

response of all nine items as follows:

Physical Limitation = 100*(Mean Response – 1)/4

477

B. The Angina Stability scale

The Angina Stability score corresponds to question 2. Responses to question 2 should

be coded numerically as follows:

1 = Much more often

2 = Slightly more often

3 = About the same

4 = Slightly less often

5 = Much less often

6 = I‘ve had no chest pain over the last 4 weeks

If the response is 6 (no chest pain over last 4 weeks) then set the response to 3 (about

the same). If the response is missing then angina stability cannot be computed and

will be missing. Otherwise, the angina stability score is computed by standardizing

the result as follows:

Angina Stability = 100*(Response – 1)/4

C. The Angina Frequency scale

The Angina Frequency score corresponds to questions 3 and 4. Responses should be

coded sequentially 1 to 6 in order of increasing health status, with 1 denoting the

response associated with the lowest health status. If at least one question response is

present then the angina frequency is computed by standardizing the mean response as

follows:

Angina Frequency = 100*(Mean Response – 1)/5

D. The Treatment Satisfaction scale

The Treatment Satisfaction score corresponds to questions 5, 6, 7 and 8. Responses

should be coded sequentially (1, 2, 3…) in order of increasing health status, with 1

478

denoting the response associated with the lowest health status. If responses to

questions 5, 6, 7 and 8 are not values 1, 2, 3, 4, or 5 then the response is set to missing.

Note that a response of 6 for question 5 is treated as a missing value. If at least two

responses are present then the treatment satisfaction score is computed by calculating

the mean response and standardizing the result as follows:

Treatment Satisfaction = 100*(Mean Response – 1)/4

E. The Quality of Life scale

The Quality of Life score corresponds to questions 9, 10 and 11. Responses should be

coded sequentially 1 to 5 in order of increasing health status, with 1 denoting the

response associated with the lowest health status. If the responses to questions 9, 10

and 11 are not values 1, 2, 3, 4 or 5 then the response is set to missing. If at least two

responses are present then the Quality of Life score may be computed by

standardizing the mean response as follows:

Quality of Life = 100*(Mean Response – 1)/4

Part VII Scoring instructions of MOS SF-36

1. The contents and structure of MOS SF-36

The MOS SF-36 is a generic health survey questionnaire and was developed by the

American Boston Institute of Health. It was widely used to assess quality of life in

general population, clinical trials and health policy evaluation. The SF-36 includes

eight domains, such as physical functioning (PF), role-physical (RP), bodily pain (BP),

general health (GH), vitality (VT), social functioning (SF), role-emotional (RE), and

mental health (MH), and one item, reported health transition (HT).

479

2. Scoring instruction of MOS SF-36

2.1 Basic steps

First, coding each item of MOS SF-36

Second, scoring of each item

Third, calculate the scores of each domain. The basic formula for scoring as follow:

Scores of each

domain =

Real scores – possible lowest scores of this domain

Possible highest scores – possible lowest scores

2.2 Handle with missing data: Sometime responders do not response to all the items

of each domain. The items that are not answered are viewed as missing data. If more

than half of the items of each domain are answered, we should calculate the scores of

this domain. The missing data is replaced with mean scores.

2.3 Scores of each domain and calculation

2.3.1 PF：Physical Functioning

Item：3

(1) Vigorous activities, such as running, lifting heavy objects, participating in

strenuous sports

(2) Moderate activities, such as moving a table, cleaning the floor

(3) Lifting or carrying groceries

(4) Climbing several flights of stairs

(5) Climbing one flight of stairs

(6) Bending, kneeling, or stooping

(7) Walking 1500 meters



(10) Bathing or dressing yourself

Coding and scoring

480

Answer Coding Scoring

Limited a lot

Limited a little

Not limited

1

2

3

1

2

3

Scoring and calculation

Add all scores of each item of this domain and calculate the final scores of PF. The

higher scores of PE, the better health status.

PF Real scores -10

20

2.3.2 RP：Role-Physical

Item：4

(1) Cut down on the amount of time you spent on work or other activities

(2) Accomplished less than you would like

(3) Were limited in the kind of work or other activities

(4) Had difficulty performing the work or other activities (for example, it took extra

effort)

Coding and scoring


Yes

No

1

2

1

2


Add all scores of each item of this domain and calculate the final scores of RP. The

higher scores of RP, the better health status.

RP = Real scores - 4

4

481

2.3.3 BP：Bodily Pain

Item：7，8




Coding and scoring of item 7


None

Very mild

Mild

Moderate

Severe

Very severe

1

2

3

4

5

6

6.0

5.4

4.2

3.1

2.2

1.0

Coding and scoring of item 7 - if individual answered both item 7 and item 8

Answer Code of item 8 Code of item 7 Scores of item 8

Not at all 1 1 6

Not at all 1 2 - 6 5

A little bit 2 1 - 6 4

Moderately 3 1 - 6 3

Quite a bit 4 1 - 6 2

Extremely 5 1 - 6 1

Coding and scoring of item 7 - if no response to item 7


Not at all 1 6.0

A little bit 2 4.75

Moderately 3 3.5

Quite a bit 4 2.25

Extremely 5 1.0


Add all scores of each item of this domain and calculate the final scores of BP. The

482

higher scores of BP, the better health status.

BP = Real scores - 2

10

2.3.4 GH：General Health

Item：1，10


10.1 I seem to get sick a little easier than other people

10.2 I am as healthy as anybody I know

10.3 I expect my health to get worse

10.4 My health is excellent

Coding and scoring of item 1&10.1-10.4

Item 1 Answer Coding Scoring

Excellent 1 5.0

Very good 2 4.4

Good 3 3.4

Fair 4 2.0

Poor 5 1.0

Item 10.1，10.3 Answer Coding Scoring

Definitely true 1 1

Mostly true 2 2

Don‘t know 3 3

Mostly false 4 4

Definitely false 5 5


Definitely true 1 5

Mostly true 2 4

Don‘t know 3 3

483

Mostly false 4 2

Definitely false 5 1


Add all scores of each item of this domain and calculate the final scores of GH. The

higher scores of GH, the better health status.

GH = Real scores - 5

20

2.3.5 VT：Vitality

Item：9.1，9.5，9.7，9.9

9.1 Did you feel full of pep?

9.5 Did you have a lot of energy?

9.7 Did you feel worn out?

9.9 Did you feel tired?

Coding and scoring


All the time 1 6

Most of the time 2 5

A good bit of the time 3 4

Some of the time 4 3

A little of the time 5 2

None of time 6 1


All the time 1 1




484


None of time 6 6


Add all scores of each item of this domain and calculate the final scores of VT. The

higher scores of VT, the better health status.

VT = Real scores - 4

20

2.3.6 SF：Social Functioning

Item：6，9.10



or groups?

9.10 Has your physical health or emotional problems interfered with your social

activities like visiting friends, relatives, etc.

Coding and scoring

Item 6 Answer Coding Scoring

Not at all 1 5

Slightly 2 4

Moderately 3 3

Quite a bit 4 2

Extremely 5 1

Item 9.10 Answer Coding Scoring

All the time 1 1





485

None of time 5 5


Add all scores of each item of this domain and calculate the final scores of SF. The

higher scores of SF, the better health status.

SF = Real scores - 2

8

2.3.7 RE：Role-Emotional

Item：5

(1) Cut down on the amount of time you spent on work or other activities

(2) Accomplished less than you would like

(3) Did work or other activities less carefully than usual

Coding and scoring


Yes 1 1

No 2 2


Add all scores of each item of this domain and calculate the final scores of RE. The

higher scores of RE, the better health status.

RE = Real scores - 3

3

486

2.3.8 MH：Mental Health

Item：9.2，9.3，9.4，9.6，9.8

9.2 Have you been a very nervous person?

9.3 Have you felt so down in the dumps that nothing could cheer you up?

9.4 Have you felt calm and peaceful?

9.6 Have you felt downhearted and blue?

9.8 Have you been a happy person?

Coding and scoring

Item 9.2，9.3，

9.6


All the time 1 1





None of time 6 6


All the time 1 6





None of time 6 1


Add all scores of each item of this domain and calculate the final scores of MH. The

higher scores of MH, the better health status.

487

MH = Real scores - 5

25

2.3.9 HT：Reported Health Transition

Item：2


Code and scoring

Answer Code

Much better now than one year ago 1

Somewhat better now than one year ago 2

About the same as one year ago 3

Somewhat worse now than one year ago 4

Much worse now than one year ago 5

（Statistics department, Public Health College, Zhongshan Medical University, Fang

Ji-Qian & Hao Yuan-Tao, 2009）

488

Appendix XIV Training Package

Training Package

This trainer package introduced how to train a registered nurse (RN) to collect data. It

included two parts (1) Researcher went through each item with the RN to help her

understand the meaning of each item, and then guide the RN how to use instructions

to help patients better understand and fill in the questionnaires; (2) Role play: Select

1-2 persons to play as patients and the researcher played as an audience, the RN

collected data one by one item according to the questionnaires. The researcher

corrected and explained timely if there was any wrong or inconsistence in order to

guaranteeing using the same instructions to collect data to each patient.

First of all, the data collector should understand the purpose of each questionnaire and

the meaning of each item of each questionnaire and how to use it.

489

Part I Exercise Stages of Change Scale

Instructions

The exercise stages of change is used to assess patient‘s current exercise stage.

1. Moderate intensity physical activity refers to any physical activity up to 3-6 METs,

such as fishing from river bank, walking or standing (3.5 METs) (see examples of

moderate activities for details).

2. Regular physical activity is any planned or intentional physical activity (e.g., tai chi,

brisk walking, bicycling, swimming) performed to increase physical fitness. Such

activity should accumulate at least 30 minutes of moderate intensity physical activity

throughout the day for more than 5 days of the week. Several 10-min sessions can be

just as effective.

3. Definition of different exercise stages

(1) Precontemplation is the stage at which individuals are currently not doing

exercise and have no intention to start exercise in the next 6 months.

(2) Contemplation is the stage at which individuals are aware that a problem exists

with sedentary behaviour and they are seriously thinking about starting to exercise in

the next 6 months.

(3) Preparation is the stage at which individuals are intending to take action to

change sedentary habits in the next 30 days or those who currently exercise some, but

not regularly.

(4) Action is the stage at which individuals modify their behaviour, experiences, or

environment to overcome their problems; they have successfully exercised regularly

for less than 6 months.

490

(5) Maintenance is the stage at which individuals have exercised regularly for more

than 6 months.

4. Item 1 = Precontemplation; Item 2 = Contemplation; Item 3 = Preparation; Item 4 =

Action; Item 5 = Maintenance.

5. The way to determine patient‘s exercise stages of change (Figure 1).

The RN used the following flowchart to assess patient‘s current exercise stages of

change. The RN should show the patient the table of examples of moderate activities

when she was asking ―Are you accumulating at least 30 minutes of moderate-intensity

physical activity on most (five or more) days of the week?‖ and asked him/her

whether he/she had done any equal activities as the examples of moderate activities?

One thing should be noted that any physical activities that patient performed was to

increase his/her physical fitness. It would not be counted if the activity was done for

housework or job. We focused on leisure time physical activities. Additionally, the

physical activity should accumulate at least 30 minutes of moderate intensity physical

activity throughout the day for more than 5 days of the week and continuing at least

10 minutes per episode.

491

Readiness to change

Are you accumulating at least 30 minutes of

moderate-intensity physical activity on most

(five or more) days of the week?

Are you accumulating at least 30

minutes of moderate-intensity

physical activity each week?

Have you been active on a

regular basis for the last six

months?

Do you intend to

increase your

physical activity?

If you are doing

physical activity

infrequently, you are in stage 3.

If you are active

consistently but for

less than six months, you are in stage 4.

If you have

maintained the new

habit for six months

or more, you are in stage 5 If you are not

even thinking

about it, you are in stage 1.

If you are giving it a

thought now and then

but not doing activity, you are in stage 2.

No Yes

Yes

Yes

Yes

No

No

No

Figure 1 Flow chart for determining the stages of change

(Marcus, Forsyth & Blair, 2003)

492

Part II Exercise Self-Efficacy Scale (ESES)

Instructions

1. Since a number of situations can make it hard to stick to physical activity regularly,

the exercise self-efficacy scale is used to measure the degree of confidence to perform

physical activity on a regular basis if you encountered the following 18 situations.

Zero means that you cannot do at all, 100 mean that you certainly can do, and 50

means that you moderately certain can do. Please record in each of the blank spaces a

number from 0 to 100 using the scale below.

0 10 20 30 40 50 60 70 80 90 100

Cannot Moderately Certain

do at all certain can do can do

2. Instructions for each item.

(1) When I am feeling tired. How many confidences do you have to perform

physical activity on a regular basis when you are feeling tired? Please select a number

from 0 to 100 to show your degree of confidence. Zero means that you cannot do at

all and 100 mean that you certainly can do it.

(2) When I am feeling under pressure from work. How many confidences do you

have to perform physical activity on a regular basis when you are feeling under

pressure from work? Please select a number from 0 to 100 to show your degree of

confidence.

(3) During bad weather. How many confidences do you have to perform physical

activity on a regular basis during bad weather? Please select a number from 0 to 100

to show your degree of confidence.

(4) After recovering from an injury that caused me to stop exercising. How many

confidences do you have to perform physical activity on a regular basis after

recovering from an injury that caused you to stop exercising? Please select a number

from 0 to 100 to show your degree of confidence.

493

(5) During or after experiencing personal problems. How many confidences do

you have to perform physical activity on a regular basis during or after experiencing

personal problems? Please select a number from 0 to 100 to show your degree of

confidence.

(6) When I am feeling depressed. How many confidences do you have to perform

physical activity on a regular basis when you are feeling depressed? Please select a

number from 0 to 100 to show your degree of confidence.

(7) When I am feeling anxious. How many confidences do you have to perform

physical activity on a regular basis when you are feeling anxious? Please select a

number from 0 to 100 to show your degree of confidence.

(8) After recovering from an illness that caused me to stop exercising. How many

confidences do you have to perform physical activity on a regular basis after

recovering from an illness that caused you to stop exercising? Please select a number


(9) When I feel physical discomfort when I exercise. How many confidences do

you have to perform physical activity on a regular basis when you feel physical

discomfort when you exercise? Please select a number from 0 to 100 to show your

degree of confidence.

(10) After a vacation. How many confidences do you have to perform physical

activity on a regular basis after a vacation? Please select a number from 0 to 100 to

show your degree of confidence.

(11) When I have too much work to do at home. How many confidences do you

have to perform physical activity on a regular basis when you have too much work to

do at home? Please select a number from 0 to 100 to show your degree of confidence.

(12) When visitors are present. How many confidences do you have to perform

physical activity on a regular basis when visitors are present? Please select a number


(13) When there are other interesting things to do. How many confidences do you

have to perform physical activity on a regular basis when there are other interesting

things to do? Please select a number from 0 to 100 to show your degree of confidence.

(14) If I don’t reach my exercise goals. How many confidences do you have to

perform physical activity on a regular basis if you don‘t reach your exercise goals?

Please select a number from 0 to 100 to show your degree of confidence.

494

(15) Without support from my family or friends. How many confidences do you

have to perform physical activity on a regular without support from your family or

friends? Please select a number from 0 to 100 to show your degree of confidence.

(16) During a vacation. How many confidences do you have to perform physical

activity on a regular basis during a vacation? Please select a number from 0 to 100 to

show your degree of confidence.

(17) When I have other time commitments. How many confidences do you have to

perform physical activity on a regular basis when you have other time commitments?


(18) After experiencing family problems. How many confidences do you have to

perform physical activity on a regular basis after experiencing family problems?


Part III Exercise Benefits and Barriers Scales

Exercise Benefits Scale (EBS)

1. Directions

The exercise benefits scale is used to measure the degree to which patients feel the

benefits of exercise. Below are statements that relate to ideas about exercise benefits.

Asking patient whether he/she agree or disagree with each statement and the degree to

which he/she you agree or disagree with each statement by circling: 1=Strongly

Disagree (SD), 2=Disagree (D), 3=Agree (A), and 4=Strongly Agree (SA).

2. Instructions of each item

(1) I enjoy exercise. Whether do you agree that you enjoy exercise? Do you strongly

agree (disagree) or only agree (disagree)?

(2) Exercise decrease feelings of stress and tension for me. Whether do you agree

that exercise decrease feelings of stress and tension for you? Do you strongly agree

(disagree) or only agree (disagree)?

495

(3) Exercise improves my mental health. Whether do you agree that exercise

improves your mental health? Do you strongly agree (disagree) or only agree

(disagree)?

(4) I will prevent heart attacks by exercising. Whether do you agree that you will

prevent heart attacks by exercising? Do you strongly agree (disagree) or only agree

(disagree)?

(5) Exercise increases my muscle strength. Whether do you agree that exercise

increases your muscle strength? Do you strongly agree (disagree) or only agree

(disagree)?

(6) Exercise gives a sense of personal accomplishment. Whether do you agree that

exercise gives a sense of personal accomplishment? Do you strongly agree (disagree)

or only agree (disagree)?

(7) Exercising makes me feel relaxed. Whether do you agree that exercising makes

you feel relaxed? Do you strongly agree (disagree) or only agree (disagree)?

(8) Exercising lets me have contact with friends and persons I enjoy. Whether do

you agree that exercising lets you have contact with friends and persons you enjoy?

Do you strongly agree (disagree) or only agree (disagree)?

(9) Exercising will keep me from having high blood pressure. Whether do you

agree that exercising will keep you from having high blood pressure? Do you strongly


(10) Exercising improves the level of my physical fitness. Whether do you agree

that exercising improves the level of your physical fitness? Do you strongly agree


(11) Exercising improves functioning of my cardiovascular system. Whether do

you agree that exercising improves functioning of your cardiovascular system? Do

you strongly agree (disagree) or only agree (disagree)?

(12) My muscle tone is improved with exercise. Whether do you agree that your

muscle tone is improved with exercise? Do you strongly agree (disagree) or only

agree (disagree)?

(13) I have improved feelings of well-being from exercise. Whether do you agree

that you have improved feelings of well-being from exercise? Do you strongly agree


(14) Exercising increases my stamina. Whether do you agree that exercising

increases your stamina? Do you strongly agree (disagree) or only agree (disagree)?

496

(15) Exercising improves my flexibility. Whether do you agree that exercising

improves your flexibility? Do you strongly agree (disagree) or only agree (disagree)?

(16) My disposition is improved with exercise. Whether do you agree that your

disposition is improved with exercise? Do you strongly agree (disagree) or only agree

(disagree)?

(17) Exercising helps me sleep better at night. Whether do you agree that exercising

helps you sleep better at night? Do you strongly agree (disagree) or only agree

(disagree)?

(18) I will live longer if I exercise. Whether do you agree that you will live longer if

you exercise? Do you strongly agree (disagree) or only agree (disagree)?

(19) Exercising helps me decrease fatigue. Whether do you agree that exercising

helps you decrease fatigue? Do you strongly agree (disagree) or only agree (disagree)?

(20) Exercising is a good way for me to meet with new people. Whether do you

agree that exercising is a good way for you to meet with new people? Do you strongly


(21) My physical endurance is improved by exercising. Whether do you agree that

your physical endurance is improved by exercising? Do you strongly agree (disagree)


(22) Exercising improves my self-concept. Whether do you agree that exercising

improves your self-concept? Do you strongly agree (disagree) or only agree (disagree)?

(23) Exercising increases my mental alertness. Whether do you agree that

exercising increases your mental alertness? Do you strongly agree (disagree) or only

agree (disagree)?

(24) Exercise allows me to carry out normal activities without tiredness. Whether

do you agree that exercise allows you to carry out normal activities without tiredness?

Do you strongly agree (disagree) or only agree (disagree)?

(25) Exercise improves the quality of my work. Whether do you agree that exercise

improves the quality of your work? Do you strongly agree (disagree) or only agree

(disagree)?

(26) Exercise is good entertainment. Whether do you agree that exercise is good

entertainment? Do you strongly agree (disagree) or only agree (disagree)?

(27) Exercise increases my acceptance by others. Whether do you agree that

exercise increases your acceptance by others? Do you strongly agree (disagree) or

only agree (disagree)?

497

(28) Exercise improves overall body functioning for me. Whether do you agree that

exercise improves overall body functioning for you? Do you strongly agree (disagree)


(29) Exercise improves the way my body looks. Whether do you agree that exercise

improves the way your body looks? Do you strongly agree (disagree) or only agree

(disagree)?

Exercise Barriers Scale (EBBS)

1. Directions

The exercise barriers scale is used to measure the degree to which patients feel

barriers to perform regular exercise. Below are statements that relate to ideas about

exercise barriers. Asking patient whether he/she agree or disagree with the following

each statement and the degree to which he/she you agree or disagree with each

statement by circling: 1=Strongly Disagree (SD), 2=Disagree (D), 3=Agree (A), and

4=Strongly Agree (SA).


(1) Exercising takes too much of my time. Whether do you agree that exercising

takes too much of your time? Do you strongly agree (disagree) or only agree

(disagree)?

(2) Exercise tires me. Whether do you agree that exercise tires you? Do you strongly


(3) Places for me to exercise are too far away. Whether do you agree that places for

you to exercise are too far away? Do you strongly agree (disagree) or only agree

(disagree)?

(4) I am too embarrassed to exercise. Whether do you agree that you are too

embarrassed to exercise? Do you strongly agree (disagree) or only agree (disagree)?

(5) It costs too much to exercise. Whether do you agree that it costs too much to

exercise? Do you strongly agree (disagree) or only agree (disagree)?

498

(6) Exercise facilities do not have convenient schedules for me. Whether do you

agree that exercise facilities do not have convenient schedules for you? Do you

strongly agree (disagree) or only agree (disagree)?

(7) I am fatigued by exercise. Whether do you agree that you are fatigued by

exercise? Do you strongly agree (disagree) or only agree (disagree)?

(8) My spouse (or significant other) does not encourage exercising. Whether do

you agree that your spouse (or significant other) does not encourage exercising? Do

you strongly agree (disagree) or only agree (disagree)?

(9) Exercise takes too much time from family responsibilities. Whether do you

agree that exercise takes too much time from family responsibilities? Do you strongly


(10) I think people in exercise clothes look funny. Whether do you agree that you

think people in exercise clothes look funny? Do you strongly agree (disagree) or only

agree (disagree)?

(11) My family members do not encourage me to exercise. Whether do you agree

that your family members do not encourage you to exercise? Do you strongly agree


(12) Exercise takes too much time from family relationships. Whether do you

agree that exercise takes too much time from family relationships? Do you strongly


(13) Exercise is hard work for me. Whether do you agree that exercise is hard work

for you? Do you strongly agree (disagree) or only agree (disagree)?

(14) There are too few places for me to exercise. Whether do you agree that there

are too few places for you to exercise? Do you strongly agree (disagree) or only agree

(disagree)?

499

Part IV Log Book for Patients’ Self-reporting and Self-evaluation of

Physical activity

Instructions

1. This is the log book for recording the details of patients‘ moderate physical activity

performed in the past one week, including the mode (see the examples of moderate

activities), frequency, intensity and duration of each session of physical activity,

whether it occur angina and the additional number of short-acting sublingual trinitrate

(GTN) or any other anti-anginal drugs tablets taken during the physical activity.

2. The RN should show the form of examples of moderate activities to each patient

and then ask him/her what kind of activities he/she had performed in the past one

week? Please record the frequency (episodes) and duration (minutes) of physical

activities in the past one week in the form with the references of the patient‘s records.

3. The intensity of physical activity was assessed by rating Borg‘s Rate of Perceived

Exertion (RPE) from 6 to 20, with 6 being very, very light (rest) and 20 being

exhaustion. Please ask each patient to recall and rate the number from 6 to 20 to

represent their perceived physical exertion.

4. Please also ask each patient to recall the mode, frequency, and duration of each

session of physical activity, and whether it occur anginal pain and the additional

number of GTN tablets or any other anti-anginal drugs taken when feeling angina

because of physical activity.


Very

light

Fairly

light

Some-

what

hard

Hard Very

hard

Very,

very

hard

Very,

very

light

500

Part V Log Book for Patients’ Self-reporting and Self-evaluation of

Angina

Instructions

1. This is the log book for recalling the details of patients‘ angina in the past one week,

including frequency, severity, and duration of angina, and the number of short-acting

sublingual trinitrate (GTN) and any other anti-anginal drugs tablets taken each day.

2. Please ask each patient to recall the details of frequency of angina, severity and

duration of each episode of angina in the past one week, and the total number of

short-acting sublingual trinitrate (GTN) and any other anti-anginal drugs tablets taken

each day. Please record this information in the form with reference to the patient‘s

records.

