Patient Education in Cardiac Rehabilitation - TSpace

Patient Education in Cardiac Rehabilitation: the role of knowledge on behavior change and its mediators

by

Gabriela Lima de Melo Ghisi

A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy

Graduate Department of Exercise Sciences University of Toronto

© Copyright by Gabriela Lima de Melo Ghisi, 2014

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Patient Education in Cardiac Rehabilitation: the role of knowledge on behavior change and its mediators

Gabriela Lima de Melo Ghisi

Doctor of Philosophy

Graduate Department of Exercise Sciences University of Toronto

2014

Abstract

The purpose of this series of studies was to investigate the relationship between patient education

and behavior change in CR and the role of knowledge on behavior change and its mediators in

the context of the Health Action Process Approach (HAPA). The first study was a systematic

review aimed to investigate the impact of education on patients’ knowledge and health behavior

change in cardiac patients. Findings from this review support the benefits of educational

interventions in CAD, through increases in patients’ knowledge and behavior change. The

second study aimed to develop and psychometrically-validate a tool to assess information needs

in CR patients. After a review by an expert panel, a pilot test, and a psychometric test in 203 CR

patients, the tool – called INCR – was demonstrated to have good reliability and validity. The

INCR was completed by 306 CR patients and 28 CR providers in the third study. Results showed

that CR patients desire information in many areas and that providers were highly cognizant of

those needs. The forth study aimed to develop and psychometrically-validate the second version

of the CADE-Q (Coronary Artery Disease Education Questionnaire), a tool to assess CR

patients’ knowledge. After a strict process, including a psychometric test in 307 CR patients, the

CADE-Q II was considered valid and reliable. Finally, the fifth study investigated: (1) changes in

knowledge and HAPA constructs among CR patients following participation in educational

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programs; and, (2) the theoretical correlates of exercise behavior change among CR patients

receiving educational interventions. There was a significant improvement in patients’ overall

knowledge, some HAPA constructs, and exercise from pre- to post-CR regardless of curriculum.

Path analysis revealed that knowledge was a significant motivational construct leading to

intention formation, and intentions to engage in physical activity were not directly related to

behavior, needing especially action planning, which was related to self-efficacy. Overall, results

from all five studies were valuable in the area of patient education in CR and showed the

importance of assessing patients’ information needs and knowledge as well as to identify

behavior determinants related to educational interventions.

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Acknowledgments

Every result described in this thesis was accomplished with the help and support of faculty,

colleagues, friends, students and family members, to whom I would like to express my gratitude.

First of all, I would like to only to thank but to dedicate this work to my husband and my very

best friend, Juliano. Your continual love, wisdom, commitment and support sustained me

throughout my phd and in my life. I feel truly blessed that you chose to share your life with me

as my partner. I love you. Thank you.

I would like to express my special appreciation and thanks to my advisors Professor Dr. Scott

Thomas and Dr. Paul Oh, whose expertise, understanding, and patience, added considerably to

my graduate experience. I would like to thank you two for encouraging my research, for giving

me freedom to pursue my independent work and never question my ability to rise to the

occasion, for believing in me and in my ideas, and for allowing me to grow as a research

scientist. Your advice on both research as well as on my career were extremely important for me

to become who I am now after four years of graduate studies. I would also like to thank my

committee members, professor Dr. Sherry Grace, professor Dr. Michale Evans, for serving as my

committee members and have generously given their time and expertise to better my work. I also

want to thank you for letting my defense be an enjoyable moment, and for your brilliant

comments and suggestions.

I am extremely grateful to the staff from the Toronto Rehabilitation Institute, including lab staff,

clinical staff, member of the Patient Education Committee, staff from the front office, other

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trainees. A special thanks to Sabrina, Trish and Priscilla for all the help and support throughout

my four years at TRI.

I would especially like to thank physicians, nurses, and nurse aids in the brain injury

rehabilitation unit at University Medical Center. All of you have been there to support me when I

recruited patients and collected data for my Ph.D. thesis.

Apart from doing research I cannot imagine how my life would be going in Canada without my

friends. Thanks to all my friends, including Andresa, Flavia, Raquel and Pauline, who supported,

enlightened and entertained me over these years.

Lastly, my great gratitude is sent to my beloved family for all their love and encouragement. For

the members of Melo, Lima and Ghisi family my special thanks to all support. For my beloved

dog Jojoe, for his love, loyalty and patience to wait for me while I was studying hard. For my

sister who always encouraged me and served as a model. For my loving, supportive, and

encouraging parents who raised me with sacrifice to provide me the best of everything, including

the best education. Your prayers and your love was what sustained me thus far. Finally, to my

father-in-law and friend Zinaldo who passed away before I finished my PhD studies: I know you

are always around to support me during the hard times and I would like to thank you for you

support and encouragement.

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Table of Contents

Acknowledgments .................................................................................................... iv!Table of Contents ..................................................................................................... vi!List of Tables ......................................................................................................... xiii!List of Figures ........................................................................................................ xvi!List of Appendices ................................................................................................ xvii!

Chapter 1 OVERALL INTRODUCTION AND LITERATURE REVIEW ..... 1!

1! Introduction ........................................................................................................... 1!2! Review of Literature .............................................................................................. 3!

2.1!Patient Education in Cardiac Care .................................................................. 3

2.1.1! Factors Influencing Patient Education Effectiveness ........................... 5!2.2!Assessing Cardiac Patients’ Information Needs and Disease-related

Knowledge ...................................................................................................... 8

2.2.1! Patients' Information Needs .................................................................. 8!2.2.2! Patients' Disease-related Knowledge .................................................. 11!

3! Theoretical Orientation ....................................................................................... 15!3.1!Social Cognitive Theory ............................................................................... 18! 3.1.1 Self-Efficacy ........................................................................................ 19!3.2!Mediating Variable Framework .................................................................... 21!3.3!The Health Action Process Approach ........................................................... 22!

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3.4!Adult Education Theories ............................................................................. 26!4! Study Purpose, Objectives and Hypothesis ......................................................... 30!

Chapter 2 OVERALL RESEARCH DESIGN AND METHODOLOGY ........ 33!

1! Design and Procedure .......................................................................................... 33!2! Setting .................................................................................................................. 35!

2.1 Development of the New Education Curriculum .......................................... 36!2.1.1! Problem Definition ............................................................................. 37!2.1.2! Theoretical Foundation ....................................................................... 38!2.1.3! Needs Analysis ................................................................................... 39!2.1.4! Program Goals & Educational Objectives .......................................... 49!2.1.5! Sequencing Instruction ....................................................................... 50!2.1.6! Instructional Strategy and Design ....................................................... 50!2.1.7! Instructional Methods and Materials .................................................. 52!2.1.8! Evaluating Instruction and Materials .................................................. 53!2.1.9! Evaluating Learning for Health Outcomes ......................................... 54!2.1.10!Discussion ........................................................................................... 55!

Chapter 3 PAPER ONE: A systematic review of patient education in cardiac patients: do they increase knowledge and promote health behavior change? ............................................................................................... 59!

1! Introduction ......................................................................................................... 59!2! Methods ............................................................................................................... 61!

2.1 Search Methods for Identification of Studies ................................................ 61!

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2.2 Inclusion and Exclusion Criteria ................................................................... 61!2.3 Data Collection and Analysis ........................................................................ 64!

3! Results ................................................................................................................. 65!3.1 Characteristics of Included Studies ............................................................... 65!3.2 Nature of Education Interventions ................................................................ 77!3.3 Knowledge .................................................................................................... 82!3.4 Behavior Change and Psychosocial Well-Being ........................................... 83!

4! Discussion and Conclusion ................................................................................. 90!4.1 Discussion ..................................................................................................... 90!4.2 Conclusion ..................................................................................................... 92!4.3 Practice Implications ..................................................................................... 92!

Chapter 4 PAPER TWO: Development and psychometric validation of a scale to assess information needs is cardiac rehabilitation: The INCR tool ...................................................................................................................... 93!

1! Introduction ......................................................................................................... 93!2! Methods ............................................................................................................... 95!

2.1 Design and Procedure .................................................................................... 95!2.2 Participants .................................................................................................... 96!2.3 Measures ........................................................................................................ 97!2.4 Statistical Analysis ........................................................................................ 97!

3! Results ................................................................................................................. 98!3.1 Participants Characteristics ........................................................................... 98!3.2 Development of the Tool ............................................................................... 98!

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3.3 Pilot Testing .................................................................................................. 99!3.4 Psychometric Validation ............................................................................... 99!3.5 Information Needs ....................................................................................... 100!