3. The severity of each episode of angina for was rated by a following visual scale

from 0 to 10, with 0 being no pain and 10 being ‗Crucifying pain‘, 5 being very

painful. Please ask patients to rate the number from 0 to 10 to represent your

perceived severity of angina.

4. Please also ask each patient recall and to rate the duration of each episode in

minutes and the total number of GTN and any other anti-anginal tablets taken each

day.

501

10

Crucifying pain

9

Crushing the heart and lungs

8

Excruciating pain

7

Unbearable

6

Indescribable

5

Very painful

4

Painful

3

Bearable

2

Quite painful

1

Slight pain

0 No pain

502

Part VI Quality of Life


Instructions

1. The Seattle Angina Questionnaire (SAQ) is a specific quality of life scale to

measure CHD patients‘ degree of physical limitation by angina, angina frequency,

angina stability, treatment satisfaction and disease perception in the past four weeks.


(1) The following is a list of activities that people often do during the week. Although

for some people with several medical problems it is difficult to determine what it is

that limits them, please go over the activities listed below and indicate how much

limitation you have had due to chest pain, chest tightness, or angina over the past 4

weeks.

a. Dressing yourself: In the past 4 weeks, whether did you have any chest pain, chest

tightness, or angina limited you to dress yourself? If you didn‘t have any limitation,

please place the ―√ ‖in the corresponding box of not limited. If you had any limitation,

please indicate how much limitation you have due to chest pain, chest tightness, or

angina: severely limited, moderately limited, somewhat limited, or a little limited.

Please select one choice which most expresses your feeling and place the ―√ ‖ in the

corresponding box. If you were Limited, or did not do for other reasons, please place

the ―√ ‖ in the box of Limited, or did not do for other reasons.

b. Walking indoors on level ground: In the past 4 weeks, whether did you have any

chest pain, chest tightness, or angina limited you to walk indoors on level ground? If

you didn‘t have any limitation, please place the ―√ ‖in the corresponding box of not

limited. If you had any limitation, please indicate how much limitation you have due

to chest pain, chest tightness, or angina: severely limited, moderately limited,

somewhat limited, or a little limited. Please select one choice which most expresses

your feeling and place the ―√ ‖ in the corresponding box. If you were Limited, or did

503

not do for other reasons, please place the ―√ ‖ in the box of Limited, or did not do for

other reasons.

c. Showering: In the past 4 weeks, whether did you have any chest pain, chest

tightness, or angina limited your showering? If you didn‘t have any limitation, please

place the ―√ ‖in the corresponding box of not limited. If you had any limitation,






d. Climbing a hill or a flight of stairs without stopping: In the past 4 weeks,

whether did you have any chest pain, chest tightness, or angina limited you to climb a

hill or a flight of stairs without stopping? If you didn‘t have any limitation, please

place the ―√ ‖in the corresponding box of not limited. If you had any limitation,






e. Gardening, vaccuming, or carrying groceries: In the past 4 weeks, whether did

you have any chest pain, chest tightness, or angina limited your gardening, vaccuming

or carrying groceries? If you didn‘t have any limitation, please place the ―√ ‖in the

corresponding box of not limited. If you had any limitation, please indicate how much

limitation you have due to chest pain, chest tightness, or angina: severely limited,

moderately limited, somewhat limited, or a little limited. Please select one choice

which most expresses your feeling and place the ―√ ‖ in the corresponding box. If you

were Limited, or did not do for other reasons, please place the ―√ ‖ in the box of

Limited, or did not do for other reasons.

f. Walking more than a block at a brisk pace: In the past 4 weeks, whether did you

have any chest pain, chest tightness, or angina limited you to walk more than a block

504

at a brisk pace? If you didn‘t have any limitation, please place the ―√ ‖in the

corresponding box of not limited. If you had any limitation, please indicate how much

limitation you have due to chest pain, chest tightness, or angina: severely limited,

moderately limited, somewhat limited, or a little limited. Please select one choice

which most expresses your feeling and place the ―√ ‖ in the corresponding box. If you

were Limited, or did not do for other reasons, please place the ―√ ‖ in the box of

Limited, or did not do for other reasons.

g. Running or jogging: In the past 4 weeks, whether did you have any chest pain,

chest tightness, or angina limited you to run or jog? If you didn‘t have any limitation,







h. Lifting or moving heavy objects (e.g., furniture, children): In the past 4 weeks,

whether did you have any chest pain, chest tightness, or angina limited you to lift or

move heavy objects (e.g., furniture, children)? If you didn‘t have any limitation,







i. Participating in strenuous sports (e.g., swimming, tennis): In the past 4 weeks,

whether did you have any chest pain, chest tightness, or angina limited you to

participate in strenuous sports (e.g., swimming, tennis)? If you didn‘t have any

limitation, please place the ―√ ‖in the corresponding box of not limited. If you had

any limitation, please indicate how much limitation you have due to chest pain, chest

tightness, or angina: severely limited, moderately limited, somewhat limited, or a little

limited. Please select one choice which most expresses your feeling and place the ―√ ‖

505

in the corresponding box. If you were Limited, or did not do for other reasons, please

place the ―√ ‖ in the box of Limited, or did not do for other reasons.

(2) Compared with 4 weeks ago, how often do you have chest pain, chest tightness, or

angina when doing your most strenuous level of activity?

I have had chest pain, chest tightness, or angina……

How often do you have chest pain, chest tightness, or angina when doing your most

strenuous level of activity in the latest 4 weeks? Compared with 4 weeks ago, do you

have chest pain, chest tightness, or angina much more often, slightly more often,

about the same, slightly less often, much less often, or you have had no chest pain

over the past 4 weeks?

(3) Over the past 4 weeks, on average, how many times have you had chest pain,


I get chest pain, chest tightness, or angina……

4 or more

times per

day

1-3 times

per day

3 or more

times per

week but not

every day

1-2 times

per week

Less than

once a

week

None over

the past 4

weeks

4. Over the past 4 weeks, on average, how many times have you had to take nitros

(nitroglycerin tablets) for your chest pain, chest tightness, or angina?

4 or more

times per

day

1-3 times

per day

3 or more times

per week but not

every day

1-2 times

per week

Less than

once a

week

None over

the past 4

weeks

506

5. How bothersome is it for you to take your pills for chest pain, chest tightness or

angina as prescribed?

Very

bothersome

Moderately

bothersome

Somewhat

bothersome

A little

bothersome

Not

bothersome

at all

My doctor

has not

prescribed

pills

6. How satisfied are you that everything possible is being done to treat your chest pain,


Not satisfied

at all

Mostly

dissatisfied

Somewhat

satisfied

Mostly

satisfied

Highly

satisfied

7. How satisfied are you with the explanations your doctor has given you about your

chest pain, chest tightness, or angina?

Not satisfied

at all

Mostly

dissatisfied

Somewhat

satisfied

Mostly

satisfied

Highly

satisfied

8. Overall, how satisfied are you with the current treatment of your chest pain,


Not satisfied

at all

Mostly

dissatisfied

Somewhat

satisfied

Mostly

satisfied

Highly

satisfied

9. Over the past 4 weeks, how much has your chest pain, chest tightness, or angina

interfered with your enjoyment of life?

507

It has severely

limited my

enjoyment of

life

It has

moderately

limited my

enjoyment of

life

It has slightly

limited my

enjoyment of

life

It has barely

limited my

enjoyment of

life

It has not

limited my

enjoyment of

life

10. If you had to spend the rest of your life with your chest pain, chest tightness, or

angina the way it is right now, how would you feel about this?

Not satisfied

at all

Mostly

dissatisfied

Somewhat

satisfied

Mostly

satisfied

Highly

satisfied

11. How often do you worry that you may have a heart attack or die suddenly?

I can‘t stop

worrying

about it

I often think

or worry

about it

I

occasionally

worry about

it

I rarely

think or

worry

about it

I never

think or

worry

about it

508

Short Form 36 Health Survey Questionnaire (SF-36)

The following questions are to assess your opinion, feeling and ability to perform

daily activities. Please choose the answer that is closest to your condition for each

question.


Excellent

Very good

Good

Fair

Poor


Much better now than one year ago

Somewhat better now than one year ago

About the same as one year ago

Somewhat worse now than one year ago

Much worse now than one year ago

3. The following items about activities you might do during a typical day. Does your

health now limit you in these activities? If so, how much?

Limited a

lot

Limited a

little

Not

limited

Vigorous activities, such as running, lifting heavy

objects, participating in strenuous sports

Moderate activities, such as moving a table,

cleaning the floor

Lifting or carrying groceries

Climbing several flights of stairs

Climbing one flight of stairs

Bending, kneeling, or stooping

509

Walking 1500 meters

Walking 800 meters

Walking 100 meters

Bathing or dressing yourself

(1) Vigorous activities, such as running, lifting heavy objects, participating in

strenuous sports: Does your health now limit you in vigorous activities, such as

running, lifting heavy objects, participating in strenuous sports? If so, how much? Is it

limited a lot or a little?

(2) Moderate activities, such as moving a table, cleaning the floor: Does your

health now limit you in moderate activities, such as moving a table, cleaning the floor?

If so, how much? Is it limited a lot or a little?

(3) Lifting or carrying groceries: Does your health now limit you in lifting or

carrying groceries? If so, how much? Is it limited a lot or a little?

(4) Climbing several flights of stairs: Does your health now limit you in climbing

several flights of stairs? If so, how much? Is it limited a lot or a little?

(5) Climbing one flight of stairs: Does your health now limit you in climbing one

flight of stairs? If so, how much? Is it limited a lot or a little?

(6) Bending, kneeling, or stooping: Does your health now limit you in bending,

kneeling, or stooping? If so, how much? Is it limited a lot or a little?

(7) Walking 1500 meters: Does your health now limit you in walking 1500 meters?

If so, how much? Is it limited a lot or a little?

(8) Walking 800 meters: Does your health now limit you in walking 800 meters? If

so, how much? Is it limited a lot or a little?

(9) Walking 100 meters: Does your health now limit you in walking 100 meters? If

so, how much? Is it limited a lot or a little?

(10) Bathing or dressing yourself: Does your health now limit you in bathing or

dressing yourself? If so, how much? Is it limited a lot or a little?


work or other regular activities as a result of your physical health?

510

Yes No


activities


Were limited in the kind of work or other activities

Had difficulty performing the work or other activities (for

example, it took extra effort)

(1) Cut down on the amount of time you spent on work or other activities: During

the past four weeks, have you had any of the problems with cutting down on the

amount of time you spent on work or other activities as a result of your physical

health?

(2) Accomplished less than you would like: During the past four weeks, have you

had any of the problems with accomplishing less than you would like on work or

other activities as a result of your physical health?

(3) Were limited in the kind of work or other activities: During the past four weeks,

have you had any of the problems with limiting in the kind of work or other activities

as a result of your physical health?

(4) Had difficulty performing the work or other activities (for example, it took

extra effort): During the past four weeks, have you had difficulty performing the

work or other activities (for example, it took extra effort) as a result of your physical

health?


work or other regular daily activities as a result of any emotional problems (such as

feeling depressed or anxious)?

Yes No


activities


Did work or other activities less carefully than usual

511

(1) Cut down on the amount of time you spent on work or other activities: During

the past four weeks, have you had any of the problems with cutting down on the

amount of time you spent on work or other activities as a result of any emotional

problems (such as feeling depressed or anxious)?

(2) Accomplished less than you would like: During the past four weeks, have you

had any of the problems with accomplishing less than you would like on work or

other activities as a result of any emotional problems (such as feeling depressed or

anxious)?

(3) Did work or other activities less carefully than usual: During the past four

weeks, have you had any of the problems with work or other activities less carefully

than usual as a result of any emotional problems (such as feeling depressed or

anxious)?



or groups?

Not at all

Slightly

Moderately

Quite a bit

Extremely


None

Very mild

Mild

Moderate

Severe

Very severe



Not at all

512

A little bit

Moderately

Quite a bit

Extremely

9. The net set of questions is about how you feel and how things have been with you

during the past four weeks. For each question, please give the one answer that comes

closest to the way you have been feeling.

How much of the time during the past

four weeks

All

the

time

Most

of

the

time

A

good

bit of

the

time

Some

of

the

time

A

little

of

the

time

None

of

time

Did you feel full of pep?

Have you been a very nervous person?

Have you felt so down in the dumps that

nothing could cheer you up?

Have you felt calm and peaceful?

Did you have a lot of energy?

Have you felt downhearted and blue?

Did you feel worn out?

Have you been a happy person?

Did you feel tired?

Has your physical health or emotional

problems interfered with your social

activities like visiting friends, relatives,

etc.

(1) Did you feel full of pep? During the past four weeks, how much of the time did

you feel full of pep? All the time, most of the time, a good bit of the time, some of the

time, a little of the time, or none of time?

(2) Have you been a very nervous person? During the past four weeks, how much

of the time have you been a very nervous person? All the time, most of the time, a

good bit of the time, some of the time, a little of the time, or none of time?

513

(3) Have you felt so down in the dumps that nothing could cheer you up? During

the past four weeks, how much of the time have you felt so down in the dumps that

nothing could cheer you up? All the time, most of the time, a good bit of the time,

some of the time, a little of the time, or none of time?

(4) Have you felt calm and peaceful? During the past four weeks, how much of the

time have you felt calm and peaceful? All the time, most of the time, a good bit of the

time, some of the time, a little of the time, or none of time?

(5) Did you have a lot of energy? During the past four weeks, how much of the time

did you have a lot of energy? All the time, most of the time, a good bit of the time,

some of the time, a little of the time, or none of time?

(6) Have you felt downhearted and blue? During the past four weeks, how much of

the time have you felt downhearted and blue? All the time, most of the time, a good

bit of the time, some of the time, a little of the time, or none of time?

(7) Did you feel worn out? During the past four weeks, how much of the time did

you feel worn out? All the time, most of the time, a good bit of the time, some of the

time, a little of the time, or none of time?

(8) Have you been a happy person? During the past four weeks, how much of the

time have you been a happy person? All the time, most of the time, a good bit of the

time, some of the time, a little of the time, or none of time?

(9) Did you feel tired? During the past four weeks, how much of the time did you

feel tired? All the time, most of the time, a good bit of the time, some of the time, a

little of the time, or none of time?

(10) Has your physical health or emotional problems interfered with your social

activities like visiting friends, relatives, etc. During the past four weeks, how much

of the time has your physical health or emotional problems interfered with your social

activities like visiting friends, relatives, etc. All the time, most of the time, a good bit

of the time, some of the time, a little of the time, or none of time?

514

10. How true or false is each of the following statements for you?

Definitely

true

Mostly

true

Don‘t

know

Mostly

false

Definitely

false

I seem to get sick a little easier

than other people

I am as healthy as anybody I

know

I expect my health to get worse

My health is excellent

(1) I seem to get sick a little easier than other people: Do you feel that you seem to

get sick a little easier than other people? Definitely true, mostly true, don‘t know,

mostly false, or definitely false?

(2) I am as healthy as anybody I know: Do you feel that you are as healthy as

anybody you know? Definitely true, mostly true, don‘t know, mostly false, or

definitely false?

(3) I expect my health to get worse: Do you feel that you expect your health to get

worse? Definitely true, mostly true, don‘t know, mostly false, or definitely false?

(4) My health is excellent: Do you feel that your health is excellent? Definitely true,

mostly true, don‘t know, mostly false, or definitely false?

515

Appendix XV Status of Normal distribution and Homogeneity of Variance of Each

Variable

The Results of Tests regarding Normal distribution and homogeneity of variance of each

variable in this study

Variable Skewness* Kurtosis* Kolmogorov-

Smirnov testa

Levene

testb

Recommended

data analysis

Exercise self-efficacy -0.535 - 0.344 -1.026 - -0.044 - - Parametric test

Exercise benefits -1.463 - 1.342 -0.207 - 4.631 + + Non-parametric

Exercise barriers -2.364 - 0.851 -1.278 - 7.822 + + Non-parametric

Moderate exercise

duration 0.850-5.084 -0.216 - 28.649 + + Non-parametric

Angina

Angina frequency 1.677 - 5.851 2.567 - 40.253 + + Non-parametric

Angina severity 1.341 - 3.068 0.788 - 13.626 + + Non-parametric

Angina duration 2.641 - 7.264 6.599 - 35.382 + + Non-parametric

SAQ

Physical limitation -1.309 - -0.319 -0.897 - 1.592 + + Non-parametric

Angina stability -1.900 - 0.691 1.041 - 7.231 + + Non-parametric

Angina frequency -2.473 - -0.950 0.006 - 5.860 + + Non-parametric

Treatment

satisfaction -1.549 - -0.232 -0.168 - 3.101 + - Non-parametric

Disease perception -1.973 - -0.219 -0.897 - 4.468 + - Non-parametric

SF-36

Physical functioning -3.264 - -1.083 0.299 - 11.565 + + Non-parametric

Role-physical -1.960 - -0.250 -1.403 - 2.912 + + Non-parametric

Bodily pain -1.215 - -0.376 -0.813 - 0.749 + + Non-parametric

General health -1.532 - -0.365 -1.087 - 1.622 + + Non-parametric

Vitality -1.604 - -0.561 -0.740 - 2.734 + - Non-parametric

Social functioning -2.005 - -0.595 -1.196 - 2.848 + + Non-parametric

Role-emotional -3.335 - -1.476 0.607 - 10.014 + + Non-parametric

Mental health -2.559 - -0.535 0.050 - 7.552 + + Non-parametric

PCS -1.854 - 0.000 -0.887 - 4.412 + + Non-parametric

MCS -2.420 - -0.564 -0.844 - 5.530 + - Non-parametric

Reported health

transition -0.386 - 0.454 -0.988 - 0.499 + + Non-parametric

Note: *the value nears to zero indicating normal distribution; a: test of normality; b: test of homogeneity of variance among the three groups; PCS: Physical Component Summary; MCS: Mental Component Summary; -: p >

0.05; +: p < 0.05.

516

Appendix XVI – The results of the baseline outcome comparisons

1. Exercise Stages of Change

Table 1 shows that there is no significant difference in the distribution of exercise

stages of change among the C, PE and ESMI groups at baseline (T0).

Table 1 Distribution of exercise stages of change at T0

C

(n=67)

n (%)

PE

(n=64)

n (%)

ESMI

(n=65)

n (%)

Kruskal-Wallis test

χ2 p

Precontemplation 10(14.9) 17(26.6) 11(16.9) 3.233 0.199

Contemplation 9(13.4) 9(14.1) 17(26.2)

Preparation 48(71.6) 38(59.4) 37(56.9)

2. Exercise Self-Efficacy (ESE)

Table 2 shows that no significant difference in exercise self-efficacy scores was found

among the three groups at baseline (T0).

Table 2 Exercise Self-Efficacy (ESE) at T0

C

(n=67)

mean(SD)

PE

(n=64)

mean(SD)

ESMI

(n=65)

mean(SD)

One-way ANOVA

F p

ESE 843.3(305.0) 809.5(307.6) 800.5(294.8) 0.368 0.692

517

3. Exercise Decisional Balance

Exercise decisional balance includes Exercise Benefits Scale (EBS) and Exercise

Barriers Scale (EBBS). As shown in Table 3, no significant differences were found in

exercise benefits and barriers scales among the three groups at baseline (T0).

Table 3 Exercise Benefits Scale (EBS) Scores and Exercise Barriers Scale (EBBS) Scores

at T0

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)

df

Kruskal-Wallis test

χ2 p

EBS 82.5(7.6) 83.7(8.0) 82.6(7.0) 2 0.032 0.984

EBBS 29.1(2.8) 29.0(3.8) 29.5(2.8) 2 0.175 0.916

4. Exercise

Table 4 shows that no significant difference was detected in both the total exercise

duration (minute/week) and moderate exercise duration (minute/week) among the

three groups at baseline (T0).

Table 4 Exercise Duration (minutes/week) at T0

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)

df

Kruskal-Wallis test

χ2 p

TED 184.2(217.8) 143.1(196.9) 112.2(162.1) 2 3.858 0.145

MED 17.2(62.9) 10.0(40.9) 15.4(36.2) 2 2.320 0.314

Note: TED: Total Exercise Duration (minute/week); MED: Moderate Exercise Duration (minute/week).

518

5. Angina

Tables 5and 6 show that no significant difference was found in the angina frequency

(episode/week), angina severity, angina duration (minute/week), angina attack, and

anti-anginal drugs taken among the three groups at baseline (T0).

Table 5 Angina Frequency, Angina Severity and Angina Duration at T0

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)

df

Kruskal-Wallis test

χ2 p

AF 1.4(3.1) 1.1(2.8) 0.9(1.4) 2 0.240 0.887

AS 0.7(1.2) 0.7(1.1) 0.5(0.7) 2 0.232 0.891

AD 13.4(33.0) 9.8(23.0) 9.3(29.4) 2 0.374 0.829

Note: AF: Angina Frequency (episodes/week); AS: Angina Severity (0-10); AD: Angina Duration

(minutes/week).

Table 6 Items on whether patients have angina attack and anti-anginal drugs taken in

the past one week at T0

C group

(n=67)

n (%)

PE group

(n=64)

n (%)

ESMI group

(n=65)

n (%)

Chi-square test

χ2 p

Angina

attack

Yes 27(40.3) 25(39.1) 25(38.5) 0.049 0.976

No 40(59.7) 39(60.9) 40(61.5)

Anti-anginal

drugs taken

Yes 17(25.4) 12(18.8) 12(18.5) 1.223 0.543

No 50(74.6) 52(81.2) 53(81.5)

519

6. Quality of life

In this study, quality of life was assessed by using Seattle Angina Questionnaire (SAQ)

and SF-36.

6.1 Seattle Angina Questionnaire (SAQ)

As shown in Table 7, no significant difference was found in each subscale scores of

SAQ among the three groups at T0.

Table 7 Subscale Scores of SAQ at T0

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)

df

Kruskal-Wallis test

χ2 p

Physical

limitation 85.5(13.1) 85.9(13.0) 82.0(12.9) 2 4.453 0.108

Angina

stability 47.0(20.7) 50.8(20.4) 51.5(20.7) 2 2.092 0.351

Angina

frequency 83.3(18.1) 84.1(19.7) 83.5(17.6) 2 0.472 0.790

Treatment

satisfaction 69.9(20.1) 68.8(18.5) 66.9(17.5) 2 1.328 0.515

Disease

perception 71.1(21.9) 69.8(21.8) 68.1(17.7) 2 1.499 0.473

6.2 SF-36

As shown in Table 8, no significant difference was found in each subscale scores and

total scores of SF-36 among the three groups at T0.

520

Table 5.15 Subscale Scores of SF-36 at T0

C group

(n=67)

mean (SD)

PE group

(n=64)

mean (SD)

ESMI group

(n=65)

mean (SD)

df

Kruskal-Wallis test

χ2 p

PF 81.4(13.6) 82.3(9.7) 78.8(16.2) 2 0.418 0.811

RP 72.0(40.0) 63.7(39.6) 67.3(39.3) 2 1.955 0.376

BP 73.7(24.8) 75.4(22.1) 75.4(22.9) 2 0.155 0.925

GH 57.4(22.8) 55.4(22.3) 57.9(23.4) 2 0.615 0.735

VT 72.5(17.6) 70.9(17.1) 68.8(18.8) 2 1.052 0.591

SF 84.5(22.1) 79.3(23.8) 80.6(21.7) 2 2.110 0.348

RE 80.6(34.9) 84.9(27.8) 79.0(36.1) 2 0.351 0.839

MH 83.0(13.9) 80.4(10.4) 80.4(12.8) 2 4.911 0.086

PCS 284.5(76.9) 276.8(65.1) 279.5(75.8) 2 1.236 0.539

MCS 320.6(67.6) 315.6(59.0) 308.8(72.2) 2 1.072 0.585

TS 605.1(124.4) 592.3(112.2) 588.3(136.1) 2 1.014 0.602

HT 3.3(1.1) 3.1(1.3) 3.3(1.1) 2 1.697 0.428



(PF + RP + BP + GH); MCS: Mental Component Summary (VT + SF + RE + MH); TS: Total Scores

of SF-36 (PF + RP + BP + GH + VT + SF + RE + MH); HT: Reported Health Transition.