4! Discussion and Conclusion ............................................................................... 105!4.1 Discussion ................................................................................................... 105!4.2 Conclusion ................................................................................................... 106!4.3 Practice Implications ................................................................................... 107!

Chapter 5 PAPER THREE: Healthcare providers’ awareness of the information needs of their cardiac rehabilitation patients throughout the program continuum ........................................................................................ 108!

1! Introduction ....................................................................................................... 108!2! Methods ............................................................................................................. 110!

2.1 Design and Procedure .................................................................................. 111!2.2 Participants .................................................................................................. 111!2.3 Measures ...................................................................................................... 112!2.4 Statistical Analysis ...................................................................................... 113!

3! Results ............................................................................................................... 114!3.1 Respondent Characteristics ......................................................................... 114!3.2 Information Needs ....................................................................................... 116!3.3 Education Delivery Formats and Gaps ........................................................ 119!3.4 Information Needs over the Course of CR .................................................. 120!

4! Discussion and Conclusion ............................................................................... 122!4.1 Discussion ................................................................................................... 122!

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4.2 Conclusion ................................................................................................... 125!4.3 Practice Implications ................................................................................... 125!

Chapter 6 PAPER FOUR: Development and psychometric validation of the second version of the Coronary Artery Disease Questionnaire (CADE-Q II) .................................................................................................... 126!


2.1 Design and Procedure .................................................................................. 128!2.2 Participants .................................................................................................. 129!2.3 Measures ...................................................................................................... 129!2.4 Statistical Analysis ...................................................................................... 130!

3! Results ............................................................................................................... 131!3.1 Participants Characteristics ......................................................................... 131!3.2 Development of the Tool ............................................................................. 131!3.3 Pilot Test ..................................................................................................... 132!3.4 Psychometric Validation ............................................................................. 132!3.5 Knowledge Assessment ............................................................................... 136!


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Chapter 7 PAPER FIVE: Behavior determinants among cardiac rehabilitation patients receiving educational interventions: an application of the health action process approach ....................................... 140!


2.1 New Educational Curriculum Development ............................................... 144

2.2 Design and Procedure .................................................................................. 145!2.3 Participants .................................................................................................. 146!2.4 Measures ...................................................................................................... 146!

2.4.1 HAPA constructs ................................................................................ 148!2.4 Statistical Analysis ...................................................................................... 150!

3! Results ............................................................................................................... 153!3.1 Respondents Characteristics ........................................................................ 153!3.2 Knowledge .................................................................................................. 156!3.3 HAPA constructs ......................................................................................... 157!3.4 Exercise behavior ........................................................................................ 157!3.5 Knowledge and theoretical determinants of exercise behavior ................... 157!

3.5.1 Preliminary Analysis .......................................................................... 157!3.5.2 Path Analysis ...................................................................................... 165!


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Chapter 8 SUMMARY OF THE RESEARCH AND GENERAL DISCUSSION .................................................................................................. 171!

1! Summary of the Research ................................................................................. 171!2! General Discussion ............................................................................................ 176!3! Limitations ........................................................................................................ 180!4! Implications and Future Directions ................................................................... 180!

References ............................................................................................................ 184!

Appendices ........................................................................................................... 221!

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List of Tables

Chapter 2

Table 2.1 – Responsibilities of the committee of CR and patient education experts ................................................................................................................. 37

Table 2.2 – Summary of the Literature review of best practice on CR patient education ............................................................................................................. 42

Table 2.3 – Main themes that emerged from patient’s focus group .................... 49

Table 2.4 – Education curriculum’s 5 program learning outcomes .................... 49

Table 2.5 – Sections of the new education curriculum for CR patients .............. 50

Chapter 3

Table 3.1 – Search Strategy ................................................................................. 63

Table 3.2 – Characteristics of the included studies describing the relationship between education knowledge and behavior change, N=42 ............................... 68

Table 3.3 – Characteristics of educational interventions (n=42) ......................... 85

Chapter 4

Table 4.1 – Sociodemographic/Clinical Characteristics of the Participants for the Psychometric Validation and INCR mean scores and differences among subgroups (N=203) .............................................................................................. 101

Table 4.2 – Mean and Standard Deviation of Clarity Rating by Experts (N=20) and Pilot Study Patients (N=20), INCR Score (N=203), and INCR Item Completion Rates ................................................................................................ 102

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Table 4.3 – Mean and Standard Deviation of educational needs per subject area, N=203 ......................................................................................................... 104

Chapter 5

Table 5.1 – Sociodemographic and Clinical Characteristics of Patient Respondents (N=306), and Mean and Standard Deviation of Total Information Needs Scores by these Characteristics ................................................................ 115

Table 5.2 – Mean and Standard Deviation of Total Information Needs by Sample, and Mean Differences .......................................................................... 117

Table 5.3 – Preferences for Educational Delivery Formats by Sample .............. 120

Table 5.4 – Mean and Standard Deviation of Patient Information Needs by Subscale and Time in CR Program, N=306 ........................................................ 121

Chapter 6

Table 6.1 – Sociodemographic and Clinical Characteristics of Patient Respondents (N=307), and Mean and Standard Deviation of CADE-Q II Scores by these Characteristics ........................................................................... 133

Table 6.2 – Mean and Standard Deviation of Clarity Rating by Pilot Study Patients (N=30), CADE-Q II Score (N=307), CADE-Q II Item Completion Rates, Cronbach’s alpha per area, and Mean Score per area .............................. 134

Table 6.3 – Factor Structure of the CADE-Q II, sorted by loading .................... 137

Chapter 7

Table 7.1 – Sociodemographic and clinical characteristics of participants overall , and by curriculum ................................................................................................ 155

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Table 7.2 – Total, subscale and item knowledge scores at pre- and post-CR in overall sample and by curriculum ....................................................................... 159

Table 7.3 – HAPA constructs and exercise behavior at pre- and post-CR in overall sample and by curriculum ................................................................................... 162

Table 7.3 – Pearson’s correlation matrix for HAPA constructs and exercise behavior post-CR (n=173) ................................................................................... 164

*Chapters 1 and 8 do not have tables.

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List of Figures

Chapter 1

Figure 1.1 – Structural paths of influence wherein perceived self-efficacy affects health habits (Bandura, 2004; p.146) ....................................................... 20

Figure 1.2 – Mediating variable model of behavior (Baranowski, Anderson & Carmack, 1998; p.282) .................................................................................... 21

Figure 1.3 – Health action process approach (Schwarzer, 1992; retrieved from http://userpage.fu-berlin.de/~health/hapa_figures.pdf) ....................................... 25

Chapter 2

Figure 2.1 – Infographic of the papers that comprise this thesis ......................... 57

Figure 2.2 – Development of the new education curriculum for CR patients (Infographic) ........................................................................................................ 58

Chapter 3

Figure 3.1 – Flow Diagram of Study Selection Process ...................................... 67

Chapter 7

Figure 7.1 – Model of the relationship between HAPA constructs, knowledge and exercise behavior ................................................................................................. 152

Figure 7.2 - Flow diagram of study participants (n=306) ................................... 154

Figure 7.3 - Modified model of the relationship between HAPA constructs, knowledge and exercise behavior ........................................................................ 166

*Chapters 2 and 4-8 do not have figures.

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List of Appendices

Appendix 1 – The INCR Scale ............................................................................ 222

Appendix 2 – The CADE-Q II Questionnaire ..................................................... 226

Appendix 3 – Assessment Booklet for Paper 5 ................................................... 235

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Chapter 1 OVERALL INTRODUCTION AND LITERATURE REVIEW

In this chapter an overall introduction and literature review characterizing coronary artery

disease as a chronic condition is presented to support the need for secondary prevention

strategies, including patient education. Furthermore, the theoretical orientation of this thesis is

described, as well as its rationale, purpose, objectives and hypothesis.

1 Introduction

The increasing incidence of chronic diseases has emerged as one of the most important health

issues in the 21st century. Cardiovascular Disease (CVD) - a chronic condition – is the leading

cause of mortality worldwide (World Health Organization [WHO], 2011) and a significant

contributor to morbidity and health-related costs (Neal, 2004; Law, Watt & Wald, 2002; Cardiac

Care Network [CCN], 2002). In Canada, CVD is also the leading cause of hospitalizations

(Statistics Canada, 2008) and, according to the Public Health Agency of Canada (2009), nine out

of ten Canadians over the age of 20 years have at least one of the following risk factors:

smoking, physical inactivity during leisure time, less than recommended daily consumption of

vegetables and fruit, stress, overweight and obesity, high blood pressure, or diabetes. Addressing

these risk factors through behavior change will not only reduce the risk of CVD, but also of

many other chronic conditions that share the same risk factors.