524

Appendix IV Screening Guidelines – Chinese Version

筛查标准指引

以下是一些条目帮助心血管医生了解每位病人是否适合参与本研究项目，

即时期匹配运动干预的项目。如果以下条目中，病人有一项不符合标准，则不

建议参与本研究。

1．年龄__________岁

符合：年龄 ≥ 18 岁。

不符合：年龄 < 18 岁。

2. 是否居住在厦门

符合：病人居住在厦门并有联系电话。

居住地址：______________________________________________

联系电话：______________________________________________

不符合：病人没有居住在厦门或没有联系电话。

3．病人的沟通和阅读汉字的能力：

符合：病人能进行沟通并有阅读能力。

不符合：病人沟通困难或沟通障碍，或病人有阅读困难。

注释：

① 能进行沟通：是指病人能明白沟通内容，可以互相沟通，语言表达准确。

② 沟通困难/沟通障碍：是指病人不能明白沟通内容，词不达意或不能沟

通。

③ 有阅读能力：是指病人能看懂基本的汉字并明白其意思。

④ 阅读困难：是指病人一点都看不懂汉字。

4．疾病诊断：心绞痛、心肌梗塞、冠状动脉介入治疗术后

符合：病人被诊断为心绞痛或心肌梗塞三个月以上，或经皮冠状动脉介入

治疗术后三个月以上。

不符合：病人被诊断为心绞痛或心肌梗塞三个月以内，或经皮冠状动脉介

入治疗术后三个月以内。

525

注释：

A.心绞痛，诊断时间_________（月/年）

诊断依据：根据 1979 年国际心脏病学会和协会及世界卫生组织的诊断标准：

1) 病史：有典型心绞痛发作病史，即由劳累或情绪激动诱发胸部不适，通常

持续 1-15 分钟，可放射至下颌、咽喉、肩、背、左臂或腕部，休息或舌下

含化硝酸甘油数分钟即可缓解。

2) 男性 40 岁、女性 45 岁以上的病人，休息时心电图有明显心肌缺血表现，

或心电图运动试验阳性，无其它原因（各种心脏病、植物神经功能失调、

显著贫血、阻塞性肺气肿、服用洋地黄、电解质紊乱）可查，并有下列三

项中的两项者：高血压、高胆固醇血症、糖尿病。

3) 或经冠状动脉造影确诊的患者，即管腔直径狭窄 70%以上。

B. 心肌梗塞（_______次），诊断时间_________（月/年）

诊断依据：根据 1979 年全国中西医结合防治冠心病、心绞痛、心律失常研究座

谈会（于上海）修订的诊断标准：

I.有下列三项之二，可诊断为急性心肌梗塞：

1) 临床症状典型：典型的病史是出现严重而持久的胸痛；

2) 心电图有异常 Q 波及/或 ST-T 有符合心肌梗塞的衍变；

3) 血清酶增高，符合心肌梗塞的过程者。

II. 有肯定资料（如心电图或血清酶）证明以往患过心肌梗塞

C.冠状动脉介入治疗术后（______次），介入治疗时间_________（月/年）

诊断依据：包括经皮冠状动脉成型术(PTCA)、冠状动脉支架置入术、冠状动脉

斑块旋磨术、激光血管成型术等技术。

5．是否病情稳定

符合：病人病情稳定。

不符合：病人病情不稳定。

注释：

病人的病情稳定与否，由心血管医生判断决定。参考指标如下：

① 病情稳定：病人生命体征平稳，即呼吸、脉搏、血压和体温基本在正常范围

内（具体测量方法参见下文）；没有发烧（口腔温度低于 37.5℃）；没有不稳

定型心绞痛或急性心肌梗塞表现。

6．是否有不稳定型心绞痛

符合：病人没有不稳定型心绞痛。

不符合：病人有不稳定型心绞痛。

注释：

（1）稳定型心绞痛：病人病情稳定，在近三个月时间内，心绞痛发作的频度、

诱因、疼痛的部位、性质及持续时间（3-5 分钟/次）大致相同。多数病人能

预知在什么情况下（如走多远、走多快、上多少台阶等）会发生心绞痛。

（2）不稳定型心绞痛：主要包括 5 种类型

6）初发性心绞痛：指病人过去从未发生过心绞痛，近 1 个月内突然出现频

http://3cha.hos.999120.net/



526

繁的劳累后心绞痛，可恶化发展成心肌梗死。

7）恶化性心绞痛：病人原有心绞痛病史，近来突然发作更频繁，疼痛程度

加重，常持续 15 分钟以上，用硝酸甘油效果不明显。

8）静息性心绞痛：心绞痛发作在卧位或休息睡眠时，疼痛剧烈，常被迫坐

起或站立。

9）变异性心绞痛：临床表现与静息性心绞痛相似，但发作时心电图有关导

联 ST 段抬高，为冠状动脉突然痉挛所致，病人迟早会发生心肌梗死。

10）梗死后心绞痛：在急性心肌梗死 1 个月后又反复发作心绞痛，提

示有可能再次发生心肌梗死。

7．是否曾经参加过任何有关心脏康复的项目

符合：病人没有参加过任何有关心脏康复的项目。

不符合：病人曾经参加过任何有关心脏康复的项目。

注释：

（2）参加有关心脏康复的项目：是指参加过任何系统的冠心病健康教育、有

组织的运动训练、或心脏康复指导及危险因素的控制等活动项目。

8．是否有认知功能障碍

符合：病人没有认知功能障碍。

不符合：病人有认知功能障碍。

注释：

（1）有下列一项，可认为病人有认知功能障碍：

5）被诊断有精神疾病

6）被诊断有老年痴呆症

7）被诊断有智力低下

8）脑中风或脑外伤后出现失语或失认现象

9．是否有精神抑郁症

符合：病人没有精神抑郁症。

不符合：病人有精神抑郁症。

注释：

（1）在本研究中，精神抑郁症是指根据医院焦虑和抑郁量表-抑郁分量表

（HADS-D）得分在 11 分以上者。

10．重度主动脉瓣狭窄

符合：病人没有重度主动脉瓣狭窄。

不符合：病人曾经被诊断为重度主动脉瓣狭窄。

注释：

（6）正常主动脉瓣口面积在 3.0cm2 以上。当瓣口面积减小为 1.5cm

2 时为轻

度狭窄；1.0cm2 时即可产生明显压力阶差，为中度狭窄；< 0.75cm

2 时可

527

出现临床症状，为重度狭窄。

（7）主动脉狭窄的常见病因为风湿性瓣膜炎、先天性畸形和老年退行性改变

所致。

（8）重度主动脉狭窄的特征性症状包括心绞痛、晕厥、心衰或猝死，且一旦

出现症状常呈进行性恶化，如不进行手术治疗，平均 2-3 年内死亡。典

型的体征是收缩期杂音以胸骨右缘第二肋间和胸骨左缘第 3、第 4 肋间

最明显，在吸入亚硝酸异戊酯或平卧时增强，在应用升压药或站立时减

弱。一般主动脉狭窄越重，杂音越强，强度达 3-4/6 级多伴有震颤，且向

颈部、锁骨上窝及心尖区传导。

（9）实验室检查：多数病例 X 线检查可见主动脉狭窄后扩张、主动脉瓣钙

化；心电图检查约 85%患者示左室肥厚；超声心动图检查可显示主动脉

开放幅度小于 15mm，开放速度减慢，瓣叶增厚；Doppler 超声可测定心

脏及血管内的血流速度，通过测定主动脉瓣血流速度可计算出最大跨瓣

压力阶差，亦可计算出主动脉瓣口面积；心导管检查是肯定主动脉瓣狭

窄诊断，且对其严重度作出判断，由于此检查是创伤性检查，一般不作

为常规检查。

（10）根据病人的病史、典型症状和体征以及实验室检查（X 线、心电图和超

声心动图），一般可以做出诊断。

11．心功能状况，按纽约心脏病学会（NYHA）心功能分级：

符合：按 NYHA 心功能分级，病人心功能状况为 I 或 II 级。

不符合：按 NYHA 心功能分级，病人心功能状况为 III 或 IV 级。

注释：

① I 级：活动量不受限制

② II 级：活动量轻度受限制，重体力活动时，患者出现疲乏、心悸、呼吸困难

或心绞痛。

③ III 级：活动量重度受限制，轻度体力活动时，患者出现疲乏、心悸、呼吸困

难或心绞痛。

④ IV级：患者不能从事体力活动，休息状态下亦有疲乏、心悸、呼吸困难或心

绞痛。

12．糖尿病

符合：病人没有糖尿病，或病人有糖尿病，但血糖控制在理想水平（空腹

血糖在 15mmol/L 以下）。

不符合：若在正常使用降血糖药情况下，目前病人血糖水平 ≥ 15mmol/L。

注释：

（3）糖尿病诊断依据：早晨空腹血糖水平 ≥ 7.0mmol/L、任意时间或 OGTT

中 2 小时血糖 ≥ 11.1mmol/L 均可诊断为糖尿病。

（4）血糖的测量以左侧无名指末端的毛细血管血，用血糖测量仪测得血糖值

为准。

528

13．高血压

符合：病人没有高血压，或病人有高血压，但血压控制较好，在服用抗高

血压药情况下，目前收缩压 < 23.94kPa (180mmHg)或舒张压 < 14.67 kPa

(110mmHg)。

不符合：病人有高血压，在服用抗高血压药情况下，目前收缩压 ≥

23.94kPa (180mmHg)或舒张压 ≥ 14.67 kPa (110mmHg)。

注释：

（3）高血压诊断依据：采用 1997 年美国高血压全国联合委员会发表的高血压

判断标准，即安静休息状态下，收缩压 ≥ 18.6kPa (140mmHg)或舒张压 ≥

12.0 kPa (90mmHg)均可诊断为高血压。

（4）血压测量的标准：

6）应用水银血压计测量右侧肱动脉的血压；

7）病人测量血压前应情绪稳定，测量前休息 15 分钟。若测量前有下列情

况发生：吸烟、运动、情绪变化等，应休息 20-30 分钟后再测量。

8）病人取坐位，手臂（肱动脉）位置与心脏在同一水平，平第四肋。

9）袖带下缘距肘窝 2-3cm，松紧以能插入一指为宜。

10）当听诊器中出现第一声搏动，此时水银柱所指的刻度，即为收缩

压；当搏动声突然变弱或消失，此时水银柱所指的刻度即为舒张压。

14．是否有心律失常。心率_________次/分钟

符合：病人心律规则，脉率在 60-100 次/分钟。

不符合：病人有窦性心动过速（脉率 ≥ 120 次/分钟）。

注释：

（1）用脉率表示心率，脉搏测量的方法如下：

5）测量右侧桡动脉的脉率

6）病人准备：取坐位，情绪稳定，测量前休息 15 分钟。若测量前有下列

活动：剧烈运动、紧张、恐惧等，应休息 20-30 分钟后再测量。

7）测量者以示指、中指、无名指的指端按压在患者桡动脉处测量。

8）使用有秒针的表，测脉搏 30 秒，乘以 2。

15．是否有心房颤动

符合：病人没有心房颤动。

不符合：病人有心房颤动。

注释：

（1）心房颤动的临床表现：心脏听诊第一心音强度变化不定，心律极不规则。

当心室率快时可发生脉搏短绌，即脉率小于心率。

16．是否有室性心律不齐

符合：病人心律规则，没有出现室性心律不齐。

529

不符合：病人出现频发室性期前收缩（≥ 5 次/分钟）、成对室性期前收缩

或室性心动过速（脉率 ≥ 120 次/分钟）、心室扑动或心室颤动的患者。

注释：

（2）室性心律不齐：最常见的是室性期前收缩。室性期前收缩常无与之直接

相关的症状。患者可感到心悸，类似电梯快速升降的失重感或代偿间歇

后有力的心脏搏动。听诊时，室性期前收缩后出现较长的停歇，室性期

前收缩之第二心音强度减弱，仅能听到第一心音。桡动脉搏动减弱或消

失。

17．是否有三度房室传导阻滞

符合：病人没有三度房室传导阻滞。

不符合：病人有三度房室传导阻滞。

注释：三度房室传导阻滞的特征如下：

（4）心房与心室活动各自独立、互不相关；

（5）心房率大于心室率，心房冲动来自窦房结或异位心房节律（房性心动

过速、扑动或颤动）；

（6）心室起搏点通常在阻滞部位稍下方。

18．是否有急性心肌炎

符合：病人没有急性心肌炎。

不符合：病人有急性心肌炎。

注释：

（3）急性心肌炎：指新近发病，临床症状如心前区不适、心率增快、胸闷、

心悸、心动过速等明显且多变，实验室检查如心肌酶谱升高，心电图示

ST 段抬高或压低和 T 波倒置、心律失常，心脏超声有左心室壁弥漫性或

局限性收缩幅度减低等变化，病程多在 6 个月以内。多数以病毒性心肌

炎为常见。

（4）病毒性心肌炎的诊断：目前分离出病毒以确诊为病毒性心肌炎的方法只

有在少数医院采用，大多数医院的诊断仅仅是通过临床症状、心电图及

酶学检查的结果推测出来的。

19．是否有急性心包炎

符合：病人没有急性心包炎。

不符合：病人有急性心包炎。

注释：

（1）急性心包炎的症状：

1) 心前区疼痛：心前区疼痛常于体位改变、深呼吸、咳嗽、吞咽、卧位尤

其当抬腿或左侧卧位时加剧，坐位或前倾位时减轻；

530

2) 心脏压塞的症状：可出现呼吸困难、面色苍白、烦躁不安、紫绀、乏

力、上腹部疼痛、浮肿、甚至休克；

3) 心包积液对邻近器官压迫的症状：呼吸困难、咳嗽或声音嘶哑、或咽下

困难等；

4) 全身症状：发冷、发热、心悸、出汗、乏力等症状，与原发疾病的症状

常难以区分。

（2）急性心包炎的体征：

1）心包摩擦音

2）心包积液的体征：

• 心脏体征：心尖搏动减弱、消失或出现于心浊音界左缘内侧处。心浊音

界向两侧扩大、相对浊音区消失，患者由坐位转变为卧位时第二、三肋

间的心浊音界增宽。心音轻而远，心率快。少数患者在胸骨左缘第三、

四肋间可听得舒张早期额外者（心包叩击音），呈拍击样。

• 左肺受压迫的征象：有大量心包渗液时，心脏向后移位，压迫左侧肺

部，可引起左肺下叶不张。左肩胛肩下常有浊音区，语颤增强，并可听

到支气管呼吸音（E wart 征）。

• 心脏压寒的征象：出现明显的心动过速，静脉压显著升高，可产生颈静

脉怒张，搏动和吸气时扩张，肝肿大伴触痛，腹水，皮下水肿和肝-颈静

脉反流征阳性等体循环淤血表现。动脉收缩压降低，脉压减小，脉搏细

弱，可出现奇脉。

20．近三个月有血栓栓塞史

符合：病人近三个月没有血栓栓塞史。

不符合：病人近三个月有血栓栓塞史。

注释：

（2）血栓栓塞性疾病：包括心肌梗死、脑血管病、肺血栓栓塞、深静脉血

栓、弥漫性血管内凝血（DIC）及其他多种疾病。

21．是否有影响运动或由于运动而病情加重的急性非心脏性疾病，如感染、肾

功能衰竭、甲亢等

符合：病人没有影响运动或由于运动而病情加重的急性非心脏性疾病，如

感染、肾功能衰竭、甲亢等。

不符合：病人有影响运动或由于运动而病情加重的急性非心脏性疾病，如

感染、肾功能衰竭、甲亢等。

注释：

I．急性感染

（1）感染：病人现场测量口腔温度 ≥ 37.5℃，则认为病人有感染（体温

______℃）

（2）体温测量方法：

5）应用水银体温计测量口温

6）病人取舒适体位，情绪稳定。测量体温前若有下列活动，如运动、进

食、冷热饮、冷热敷、洗澡、坐浴、灌肠等，应休息30分钟后再测量。

531

7）将水银体温计甩至35℃以下

8）将口表水银端斜放于舌下热窝处闭口，测量3分钟。

II．急慢性肾功能衰竭

5) 急性肾功能衰竭：是由各种原因引起的肾功能在短时间内（几小时至几

周）突然下降而出现的氮质废物滞留和尿量减少综合征。主要表现为氮

质废物血肌酐（Cr）和尿素氮（BUN）升高，水、电解质和酸碱平衡紊

乱，及全身各系统并发症。常伴有少尿（< 400ml/d）,但也可以无少尿表

现。

6) 急性肾功能衰竭的诊断一般是基于血肌酐的绝对或相对值的变化来诊

断，如血肌酐绝对值每日平均增加44.2umol/L或88.4umol/L；或在24~72

小时内血肌酐值相对增加25%~100%。

7) 慢性肾功能衰竭：是指慢性肾脏病引起的肾小球滤过率（GFR）下降及

与此相关的代谢紊乱和临床症状组成的综合征。

8) 慢性肾功能衰竭的诊断，根据病史、体征和实验室检查即可做出诊断。

III．甲状腺功能亢进症（甲亢）

（1）甲亢的诊断：具备以下三项，诊断即可成立。

4）高代谢症状和体征

5）甲状腺肿大

6）血清TT4 、FT4增高，TSH减低。

532

Appendix V Information Sheet – Chinese Version

有关资料

时期匹配运动干预对冠心病患者的效果研究

诚邀您参加由何淑贞博士、薛咏红博士、阮国强副主任医师(心脏病专科医师)

和谢强主任医师（心脏病专科医师）负责监督，朱丽霞同志负责执行的研究计

划。朱同志是香港理工大学护理学院学生。

这项研究的目的是评估时期匹配运动干预对冠心病患者的效果。根据随

机分配的原则，您可能会参与不同的研究组别。研究活动包括如常的护

理服务或 2 小时的健康教育±为期 8 周的时期匹配运动行为干预活

动。这 8 周的干预是要每周进行 1 次 1 5 -3 0 分钟的干预活动。无论您

是属于那一组别，您都要在干预开始之前、干预结束时和干预结束后 3

个月和 6 个月填写一些问卷。

规律运动已被证实对心脏病患者有益 ,所以时期匹配运动干预旨在引导

冠心病患者运动将会对参与本研究的患者有益。然而，在运动期间，您

可能会出现轻微的胸部不适。为减少可能出现的胸部不适，在您参与研

究之前 , 一名心脏专科医生将评估您的身体和心理精神状况、开具运动

剂量和监督您的运动进度。如果在运动过程中有出现任何不适，可以随

时与朱丽霞同志联络 ,寻求帮助。

您享有充分的权利在研究开始之前或之后决定退出这项研究，而不会受到任何

对您不正常的待遇或被追究责任。凡有关您的资料将会保密及加上编码。所有

资料，只有研究人员得悉。

如果您对这项研究有任何的不满，可随时与香港理工大学人类实验对象操守小

组委员会秘书吕小姐联络(地址：香港理工大学研究事务处 M502 室转交)。如果

您想获得更多有关这项研究的资料，请与朱丽霞同志联络，或联络她的导师何

淑贞博士。

谢谢您参与这项研究

主要研究员(PI)

朱丽霞

533

Appendix VI Consent Form – Chinese Version

参与研究同意书

时期匹配运动干预对冠心病患者的效果研究

本人____________同意参加由何淑贞博士、薛詠红博士、阮国强副主任医师和

谢强主任医师负责监督，朱丽霞同志执行的研究项目

我理解此研究所获得的资料可用于未来的研究和学术交流然而

我有权保护自己的隐私 , 我的个人资料将不能泄漏

我对所附资料的有关步骤已经得到充分的解释我理解可能会出

现的风险我是自愿参与这项研究

我理解我有权在研究过程中提出问题, 并在任何时候决定退出研

究而不会受到任何不正常的待遇或被追究责任

参加者姓名:

参加者签名:

父母姓名或监护人姓名 : (如需要)

父母或监护人签名: (如需要)

研究人员姓名: 朱丽霞

研究人员签名:

日期:

534

Appendix VII Protocol of Weekly Patient Education Session – Chinese Version

每周健康教育的协议书

（I）核对依从性

1. 在过去的一周里，您做运动了吗？

2. 做了什么运动？

3. 在过去的一周里，您做了几天运动？

4. 每天做多久运动？

5. 您的活动日志上记录的自我辛苦评估指数是多少？

6. 运动时您有什么感觉？是否呼吸增快？是否出汗？

7. 运动过程中有什么不舒服吗？

8. 是否因为运动服用了抗心绞痛药物？若有，那服用了多少片/粒？

（II）健康教育

1. 讲解规律运动的益处和重要性。

535

Appendix VIII Guidelines for Exercise Prescription – Chinese Version

冠心病病人的运动处方

A. 运动处方时应注意的一般规则（运动处方网站，2009）

建议

运动模式 • 任何使用大肌群的身体活动

• 例如：步行（3.0-4.0 英里/小时，相当于 4.8-6.4 公里/小

时）、慢骑自行车（13-19 公里/小时）等 [参见中等强度活

动的例子]

运动强度 • 中等剧烈程度（3-6METs 的活动）[参见中等强度活动的

例子]

• 起始强度一般较健康人士的建议强度为低

运动所需时

间

• 通常较健康人士长

• 每天连续或累积进行 30-60 分钟运动（每次至少 10 分钟）

运动次数 • 通常较健康人士多

• 以一周最少五天较为合适，每天进行更佳

运动进度 • 通常较健康人士缓慢

• 根据每人的能力、目标与喜好而定

• 目标之一应该是增加带氧能力及减低最大心肌氧气的需求

(submaximal myocardial oxygen demands)。

特别考虑 • 处方的活动须切合个人目标。

• 活动须有趣及易于进行。

• 於开具运动处方时，应小心评估及考虑所服药物、进餐时

间、相关并发症／缺陷／损伤／风险等因素，以及所有可

能因运动而恶化，但无明显临床病征的健康问题。

• 留意各种异常症状（如胸痛、头晕、心律不正常等），以

便对运动处方作出适当的修正。

• 体适能水平较低的病人，其运动计划应以较低强度起首。

• 运动后数小时可能出现血糖过低的情况。

536

B. 冠心病病人的运动处方方案（运动处方网站，2009）

基本作用增强心脏功能，减少心绞痛和心梗的发生率，提高生活质量

运动模式带氧运动为主，如：步行（4.8-6.4 公里/小时） [具体参

见中等强度活动的例子]

参考中等强度活动的例子，选择一项或几项您感兴趣的活

动来执行

运动强度中等强度运动（3-6 METs）

活动必须达到一定的强度才有效果，对冠心病患者来说，

活动达到中等强度为宜。您可以应用自我辛苦评估指数

（RPE）来判断您的活动水平。您的活动必须达到 RPE

11-13，即感觉轻松至有点辛苦为准。

运动所需时间每天 30-60 分钟，每次至少 10 分钟

运动次数一周至少五天

运动停止指征若出现以下的症状或体征，马上停止运动 (Briffa, Maiorana,

Sheerin et al., 2006)：

• 典型的胸痛或胸部不适，或放射到肩部、下颌部、颈

部或手臂；或感受到以前心肌梗塞的症状；

• 眩晕、头晕或身体虚弱；

• 呼吸困难或气喘

• 不典型出汗

• 过度疲倦

• 腿痛限制其功能

• 身体无法继续运动

特别考虑应结合考虑病人的健康状况、性格、喜好和服药情况等开运

动处方

联络方式若运动过程中出现任何不适，可随时与研究者联系。

537

中等强度活动的例子（3-6 METs）

（摘自 Ainsworth, Haskell, Whitt et al., 1993）

活动类型 METs 中等强度的活动例子

运动 3.3-5.0 散步（4.8-6.4 公里/小时）

4.5 打羽毛球（非竞赛性的）

6.0 篮球（非竞赛性的）

3.0 保龄球

4.0 乒乓球

4.0 太极拳

5.0 双打网球

3.0 排球（非竞赛性的）

5.0 垒球或棒球

6.0 游泳（非竞赛性的）

4.0-6.0 慢骑自行车（13-19 公里/小时）

3.0-5.5 踏固定脚踏车（50-100 瓦）

6.0 郊游（徒步），爬山

保健操和跳

舞

3.5 健身操（一般的，家里运动，如：背部运动）

4.0 体操（一般的）

4.8 跳扭秧歌、爵士舞、吉特巴舞

3.0-4.5

迪斯科、民族舞、广场舞、华尔兹舞、慢舞或探戈

舞

4.0 打鼓（腰鼓）

日常活动 3.5 拖地板

3.0-3.5 爬楼梯（上下楼梯）

4.0-5.0 走/跑：与小孩一起玩（仅活动期间）

3.0-4.5 走路（4.0-5.6 公里/小时，手提少于 22.5 斤的物

品）

Reference



MET intensities. Medicine & Science in Sports & Exercise, 32(9), s498-s516.

Exercise prescription website. (2009). Prescription guidelines. Available at:

http://exerciserx.cheu.gov.hk/html/eng/index.asp?n=sec2_Guidelines (accessed

April 2009).



disease: recommendations of the National Heart Foundation of Australia.