Coronary Artery Disease (CAD) – the most common type of CVD – is a chronic condition that

carries a high risk of recurrent events. Secondary prevention relies on early detection of disease

process and application of interventions to prevent progression of disease (Stone, Arthur, &

Suskin, 2009). These strategies to control CAD are highly effective, but multifactorial (i.e.

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multiple interventions conducted over time may be employed to sustain outcomes, including

behavior change), necessitating patient awareness and adherence to optimize health outcomes

(Clark, Hartling, Vandermeer, & McAlister, 2005; Stone, Arthur, & Suskin, 2009; Heran et al.,

2011). Therefore, the treatment of CAD requires optimal medical management, including not

only drug therapy and revascularization, but also behavior change techniques (e.g. risk factor

modification, stress management, and physical activity promotion) and patient education. Indeed,

findings from recent systematic reviews demonstrate the importance of patient education in CAD

patients, in improving self-management behaviors, health-related quality of life and potentially

reducing healthcare costs (Mullen, Mains, & Velez, 1992; Dusseldorp et al., 1999; Aldcroft et

al., 2011; Schadewaldt & Schultz, 2011; Brown et al., 2012; Ghisi et al., 2014a). While most

CAD patients will receive some education if hospitalized, it is often forgotten, too brief, and

focused appropriately on acute recovery (which leaves no time to educate on chronic self-

management) (Mullen et al., 1992; Stone et al., 2009; Aldcroft et al., 2011; Berra, Miller, &

Jenning, 2011; Ghisi et al., 2014a).

Cardiac rehabilitation (CR), which is a comprehensive outpatient program of secondary

prevention and lifestyle counselling, has been shown to reduce mortality, improve functional

capacity, and decrease re-hospitalization and overall medical costs (Clark et al., 2005; Heran et

al., 2011; Lam et al., 2011; Lawler, Filion & Eisenberg, 2011). CR – which is often delivered by

a multi-disciplinary team of healthcare providers trained to be health educators – has several core

components: lifestyle and medical risk factor management, psychosocial health,

cardiopulmonary therapies, long term management, audit and evaluation, health behavior change

and patient education, this last topic being the focus of my studies (British Association for

Cardiovascular Prevention and Rehabilitation [BACPR], 2012).

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Patient education has been formally defined as “the process by which health professionals and

others impart information to patients that will alter their health behaviors or improve their health

status” (Koongstvedt, 2001). As a facilitator of behavior change, patient education therefore

plays a key role in the management of CAD (Brown et al, 2012). While the important role of

patient education has been well-recognized in CR practice (e.g., clinical practice guidelines and

quality indicators), CR patients’ information needs, patient knowledge in CR, and the best way

to structure and deliver educational interventions has only poorly been investigated.

2 Review of Literature

2.1 Patient Education in Cardiac Care

The simple act of teaching cardiac patients has been identified as a prerequisite to create a sense

of well-being and optimism about the future and a positive influence to make healthy choices in

daily life, better manage their disease and avoid adverse outcomes (Karner, Goransoon &

Bergdahl, 2003; Alm-Roijet et al, 2006; Kayaniyil et al, 2009). Increased patient satisfaction and

perception of control, as well as reduced levels of psychological distress are all variables

associated with effective health information provision (Wingham et al., 2006; Parry et al., 2009).

There is a growing body of literature that contributes to our understanding of patient education

effectiveness. This literature includes many studies in which knowledge of CAD has been shown

to strongly influence symptom recognition (Zalesskaya et al., 2005; DeVon et al., 2010),

advocacy for physician screening (Bolman et al., 2005), attitudes towards the disease (Bellman et

al., 2009), and provide motivation for self-care and individual behavior change (Dickson, Tkas &

Riegel, 2008; Bellman et al., 2009). Likewise, inadequate understanding of the disease may

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cause unwarranted emotional distress, inappropriate coping behavior, and non-compliance with

medical advice (Monane et al., 1994; Blyth et al., 1997), leading to unnecessary disease

progression (Zalesskaya et al., 2005, Sui et al., 2008).

Jolliffe et al. (2000) systematically compared the effectiveness of exercise-only CR versus more

comprehensive programs (including education and/or psychosocial counseling) on clinical

endpoints, such as rehospitalisation and mortality. Exercise-only CR reduced deaths by 31 per

cent versus 26 per cent in comprehensive CR programs. There was a significant net reduction in

total cholesterol and LDL cholesterol in the comprehensive cardiac rehabilitation group, but not

the exercise only rehabilitation group. Despite the fact that exercise-based CR appears to be

effective in reducing cardiac deaths, the evidence base is weakened by poor quality trials.

Moreover, it is not clear from this review whether exercise only or a comprehensive CR

intervention is more beneficial since the quality of reporting overall was poor, with generally

high losses to follow up.

A recent systematic review (Brown et al., 2012) assessed the effects of patient education on

mortality, morbidity, health-related quality of life (HRQoL) and healthcare costs in people with

CAD. This was the first study to find evidence to suggest that education can improve HRQoL

and decrease healthcare costs by reductions in downstream healthcare utilization. No evidence

that patient education reduced CAD-related morbidity, mortality, revascularization, compared to

no educational interventions was found. The ‘dose’ of the education intervention varied

substantially across the 13 studies included, and most studies had a relatively short follow-up

(Brown et al., 2012). However, effect size of the summative effects of education on mortality

(25% risk reduction) and morbidity (17- 42% risk reduction) are clinically important outcomes,

particularly in the context of the large number of individuals with CAD.

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2.1.1 Factors Influencing Patient Education Effectiveness

The literature also provides some insight into a number of factors, which may influence patient

education effectiveness. Most often cited is educational level and how higher levels of education

may be a marker for higher levels of disease-specific knowledge (Potvin Richard & Edwards,

2000; Sui et al., 2008; Loucks et al., 2009; Lainscak, Farkas & Jaarasma, 2010). Education level

is a market of socioeconomic status (Kaplan & Keil, 1993; Fishella & Tancredi, 2008), and

patients with higher education may have better understanding and knowledge of their disease

process and treatment thereof (Sui et al., 2008). They also have easier access to high quality

health care (Feldman et al., 1989). Patients with lower education levels are less likely to have a

regular primary care physician (Rask et al., 1994), to see or consult a cardiologist (Rathore et al.,

2006), or be adherent to therapeutic recommendations (Jackson et al., 2005). In addition, lower

education level has been shown to be associated with poor quality of life, anxiety, physical and

emotional distress (Riedinger, Dracup & Brecht, 2000), and an inability to actively participate in

self-care recommendations (Vinson et al., 1990; Chin & Goldman, 1997; DeWalt et al., 2006;

Loucks et al., 2009). Results from these studies should be interpreted with caution, since other

factors may influence the relationship between patient education and socioeconomic level, such

as providers’ job execution and environment preventing learning.

Besides educational level, culture has been cited as an essential indicator that influences the way

patients interact with health systems, participate in prevention activities, choose health-related

lifestyle, and understand health and illness (London, 2008; Burns-Gibson & Koso, 2010). The

potential for misdiagnosis and mistreatments may increase significantly when the healthcare

provider is not culturally appropriate. Thus, the quality of care and patient education is also

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impacted when the care provided is not culturally congruent (Niemeier, Burnett & Whitaker,

2003; Burns-Gibson & Koso, 2010).

Health literacy has been defined as a set of skills that people need to function effectively in the

health care environment (Berkman et al., 2011). It is also an important determinant of patients’

knowledge, and usually health knowledge is viewed as part of health literacy. According to U.S.

Department of Education (2006), approximately 80 million U.S. adults are thought to have

limited health literacy, which puts them at risk for poorer health outcomes. Thus, studies showed

that rates of limited health literacy are higher among elderly, minority, and poor persons and

those with less than a high school education. Low health literacy is associated with poorer health

outcomes and poorer use of health care services, including patient education (Berkman et al.,

2011).

Other factors that influence patient education include: age (Lane & Evans, 1979; Cranton, 1989;

Brown, 1992; Kirkland et al, 1999), and gender (Bubela et al., 1990; Stewart et al., 2004;

Kayaniyil et al., 2009). Chronological age can be an important factor to consider when

evaluating and planning instruction education and studies have shown that younger patients learn

more than older patients (Brown, 1992; Clark et al., 1992; Clark et al., 2006); however,

according to Cranton (1989) a statement of age only renders very general information since

individuals within the same age group may be completely different in other aspects, such as

educational level. Therefore, age should always be coupled with other information. Although the

role of gender in medical information seeking and decisional preferences is largely unexplored, a

few studies suggest that women may be better informed and more active in the decision process

than men (Mansell et al., 2000; Stewart et al., 2004).