Medical Journal of Australia, 184(2), 71-75.

http://exerciserx.cheu.gov.hk/html/eng/index.asp?n=sec2_Guidelines

538

C. 行动前身体状况记录

一名心血管医生评估病人身体状况。以下是一些条目帮助心血管医生了解

每位病人的身体状况，以便了解该病人是否适合开始运动，即进入行动阶段。

如果该病人可以进入行动阶段，则医生将帮助病人开出运动处方，确保病人运

动安全。同时，帮助病人在家里运动时可以自行监测。

1．血压_________毫米汞柱

2．心率/脉率_________次/分钟

3．是否病情稳定 ① 是 ② 否

4．是否有不稳定型心绞痛 ① 是 ② 否



② II 级：活动量轻度受限制，重体力活动时患者出现疲乏、心悸、呼吸困难

或心绞痛。

③ III 级：活动量重度受限制，轻度体力活动时患者出现疲乏、心悸、呼吸

困难或心绞痛。

④ IV 级：患者不能从事体力活动，休息状态下亦有疲乏、心悸、呼吸困难

或心绞痛。

6．是否有窦性心动过速（> 120 次/分） ①是 ② 否

7．是否有心房颤动 ①是 ② 否

8．是否有室性心律不齐 ①是 ② 否

9．是否有三度房室传导阻滞 ①是 ② 否

10．是否有重度主动脉瓣狭窄 ①是 ② 否

11．是否有急性心肌炎 ①是 ② 否

12．是否有急性心内膜炎 ①是 ② 否

539

13．近三个月有栓塞史 ①是 ② 否


功能衰竭、甲亢等 ①是 ② 否

评估结果：该病人是否可以进行运动 ①可以 ②不可以

心血管医生签名: ____________________

日期: ______________________________

540

D. 运动处方记录表

建议的运动形式

运动时间(分/天)

运动强度(RPE)

运动次数（次/周）

运动的进度

自我辛苦评估指数(RPE)