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While most CAD patients will receive some education if hospitalized, it is often forgotten, too

brief, and focused appropriately on acute recovery (which leaves no time to educate on chronic

self-management) (Aldcroft et al., 2011; Ghisi et al., 2014a). The real education in cardiac care

usually occurs during patients participation in CR programs, in which patient education is a core

component, as mentioned previously (BACPR, 2012). CR programs are offered over several

months permitting repeated patient contact with these providers, enabling fulsome education

regarding the numerous lifestyle changes and treatments shown to reduce risk over time (Berra et

al., 2011).

To deliver effective patient education, educators must understand what information needs

patients might have when they enter CR, and what they already know from health education

received at other points of their cardiac care journey (Ghisi et al., 2014a). Moreover, educators

should be aware of social determinants of health, which may impact patient’s health literacy.

They also need to consider the nature of the patient’s cardiac condition, risk factors, and their

health behaviors to tailor and optimize education delivery (Nutbeam, 2000). Unfortunately, much

previous literature on cardiac patient education has demonstrated that educators are often

unaware or inaccurately-perceive patients’ educational needs, as well as the characteristics

affecting patients’ ability to learn (Casey et al., 1984; Moynihan et al., 1984; Aldcroft et al.,

2011; Ghisi et al., 2013a). Clearly, this can result in less engaged and informed patients, and thus

potentially negatively impact not only their educational outcomes, but also their health outcomes.

Furthermore, patient education in coronary patients should be comprehensive, focusing not only

in the CR, but also in other phases of treatment (at the time of diagnosis, in hospital) (Cranton,

1989; Su, Herron & Osisek, 2011). Patient-centered education involves a commitment to

tailoring education to the needs and preferences of the patient, understanding factors that

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influence this process and including family and friends’ needs (Furze et al., 2002). This

participatory approach may empower patients to change their behaviors and improve health

outcomes.

2.2 Assessing Cardiac Patients’ Information Needs and Disease-related Knowledge

A cardiac educational program comprises the individual’s interests, habits and socioeconomic

lifestyle (Egan, 1999). Active components of this program include the assessment of learning

needs and knowledge, which can be a useful tool to enhance patients’ experience in CR and

should be addressed in all cardiac educational programs during the early phase of development

(McLennan et al, 1996; Czar & Engler, 1997). Therefore, the assessment of cardiac patients’

information needs and knowledge are key factors for developing and delivering educational

programs. Particularly in CR this is problematic, since before this project there was no available

tool psychometrically validated to assess information needs in CR. In addition, few tools were

assessing cardiac patients’ knowledge, most of them not focusing on patient education

(McLennan et al, 1996; Czar & Engler, 1997).

2.2.1 Patients’ Information Needs

In regards to information needs, the “needs-based” approach, according to Timmins & Kaliszer

(2003) has been described as a means of educating cardiac patients, attempting to identify and

meet the needs of the individual. Analysis of the literature revealed a learning need to be a

personal item about which individuals required information. However, in its broadest sense, a

learning need can be defined as the gap between competencies specified and the present level of

development by the learner (Timmins, 2006). The crucial element in the assessment of this “gap”

is the learners’ own perception of the discrepancy between where they are now and where they

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want to be. A learning need occurs as a result of the individual’s natural coping mechanism,

whereby they seek out information in response to a problem-focused approach (Czar & Engler,

1997). The information received helps them to adapt to their situation. Learning needs were

identified as unique to individuals and subjective in nature (Timmins & Kaliszer, 2003).

Studies suggest that after an acute event patients view different categories as areas where

learning needs exist. When patients are admitted to hospital, they experience a state of shock and

disbelief, the severity of illness is realized, and survival issues become grave concerns. During

this earliest stage of hospitalization, patients usually are motivated to learn and meet their

physiological requirements and satisfy their need for safety. Educational needs identified in this

phase included: when to call a doctor, signs and symptoms of MI, diagnostic procedures, among

others (Wang, 1994). After a while, patients improve and the need for information regarding diet,

physical activity, and follow-up arises (Ashton, 1997; Hughes, 2000). After hospital discharge,

patients’ needs change once more, and become related to resumption of regular activities and

prognostic, including information about the risk of recurrence, the level of heart muscle damage,

discharge medications, appropriate levels of physical activity and diet (Timmins & Kaliszer,

2003; Astin et al, 2008). Therefore, learning needs may change over time, depending on which

stage of treatment and/or recovery cardiac patients are in.