心血管医生签名: ________________ 日期: ________________

很

轻

松

轻松

有

点

辛

苦

辛苦

很

辛

苦

非

常

辛

苦

非

常

轻

松

541

Appendix IX Exercise Stage-Matched Pamphlets – Chinese Version

香港理工大学护理学院

意向前期小册子

542

内容提要：

我为什么要运动？

我如何才能变得更积极

积极生活方式的要点

回忆我曾经成功改变的习惯

琳达的传奇故事

运动：它能给我什么？

「。。。获得规律运动的好

处，您不一定要走出去或花

几个小时在健身房里」

543

有许多的理由可以问答这个难题——您为什么要运动？每个人都有自己的

理由去参与运动，从运动后的良好感觉到期待几个月甚至长期的健康和长寿等

益处都是您需要运动的理由。

规律运动的长期好处您可能很熟悉了。每个人都知道运动可以降低患冠心

病、糖尿病、甚至癌症的危险。不要惊讶于运动带来这么多健康的益处，规律

的运动还可以延长您的寿命。运动也有许多心理方面的好处。您可能能感觉

到，规律运动可以减少抑郁和压力，并提高认识能力、健康和生活质量。

尽管这些长期益处很重要，您可能想知道积极的运动对您目前有什么好

处？规律运动可以增强您的心肺功能、促进全身血液循环、降低您的体重和血

压、减少胸部不适和疼痛（参阅琳达的传奇故事）、降低您体内「坏胆固醇」

（低密度脂蛋白胆固醇）并增加您体内「好胆固醇」（高密度脂蛋白胆固醇）

水平。大量的研究已表明，规律的运动可以延缓或改善动脉粥样硬化，甚至缩

小粥样硬化的斑块，减少心肌梗塞的发生率，从而延长您的寿命和提高您的生

活质量。同时，规律运动能促进冠状动脉侧支循环的建立，改善心脏的血液供

应，有利于冠心病的康复，也能降低心绞痛发作的次数和心肌梗塞的复发率。

规律运动还能增加您的动作的灵活度和日常的活动能力。也许，在某天下午，

您能感受到您和您的孙子或儿子一起游玩，而没有以前感受到的那种胸部不

适。此外，规律运动还可以改善您的睡眠、增强您的食欲，并有助于您建立健

康形象及增强自信心。

这些事情听起来感觉很好，但您可能仍然没有信心，认为得了冠心病后不

能运动。您可能认为运动会增加心脏的负担，导致心绞痛或心脏病的发作。其

实许多的研究均已证实，适当的低-中强度的运动不但对冠心病没有害处，反而

有利于冠心病的康复，减少心绞痛或心脏病发作的次数。尽管如此，您可能仍

然认为运动是很无聊和痛苦的事。不管您相信与否，规律运动不一定要到室外

或花几个小时在健身房里运动。您可以将运动纳入到您的日常生活活动中，在

中等强度运动水平即可（参阅积极生活方式的要点）。运动一段时间之后，您

将会发现您越来越喜欢运动，并寻求更多的运动。

我为什么要运动？

544

首先，您必须知道从不运动到运动的生活方式转变不是一夜之间就能完成

的事。以下是一些策略，可帮助您准备成为积极的生活方式：

1. 学习更多有关运动的知识

虽然您还没准备好参加规律的运动，但是，如果您每天关注一下您身边的

所有信息，您会惊讶于您所学到的知识。

- 跟您的朋友、家人和同事交谈为什么他们要运动？

- 跟您的医生交谈，看他/她是如何看待健康和运动？

- 阅读报子上有关运动和运动益处的信息。

- 寻找媒体上有关运动的正面例子

2. 着眼于运动的好处

在我们开始一种新的行为之前，我们经常所想的往往都是那些不改变我

们原来行为的各种理由。我相信您现在就可以列出许多为什么您不能进行积极

生活方式的理由。然而，您不能着眼于这些负面的因素。相反，您应该想想您

必须运动的各种理由。

为了帮助您开始思考运动能给您带来的各种好处，请试着完成下列的表

格。我们已经帮您填好几个常见的运动好处。但是，您要记住，每个人都有自

己的目标和运动的理由。写下您将获得的规律运动的好处。

我如何才能变得更积极

545

规律运动的好处

着眼于为什么您必须运动，而不是不运动的理由：

1. 我可以控制体重

2. 我可以降低血压

3. 我可以更轻松地完成更多的活动

4. ___________________________________________

5. ___________________________________________

6. ___________________________________________

7. ___________________________________________

8. ___________________________________________

9. ___________________________________________

10. ___________________________________________

546

运动机会就在您的身边——只要动，就行

不管您相信与否，您每天有很多的机会可以运动。尽量利用这些机会，使

运动成为您生活的一部分。近来的研究表明，一天中积累的运动同样对您的健

康非常有益。您可以将一天 30-60 分钟的运动，分成 2-3 次来完成，每次运动

十几分钟。这样一天中累积的运动与一次性完成的运动同样有效。

使用楼梯

用爬楼梯代替乘电梯来增加您每天的运动量是一种简便易行的方式。选择

爬楼梯，您将成为「不用电梯者」。假如您要去的地方楼层太高，您可以先爬

几层，然后再乘电梯。例如，马女士，41 岁，上班族，半年前突发心肌梗塞，

急诊进行经皮冠状动脉支架植入术，出院后不敢运动，病后自感体质虚弱，容

易感冒。经过医务人员指导后，知道运动对冠心病康复的重要性。此后，马女

士决定每天锻炼 30 分钟。由于上班比较忙，没有时间去健身房，所以她决定利

用每天上下班和办事时爬楼梯（16 层）代替乘电梯来锻炼身体。果然，两个月

后，马女士的身体状况改善很多，走起路来也轻松多了。

尽可能的走路

为什么不提前下公共汽车一两站，然后走路到您要去的地方？这样您可以

散步 10-15 分钟。

在午餐休息期间，散步 10-15 分钟，这是一个非常好的方式。不仅可以运

动，还可以给您时间，对前一天和今天所做的工作进行一个新的回顾。此外，

餐后和同事一起散步也提供了一个社交机会。如果您已经退休，每天餐后和家

人一起散步，可增进家人感情。

毫无疑问，当您想泊车时，发现前面有一停车场时，您肯定会很高兴。但

是，想想您必须绕停车场一圈去停车，这会使您觉得很扫兴，尤其是您就近有

积极生活方式的要点

547

一个停车位。如果您就近泊车，只要多走几分钟的路，而不需要绕一圈，这样

也可以节省时间。多好！

参加计划运动

尽管一天中累积起来的运动有很多好处，但这并不意味着您不需要尝试或

安排一些规律的、更大强度的运动，尤其是您想强健您的心脏、减轻体重或达

到健身的目的。试着计划去健身房，或餐后更大强度的散步。

548

我相信您可以成功地改变这种静坐的生活方式。为了让您有信心改变成积

极的运动者，请您花几分钟时间填写以下表格，有关您「过去成功的记录」。

想想您曾经成功地改变了哪些习惯，这样会让您找回信心。

A. 我曾经改变的习惯

1. __________________________________________________________________

2. __________________________________________________________________

3. __________________________________________________________________

B. 帮助我成功改变这些习惯的因素

1.___________________________________________________________________

2.___________________________________________________________________

3.___________________________________________________________________

C. 阻碍我改变的因素

1.___________________________________________________________________

2.___________________________________________________________________

3.___________________________________________________________________

回忆我曾经成功改变的习惯

549

开始更多的运动决不是件容易的事。琳达曾认为，她绝不可能成为一名积

极的运动者。在她 50 岁时，她的体重是 90 公斤（200 磅），有高血压和冠心

病。偶有胸闷，并且心电图检查有心肌缺血的表现。

退休前，琳达忙于工作和家务，觉得没有时间运动。去年夏天，琳达与家

人一起去华盛顿旅游，她一路非常困难的爬上林肯纪念堂，一路上呼吸困难和

气喘。也就在那个时候，琳达决定开始每天多参与运动。一年后，琳达成功地

成为规律的运动者。胸闷的次数减少，并且心电图也恢复正常了。她每天选择

爬楼梯代替乘电梯。跟她的医生交谈后，琳达开始每天晚餐后散步 5-10 分钟。

虽然这很不容易，但她决定再也不要因为进行一些简单的运动而感到尴尬。

这样运动几个星期后，她开始每天午餐后散步，并逐渐扩展到晚餐后也散

步，每天散步 20 分钟。她感觉这样很好，并慢慢喜欢散步。当她丈夫称赞她是

「运动者」，她特别高兴。她从来没有想到自己能达到这种境界，但她成功地

做到将运动成为生活的一部分。她现在每天都能享受规律运动给她带来的各种

好处，特别是身体强壮了，走起路来轻松多了，胸闷的次数越来越少了。

琳达的传奇故事

550


意向期小册子

551

内容提要：

我准备好要开始运动了

拒绝负面的影响

运动能给我什么好处？

为什么没有行动？

「主动」学习积极的生活方式

成为一个积极的人

如果我没有运动会怎样？

迈向成功

「当您在想是否可以做时，

一些人早已开始做了」

运动：我准备运动了

552

当您真的开始考虑增加您的活动量水平时，这表明您已经跨出了很关键的

一步，即您已经成功地迈向将运动纳入到您的日常生活之中的非常关键的一

步。

在您真正体验到一种积极的生活方式之前，您还需要迈出几个关键的步

伐。有几个可靠的策略，您可以用来帮助您上路。

在这份小册子里，有几种策略您可以用来帮助您巩固您的承诺——使运动

成为您生活的一部分。

您现在正在考虑的生活方式的改变很重要，并且能给您的健康和生命带来

很多好处。准备好承诺拥有一个健康、积极的生活！

我准备好要开始运动了

553

您考虑越多关于开始规律的运动，您就会越相信规律运动的益处。然而，

您可能仍然怀疑您的能力，并只关注许多规律运动的坏处。

运动的负面因素，如花时间、需要能量、和可能感觉疼痛等。所有这些沉

重的思想负担都会影响您的行动。然而，在您准备好真正开始规律运动之前，

您必须要控制那些您认为规律运动不好的负面因素。

方法之一：您将这些负面的因素（如没有时间），简单地当作您必须克服

的障碍物。您不要特意安排一个小时或走几段路程的时间到室外运动，您可以

简单地将这些运动纳入到您的日常生活中，如步行去某个地方办事而不需要等

公共汽车，或选择爬楼梯而不要每次乘电梯等。

方法之二：尽管刚开始时可能会有困难，一旦您学会将运动纳入到您的日

常生活中，您会轻松地完成所要达到的运动水平。想想您是如何形成每天刷牙

的习惯？您也可以将运动形成您生活的一部分。难道您不可以形成一种类似刷

牙的习惯？而且这种习惯对您的生理和精神都有很多好处。

拒绝负面的影响

554

适量的规律运动对于冠心病患者的康复是非常重要的。它可以给您带来许

多好处：

有助于强健您的心肺功能

有助于冠状动脉侧支循环的建立

有助于减少胸痛和呼吸困难

有助于预防支架再狭窄或心梗再发作

有助于降低血脂

有助于减轻压力

有助于控制体重

有助于减低血压

有助于增强体能

有助于睡眠

有助于建立健康形象及增强自信心

__________________________________________

__________________________________________

__________________________________________

哇，运动原来有这么多的好处，赶紧行动吧！

运动能给我什么好处？

555

——参加规律运动的难处？

尽管您知道规律运动有许多的好处，您可能也想运动，但您可能仍然没

办法行动起来。到底是什么原因阻碍您的行动？为了更好的帮您解决阻碍您行

动的难处，请写下您认为参加规律运动的坏处或难处。我们已经帮您填好几个

常见的运动坏处或难处。写下您将参加规律运动的坏处或难处。

1. 太多工作

2. 害怕心脏病发作

3. 无聊

4.________________________________________________

5.________________________________________________

6.________________________________________________

7.________________________________________________

8.________________________________________________

9.________________________________________________

10._______________________________________________

根据您所写下的执行运动的难处，想想您如何克服这些困难？如果您是

因为有太多工作而没时间运动，那么您就想想其实运动不一定要花很多时间特

意到室外或健身房去运动，您可以简单地将运动纳入到您的日常生活中，如走

路去菜市场买菜、走路去某个地方办事、或平常利用爬楼梯代替乘电梯等。一

天中累积的运动也同样有效。想想一次十几分钟是不是很快? 如果担心运动会

诱发心脏病发作，那么您可以先跟心血管医生咨询，谈谈您是否可以运动？谈

谈运动对您是否有好处？我想医生会告诉您，适当的规律运动对预防心脏病发

作有帮助。如果您认为运动很无聊，那么您就多想想运动对您疾病的康复有多

么重要。如果。。。。。。

为什么没有行动？

556

当您开始尽量少去思考运动的不良后果或运动的难处时，您仍然应该努力

学习有关运动的信息，并在规律运动的益处表格中，增加规律运动对您生活的

好处的点子。努力学习更多有关运动的知识，您需要从一个被动学习者变成一

个主动的学习者。主动的学习者是不断地寻求运动的新知识和信息来源。这种

学习方式包括您询问有关运动的问题。

您可能会自问：我需要做多少的运动？您可能会在这份小册子中获得一些

这方面的信息，但您也可以在报纸上有关运动的栏目里找到答案。假如您听说

在某份报纸上有一则关于运动方面的研究，您可以试着去找出这份报纸，然后

念给自己听。您需要自己去寻找您想要的答案。

您也许也想知道什么运动对您最好？最好的方法是问您身边的人，看他们

做什么运动或喜欢什么运动？尝试几种运动，然后自己决定看要做哪种运动？

最好的运动是您喜欢的运动。想想您喜欢什么，然后想想做这种运动是否可以

使您成为更积极。假如您喜欢自然，那么到室外散步；假如您喜欢看书，那么

您可以一边脚踏固定自行车，一边看书；假如您喜欢集体活动，您可以加入一

个社区联盟。

您也许也想知道规律运动对您的心理健康有什么好处？询问那些您认识的

积极运动的人，问他们运动给他们带来什么好处？问他们运动后是否感觉好多

了？是否运动后头脑更清醒？是否运动后缓解他们生活中的压力？

形成自己的一套问题，这些问题是您想要回答的，然后积极去寻找它们的

答案。您需要不断地学习有关运动的知识，了解运动会对您有什么特别的好

处？当有关运动的好处不断增加，同时坏处不断减少时，您将开始运动了。

「主动」学习积极的生活

方式

557

使规律运动成为您生活的一部分，最重要的一步是学会确认自己是否是积

极的人。您如何想象自己，将决定您的行为。

假如您认为自己是一个善良、有激情的人，您将会主动帮助别人，倾听他

们的困难在哪里？假如您认为自己是一个积极的人，想想这种人该拥有哪些行

为？

您需要花点时间思考，您目前的行为如何帮助您定义您自己。如果您回家

后马上扑通一声坐到沙发上，然后打开电视，您是什么想的？想想您为什么这

样做？问问您自己，一个积极的人应该做什么？积极的人，不是坐在餐桌前与

您爱人谈论您今天是怎样过，而是一边散步一边谈论您今天的事。

当您认识到改变一些行为可以改变您的个性时，您可以开始改变一些行为

来帮助您成为您想要的那种人。想想成为您想要的那种人后，您会是什么感

觉？然后坦诚地问自己，您目前的习惯和行为是否能使您成为那种人？

假如答案是否定的话，那么您应该改变您的行为，改造您的自我形象。

成为一个积极的人

558

——朝着健康的生活方式前进

另一种很重要的方法使您增加运动的欲望，是想象一下如果不运动，您的

生活会是怎样？尽管这种想象过程并不好受，但可以促使您想改变这种生活方

式。

不活动的结果是很不好的。想想发胖时您会有什么感觉？想想一天比一天

虚弱时您会有什么感觉？想想血脂和胆固醇增高时会怎样？想想心绞痛发作时

您会有什么感受？想想由于心脏病发作而死，您的家人和朋友会有什么感受？

每天晚上吃饭后只是坐在那里，您是否感到羞愧？不活动的生活方式就像一颗

炸弹，随时都可能爆发。它的不良后果会影响您的一生和您身边的人。

当您想保持这种不活动状态时，回想这些不活动的不良感觉会有效的帮助

您认识到为什么您需要运动。那些情景您都不想去体验。幸运的是，决定权在

于您自己手中。您可以积极运动，做任何事情去预防这些不良事件的发生，或

者您可以不活动，被动地等待他们的来临。

您是唯一一个具有能力改变您自己生活的人。其他人只能给您提供帮助或

指导，但您必须执行那些行为。

如果我没有运动会怎样？

559

改变一种生活方式不是一件容易的事，您应该朝正确的方向，每次迈出几

小步。

当您读完这份小册子时，您应该对自己承诺：今天快速行走 5 分钟。然后

逐渐实现您的运动目标。

如果说，目前建议您每天走路 10 000 步左右，这是不现实的，您必须从

每天几小步开始。要知道「千里之行始于足下」。

今天只要散步，不要跑步。只要 5 分钟，不要多。当您完成 5 分钟散步，

您有什么感觉？5 分钟是不是过得很快？

从 5 分钟开始，然后 10 分钟，逐渐实现您的运动目标。

现在开始散步吧！

迈向成功

560


准备期小册子

561

内容提要：

准备，出发

使您的承诺正式化

每个人都需要帮助

认识您的理想

我应该做哪些运动？

运动时，我应该注意什么？

形成您的运动目标

我的运动目标表

运动：我正在路上

「要记住，是您使这一承诺变

成有益于您自己和您的健康」

562

您开始准备将运动成为您生活的一部分。也许您早已开始增加您的活动量

水平，正在寻找如何将运动纳入到您的生活中。恭喜您！

现在是准备将您的运动上升到更高一个水平。有几种方法，您可以用来帮

助您开始规律运动的生活方式。有几个重要的方法帮助您使您的承诺正式化，

如：学习如何建立合理的运动目标；学习如何寻求别人的帮助，使您成为积极

的人；进一步发展成为一个积极人的自我形象。

您已经很好地朝规律运动的方向前进。使用这份小册子中谈到的方法，您

可以成功地将运动成为您生活的一部分。

准备，出发

563

正如您准备成为积极的规律运动者，有一种方法您可以用来增强您的承

诺，那就是设定您的运动目标，并形成正式的计划书。

我们都喜欢拟一份「要做」的表，然后每天核对是否完成（至少我们希望

每一项都完成）。同样的方法可以用来实现您规律运动的承诺。当您实现您的

目标时，您会增加自信和自豪感。

但是为了使您的方法有效，您要为自己设定一个实际可行的运动目标。要

想知道有关设定合适的运动目标的详细信息，您一定要阅读「形成您的运动目

标」那一栏的内容。

设定好您个人的运动目标后，您需要将这些目标正式化。当您将这些目标

写下来或告诉别人您要达到的运动目标，会减少您忽略这些目标。这样，您就

不会说「我下次再做或这不是您真正想做的」。您要对自己的行动或不行动负

责。

为帮助您形成正式的目标，我们提供给您个人的运动目标表，附在这份小

册子的最后一页。请花点时间，将这个表格给填了，然后贴在您容易看到的地

方。最好是每个地方都能看到它。要记住，是您使这一承诺变成有益于您自己

和您的健康。

使您的承诺正式化

564

帮助您实现运动目标，一种很好的方法是寻找一个会支持您运动的朋友或

伙伴。这个人可以是一个啦啦队队长，鼓励您运动；也可以是监视器，当您不

想运动时提醒您；或是一个人与您一块改变运动行为。您的理想伙伴是拥有这

三个特点。

您的伙伴应该知道您的运动目标，您要告诉他如何更好的帮助您。您得到

的帮助一定是积极、正面的帮助。任何批判和大喊大叫都不利于刺激您坚持您

的运动方案。

您的伙伴可以是您的爱人或同事，甚至您的孩子或孙子也可以作为您的伙

伴来支持您运动。关键的是得到一个支持的伙伴，帮助您改变您的生活方式。

给您举个例子，陈 XX，男，57 岁，诊断冠心病 2 年，患病后不敢运动，经常

感觉胸闷。经医务人员的指导后，知道运动对他的疾病康复有好处。为了让自

己能坚持运动，他向家人宣布自己要坚持运动，并获得家人的支持。此后，每

天运动时间一到，家人都会提醒他「时间到了，要开始运动了」。他的女儿还

会特意叫儿子（即陈 XX 的孙子）陪爷爷一起打球。这样，陈 XX 成功地坚持

了规律运动。经过 4 周的规律运动后，陈 XX 明显地感觉到人越来越舒服，走

路越来越轻松，胸闷的情况也逐渐减少。由于陈 XX 享受到运动的益处，自然

越来越喜欢运动了。半年后，运动已成为他生活的一种乐趣。

每个人都需要帮助

565

当您继续努力使运动在您的生活中成为一种习惯，您需要继续定义您自己

是一个积极生活的人。这样，在您的生活中，您已经成功地建立一种您是谁的

感觉。现在，您需要继续让您的行动证实您是一个比较积极的人。

过去的任何会妨碍您成为积极人的行为，您都要将它们放弃。知道每天

晚上都可以回家吃饭，然后坐下来看「必须要看的电视节目」，您可能很开

心。然而，这种开心多数是因为您规律运动使您的身体舒适所带来的。您可能

会反驳说，这只是您每天做的事情或是您性格的一部分。

但是，您感觉舒适的唯一理由，是因为长期以来您一直这么做。改变您的

行为和习惯是很痛苦的事，但是只要您认识到只要花一点点时间和精力，运动

就会成为您生活的一部分。餐后或工作后散步一会儿，将成为您每天很舒适的

活动。当您重新定位您要做什么时，您要对自己有耐心。记住您所作的一切是

为您自己成为一个比较积极的人，并记住这值得您去努力。

认识您的理想

566

近来的科学研究已经表明，获得规律运动的益处，不要象您以前所认为的

那样，必须几乎每天在健身房里剧烈运动 30 分钟。其实，一周中多数时间里，

进行中等强度的运动，每天累积 30 分钟以上，同样可以获得健康的益处。这意

味着，您可以将几次运动纳入到您的日常生活中，来达到运动的目的。您现在

有几种选择来达到运动的目的，从参加几个十分钟的运动课程，一次 30 分钟的

运动课程，或室外在要求的运动强度下运动 20-30 分钟。这种富有弹性的运动

选择方式将使您更容易地将运动的目的和您的生活以及情境需求融入一起。

中等强度的运动——那是什么？

您可能很想知道，到底您应该做多大强度的运动，才算是中等强度的运

动？最经典的中等强度的运动方式是快步行走！在商场里闲逛不属于快步行

走。您必须带有「目的」的散步。生活式运动的概念是您可以将运动纳入到您

的生活之中的运动。但是，您可能会误认为您生活中已经有足够的活动。您要

知道，在办公室游荡或在花园里走走，这是不够的。您必须使您的心率和呼吸

比平常加快，这样的运动才有效。如果您所进行的锻炼不能使您轻微的气喘，

那么它就无法使您的心肺强健。这也是为什么从事一份忙碌的工作却无法达到

锻炼作用的原因。

在现实生活中，没有人能够控制每个小时固定走路或骑车几公里或几千

米。最好判断中等运动强度的是您自己。您要学会留心观察您的身体。您要知

道什么时候心率加快和呼吸加速。由于每个人的基础健康状况不同，每个人达

到中等强度的运动量会不一样。学会测量和监测您的脉搏，帮助您感觉如何转

化为每分钟的心跳。

您要记住的是，中等强度的运动是没有疼痛或痛苦的运动。如果您感觉到

疼痛或无法继续运动，您必须停止运动，这表明您已经运动过量了。中等强度

的运动是您能维持这种运动，并能持续一段较长时间。

我应该做哪些运动？

567

合适运动量的标志是：运动时稍出汗，轻度呼吸加快但不影响讲话，早晨

起床时感觉舒适，无疲劳感或其他不适感。运动后如感到轻快，食欲、睡眠较

好，表明运动量适宜。如果运动后头晕、胸闷、心悸、气短、食欲减退、睡眠

不佳、明显疲乏，说明运动量过大。

假如您增加活动量后没有感觉不适，您可以考虑在您的生活中增加一些更

大强度的运动。这表明您可以去健身房，游泳池游几个来回，参加有氧运动班

或散步后慢跑一会儿。这些比较大强度的运动将真正改善您的健康。

常见的中等强度活动的例子

对于冠心病患者来说，其实最好的中度运动是快速行走（80-100 米 /分

钟）。以下是一些相当于中等强度活动的例子。

日常活动

用手拖地板

爬楼梯（上下楼梯）

走/跑：与小孩一起玩（仅活动期间）

走路（4.0-5.6 公里/小时，手提少于 22.5 公斤的物品）

运动

散步（4.8-6.4 公里/小时）

打太极拳

双打网球

乒乓球

羽毛球（非竞赛性的）

排球（非竞赛性的）

篮球（非竞赛性的）

保龄球

垒球或棒球

慢骑自行车（13-19 公里/小时）

踏固定脚踏车（50-100 瓦）

游泳

郊游（徒步）、爬山

568

保健操

健身操（一般的、家里运动，如：背部运动）

体操（一般的）

减肥体操

跳舞

跳扭扭舞、扭秧歌、爵士舞、吉特巴舞

迪斯科、民族舞、广场舞、华尔兹舞、慢舞或探戈舞

打鼓（腰鼓）

569

对大多数冠心病患者来说，适量的运动是安全的。为预防意外，冠心病患

者进行运动时应注意以下一些事项：

运动前要先有心血管医生的检查及对运动量的推荐。

冠心病病人应随身携带硝酸甘油丸或其它抗心绞痛药物，如麝香保心

丸、速效救心丸或丹参滴丸等，以备胸口痛时放在舌下。

运动前应做准备活动（热身运动），运动后应做整理运动。一般采用散

步、体操等活动，分别是 5-10 分钟。准备活动和整理活动不充分是造成

锻炼意外的最常见原因。

在太饿或太饱、太冷或太热的环境、身体疲劳、盛怒及心情太差时，都

应避免运动。饱餐后休息 2 小时才做运动。避免出入温差太大的场所。

运动后切忌马上进行热水澡，最好是运动后半小时再洗澡，以减低对心

脏的冲击及预防运动后的暴毙。

避免推举重物等用力的工作，如需要时，保持呼吸畅顺，切忌忍气。

注意空气流通，注意心跳是否过度加快或不规律。

要避免竞技性运动，避免加速过急的运动，如快速地爬楼梯竞赛。

感冒或发热后要在症状和体征消失 2 天以上才能恢复运动。

清晨气温较低，不适宜心脏病患者进行锻炼，因此最好是上午或傍晚出

去锻炼。

运动停止指征

若出现以下的症状或体征，应马上停止运动：

• 典型的胸痛或胸部不适，或放射到肩部、下颌部、颈部或手臂；或感受

到以前心肌梗塞的症状；

• 眩晕、头晕或身体虚弱；

• 呼吸困难或气喘

• 不典型出汗

运动时，我应该注意什么？

570

• 过度疲倦

• 腿痛限制其功能

• 身体无法继续运动

运动时还需要记住的要点

如果运动时您喘不过气以至无法说话，休息，直到仅有轻微的喘息再继

续。

如果您感觉胸痛，休息直至疼痛消失。如果胸痛规律发生，则需要告知医

生。如果您有心绞痛则服药后再继续锻炼。

按计划进行，不要在短期内做过量的运动，这会延缓您的康复，甚至发生

危险。欲速则不达。

如果您某天锻炼时感觉不好，不要因此而烦恼，每个人都可能发生这种情

况。问问自己是否已经比过去的几天运动量大了些，这可以解释为什么您

感觉有点疲劳。

571

为了体验您实现运动目标时的成功感觉，您要学会设定合适的目标，包括

形成现实可行的改变您行为的期望。开始时，您的目标，重点是如何使短期的

目标或行为帮助您实现您要追求的长期效益。

形成规律的运动不是一夜之间就能实现的。假如您已经不活动一段时间，

您需要慢慢进入这一新的生活方式。您知道，形成积极的运动习惯是第二自

然，但这种自然只能慢慢来。就象减肥一样，您不能奢望在没有参加积极的活

动和将饮食改变纳入到新的健康的生活方式之中，会迅速地减轻体重。现在，

您集中精力形成一些短期的目标，然后慢慢增加您的活动量。

这份小册子的最后一页是提供给您一次机会，让您设定一些您自己可执行

的运动目标。刚开始时，您可以每天在午餐和晚餐后散步 10 分钟；您可以爬楼

梯；也可以设定具体的目标。要记住，是您使这些改变发生，是您希望从运动

中得到什么好处，也是您如何更好地帮助这些好处发生？

填好您的目标、签名和执行日期，然后将这份表格放在您和别人都可以看

到的地方。每当您看到这份表格，您都要核对一下您是否完成那些行为？如果

您没有实现您的目标，不要气馁。一般人在成功地改变行为之前，需要相同的

「新年改革」3 次。使用这份小册子中介绍的方法帮助您改变行为，但要预见

一些挫折或困难。关键是确信目标是可行的、合理的。着眼于您完成了哪些行

为，然后加倍努力实现目标。

形成您的运动目标

572

我将每天散步________分钟

我将尽可能地爬楼梯

我将______________________________

我将尽最大努力使运动成为我生活的一部分

我能并将成为一个积极运动的人

签名___________________

日期___________________

我的运动目标

573


行动期小册子

574

内容提要：

朝着积极的生活方式前进

发展健康的替代方法

奖励您自己——您做了一件好事

润色您的日常活动

不活动——千万不能不活动

问题解决的艺术——IDEA 表格

运动：我正在「动」

「朝着您的目标前进」

575

您应该为自己感到自豪，您所作的一切都是有益于您的健康。只要您留

意，规律的运动会给您的精神和生理健康带来许多好处。关键在于您要坚持将

运动纳入到您的生活中。

坚持规律的运动可能会遇到一些小的挫折，但是在这份小册子中，您会发

现许多方法，可以帮助您朝向您的运动目标前进。

当您努力保持一种规律运动的健康生活方式时，您要学会如何避免那些可

能使您不运动的情况，学会巩固您运动行为的思想，以及形成您自己的奖励方

式。不断地增加您运动选择的多样化也是很重要的。每天重复同样的运动会很

烦并且会减少动力。

恭喜您！您已经很好地朝着积极的生活方式前进。现在只要继续前进就

行！

朝着积极的生活方式前进

576

当您不断地努力使运动成为您每天生活的一部分，您会不时地被诱惑返回

到您以前不运动的坏生活习惯中。想想所有可能让您在节假日里逃脱运动的

「坏」情况。您要知道您在什么情况下或什么时候不想运动，然后努力去重新

调整您的运动目标。

当您不幸回复到原来静坐的生活方式时，您可以想象为什么您不能活动的

所有理由？这时候需要您和您自己进行对话。假如您认为运动会花费太多时

间，提醒您自己每次 10 分钟很快，每次运动可以累加起来。如果您认为运动会

出很多汗，提醒您自己运动后感觉多好。

想想所有您可能得到的将运动纳入您生活中的机会，来代替旧的、不活动

的习惯。假如您喜欢看电视，那就找些可以在家里做的运动，如：在跑步机上

走或在固定自行车上踏，这样您可以一边看电视一边运动。假如家里没有跑步

机或固定自行车，您可以在大厅或阳台进行原地踏步走/跑，或做做体操。假如

您喜欢散步，可以试着每天走路或骑自行车去菜市场买菜，而不用去挤公共汽

车。假如您喜欢午餐后坐在那里和您同事聊天，可以试着叫他们一块散步，这

样您们可以边谈话边活动。

您有可能会被诱惑回复到原来旧的生活习惯轨道上，您应该提前计划如何

避免这些情况发生，使您一直保持运动是生活的一部分。

发展健康的替代方法

577

当您不断地实现您的运动目标时，您可能对自己和您的健康感觉越来越

好。不断的进步，本身就是一种奖励，但是您还是需要花点时间庆祝自己的进

步。形成规律的运动不是一件容易的事，虽然您做得越多，运动越会成为您生

活的一部分。

有几种方式可以奖励您自己，奖励您努力保持运动。假如您有一套的运

动目标（如果您没法坚持运动，您就列出您如何想将运动成为生活的一部

分），简单的奖励方式是在那些您已经实现或正要实现的目标上打「√」。这

种简单的「已做」的核对方式经常是一个很大的奖励，能增加您的自信。假如

您没有达到一些目标，那么想想目标实现后，打「√」的感觉多好。

当您成功地避免一些可能使您不运动的情景时，奖励自己一个背上有文

字的牌子。鼓励的话或想法，如：「做得好！」或「我能做到」。这些都能给

您带来很大的动力。您可以自己给自己助威。如果您表现好的行为，那么您有

权利对自己感觉好点。干吧！「继续下去」。

如果您不想自己担任啦啦队队长，您可以招募您身边的人来帮助您。如

果他们知道您的运动目标，他们会帮助并鼓励您。让您的家人、朋友、或同事

来鼓励您，使您实现您的目标，这样您的努力就不会被人忽视。

最后一种奖励方式，是给自己建立一个行为协议。如果您能顺利地实现

这个特别的、有挑战性的目标时，您可以选择一种特别的奖励方式。但是千万

不要奖励您不运动。假如您计划一个特别的旅行或假期，要保证这种旅行或假

期能将运动成为您每天的活动之一。让您假期里的新风景作为您的奖励，只要

您走一段路程就有一个风景。

奖励您自己——您做了一件好事

578

要使运动成为您每天生活的一部分，很重要的一点是您不要对运动感到

无聊。这看起来好像与建议您使规律运动成为一种习惯相矛盾，您要参加一些

您喜欢的运动或在您喜欢的环境下运动。

就拿散步来说，假如您要实现您的运动目标，您可以在校园周围或邻近

地区找一条新的可以散步的路线。新的风景或更多富有挑战性的路线会增加您

运动路线的多样化，并给您一些期望继续走下去。只要您不断增添一些不同的

运动方式，习惯就不会变的无聊。使用新的运动和环境来增加一些「香料」，

从而实现您的运动目标。

另一种帮助您不断实现您的运动目标的方法，是尝试更富有挑战性的任

务。如果您每天晚上散步一英里（1.6 公里），试着一公里或一半或设定一个目

标，使走的速度比上周快一点。当您越来越积极运动时，您会发现您所做的努

力使静坐的生活变成运动的生活方式越来越容易。为使您保持较高的动力，您

要给自己一个有足够挑战性的目标，这样当您实现目标时，会有一种成就感。

您可能也想尝试完全不同的运动。只要您小心不要过量，您可以试着进

行一些新的运动。打壁球或参加一篮球队或垒球队。您也可以在健身房尝试一

些新的设备。假如您已经瞄准那个新的运动仪器，干吧，试一下。您可能会发

现那种活动您很喜欢。

关键是要确信您的运动方式不断变化，这样您就不会停滞不前，去改变

那种您决定改变的静坐生活方式。保持不同、新颖、和挑战性，不久您就会惊

讶于有这么多种的运动。参加这些运动可以形成规律运动的习惯。

润色您的日常活动

579

在您努力成为积极运动的人的过程中，您将面对的最主要的障碍之一，是

那些诱惑您不活动的情景。不好的天气，如：下雨、下雪、或寒冷，这会使人

很想待在室内，什么都不想做。不幸的是，您不能什么都不做。为保持积极运

动，您要开始明白在哪些情景下，对您实现运动目标最有挑战性。

下列单子包含每个人努力成为规律运动者可能遭遇的几个常见阻碍，回顾

这个单子，在底下增加一些您自己的阻碍因素。

很难运动。。。。

1. 在恶劣的天气里

2. 在休假中或假期里

3. 当家里有客人来访时

4. 当家里有太多事要做时

5. 当您面对工作的最后期限时

6. 当您感觉累时

7. 当您的伙伴不能陪您一块运动时

8. _____________________________________

9. _____________________________________

10. ____________________________________

看看这个单子，您可能会有一种想战胜的感觉，或想如何保持规律的运

动。知道自己什么时候或在什么情况下会被诱惑不运动，是您保持积极生活方

式的关键一步。

既然您承认在某些情况下会导致您不想运动，关键是努力避免这些情景，

或设定计划帮助您应对这些情况的发生。

不活动——千万不能不活动

580

例如，当天气不允许您外出散步，您可以试着在屋里或在附近的购物中心

散步，如可以在室内做体操或原地踏步走/跑。形成您自己的天气管理计划，这

样当恶劣天气来临时，您已经知道如何继续您的运动计划。

同样，在节假日紧张的时间里，不是限制您的活动，而是应该更加留意寻

找时间来运动。运动的时候，可能会给您一个机会清理一下您的头脑。努力做

一些对您有益的事，而不是总在想那些苦恼的事。

如果家里有客人来访，您可以试着餐后与客人一起出去散散步，这样您们

可以一边聊天一边锻炼，一举两得，而不是坐在那里聊。如果家里有太多的事

要做时，您可以尽量将运动纳入到您的日常活动中，也可以寻求家人的帮助来

完成您的运动目标。

对于每种这样的情景，您都要准备好如何克服这些阻碍因素，然后继续实

现您的运动目标。另一种可以帮助您实现您的目标的方法是，在您家里或办公

室里放置一些提醒物来提醒和鼓励您运动。您可以在周边放置便利贴（百事

贴）、寄给自己一张明信片提醒您去运动、给自己寄一种提醒物、或在您家门

口放置一双运动鞋等提醒您去运动。您也可以给自己的手机设定一个闹钟，每

天提醒自己要锻炼。总之，关键是在您周围给您足够的正面信息，这样您可以

克服那些负面的情景来鼓励您坚持运动。

最后一种战胜那些使您不运动的诱惑的方法，是坚持制定或「修改」活动

表。通过每天制定一套的特定计划和目标，这些目标您可以预见可能遇到的阻

碍或困难，然后制定相应的计划。多样的运动选择方式，会允许您根据当天的

天气或您的时间，选择最合适的运动方式来实现您的目标。

您已经很好地将运动成为您生活的一部分。接下来的努力是防止您返回到

原来静坐的生活方式，这是非常值得努力的事。想想运动给您生活带来所有有

益的事。继续沿着您的目标前进！

581

使用 IDEA 表格

I——发现阻碍您运动的困难

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

D——形成解决问题的方法（越具体越好）

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

E——评估这些方法。在下面的空白处，写下您要尝试的方法。当您写计划

时，您要写下执行的具体时间.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

A——分析计划是否有效？如果有需要，请修订计划。假如您的计划执行很

好，给五个星星。假如计划执行不好，只有两个星星，那您写下如何使它变成

五个星星的计划？假如您的计划完全泡汤，请重新回顾一下您上面列出的解决

方法的单子，重新再试一下。（记住，计划效果不好不等于完全失败。计划朝

向解决问题的方向，一般都会有效。只有放弃才是真正的失败）

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

问题解决的艺术

582


维持期小册子

583

内容提要

维持积极的生活方式

如何维持运动的习惯？

不是世界末日

是您的生活方式——要负责

帮助发生变化

「您做得很好！运动是您

生活的一部分」

运动：我一辈子做运动！

584

您已经努力使运动成为您生活的一部分，您必须执行您的承诺。您已经做

了很多有助于增强您躯体和精神健康的工作。相信运动成为您生活的一部分会

让您感觉很好。

尽管您已经成功地实现您为自己所设定的运动目标，但现在不是说可以放

松了。您已经形成的运动习惯对您非常有益，但您仍然需要警惕任何可能倒退

的现象，这会让您返回到原来不运动的状态。

确保您坚持运动的最好方式，是学会如何有效的管理您可能碰到的各种倒

退现象；当坚持运动有困难时，您要像以前一样计划时间；加强认同做一个积

极的人，把她作为您行为改变的模范。

维持积极的生活方式

585

您应该选择的运动是。。。。。

感兴趣的。。。

如果您并不喜欢这项运动就很难坚持。如果您过去进行过骑单车、散步、

游泳、跳舞、打保龄球、羽毛球等运动，那么尝试重新开始这些项目。

规律的。。。

如果您不能很好地坚持，可以参加一些有组织的运动，如运动课程。如果

天气不好，做些您能做的事情，游泳是特别好的运动项目，因为您全年都可以

进行，如果您不会游泳，可以参加游泳培训班。

多样化的。。。

多进行几种运动，以便当您对一项运动感觉厌烦时，可以进行其他的运

动。

就近的。。。

旅行花费高且耗时，您很容易放弃。如果在您居住地区附近没有什么可去

的地方，您可在家使用划船机或脚踏车运动机，也可以在家里大厅或阳台进行

原地踏步跑，这些运动可能很乏味，所以您可以边运动边看电视节目。

融入生活的。。。

使运动成为您生活的一部分，尽量步行或骑自行车上班或购物。

如何维持运动的习惯？

586

要发生的总会发生。最终您可能倒退或没有实现您的运动目标，这可能是

由于恶劣的天气、工作的额外需求、或假期的压力等造成的。但不管是什么原

因引起的，您都要准备好应对这些情况，以使您回到朝向健康的运动生活方

式。

您要知道，您不是失败了，这也不是世界末日。倒退现象是我们生活中做

每件事情都会碰到的情况。人与人的区别在于他们对付倒退的能力。

有一些方法可以使您恢复积极运动的习惯。第一，您要尽可能地恢复规律

运动。不要浪费时间哀叹您丢失的运动机会，恢复积极的运动状态。倒退不是

永久的，并且您有能力决定倒退时间的长短，尽可能使您返回的静坐生活方式

短些。

您要保持积极和有目标。即使您没有达到您的目标，您所做的工作也没有

浪费。记住，您要实现的事情不是一夜之间就能做到的。暂时的倒退，也不会

使您重新回到静坐的生活方式。只要有积极的态度，您就会重新积极起来。

一辈子运动的挑战是您可能在某一时间会倒退，当倒退时，要保证尽可能

的积极和重新恢复积极的运动方式。因为您是一个积极生活的人！

不是世界末日

587

使运动一直成为您生活的一部分可能不容易，但您能做到。您要庆祝自己

一直以来的努力。使用一些策略，您可以在以后的十几年里，保持积极运动状

态，然后一生享受运动带来的好处。

当您遇到不寻常的情况时，是您发生倒退的最危险的时刻。如果您没有准

备好如何应对这种新的或特别的压力事件，您可能会返回到原来的旧习惯中，

即静坐的生活方式。这些刺激会非常强烈地诱惑您返回到以前的行为中，但是

只要有合适的计划，当这些情况发生时，您可以应付自如。

您要确信提前计划这些可能妨碍您常规运动的不寻常情况。假如您在休

假，那么要保证您随身携带运动服，并了解您去的地方是否有健身设施或可以

散步和慢跑的场所。

当事情意外地发生时，您要花点时间重新审核您的运动目标，然后回答为

什么您要执行这些目标。回顾您的运动目标，会给您一个机会去计划如何坚持

运动，或如何应对可能出现的不运动现象。

您也需要偶尔花点时间提醒自己为什么要运动。观看运动有益的电视节目

或新闻报道，祝贺自己的行为。对每个麻烦或障碍，您都能想想为什么您不运

动，挑战自己想出 4 到 5 个为什么您要运动的理由。

虽然您现在是积极的运动者，但您可能忘记您是怎样开始运动的。偶尔提

醒自己从积极运动中得到的好处，这会给您坚持运动带来很大的动力。

另一个满足您一辈子运动的挑战，是使运动成为一种习惯，成为您每天生

活的一部分。就像每天洗澡，最后您可能养成每天运动的习惯，至感觉不太像

您自己的程度，直到您每天坚持散步 30 分钟。

这种运动的习惯，是保证您一辈子运动的关键一步，它会让您坚持运动。

是您的生活方式——您要负责

588

假如您身边有人每天运动，然后正在享受规律运动带来的各种好处，那么

您要意识到这些人可能会帮助您发生变化。把他们作为榜样或模范，这会帮助

您建立自己作为一个积极的人的形象，防止返回到静坐的生活方式中的有力武

器。

模范是什么意思？将模范作为「活动刑警」会得罪很多人，这会比鼓励成

为积极的人更多。人们会简单地回避您。您所要做的是当他们乘电梯时，您爬

楼梯。假如他们问为什么您要爬楼梯，那么您就与他们分享您的体验和感受，

也许他们下次会选择加入您的队伍，一起爬楼梯。您也可以邀请别人每天一起

散步。假如有人想跟您一起散步，您应该与他们分享您的知识来帮助他们养成

运动是生活一部分的习惯。

规律运动对您一生的好处已很明显了，所以别人找您作为他们的模范，您

的职责是帮助他们发生变化，帮助那些将您作为规律运动正面效益的榜样的人

发生变化。

您要为您的成就感到自豪。但是除了成就感外，您要知道您还有一些责

任。完成责任的最好方法是维持您健康的和积极的生活方式以及乐观的生活态

度。

帮助发生变化

589

References

Blair, S.N., Dunn, A.L., Marcus, B.H., Carpenter, R.A., & Jaret, P. (2001). Active

living every day. Champaign, IL: Human Kinetics.





N.L. & Allan, R.M. (2006). Physical activity for people with cardiovascular disease:

recommendations of the National Heart Foundation of Australia. Medical Journal of

Australia, 184(2), 71-75.

Marcus, B.H., Forsyth, L.H. & Blair S. (2003). Motivating people to be physically

active. United States: Human Kinetics.



院外自助式心脏康复手册（未出版）. 香港理工大学护理学院，香港中文大学护

理学院和中国协和医科大学护理学院编制。

590

Appendix XI Screening Form – Chinese Version

第一部份个人资料

1．性别： ①男 ② 女

2．年龄：________岁

3．婚姻状况：

①未婚 ②已婚 ③离婚 ④分居 ⑤丧偶

4．教育程度

①没有正规教育 ②小学 ③初中 ④高中/中专

⑤大学专科 ⑥大学本科及以上

5．目前就业状况

①没有工作 ②兼职 ③ 全职

6．职业（退休前）

①体力劳动者 ② 技术人员 ③ 文职人员 ④ 管理人员

⑤专业人员 ⑥经商人员 ⑦其他_____________

7．宗教信仰

① 没有 ②佛教 ③基督教 ④ 伊斯兰教 ⑤天主教

⑥道教 ⑦其他_____________

8．家庭每月收入

①￥1000 以下 ②￥1001-3000 ③￥3001-5000 ④￥5001-7000

⑤￥7001-10000 ⑥￥10001 以上

9．医疗费用支付方式

①公费 ② 部分公费 ③ 医保 ④全部自费

10．居住情况

① 独居 ② 与朋友同居 ③与配偶同居

④与子女同居 ⑤与配偶和子女同居

591

第二部份临床资料

1．诊断

①心绞痛 ② 心肌梗塞

2．冠状动脉介入治疗

①无 ② 有

3．冠心病家族史（50 岁前发病）

①无 ② 有

4．糖尿病 ① 无 ② 有

5．高血压 ① 无 ②有（血压_________毫米汞柱）

6．吸烟状况（使用香烟、雪茄、小雪娇、烟斗烟草、或任何其它形式的烟草）

①从未吸烟

②以前吸烟（平均每天吸____支/天），现已戒烟。

③目前吸烟（平均每天吸____支/天）

7．饮酒状况

①从未饮酒

②以前饮酒（饮酒量______克/周），现已戒酒。

③目前饮酒（饮酒量______克/周）

8．目前口服药物

8.1 硝酸酯类_________________________________________________________

8.2 β-阻滞剂__________________________________________________________

8.3 血管紧张素转换酶抑制剂____________________________________________

8.4 钙通道阻滞剂______________________________________________________

8.5 降脂药____________________________________________________________

8.6 抗血小板药_______________________________________________________

8.7 其他______________________________________________________________

592

第三部分综合性医院抑郁量表

情绪在大多数疾病中起着重要作用，如果医生了解你的情绪变化，他们就能

给你更多的帮助。这个测定表是专门设计帮助医生了解你的情绪，请你阅读以

下各个项目，在其中最符合你上个月以来的情绪的答案下划一条线。对这些问

题的回答不要作过多的考虑，对每个问题立即作出回答比考虑后再回答更为正

确。

类别问题回答评分

D1 我对以往感兴趣的事情还是有兴

趣

肯定一样

不像以往那样多

只有一点儿

基本上没有了

0

1

2

3

D2 我能够哈哈大笑，并看到事物好

的一面

我经常这样

现在已经不大这样了

现在肯定是不太多了

根本没有

0

1

2

3

D3 我感到愉快根本没有

并不经常

有时

大多数时间

3

2

1

0

D4 我对自己的仪容（打扮自己）失

去兴趣

肯定

并不像我应该做到的那样关心

我可能不是非常关心

我仍像以往一样关心

3

2

1

0

D5 我对一切都是乐观地向前看差不多是这样做的

并不完全是这样做的

很少这样做

几乎从来不这样做

0

1

2

3

593

D6 我好像感到情绪在渐渐低落几乎所有的时间

很经常

有时

根本没有

3

2

1

0

D7 我能欣赏一本好书或一项好的广

播或电视节目

常常

有时

并非经常

很少

0

1

2

3

总分______________

第四部分筛查项目

以下是一些条目帮助心血管医生了解每位病人是否适合参与本研究，即时期

匹配运动行为干预的项目。如果以下条目中，病人有一项不符合标准，则不建

议参与本研究。

1．年龄__________岁

① 小于 18 岁 ② 大于等于 18 岁

2．是否居住在厦门

① 是，地址___________________________________________________

联系电话：_________________________________________________

② 否

3．病人的沟通和阅读汉字的能力：

1）语言沟通能力 ① 能进行沟通 ② 沟通困难/沟通障碍

2）阅读汉语的能力 ① 有阅读能力 ② 阅读困难

594

4．疾病诊断：心绞痛心肌梗塞

① 心绞痛，诊断时间_________（月/年）

② 心肌梗塞，诊断时间_________（月/年）

③ 冠状动脉介入治疗术后，介入治疗时间_________（月/年）

5．是否病情稳定 ① 是 ② 否

6．是否有不稳定型心绞痛 ① 是 ② 否

7．是否曾经参加过任何有关心脏康复的项目 ① 是 ② 否

8．是否有认知功能障碍 ① 是 ② 否

9．是否有精神抑郁症 ① 是 ② 否

10．是否有重度主动脉狭窄 ① 是 ② 否



② II 级：活动量轻度受限制，重体力活动时患者出现疲乏、心悸、呼吸困难

或心绞痛。

③ III 级：活动量重度受限制，轻度体力活动时患者出现疲乏、心悸、呼吸

困难或心绞痛。

④ IV 级：患者不能从事体力活动，休息状态下亦有疲乏、心悸、呼吸困难

或心绞痛。

12．糖尿病

① 无

② 有，空腹血糖______________

595

13．高血压

① 无

② 有（血压_________毫米汞柱）

14．心率/脉率_________次/分钟

15．是否有窦性心动过速（> 120 次/分） ①是 ② 否

16．是否有心房颤动 ①是 ② 否

17．是否有室性心律不齐 ①是 ② 否

18．是否有三度房室传导阻滞 ①是 ② 否

19．是否有收缩压大于 180mmHg 或舒张压大于 110mmHg ①是 ② 否

20．是否有急性心肌炎 ①是 ② 否

21．是否有急性心内膜炎 ①是 ② 否

22．近三个月有栓塞史 ①是 ② 否


功能衰竭、甲亢等 ①是 ② 否

筛选结果： ① 推荐 ② 不推荐

心血管医生姓名: _______________ 签名: _________________

日期: _________________

596

Appendix XII Questionnaires – Chinese Version

第一部分活动之变动时期问卷

说明：规律的身体活动是指任何有计划的身体活动〈如太极拳，快步行走，骑

脚踏车，游泳等〉，用以增加身体体能。这样的活动应该累积每天至少 30 分钟

（每次至少 10 分钟）的中度身体活动，每星期多于五天〈参见中等强度活动的

例子〉。执行这样的活动不需要一次做完，几次十几分钟的活动时间也能够有

效。身体活动不需要痛苦才会有效，但应该做到增加您的呼吸速率和引起您流

汗的程度。

问题：

按照以上定义，您是否从事于规律的身体活动？（选一个答案）

1 = 没有，而且我不打算在未来的六个月内去做。

2 = 没有，但我打算在未来的六个月内去做。

3 = 没有，但我打算在未来的 30 天内去做。

4 = 是，我已经从事于规律的身体活动少于六个月。

5 = 是，我已经从事于规律的身体活动多于六个月。

1 = 前意向期

2 = 意向期

3 = 准备期

4 = 行动期

5 = 维持期

597

中等强度活动的例子

(摘自 Ainsworth, Haskell, Whitt et al., 1993)

活动类型 METs 中等强度的活动

运动 3.3-

5.0 散步（4.8-6.4 公里/小时）

4.5 羽毛球（非竞赛性的）

4.0 乒乓球

4.0 太极拳

3.0 保龄球

5.0 双打网球

3.0 排球（非竞赛性的）

6.0 篮球（非竞赛性的）

5.0 垒球或棒球

6.0 游泳（非竞赛性的）

4.0-

6.0 慢骑自行车（13-19 公里/小时）

3.0-

5.5 踏固定脚踏车（50-100 瓦）

6.0 郊游（徒步），爬山

保健操和跳

舞

3.5 健身操（一般的，家里运动，如：背部运动）

4.0 体操（一般的）

4.8 跳扭秧歌、爵士舞、吉特巴舞

3.0-

4.5

舞厅（如：迪斯科、民族舞、广场舞、华尔兹舞、慢舞

或探戈舞）

4.0 打鼓（腰鼓）

日常活动 3.5 拖地板

3.0-

3.5 爬楼梯（上下楼梯）

4.0-

5.0 走/跑：与小孩一起玩（仅活动期间）

3.0-

4.5 走路（4.0-5.6 公里/小时，手提少于 22.5 斤的物品）

其它（具

体）

3.0-

6.0

598

第二部分运动自我效能量表

以下所描述的许多状况会影响规律的身体活动（每周五次或五次以上），

根据下面的问题，估计您能执行规律运动的自信程度，从 0 到 100 分，将符合

您情况的数值填在横线上。

0 10 20 30 40 50 60 70 80 90 100

完全不能做中度肯定能做肯定能做

(0-100)

1．当我觉得疲劳时 ___________

2．当我觉得工作有压力时 ___________

3．天气不好时 ___________

4．因受伤停止了运动，等损伤愈合后 ___________

5．正在经历或刚经历了个人问题后 ___________

6．当我觉得沮丧时 ___________

7. 当我觉得焦虑时 ___________

8．因疾病而使我停止运动康复后 ___________

9. 当我运动觉得不舒服时 ___________

10．在假期后 ___________

11．当我在家里有太多工作要做时 ___________

12．当有客人来访时 ___________

13．当有其他有趣的事情要做时 ___________

14．如果我没有达到自己的运动目标时 ___________

15．没有我的家人和朋友的支持时 ___________

599

16．在假期中 ___________

17．当我有其他的事情约定时 ___________

18．在经历家庭事件后 ___________

总分 ___________

第三部分运动益处和阻碍量表

运动益处量表

说明：以下叙述是关于运动的一些想法，请用圈选的方式，指出您对每个叙述

同意或不同意的程度。

1 = 强烈不同意

2 = 不同意

3 = 同意

4 = 强烈同意

1. 我从运动得到乐趣。 1 2 3 4

2. 运动减少我紧张和压力的感觉。 1 2 3 4

3. 运动增进我的心理健康。 1 2 3 4

4. 运动将预防我发生心脏病。 1 2 3 4

5. 运动会增强我的肌肉力量。 1 2 3 4

6. 运动给予我个人成就感。 1 2 3 4

7. 运动使我觉得放松。 1 2 3 4

8. 运动让我和我喜欢的朋友及人们有联系。 1 2 3 4

9. 运动将使我远离高血压。 1 2 3 4

10.运动改善我的心脏血管系统功能。 1 2 3 4

11.运动增进我的身体体能的强度。 1 2 3 4

12.运动增进我的肌肉结实。 1 2 3 4

13.因为运动，我感觉自己比较健康。 1 2 3 4

600

14.运动增进我的耐力。 1 2 3 4

15.运动增进我的柔软度。 1 2 3 4

16.运动改善我的脾气。 1 2 3 4

17.运动帮助我晚上睡的较好。 1 2 3 4

18.假如我做运动，我将会活的久一点。 1 2 3 4

19.运动帮助我减少疲劳。 1 2 3 4

20.运动是让我遇见新朋友的好方法。 1 2 3 4

21.运动改善我的身体持久力。 1 2 3 4

22.运动改善我对自己的想法。 1 2 3 4

23.运动增加我心理上的警觉性。 1 2 3 4

24.运动可使我做正常活动(如煮饭、购物、

园艺、清洁等)时不会觉得疲倦。 1 2 3 4

25.运动改善我的工作品质。 1 2 3 4

26.运动是好的娱乐。 1 2 3 4

27.运动增加其它人对我的接受度(如较喜

欢与我相处、较接受我的想法等)。 1 2 3 4

28.运动增进我整体的身体功能。 1 2 3 4

29.运动改善我身体的外观(如看起来较健康、

较年轻等)。 1 2 3 4

601

运动阻碍量表

说明：以下叙述是关于运动的一些想法，请用圈选的方式，指出您对每个叙述

同意或不同意的程度。

1 = 强烈不同意

2 = 不同意

3 = 同意

4 = 强烈同意

1.运动用掉太多我的时间。 1 2 3 4

2.运动让我疲倦。 1 2 3 4

3.做运动的地方离我太远。 1 2 3 4

4.我觉得很不自在去做运动。 1 2 3 4

5.运动要花太多的钱。 1 2 3 4

6.做运动场所的时间表对我是不方便的。 1 2 3 4

7.运动使我觉得疲惫不堪。 1 2 3 4

8.我的配偶(或其它重要的人)不鼓励运动。 1 2 3 4

9.运动用掉太多家庭责任的时间(如做家务、

农务、照顾生病的家人等)。 1 2 3 4

10.我觉得人们做运动时的衣服看起来可笑。 1 2 3 4

11.我的家人不鼓励我去做运动。 1 2 3 4

12.运动用掉太多家庭互动的时间(如与家人

相处、家庭聚会等)。 1 2 3 4

13.对我而言，做运动是困难的事情。 1 2 3 4

14.我能做运动的场所太少了。 1 2 3 4

602

第四部分身体活动自我报告与自我评价表

指导语：该表格用于记录您每天进行中等强度体力活动的情况，包括体力活动

的种类（参见中等强度活动的例子）、次数、强度、持续时间、是否发生心绞

痛以及因为体力活动额外服用抗心绞痛药物的情况？体力活动的强度用 Borg 自

我辛苦评估指数（RPE），从 6 至 20。6 表示非常轻松（安静休息时感觉），

20 表示精疲力竭。请记录您每次体力活动时感觉到的辛苦程度，请选择从 6 到

20 的数字表示您的体力活动强度。同时，记录每次体力活动的种类、次数、持

续的时间（分钟）、运动时是否发生心绞痛以及因为运动需要额外服用硝酸甘

油或其它抗心绞痛药物使用的片数（即扣除平时常规服用的片数）。

自我辛苦评估指数

非

常

轻松

很

轻

松

轻

松

有

点

辛苦

辛

苦

很

辛

苦

非

常

辛苦

非

常

轻松

603

日期

体力活动情况

合计

星期一星期二星期三星期四星期五星期六星期日

体力活动的种类

体力活动的次数

体力活动的强度 (RPE: 6-20)

体力活动的持续时间（分钟）

体力活动时是否发生

心绞痛

无

有

因为体力活动需要额外服用硝

酸甘油类或其它抗心绞痛药物

（片数）

604

第五部分心绞痛自我报告与自我评价表

指导语：该表格用以记录您每天心绞痛发生的情况。请详细记录您出现心绞痛

的次数、每次疼痛的强度、持续时间、及每天服用抗心绞痛药物使用的片数。

心绞痛疼痛的强度用下列的疼痛评估量表从 0 至 10 表示，0 表示您没有疼痛，5

表示有十分痛，10 表示痛到死，依据您感受的疼痛情况选择从 0 到 10 的数字表

示您的疼痛强度。请您记录每次心绞痛发作持续的时间（分钟）和每天硝酸甘

油或其它抗心绞痛药物使用的次数及数量（片/粒数）。

10

痛到死

9

痛摧肺腑

8

剧痛

7

不可忍受

6

难以形容

5

十分痛

4

好痛

3

可以忍受

2

颇痛

1

微痛

0 不痛

605

日期

心绞痛情况

合计*

星期一星期二星期三星期四星期五星期六星期日

心绞痛发作次数

心绞痛的强度 (0-10)

每次心绞痛发作持续

的时间（分钟）

每天含服硝酸甘油或

其它抗心绞痛药物的

片数

注释：*合计时心绞痛的强度算平均每次心绞痛疼痛的强度

606

第六部分生活质量调查问卷

西雅图心绞痛问卷

1．下列是一般人在一周当中经常进行的活动。虽然对某些有严重疾病的患者，

他们的日常活动受到限制的原因很难确定，请就下列的活动，指出您在过去 4

星期中，因为胸痛、胸闷、或心绞痛而受到限制的程度。

（请在每一行相应的□内打“√”）

有极

大限

制

有较

大限

制

有一

些限

制

有很

少限

制

没有

任何

限制

因其他原因受限

制或没有进行此

活动

自己穿衣服 □ □ □ □ □ □

在室内的平地行走 □ □ □ □ □ □

淋浴 □ □ □ □ □ □

上小山坡或上一层楼梯

而中途不休息 □ □ □ □ □ □

整理花园、吸尘或提携

杂物 □ □ □ □ □ □

快速地走一个街口以上 □ □ □ □ □ □

跑步或慢跑 □ □ □ □ □ □

提起或移动重物（如家

具、小孩） □ □ □ □ □ □

参与激烈运动（如游泳

和打网球） □ □ □ □ □ □

2．与 4 星期前比较，当您进行最激烈的活动时，胸痛、胸闷或心绞痛等情形有

多常发生？

更常发生较常发生大致一样较少发生更少发生过去四星期中从

未发生胸痛

□ □ □ □ □ □

607

3．在过去 4 星期中，平均而言，您曾发生过几次胸痛、胸闷或心绞痛？

我发生过胸痛、胸闷或心绞痛„„

每天 4 次

或以上

每天

1-3 次

每星期 3 次或以

上，但不是每天

发生

每星期

1-2 次

每星期少

于 1 次

过去四星期

中从未发生

□ □ □ □ □ □

4．在过去 4 星期中，平均而言，您曾因胸痛、胸闷或心绞痛而服用过几次舌下

含片（如硝化甘油粒或救心药）或其它抗心绞痛药物？

我曾服用过几次舌下含片„„

每天 4 次

或以上

每天

1-3 次



服用

每星期

1-2 次

每星期少

于 1 次

过去四星期

中从未服用

□ □ □ □ □ □

5. 服用医生所开给您治疗胸痛、胸闷或心绞痛的药物会对您造成多少困扰？

有极大困

扰

有较大困

扰

有一些困

扰

有很少困

扰

没有任何

困扰

医生没开

处方

□ □ □ □ □ □

6．对于您的胸痛、胸闷或心绞痛的所有治疗，您的满意度如何？

完全不满意大多不满意有些满意大多满意非常满意

□ □ □ □ □

608

7．对于您的医生曾向您解释说明有关您的胸痛、胸闷或心绞痛情形，您的满意

度如何？


□ □ □ □ □

8．总的来说，对于目前您胸痛、胸闷或心绞痛等的治疗情形，您的满意度如

何？


□ □ □ □ □

9．过去 4 星期中，因为胸痛、胸闷或心绞痛而影响您享受生活的程度有多大？

极大影响

我的生活享受

较大影响

我的生活享受

有一些影响

我的生活享受

很少影响

我的生活享受

没有任何影响

我的生活享受

□ □ □ □ □

10．假如在您今后的生活中胸痛、胸闷或心绞痛的状况与现在一样，您对此的

感觉如何？


□ □ □ □ □

11．您有多常想到或担心您可能会心脏病发作和突然死亡？

我无法停止想

到或担心

我经常想到

或担心

我有时会想

到或担心

我很少想

到或担心

我从未想到

或担心

□ □ □ □ □

609

健康状况调查问卷（SF-36）

下面的问题是询问您对自己健康状况的看法、您的感觉如何以及您进行日常活

动的能力如何。如果您没有把握如何回答问题，尽量作一个最好的答案，并在

您认为最适合您的答案上打一个“√”。

1．总体来讲，您目前的健康状况是：

非常好

很好

好

一般

差

2．跟一年前相比，您觉得您现在的健康状况是：

比一年前好多了

比一年前好一些

和一年前差不多

比一年前差一些

比一年前差多了

健康和日常活动

3．以下这些问题都与日常活动有关。您目前的健康状况是否限制了这些活动？

如果有限制，程度如何？

有很多

限制

有一点

限制

根本没

限制

⑴重体力活动（如跑步、搬重物、激烈活动等）

⑵一般体力活动（如移桌子、扫地、做操等）

⑶手提日杂用品（如买菜、购物等）

⑷上几层楼梯

610

⑸上一层楼梯

⑹弯腰、屈膝、下蹲

⑺步行 1500 米左右的路程

⑻步行 800 米左右的路程

⑼步行约 100 米的路程

⑽自己洗澡、穿衣

4．在过去四个星期里，您的工作和日常活动有没有因为身体健康的原因而出现

以下这些问题？

有没有

⑴减少了工作或其他活动的时间

⑵本来想要做的事情只能完成一部分

⑶想要做的工作与活动的种类受到限制

⑷完成工作或其他活动有困难（比如：感到格外吃力）

5．在过去四个星期里，您的工作和日常活动有没有因为情绪问题（如感到消沉

或者忧虑）的原因而出现以下问题？

有没有



⑶工作或从事其他活动时不如平时仔细

6．在过去四个星期里，您的身体健康状况或情绪不好在多大程度上影响了您与

家人、朋友、邻居或单位同事的正常社交活动？

根本没有影响

很少有影响

有中度影响

有较大影响

有极大影响

611

7．在过去四个星期里，您有身体上的疼痛吗？

根本没有疼痛

有很轻微疼痛

有轻微疼痛

有中度疼痛

有严重疼痛

有很严重疼痛

8．在过去四个星期里，您身体上的疼痛影响您的正常工作吗？（包括上班和家

务活动等）？

根本没有影响

有一点影响

有中度影响

有较大影响

有极大影响

您的感觉

9．以下这些问题有关过去一个月里您的感觉如何以及您的情况如何。（对每一

条问题，请钩出最接近您的感觉的那个答案）

在过去一个月里持续的时间所有的

时间

绝大部

分时间

比较多

时间

一部分

时间

小部分

时间

没有此

感觉

⑴您觉得生活充实吗？

⑵您感到精神紧张吗？

⑶您感到垂头丧气，什么事

情都不能使您振作起来吗？

⑷您感到心平气和吗？

⑸您感到精力充沛吗？

⑹您感到情绪低落吗？

⑺您感到精疲力竭吗？

612

⑻您感到快乐吗？

⑼您感到疲乏吗？

⑽您的健康限制了您的社交

活动（如走亲访友）吗？

10．请对下面的每一句话，选出最符合您情况的答案？

（每一横行只打一个钩）

绝对

正确

部分

正确

不能

肯定

大部分

错误

绝对

错误

⑴我好像比别人容易生病

⑵我和我认识的人一样健康

⑶我感到我的健康状况在变坏

⑷我的健康状况非常好

613

Appendix XIII Scoring Instructions – Chinese Version

第一部分规律身体活动之变动时期问卷计分和统计说明

规律身体活动之变动时期问卷可以用三种统计方法来处理：① 在每个数

据收集的阶段（如：T0, T1, T2 和 T3），对每个规律身体活动之变动时期的分布

情况，可以用频数进行统计。由于五个时期（前意向期、意向期、准备期、行

动期和维持期）之间是等级资料，本研究中有三个组（对照组、一般健康教育

组和时期匹配运动干预组），所以组间比较可以应用秩和检验（K-W test）进

行分析，组内比较可以用 M 检验（Friedman test）进行分析。② 将干预后或随

访时的规律身体活动之变动时期的变动情况与干预前比较，将其数据看成是计

数资料，即如果个体干预后向前移动一个时期或以上（如：从前意向期向意向

期移动或行动期移动）则为进步；如果个体干预后向后或倒退一个时期或以上

（如：从意向期向前意向期移动或行动期向前意向期移动）则为退步；如果个

体干预后运动时期没有改变则为稳定。可以用频数进行统计，然后组间比较可

以应用秩和检验（K-W test）进行分析，组内比较可以用 M 检验（Friedman

test）进行分析。 ③ 干预前后的规律身体活动之变动时期的效果变成计量资料

来分析，即如果个体干预后向前移动一个时期（如：从前意向期向意向期移动

或意向期向行动期移动）得 1 分；如果个体干预后向前移动两个时期（如：从

前意向期向行动期移动）得 2 分，以此类推。如果个体干预后向后或倒退一个

时期（如：从意向期向前意向期移动或行动期向意向期移动）得负 1 分；如果

倒退两个时期（如：从行动期向前意向期移动）得负 2 分，以此类推。最后可

以做均数分析。对 T1 (T1-T0), T2 (T2-T0) 和 T3 (T3-T0) 的得分，用单因素方差分

析或 K-W 非参数检验（如果数据不呈正态分布或方差齐性不齐）。组内不同时

间点的比较可用重复测量的方差分析或 M 检验（Friedman test）进行分析。

(Nigg, 2002, cited in G.J. Welk (Ed)).

614

第二部分运动自我效能量表计分和统计说明

运动自我效能量表包括 18 条条目，每条条目的得分介于 0 分（完全不能

做）至 100 分（肯定能做）之间。可以将运动自我效能量表中每一条条目所得

分数相加，求得总分。总分范围是 0 分至 1800 分。分数越高说明越有信心执行

规律的身体活动。该数据是计量资料，可以求得均分，然后应用双因素重复测

量的方差分析进行检验组内和组间得分的差异。如果数据呈正态分布并且方差

齐性检验齐的话，每个时间点的组间之间比较用单因素方差分析（如 T0, T1, T2

和 T3），每个组内不同时间点的比较可用重复测量的方差分析。如果数据不呈

正态分布或方差齐性检验不齐的话，则每个时间点的组间之间比较用非参数的

秩和检验(K-W test)，每个组内不同时间点的比较可用 M 检验 (Friedman test)。

第三部分运动益处和障碍量表计分和统计说明

运动益处和障碍量表可以作为一个总量表或分成两个次量表，即运动益

处量表和运动障碍量表。该量表的每条条目有四个等级的答案，即从非常同意

（4）至非常不同意（1）。如果该量表作为一个总量表来看，则运动障碍量表

条目的计分是反向得分，即非常同意得 1 分，非常不同意得 4 分。

丢失数据可以有两种方法处理：如果超过 5%的条目没有回答，则建议将

这份问卷丢弃；如果少于 5%的条目没有回答，则用中位数代替丢失的数据以防

错误的低得分。

该量表总体得分介于 43 至 172 分之间。分数越高说明个体越感觉运动有

好处。当两个量表单独使用时，运动益处量表的得分介于 29 至 116 分之间，运

动障碍量表的得分介于 14 至 56 分之间。如果两个量表单独使用，运动障碍量

表的计分不需要反向计分，这时，运动障碍量表的分数越高，说明个体感受到

的运动障碍越大。

在本研究中，运动益处和障碍量表作为两个次量表来用。两个次量表的

得分分开来计算。该数据是计量资料，可以求得均分，然后应用双因素重复测

量的方差分析进行检验组内和组间得分的差异。如果数据呈正态分布并且方差

615

齐性检验齐的话，每个时间点的组间之间比较用单因素方差分析（如 T0, T1, T2

和 T3），每个组内不同时间点的比较可用重复测量的方差分析。如果数据不呈

正态分布或方差齐性检验不齐的话，则每个时间点的组间之间比较用非参数的

秩和检验(K-W test)，每个组内不同时间点的比较可用 M 检验 (Friedman test)。

第四部分身体活动自我报告与自我评价日志计分和统计说明

1．身体活动时间：计算在过去一周里，进行任何有计划/有目的（为增强健康

而进行的）的活动时间和中等强度活动的时间。中等强度活动的时间是依据

病人进行中等强度活动例子表格中活动的时间来算。该数据是计量资料，可

以求得均分，然后应用双因素重复测量的方差分析进行检验组内和组间得分

的差异。如果数据呈正态分布并且方差齐性检验齐的话，每个时间点的组间

之间比较用单因素方差分析（如 T0, T1, T2 和 T3），每个组内不同时间点的

比较可用重复测量的方差分析。如果数据不呈正态分布或方差齐性检验不齐

的话，则每个时间点的组间之间比较用非参数的秩和检验(K-W test)，每个

组内不同时间点的比较可用 M 检验 (Friedman test)。

2．抗心绞痛药物使用的次数和片数或粒数：计算在过去一周里，因为运动或身

体活动出现胸痛、胸闷或心绞痛而服用任何抗心绞痛药物的次数和数量（片

/粒），例如：硝酸甘油、麝香保心丸、丹参滴丸或速效救心丸的次数和片/

粒数。虽然这几种药物都具有抗心绞痛作用，但这几种药物的服用方法的和

使用剂量不同，不能进行简单的服用片数或粒数进行比较。根据病人是否服

用抗心绞痛的药物，可将数据视为分类资料。进行频数统计，然后用卡方检

验进行统计分析。对于抗心绞痛药物使用的次数可视为计量资料，根据数据

是否呈正态分布和方差齐性与否，每个时间点（如 T0, T1, T2 和 T3）的组间

之间比较用单因素方差分析或用非参数的秩和检验(K-W test)，每个组内不

同时间点的比较用重复测量的方差分析或 M 检验 (Friedman test)。

非

常

轻

松

616

第五部分心绞痛自我报告和自我评价日志计分和统计说明

1．心绞痛发作次数（次数/周）：计算在过去的一周里，病人心绞痛发作的次

数。该数据是计量资料，根据数据是否呈正态分布和方差齐性与否，每个时

间点（如 T0, T1, T2 和 T3）的组间之间比较用单因素方差分析或用非参数的

秩和检验(K-W test)，每个组内不同时间点的比较用重复测量的方差分析或

M 检验 (Friedman test)。

2．心绞痛的强度（0-10）：根据疼痛评估量表，心绞痛疼痛的强度用从 0 至 10

表示，0 表示您没有疼痛，5 表示有十分痛，10 表示痛到死。如果患者选微

痛，计 1 分；选颇痛计 2 分；依此类推。计算在过去的一周里，平均每次心

绞痛疼痛的强度。该数据是计量资料，根据数据是否呈正态分布和方差齐性

与否，每个时间点（如 T0, T1, T2 和 T3）的组间之间比较用单因素方差分析

或用非参数的秩和检验(K-W test)，每个组内不同时间点的比较用重复测量

的方差分析或 M 检验 (Friedman test)。

3．心绞痛发作的时间（分钟/周）：计算在过去的一周里，心绞痛发作的总的

时间，即一周内每次心绞痛发作时间的总和。该数据是计量资料，根据数据

是否呈正态分布和方差齐性与否，每个时间点（如 T0, T1, T2 和 T3）的组间

之间比较用单因素方差分析或用非参数的秩和检验(K-W test)，每个组内不

同时间点的比较用重复测量的方差分析或 M 检验 (Friedman test)。

4．根据病人是否出现心绞痛，可将数据视为分类资料。进行频数统计，然后用

卡方检验进行各个时间点（如 T0, T1, T2 和 T3）组间统计分析，用 Cochran‘s

Q 检验进行组内比较。

5．抗心绞痛药物的使用：计算在过去的一周里，使用抗心绞痛药物的片数或粒

数。例如：硝酸甘油、麝香保心丸、丹参滴丸或速效救心丸的次数和片/粒

数。虽然这几种药物都具有抗心绞痛作用，但这几种药物的服用方法的和使

用剂量不同，不能进行简单的服用片数或粒数进行比较。根据病人是否服用

抗心绞痛的药物，可将数据视为分类资料。进行频数统计，然后用卡方检验

进行各个时间点（如 T0, T1, T2 和 T3）组间统计分析，用 Cochran‘s Q 检验进

行组内比较。

617

第六部分西雅图心绞痛问卷计分说明

西雅图心绞痛问卷包括以下五个部分：

A. 躯体受限

躯体受限次量表的得分是对应问题1a 至 1i 。1a 至1i 答案数字编码如下：

1 = 有极大限制

2 = 有较大限制

3 = 有一些限制

4 = 有很少限制

5 = 没有任何限制

6 = 因其他原因受限制或没有进行此活动

如果1a 至1i 的回答不是1、2、3、4或5，那么该条目被当作丢失。值得

一提的是，当回答是6时也被认为是丢失。丢失的数据用该活动水平的平均值来

代替。活动被分为三层活动水平。最低层包括穿衣、走路和淋浴（1a, 1b 和

1c）；中间层是爬坡或爬楼梯、整理花园和快速地走一个街口以上（1d, 1e 和

1f）; 最高层是慢跑、提重物和激烈运动（1g, 1h 和1i）。如果一组中任何一条

条目丢失，那么用该组中其它条目的均值来代替。如果所以最低或最高层的条

目都丢失，则用中间层的均数值来代替。如果中间层的所以条目都丢失，则用

最高层和最低层和的均数值来代替。如果该躯体受限次量表中有4条以上的条目

的数字丢失，那么就没有合理的计算方法来代替丢失值。计算丢失值以后，躯

体受限次量表的得分为标准化的9条条目平均值，计算方式如下：

躯体受限 = 100*(平均值 – 1)/4

B. 心绞痛稳定性

心绞痛稳定性的得分对应于问题2。问题2的答案数字编码如下：

1 = 更常发生

618

2 = 较常发生

3 = 大致一样

4 = 较少发生

5 = 更少发生

6 = 过去四星期中从未发生胸痛

如果答案为6（过去四星期中从未发生胸痛）则设置为答案3（大致一

样）相同。假如没有回答，那心绞痛的稳定性则无法计算，将被认为是丢失。

否则，心绞痛稳定性的标化计算方式如下：

心绞痛稳定性 = 100*(答案的相应编码 – 1)/4

C. 心绞痛频率

心绞痛频率得分对应于问题3和4。根据健康状况的改善，答案按顺序相

应地被编码为1至6，1为健康状况最差。如果至少有一条条目回答，则心绞痛的

频率标化计算方式如下：

心绞痛频率 = 100*(平均值 – 1)/5

D. 治疗满意度

治疗满意度的得分对应于问题5、6、7和8。根据健康状况的改善，答案

按顺序相应地被编码为1至6，1为健康状况最差。如果问题5、6、7和8的回答不

是1、2、3、4或5，那么该问题视为丢失。值得注意的是，如果问题5的回答是

6，那么也被视为丢失。假如至少有两个条目有回答，那么治疗满意度的标化计

算方式如下：

治疗满意度 = 100*(平均值 – 1)/4

619

E. 生活质量

生活质量的得分对应于问题9、10和11。根据健康状况的改善，答案按顺

序相应地被编码为1至5，1为健康状况最差。如果问题9、10和11的回答不是1、

2、3、4或5，则被认为是丢失。假如至少有两个条目有回答，那么生活质量的

标化计算方式如下：

生活治疗 = 100*(平均值 – 1)/4

第七部分 SF-36计分说明

1. SF-36的内容与结构

2. SF-36计分方法：

2.1 基本步骤

2.2 关于缺失值的处理

2.3 健康状况各方面得分及换算

1. SF-36的内容与结构

SF-36 是美国波士顿健康研究所研制的简明健康调查问卷，被广泛应用

于普通人群的生存质量测定、临床试验效果评价以及卫生政策评估等领域。SF-

36 作为简明健康调查问卷，它从生理机能、生理职能、躯体疼痛、一般健康状

况、精力、社会功能、情感职能以及精神健康等8 个方面全面概括了被调查者

的生存质量。

1.1 生理机能（PF：Physical Functioning）：测量健康状况是否妨碍了正常的生

理活动。用第3 个问题来询问PF。

1.2 生理职能（RP：Role-Physical）：测量由于生理健康问题所造成的职能限

制。

1.3 躯体疼痛（BP：Bodily Pain）：测量疼痛程度以及疼痛对日常活动的影响。

620

1.4 一般健康状况（GH：General Health）：测量个体对自身健康状况及其发展

趋势的评价。

1.5 精力（VT：Vitality）：测量个体对自身精力和疲劳程度的主观感受。

1.6 社会功能（SF：Social Functioning）：测量生理和心理问题对社会活动的数

量和质量所造成的影响，用于评价健康对社会活动的效应。

1.7 情感职能（RE：Role-Emotional）：测量由于情感问题所造成的职能限制。

1.8 精神健康（MH：Mental Health）：测量四类精神健康项目，包括激励、压

抑、行为或情感失控、心理主观感受。

除了以上8个方面外，SF-36 还包含另一项健康指标：健康变化（HT：Reported

HealthTransition），用于评价过去一年内健康状况的总体变化情况。

2. SF-36计分方法：

2.1 基本步骤：第一步，量表条目编码；

第二步，量表条目计分；

第三步，量表健康状况各个方面计分及得分换算。得分换算的基本公式

为：

换算得分 = 实际得分 - 该方面的可能的最低得分

.100 该方面的可能的最高得分与最低得分之差

2.2 关于缺失值的处理：有时应答者没有完全回答量表中所有的问题条目，我们

把没有答案的问题条目视为缺失。我们建议在健康状况的各个方面所包含的多

个问题条目中，如果应答者回答了至少一半的问题条目，就应该计算该方面的

得分。缺失条目的得分用其所属方面的平均分代替。

2.3 健康状况各方面得分及换算：

621

2.3.1 生理机能（PF：Physical Functioning）

问题条目：3

(1) 重体力活动(如跑步、举重物、激烈运动等)

(2) 适度活动(如移桌子、扫地、做操等)

(3) 手提日杂用品（如买菜、购物等）

(4) 上几层楼梯

(5) 上一层楼梯

(6) 弯腰、曲膝、下蹲

(7) 步行1500米左右的路程

(8) 步行800米左右的路程

(9) 步行约100米的路程

(10) 自己洗澡、穿衣

条目编码及计分

答案条目编码条目计分

有很多限制

有一点限制

根本没限制

1

2

3

1

2

3

方面计分及换算

将各个条目得分相加得实际得分，再按下式算得最终得分PF。PF得分越高，健

康状况越好。

PF = 实际得分-10

.100 20

2.3.2 生理职能（RP：Role-Physical）

问题条目：4

(1) 减少了工作或其他活动的时间

(2) 本来想要做的事情只能完成一部分

622

(3) 想要做的工作或活动的种类受到限制

(4) 完成工作或其他活动有困难 (比如，需要额外的努力)

条目编码及计分


有

没有

1

2

1

2


将各个条目得分相加得实际得分，再按下式算得最终得分RP。RP 得分越高，

健康状况越好。

RP = 实际得分-4

.100 4

2.3.3 躯体疼痛（BP：Bodily Pain）

问题条目：7，8

7. 在过去四个星期里, 您有身体上的疼痛吗?

8. 在过去四个星期里, 身体上的疼痛影响您的正常工作吗（包括上班工作和家务

活动）?

条目7的编码及计分


根本没有疼痛

有很轻微疼痛

有轻微疼痛

有中度疼痛

有严重疼痛

有很严重疼痛

1

2

3

4

5

6

6.0

5.4

4.2

3.1

2.2

1.0

条目8的编码及计分-----如果对条目7和8均做了回答

623

答案如果条目8的编码为且条目7的编码为那么条目8的计

分为

根本没有影响 1 1 6

根本没有影响 1 2 至 6 5

有一点影响 2 1 至 6 4

有中度影响 3 1 至 6 3

有较大影响 4 1 至 6 2

有极大影响 5 1 至 6 1

条目8的编码及计分-----如果对条目7没有做回答


根本没有影响 1 6.0

有一点影响 2 4.75

有中度影响 3 3.5

有较大影响 4 2.25

有极大影响 5 1.0


将各个条目得分相加得实际得分，再按下式算得最终得分BP。BP 得分越高，


BP = 实际得分-2

.100 10

2.3.4 一般健康状况（GH：General Health）

问题条目：1，10

1. 总体来讲, 您的健康状况是

10.1 我好象比别人容易生病

10.2 我跟我认识的人一样健康

10.3 我认为我的健康状况在变坏

624

10.4 我的健康状况非常好

条目1&10.1-10.4的编码及计分

问题条目1 答案条目编码条目计分

非常好 1 5.0

很好 2 4.4

好 3 3.4

一般 4 2.0

差 5 1.0

问题条目10.1，

10.3 答案条目编码条目计分

绝对正确 1 1

大部分正确 2 2

不能肯定 3 3

大部分错误 4 4

绝对错误 5 5

问题条目10.2，

10.4 答案条目编码条目计分

绝对正确 1 5

大部分正确 2 4

不能肯定 3 3

大部分错误 4 2

绝对错误 5 1


将各个条目得分相加得实际得分，再按下式算得最终得分GH。GH 得分越高，


GH = 实际得分-5

.100 20

625

2.3.5 精力（VT：Vitality）

问题条目：9.1，9.5，9.7，9.9

9.1 您觉得生活充实吗？

9.5 您精力充沛吗？

9.7 您觉得筋疲力尽吗？

9.9 您感觉疲劳吗？

条目的编码及计分

问题条目9.1，9.5 答案条目编码条目计分

所有的时间 1 6

大部分时间 2 5

比较多时间 3 4

一部分时间 4 3

小部分时间 5 2

没有此感觉 6 1


所有的时间 1 1

大部分时间 2 2

比较多时间 3 3

一部分时间 4 4

小部分时间 5 5

没有此感觉 6 6


将各个条目得分相加得实际得分，再按下式算得最终得分VT。VT得分越高，


VT = 实际得分-4

.100 20

626

2.3.6 社会功能（SF：Social Functioning）

问题条目：6，9.10

6. 在过去的四个星期里, 您的身体健康或情绪不好在多大程度上影响了您与家

人、朋友、邻居或集体的正常社交活动?

9.10 您的健康限制了您的社交活动(如走亲访友)吗？


问题条目6 答案条目编码条目计分

根本没有影响 1 5

很少有影响 2 4

有中度影响 3 3

有较大影响 4 2

有极大影响 5 1

问题条目9.10 答案条目编码条目计分

所有的时间 1 1

大部分时间 2 2

比较多时间 3 3

一部分时间 3 3

小部分时间 4 4

没有此感觉 5 5


将各个条目得分相加得实际得分，再按下式算得最终得分SF。SF得分越高，健

康状况越好。

SF = 实际得分-2

.100 8

627

2.3.7 情感职能（RE：Role-Emotional）

问题条目：5

(1) 减少了工作或其它活动的时间

(2) 本来想要做的事情只能完成一部分

(3) 做工作或其它活动不如平时仔细



有 1 1

没有 2 2


将各个条目得分相加得实际得分，再按下式算得最终得分RE。RE 得分越高，


RE = 实际得分-3

.100 3

2.3.8 精神健康（MH：Mental Health）

问题条目：9.2，9.3，9.4，9.6，9.8

9.2 您是一个精神紧张的人吗？

9.3 您感到垂头丧气，什么事都不能使您振作起来吗？

9.4 您觉得平静吗？

9.6 您的情绪低落吗？

9.8 您是个快乐的人吗？


问题条目9.2，

9.3，9.6 答案条目编码条目计分

所有的时间 1 1

大部分时间 2 2

628

比较多时间 3 3

一部分时间 4 4

小部分时间 5 5

没有此感觉 6 6


所有的时间 1 6

大部分时间 2 5

比较多时间 3 4

一部分时间 4 3

小部分时间 5 2

没有此感觉 6 1


将各个条目得分相加得实际得分，再按下式算得最终得分MH。MH得分越高，


MH = 实际得分-5

.100 25

2.3.9 健康变化（HT：Reported Health Transition）

问题条目：2

2. 跟一年前相比, 您觉得您现在的健康状况是:


答案条目编码

比一年前好多了 1

比一年前好一些 2

和一年前差不多 3

比一年前差一些 4

比一年前差多了 5

（中山医科大学公共卫生学院卫生统计学教研室方积乾、郝元涛, 2009）

629

Appendix XIV Training Package – Chinese Version

教练包

这个教练包是介绍如何训练研究助理收集数据。主要包括两个步骤：（1）研究

者和研究助理一起过目每一个条目，并解释每个条目的意思和如何使用指导

语，以便研究对象能更好的理解和填写问卷；（2）角色扮演：选择 1-2 个人扮

演病人，研究者作为观众，研究助理根据问卷上的条目一一询问“病人”来收

集数据。对有异议的地方，研究者及时给以更正和解释，以确保每条条目尽量

使用统一的指导语。

首先，作为数据收集者必须明白每个量表使用的目的、每个量表中每条条目的

意思以及每个量表使用的注意事项。以下我们一一来介绍每个量表。

630

第一部分规律身体活动之变动时期问卷

说明：

规律身体活动之变动时期问卷是用来评估病人目前的运动行为处于哪个

时期。其中：

1．中等强度身体活动：是指代谢当量为3-6代谢当量（MET）的活动，如：站在

河边钓鱼（3.5MET）（具体参见中等强度活动的例子）。

2．规律的身体活动：是指任何有计划/有目的（为增强健康而进行的）的活

动。这种活动必须累积每天至少30分钟（每次至少10分钟）的中等强度身体活

动，每星期至少五天。

3．不同运动时期的定义

（1）意向前期：是指个体目前没有进行任何运动，并且不打算在未来的六个

月里开始运动。

（2）意向期：是指个体已经意识到久坐行为是有问题的，而且他/她认真地考

虑在未来的六个月里开始运动。

（3）准备期：是指个体打算在未来的30天里采取行动，改变静坐的习惯，或

个体已经开始一些运动，但不规律。

（4）行动期：是指个体改变他（她）的行为、体验或环境来克服他的问题；

他已经成功地进行规律运动少于6个月。

（5）维持期：是指个体已经维持规律运动6个月以上。

4．问卷中：1 =意向前期，2 = 意向期，3 = 准备期，4 = 行动期，5 = 维持期

5．决定运动/身体活动变化之时期的方法（见图 1）

研究助理用图 1 的流程图来评估病人目前的运动时期。当问到“您是否每周绝

大多数时间（5 天或以上）累积做每天至少 30 分钟的中等强度活动？”时，研

究助理要出示中等强度活动例子的表格给病人，问他/她是否进行表格中所列的

631

活动或与表格中所列的活动量相当的活动（3-6METs）。值得一提的是，病人

所进行的这些活动必须是为了增强身体健康而进行的有目的的运动，若是为了

家庭或工作责任而进行的活动，则不计算在内。此外，每天累计做至少 30 分钟

的中等强度活动，其中每回的活动时间必须 10 分钟以上方有效。

改变意愿

您是否每周绝大多数时间（5 天或以上）累

积做每天至少 30 分钟的中等强度运动？

您是否累积每周做至少

30 分钟的中等强度运动？

在过去的 6 个月里，您是

否曾做过规律的运动？

您愿意增加您的

体力活动？

如果您偶尔做运动，

那您是处于准备期。

如果您坚持运动，但

少于 6 个月，那您是

处于行动期

如果您维持这种新

行为 6 个月以上，

那您是处于维持期

如果您从未考虑

过，那您是处于意

向前期

如果您曾考虑过，但

还没开始行动，那您

是处于意向期

否是

是

是

是

否否

否

图 1 决定运动时期的流程图 (Marcus, Forsyth & Blair, 2003)

632

第二部分运动自我效能量表

说明：

1．由于很多状况可能会影响您维持或进行规律的身体活动，运动自我效能量表

是用来测量假设您遇到以下 18 种情况（量表的内容）时，您有多少信心执行规

律的身体活动。0 表示完全不能做或完全没有信心做，100 表示肯定能做或肯定

有信心做，50 表示中度肯定能做（如下刻度）。从 0 到 100 分，将符合您情况

的数值填在横线上。

0 10 20 30 40 50 60 70 80 90 100

完全不能做中度肯定能做肯定能做

2．量表上每个指标使用的指导语

（1）当我觉得疲劳时：当您觉得疲劳时，您有多少信心完成每周五次或五次以

上的规律身体活动？从 0 至 100 分选一个数字表示您能执行的信心程度。

0 表示完全不能做或完全没有信心做，100 表示肯定能做或肯定有信心

做。

（2）当我觉得工作有压力时：当您觉得工作上有压力时，您有多少信心完成每

周五次或五次以上的规律身体活动？从 0 至 100 分选一个数字表示您能执

行的信心程度。

（3）天气不好时：当天气不好时（如下雨、太冷或太热），您有多少信心完成

每周五次或五次以上的规律身体活动？从 0 至 100 分选一个数字表示您能

执行的信心程度。

（4）因受伤停止了运动，等损伤愈合后：如果您因为身体受伤停止了运动，那

损伤愈合后，您有多少信心完成每周五次或五次以上的规律身体活动？从

0 至 100 分选一个数字表示您能执行的信心程度。

（5）正在经历或刚经历了个人问题后：如果您正在经历或刚经历了个人问题

（如：感情或婚姻问题）之后，您有多少信心完成每周五次或五次以上的

规律身体活动？从 0 至 100 分选一个数字表示您能执行的信心程度。

633

（6）当我觉得沮丧时：当您觉得沮丧（灰心失望）时，您有多少信心完成每周

五次或五次以上的规律身体活动？从 0 至 100 分选一个数字表示您能执行

的信心程度。

（7）当我觉得焦虑时：当您觉得焦虑时，您有多少信心完成每周五次或五次以

上的规律身体活动？从 0 至 100 分选一个数字表示您能执行的信心程度。

（8）因疾病而使我停止运动康复后：如果您因为疾病（如：感冒）而停止运动

（或规律身体活动），等疾病康复后，您有多少信心完成每周五次或五

次以上的规律身体活动？从 0 至 100 分选一个数字表示您能执行的信心程

度。

（9）当我运动觉得不舒服时：当您运动（或规律身体活动）觉得不舒服时，您

有多少信心完成每周五次或五次以上的规律身体活动？从 0 至 100 分选一

个数字表示您能执行的信心程度。

（10）在假期后：在假期（如度假、节假日、过年、过节）后，您有多少信心

完成每周五次或五次以上的规律身体活动？从 0 至 100 分选一个数字表示

您能执行的信心程度。

（11）当我在家里有太多工作要做时：当您在家里有太多工作（或事情）要做

时，您有多少信心完成每周五次或五次以上的规律身体活动？从 0 至 100

分选一个数字表示您能执行的信心程度。

（12）当有客人来访时：当您家里有客人来访时，您有多少信心完成每周五次

或五次以上的规律身体活动？从 0 至 100 分选一个数字表示您能执行的信

心程度。

（13）当有其他有趣的事情要做时：当您有其他有趣的事情（您感兴趣的事

情，如：看电视节目）要做时，您有多少信心完成每周五次或五次以上的

规律身体活动？从 0 至 100 分选一个数字表示您能执行的信心程度。

（14）如果我没有达到自己的运动目标时：如果您没有达到自己的运动目标

（每周至少五次以上的运动）时，您有多少信心完成每周五次或五次以上

的规律身体活动？从 0 至 100 分选一个数字表示您能执行的信心程度。

（15）没有我的家人和朋友的支持时：如果您的家人和朋友都不支持时，您有

多少信心完成每周五次或五次以上的规律身体活动？从 0 至 100 分选一个

数字表示您能执行的信心程度。

634

（16）在假期中：如果您正在度假（如，旅游、出游等）或正在节假日、过年

过节中，您有多少信心完成每周五次或五次以上的规律身体活动？从 0 至

100 分选一个数字表示您能执行的信心程度。

（17）当我有其他的事情约定时：当您有其他的事情约定时，您有多少信心完

成每周五次或五次以上的规律身体活动？从 0 至 100 分选一个数字表示您

能执行的信心程度。

（18）在经历家庭事件后：如果在您经历家庭事件（如：重大的家庭经济问题

或亲人去世等）后，您有多少信心完成每周五次或五次以上的规律身体活

动？从 0 至 100 分选一个数字表示您能执行的信心程度。

第三部分运动益处和阻碍量表

运动益处量表

说明：

1．运动益处量表是用来测量病人认为运动有什么好处。研究助理可以针对每条

叙述问病人是否同意该叙述，以及同意或不同意的程度。如果病人强烈不同意

该叙述则选 1，只是不同意选 2，同意选 3，强烈同意则选 4。


（1）我从运动得到乐趣：您是否同意您从运动中得到乐趣？是强烈（不）同

意或只是（不）同意？

（2）运动减少我紧张和压力的感觉：您是否同意运动减少您紧张和压力的感

觉？是强烈（不）同意或只是（不）同意？

（3）运动增进我的心理健康：您是否同意运动增进您的心理健康？是强烈

（不）同意或只是（不）同意？

（4）运动将预防我发生心脏病：您是否同意运动将预防您发生心脏病？是强

烈（不）同意或只是（不）同意？

（5）运动会增强我的肌肉力量：您是否同意运动会增强您的肌肉力量？是强


635

（6）运动给予我个人成就感：您是否同意运动给予您个人成就感？是强烈


（7）运动使我觉得放松：您是否同意运动使您觉得放松？是强烈（不）同意

或只是（不）同意？

（8）运动让我和我喜欢的朋友及人们有联系：您是否同意运动让您和您喜欢

的朋友及人们有联系？是强烈（不）同意或只是（不）同意？

（9）运动将使我远离高血压：您是否同意运动将使您远离高血压？是强烈


（10）运动改善我的心脏血管系统功能：您是否同意运动改善您的心脏血管系

统功能（如增强心脏功能）？是强烈（不）同意或只是（不）同意？

（11）运动增进我的身体体能的强度：您是否同意运动增进您的身体体能的强

度（如：增强体质）？是强烈（不）同意或只是（不）同意？

（12）运动增进我的肌肉结实：您是否同意运动可以增进您的肌肉结实？是强


（13）因为运动，我感觉自己比较健康：您是否同意因为运动，您感觉自己比

较健康？是强烈（不）同意或只是（不）同意？

（14）运动增进我的耐力：您是否同意运动可以增进您的耐力（即您做同一强

度的活动，可以活动的更久一点或活动的强度更大一点）？是强烈


（15）运动增进我的柔软度：您是否同意运动可以增进您的柔软度（如：活动

更灵活）？是强烈（不）同意或只是（不）同意？

（16）运动改善我的脾气：您是否同意运动可以改善您的脾气？是强烈（不）

同意或只是（不）同意？

（17）运动帮助我晚上睡的较好：您是否同意运动帮助您晚上睡的更好？是强


（18）假如我做运动，我将会活的久一点：您是否同意假如您做运动，您将会

活的久一点？是强烈（不）同意或只是（不）同意？

（19）运动帮助我减少疲劳：您是否同意运动帮助您减少疲劳？是强烈（不）

同意或只是（不）同意？

（20）运动是让我遇见新朋友的好方法：您是否同意运动是让您遇见新朋友的

636

好方法？是强烈（不）同意或只是（不）同意？

（21）运动改善我的身体持久力：您是否同意运动改善您的身体持久力（即您

做同一强度的活动，可以活动的更久一点）？是强烈（不）同意或只是

（不）同意？

（22）运动改善我对自己的想法：您是否同意运动改善您对自己的想法（改善

对自己的看法，如: 因为运动，您认为自己是一个积极者）？是强烈


（23）运动增加我心理上的警觉性：您是否同意运动增加您心理上的警觉性

（反应灵敏）？是强烈（不）同意或只是（不）同意？

（24）运动可使我做正常活动(如煮饭，购物，园艺，清洁等)时不会觉得疲

倦：您是否同意运动可使您做正常活动(如煮饭，购物，园艺，清洁等)

时不会觉得疲倦？是强烈（不）同意或只是（不）同意？

（25）运动改善我的工作品质：您是否同意运动改善您的工作品质（工作质

量）？是强烈（不）同意或只是（不）同意？

（26）运动是好的娱乐：您是否同意运动是好的娱乐？是强烈（不）同意或只

是（不）同意？

（27）运动增加其它人对我的接受度(如较喜欢与我相处，较接受我的想法

等)：您是否同意运动增加其它人对您的接受度(如较喜欢与我相处，较

接受您的想法等)？是强烈（不）同意或只是（不）同意？

（28）运动增进我整体的身体功能：您是否同意运动增进您整体的身体功能？

是强烈（不）同意或只是（不）同意？

（29）运动改善我身体的外观(如看起来较健康，较年轻等)：您是否同意运动

改善我身体的外观(如看起来较健康，较年轻等)？是强烈（不）同意或

只是（不）同意？

637

运动阻碍量表

说明：

1．运动阻碍量表是用来评估哪些因素阻碍病人进行运动。你可以针对每个叙述

问病人是否同意该叙述，以及同意或不同意的程度。如果病人强烈不同意该叙

述则选 1，只是不同意选 2，同意选 3，强烈同意则选 4。


（1）运动用掉太多我的时间：您是否同意运动会用掉太多您的时间？是强烈


（2）运动让我疲倦：您是否同意运动会使您疲倦？是强烈（不）同意或只是

（不）同意？

（3）做运动的地方离我太远：您是否同意做运动的地方离您太远？是强烈


（4）我觉得很不自在去做运动：您是否同意您觉得很不自在去做运动？是强


（5）运动要花太多的钱：您是否同意运动要花太多的钱？是强烈（不）同意

或只是（不）同意？

（6）做运动场所的时间表对我是不方便的：您是否同意做运动场所的时间表

对您是不方便的？是强烈（不）同意或只是（不）同意？

（7）运动使我觉得疲惫不堪：您是否同意运动使您觉得疲惫不堪？是强烈


（8）我的配偶(或其它重要的人)不鼓励运动：您是否同意您的配偶(或其它重

要的人)不鼓励您去运动？是强烈（不）同意或只是（不）同意？

（9）运动用掉太多家庭责任的时间(如做家务，农务，照顾生病的家人等)

：您是否同意运动用掉太多您家庭责任的时间(如做家务，农

务，照顾生病的家人等)？是强烈（不）同意或只是（不）同意？

（10）我觉得人们做运动时的衣服看起来可笑：您是否同意您觉得人们做运动

时的衣服看起来可笑？是强烈（不）同意或只是（不）同意？

（11）我的家人不鼓励我去做运动：您是否同意您的家人不鼓励您去做运动？

638

是强烈（不）同意或只是（不）同意？

（12）运动用掉太多家庭互动的时间(如与家人相处，家庭聚会等)：您是否同

意运动用掉太多家庭互动的时间(如与家人相处，家庭聚会等)？是强烈


（13）对我而言，做运动是困难的事情：您是否同意对您来说，做运动是困难

的事情？是强烈（不）同意或只是（不）同意？

（14）我能做运动的场所太少了：您是否同意您能做运动的场所太少了？是强


第四部分身体活动自我报告与自我评价表

说明：

（1）该表格用于记录研究对象在过去一周里进行中等强度体力活动的情况，

包括体力活动的种类、次数、强度、持续时间、是否发生心绞痛以及因

为体力活动额外服用抗心绞痛药物的情况？

（2）您（研究助理）可以出示中等强度活动的例子的表格给病人，问病人在

过去一周里进行了哪些体力活动？结合研究对象自我记录的身体活动情

况，将在过去一周中每天身体活动的次数，每次活动持续的时间（用分

钟表示），填写在相应的表格里。

（3）每次体力活动的强度用 Borg 自我辛苦评估指数（RPE），从 6 至 20 表

示。6 表示非常轻松（安静休息时感觉），20 表示精疲力竭。请研究对

象回忆在过去的一周里，您每次进行体力活动时感觉到的辛苦程度，选

择从 6 到 20 的数字表示您的体力活动强度，并将数字填写在相应的表格

里。

（4）同时，请研究对象回忆每次活动（运动）时是否发生心绞痛以及因为活

动（运动）需要额外服用硝酸甘油或其它抗心绞痛药物使用的片数（即

扣除平时常规服用的片数）。

639

自我辛苦评估指数

第五部分心绞痛自我报告与自我评价表

说明：

（1）该表格记录研究对象在过去一周里心绞痛发生的情况，包括心绞痛的次

数、每次疼痛的强度、持续时间、及每天服用抗心绞痛药物使用的片

数。

（2）请您（研究对象）详细回忆在过去一周里，您出现心绞痛的次数、每次

疼痛的强度、持续时间、及每天服用抗心绞痛药物使用的片数。结合研

究对象记录的情况，将这些指标记录在相应的表格里。

（3）心绞痛疼痛的强度用下列的疼痛评估量表从 0 至 10 表示，0 表示您没有

疼痛，5 表示有十分痛，10 表示痛到死，依据您感受的疼痛情况选择从

0 到 10 的数字表示您每次的疼痛强度，并填写在相应的表格里。

（4）请研究对象回忆每次心绞痛发作持续的时间（分钟）和每天硝酸甘油或

其它抗心绞痛药物使用的次数及数量（片/粒数）（每天的总片/粒数）。

很

轻

松

轻松

有

点

辛苦

辛苦

很

辛

苦

非

常

辛苦

非

常

轻松

640

10

痛到死

9

痛摧肺腑

8

剧痛

7

不可忍受

6

难以形容

5

十分痛

4

好痛

3

可以忍受

2

颇痛

1

微痛

0 不痛

第六部分生活质量调查问卷

西雅图心绞痛量表

说明：

1．西雅图心绞痛量表是冠心病特异生活质量量表，用来测量冠心病病人在过去

4 个星期中，因为心绞痛日常活动受限制的程度、心绞痛发生的频率、心绞痛

的稳定性、治疗满意度以及疾病感知的情况。


（1）下列是一般人在一周当中经常进行的活动，指出您在过去 4 星期中，因

为胸痛、胸闷、或心绞痛而活动受到限制的程度。针对每一项活动，在

每一行相应的有极大限制、有较大限制、有一些限制、有很少限制、没

有任何限制、或因其他原因受限制或没有进行此活动的□内打「√」。

641

（请在每一行相应的□内打「√」）

有极

大限

制

有较

大限

制

有一

些限

制

有很

少限

制

没有

任何

限制

因其他原因受限

制或没有进行此

活动

自己穿衣服 □ □ □ □ □ □

在室内的平地行走 □ □ □ □ □ □

淋浴 □ □ □ □ □ □

上小山坡或上一层楼梯

而中途不休息 □ □ □ □ □ □

整理花园、吸尘或提携

杂物 □ □ □ □ □ □

快速地走一个街口以上 □ □ □ □ □ □

跑步或慢跑 □ □ □ □ □ □

提起或移动重物（如家

具、小孩） □ □ □ □ □ □

参与激烈运动（如游泳

和打网球） □ □ □ □ □ □

指导语：

a. 自己穿衣服：在过去的 4 星期中，您是否有因为胸痛、胸闷、或心绞

痛而影响您自己穿衣服，若没有任何限制，则在此相应的□内打

「√」；若有受限制，那受限制的程度怎样：有极大限制、有较大限

制、有一些限制、有很少限制、或因其他原因受限制或没有进行此活

动？请选一项符合您自己的情况并在相应的□内打「√」。

b. 在室内的平地行走：在过去的 4 星期中，您是否有因为胸痛、胸闷、

或心绞痛而限制您在室内的平地行走，若没有任何限制，则在其相应

的□内打“√”；若有受限制，那受限制的程度怎样：有极大限制、

有较大限制、有一些限制、有很少限制、或因其他原因受限制或没有

进行此活动？请选一项符合您自己的情况并在相应的□内打「√」。

c. 淋浴：在过去的 4 星期中，您是否有因为胸痛、胸闷、或心绞痛而限

制您淋浴，若没有任何限制，则在其相应的□内打「√」；若有受限

642

制，那受限制的程度怎样：有极大限制、有较大限制、有一些限制、

有很少限制、或因其他原因受限制或没有进行此活动？请选一项符合

您自己的情况并在相应的□内打「√」。

d. 上小山坡或上一层楼梯而中途不休息：在过去的 4 星期中，您是否有

因为胸痛、胸闷、或心绞痛而限制您上小山坡或上一层楼梯而中途不

休息，若没有任何限制，则在其相应的□内打「√」；若有受限制，

那受限制的程度怎样：有极大限制、有较大限制、有一些限制、有很

少限制、或因其他原因受限制或没有进行此活动？请选一项符合您自

己的情况并在相应的□内打「√」。

e. 整理花园、吸尘或提携杂物：在过去的 4 星期中，您是否有因为胸

痛、胸闷、或心绞痛而限制您整理花园、吸尘或提携杂物，若没有任

何限制，则在其相应的□内打「√」；若有受限制，那受限制的程度

怎样：有极大限制、有较大限制、有一些限制、有很少限制、或因其

他原因受限制或没有进行此活动？请选一项符合您自己的情况并在相

应的□内打「√」。

f. 快速地走一个街口以上: 在过去的 4 星期中，您是否有因为胸痛、胸

闷、或心绞痛而限制您快速地走一个街口以上，若没有任何限制，则

在其相应的□内打「√」；若有受限制，那受限制的程度怎样：有极

大限制、有较大限制、有一些限制、有很少限制、或因其他原因受限

制或没有进行此活动？请选一项符合您自己的情况并在相应的□内打

「√」。

g. 跑步或慢跑: 在过去的 4 星期中，您是否有因为胸痛、胸闷、或心绞

痛而限制您跑步或慢跑，若没有任何限制，则在其相应的□内打

「√」；若有受限制，那受限制的程度怎样：有极大限制、有较大限

制、有一些限制、有很少限制、或因其他原因受限制或没有进行此活

动？请选一项符合您自己的情况并在相应的□内打「√」。

h. 提起或移动重物（如家具、小孩）: 在过去的 4 星期中，您是否有因

为胸痛、胸闷、或心绞痛而限制提起或移动重物（如家具、小孩），

若没有任何限制，则在其相应的□内打「√」；若有受限制，那受限

制的程度怎样：有极大限制、有较大限制、有一些限制、有很少限

643

制、或因其他原因受限制或没有进行此活动？请选一项符合您自己的

情况并在相应的□内打「√」。

i. 参与激烈运动（如游泳和打网球）: 在过去的 4 星期中，您是否有因

为胸痛、胸闷、或心绞痛而限制参与激烈运动（如游泳和打网球），

若没有任何限制，则在其相应的□内打「√」；若有受限制，那受限

制的程度怎样：有极大限制、有较大限制、有一些限制、有很少限

制、或因其他原因受限制或没有进行此活动？请选一项符合您自己的

情况并在相应的□内打「√」。

（2）与 4 星期前比较，当您进行最激烈的活动时，胸痛、胸闷或心绞痛等情

形有多常发生？：最近 4 个星期，当您进行最激烈的活动时，胸痛、胸

闷或心绞痛等发生的情形，与 4 星期以前进行最激烈的活动时，胸痛、

胸闷或心绞痛等发生的情形相比是：

更常发生较常发生大致一样较少发生更少发生过去四星期中从

未发生胸痛

□ □ □ □ □ □

（3）在过去 4 星期中，平均而言，您曾发生过几次胸痛、胸闷或心绞痛？

我发生过胸痛、胸闷或心绞痛„„

每天 4 次

或以上

每天

1-3 次



发生

每星期

1-2 次

每星期少

于 1 次

过去四星期

中从未发生

□ □ □ □ □ □

（4）在过去 4 星期中，平均而言，您曾因胸痛、胸闷或心绞痛而服用过几次舌

下含片（如硝化甘油粒或救心药）或其它抗心绞痛药物？

我曾服用过几次舌下含片„„

644

每天 4 次

或以上

每天

1-3 次



服用

每星期

1-2 次

每星期少

于 1 次

过去四星期

中从未服用

□ □ □ □ □ □

（5）服用医生所开给您治疗胸痛、胸闷或心绞痛的药物会对您造成多少困

扰？

有极大困

扰

有较大困

扰

有一些困

扰

有很少困

扰

没有任何

困扰

医生没开

处方

□ □ □ □ □ □

（6）对于您的胸痛、胸闷或心绞痛的所有治疗，您的满意度如何？


□ □ □ □ □

（7）对于您的医生曾向您解释说明有关您的胸痛、胸闷或心绞痛情形，您的满

意度如何？


□ □ □ □ □

（8）总的来说，对于目前您胸痛、胸闷或心绞痛等的治疗情形，您的满意度如

何？


□ □ □ □ □

645

（9）过去 4 星期中，因为胸痛、胸闷或心绞痛而影响您享受生活的程度有多

大？

极大影响

我的生活享受

较大影响

我的生活享受

有一些影响

我的生活享受

很少影响

我的生活享受

没有任何影响

我的生活享受

□ □ □ □ □

（10）假如在您今后的生活中胸痛、胸闷或心绞痛的状况与现在一样，您对此

的感觉如何？


□ □ □ □ □

（11）您有多常想到或担心您可能会心脏病发作和突然死亡？

我无法停止想

到或担心

我经常想到

或担心

我有时会想

到或担心

我很少想

到或担心

我从未想到

或担心

□ □ □ □ □

健康状况调查问卷（SF-36）

下面的问题是询问您对自己健康状况的看法、您的感觉如何以及您进行日常活

动的能力如何。如果您没有把握如何回答问题，尽量作一个最好的答案，并在

您认为最适合您的答案上打一个“√”。

1．总体来讲，您目前的健康状况是：

非常好

很好

好

一般

差

646

2．跟一年前相比，您觉得您现在的健康状况是：

比一年前好多了

比一年前好一些

和一年前差不多

比一年前差一些

比一年前差多了

健康和日常活动

3．以下这些问题都与日常活动有关。您目前的健康状况是否限制了这些活动？

如果有限制，程度如何？

有很多

限制

有一点

限制

根本没

限制

⑴重体力活动（如跑步、搬重物、激烈活动等）

⑵一般体力活动（如移桌子、扫地、做操等）

⑶手提日杂用品（如买菜、购物等）

⑷上几层楼梯

⑸上一层楼梯

⑹弯腰、屈膝、下蹲

⑺步行 1500 米左右的路程

⑻步行 800 米左右的路程

⑼步行约 100 米的路程

⑽自己洗澡、穿衣

指导语：

（1）重体力活动（如跑步、搬重物、激烈活动等）：您目前的健康状况是否

限制了您的重体力活动（如跑步、搬重物、激烈活动等）？如果有限

制，程度如何？是有很多限制还是有一点限制？

（2）一般体力活动（如移桌子、扫地、做操等）：您目前的健康状况是否限

制了您的一般体力活动（如移桌子、扫地、做操等）？如果有限制，程

度如何？是有很多限制还是有一点限制？

647

（3）手提日杂用品（如买菜、购物等）：您目前的健康状况是否限制了您手

提日杂用品（如买菜、购物等）？如果有限制，程度如何？是有很多限

制还是有一点限制？

（4）上几层楼梯：您目前的健康状况是否限制了您上几层楼梯（两层以上，

不停）？如果有限制，程度如何？是有很多限制还是有一点限制？

（5）上一层楼梯：您目前的健康状况是否限制了您上一层楼梯？如果有限

制，程度如何？是有很多限制还是有一点限制？

（6）弯腰、屈膝、下蹲：您目前的健康状况是否限制了您弯腰、屈膝、下

蹲？如果有限制，程度如何？是有很多限制还是有一点限制？

（7）步行 1500 米左右的路程：您目前的健康状况是否限制了您步行 1500 米

左右的路程？如果有限制，程度如何？是有很多限制还是有一点限制？

（8）步行 800 米左右的路程：您目前的健康状况是否限制了您步行 800 米左

右的路程？如果有限制，程度如何？是有很多限制还是有一点限制？

（9）步行约 100 米的路程：您目前的健康状况是否限制了您步行约 100 米的

路程？如果有限制，程度如何？是有很多限制还是有一点限制？

（10）自己洗澡、穿衣：您目前的健康状况是否限制了您自己洗澡、穿衣？如

果有限制，程度如何？是有很多限制还是有一点限制？

4．在过去四个星期里，您的工作和日常活动有没有因为身体健康的原因而出现

以下这些问题？

有没有



⑶想要做的工作与活动的种类受到限制

⑷完成工作或其他活动有困难（比如：感到格外吃力）

指导语：

（1）在过去四个星期里，您的工作和日常活动有没有因为身体健康的原因而

出现减少了工作或其他活动的时间。


出现本来想要做的事情只能完成一部分。

648


出现想要做的工作与活动的种类受到限制


出现完成工作或其他活动有困难（比如：感到格外吃力）

5．在过去四个星期里，您的工作和日常活动有没有因为情绪问题（如感到消沉

或者忧虑）的原因而出现以下问题？

有没有



⑶工作或从事其他活动时不如平时仔细

指导语：

（1）在过去四个星期里，您的工作和日常活动有没有因为情绪问题（如感到

消沉或者忧虑）的原因而出现减少了工作或其他活动的时间。


消沉或者忧虑）的原因而出现本来想要做的事情只能完成一部分。


消沉或者忧虑）的原因而出现工作或从事其他活动时不如平时仔细。

6．在过去四个星期里，您的身体健康状况或情绪不好在多大程度上影响了您与

家人、朋友、邻居或单位同事的正常社交活动？

根本没有影响

很少有影响

有中度影响

有较大影响

有极大影响

7．在过去四个星期里，您有身体上的疼痛吗？如果有，疼痛的程度？

根本没有疼痛

有很轻微疼痛

649

有轻微疼痛

有中度疼痛

有严重疼痛

有很严重疼痛

8．在过去四个星期里，您身体上的疼痛影响您的正常工作吗？（包括上班和家

务活动等）？

根本没有影响

有一点影响

有中度影响

有较大影响

有极大影响

您的感觉

9．以下这些问题有关过去一个月里您的感觉如何以及您的情况如何。（对每一

条问题，请钩出最接近您的感觉的那个答案）

在过去一个月里持续的时间所有的

时间

绝大部

分时间

比较多

时间

一部分

时间

小部分

时间

没有此

感觉

⑴您觉得生活充实吗？

⑵您感到精神紧张吗？

⑶您感到垂头丧气，什么事

情都不能使您振作起来吗？

⑷您感到心平气和吗？

⑸您感到精力充沛吗？

⑹您感到情绪低落吗？

⑺您感到精疲力竭吗？

⑻您感到快乐吗？

⑼您感到疲乏吗？

⑽您的健康限制了您的社交

活动（如走亲访友）吗？

650

指导语：

（1）在过去一个月里，您觉得生活充实吗？如果有，有多少时间觉得生活充

实？

（2）在过去一个月里，您感到精神紧张吗？如果有，有多少时间感到精神紧

张？

（3）在过去一个月里，您感到垂头丧气，什么事情都不能使您振作起来吗？

如果有，有多少时间感到垂头丧气，什么事情都不能使您振作起来？

（4）在过去一个月里，您感到心平气和吗？如果有，有多少时间感到心平气

和？

（5）在过去一个月里，您感到精力充沛吗？如果有，有多少时间感到精力充

沛？

（6）在过去一个月里，您感到情绪低落吗？如果有，有多少时间感到情绪低

落？

（7）在过去一个月里，您感到精疲力竭吗？如果有，有多少时间感到精疲力

竭？

（8）在过去一个月里，您感到快乐吗？如果有，有多少时间感到快乐？

（9）在过去一个月里，您感到疲乏吗？如果有，有多少时间感到疲乏？

（10）在过去一个月里，您觉得您的健康限制了您的社交活动（如走亲访友）

吗？如果有，有多少时间觉得您的健康限制了您的社交活动（如走亲访

友）？

10．请对下面的每一句话，选出最符合您情况的答案？

（每一横行只打一个钩）

绝对

正确

部分

正确

不能

肯定

大部分

错误

绝对

错误

⑴我好像比别人容易生病

⑵我和我认识的人一样健康

⑶我感到我的健康状况在变坏

⑷我的健康状况非常好

651

指导语：

（1）您是否觉得您好像比别人容易生病？正确、错误或不能肯定？绝对正确

或绝对错误？

（2）您是否觉得您和您认识的人一样健康？正确、错误或不能肯定？绝对正

确或绝对错误？

（3）您是否感到您的健康状况在变坏？正确、错误或不能肯定？绝对正确或

绝对错误？

（4）您是否觉得您的健康状况非常好？正确、错误或不能肯定？绝对正确或

绝对错误？

Copyright Undertaking - PolyU Electronic Theses

Documents

Transcript of Copyright Undertaking - PolyU Electronic Theses