Furthermore, personal and sociodemographic characteristics appear to be related to different

needs (Stewart et al, 2004). Gender, age, and educational level are some examples of

characteristics associated with information needs and decisional preferences. Although some

studies have shown that higher information needs are associated with being a woman (Marcuccio

et al, 2003; Stewart et al, 2004), younger age (Arora et al, 2000) and higher educational status

10

(Degner & Sloan, 1992), there is contradictory evidence (Mahler & Kulik, 1991; Czar & Engler,

1997).

In addition, there is a difference between patients’ and health professionals’ perceptions of what

constitute priority educational needs. Turton (1998) showed that patients appear to favor

practical information about their condition, its cause and prevention, whereas health

professionals are more focused on medical aspects of care such as medications, anatomy and

physiology. These incongruities have implications for health care delivery and for the

development of educational programs.

The literature highlights the importance of a comprehensive understanding of patients’ health

information needs as a logical first step in the development of educational programs. Despite the

fact that there are tools to assess information needs of cardiac patients following

revascularization (Goodman, 1997; Brezynskie et al, 1998; Astin et al, 2008), acute coronary

syndrome (Czar & Engler, 1997; Nakano, Mainz & Lomborg, 2008), MI (Casey, O’Connel &

Price, 1984; Moynihan, 1984; Orzeck & Staniloff, 1987; Bubela et al, 1990; Chan, 1990;

Wingate, 1990; Moser, Dracup & Marsden, 1993; Mirka, 1994, Larson et al, 1996; Ashton,

1997; Hughes, 2000; Timmins & Kaliszer, 2003; Decker et al, 2007; Smith & Liles, 2007), and

heart failure (Wehby & Brenner, 1999; Lile, Buhmann & Roders, 1999), to my knowledge, there

were no validated tools to assess information needs in CR and a previous literature review (Scott

& Thompson, 2003) failed to identify any available and validated tool to assess information

needs in coronary patients in cardiac rehabilitation programs. Chapter 3 of this thesis describes

the development and psychometric validation of a scale to assess information needs in cardiac

rehabilitation.

11

2.2.2 Patients’ Disease-related Knowledge

In regards to patients’ knowledge, this measure has been usually assessed through investigator-

generated open-ended and closed-ended questionnaires. To date, there are different types of

questionnaires and studies assessing cardiac patients’ knowledge in the literature, most of them

are designed for heart failure patients. Despite well-established benefits from patient education in

the CR setting, there are few psychometric-validated questionnaires published in the literature

assessing cardiac patients’ knowledge applicable to CR programs or that could be integrated into

the routine management of this population. To my knowledge, only 5 studies aimed to develop a

psychometrically-valid measure of CR patients’ knowledge: the Cardiac Knowledge

Questionnaire (CKQ), the Coronary Heart Disease Knowledge Test, the Knowledge Inventory,

the Maugeri Cardiac Prevention Questionnaire (MICRO-Q), and the Coronary Artery Disease

Education Questionnaire (CADE-Q).

The CKQ consists of 3 subscales addressed to assess different aspects of CAD: the Basic Cardiac

Knowledge Scale (BCKS), a 30-item scale to measure knowledge about the cardiovascular

system and nature of CAD; the Cardiac Lifestyle Knowledge Scale (CLKS), a 15-item scale

about behavioral aspects of the cause and consequences of a heart attack; and, the Cardiac

Misconceptions Scale (CMS), a 10-tem scale about prognostic implications of MI. The CKQ

was developed by Maeland & Havik (1987) with input from expert panels of cardiologists,

cardiac nurses, and physical therapist. Cronbach’s alpha was 0.84 for the BCKS, 0.69 for the

CLKS, and 0.74 for the CMS. All scales were demonstrated to be sensitive to change in patients

groups after a CR. The CKQ scales have limitations. Firstly, the psychometric-validation was not

established in a group of patients; therefore its applicability to cardiac patients use is unknown.

Secondly, in a subsequent study (Lidell & Fridlung, 1996) the subscales showed lower internal

12

consistency (BCKS=0.78;CLKS=0.50;CMS=0.40), which may demonstrate the inability to use

the CKQ in other studies.

The Coronary Heart Disease Knowledge Test is a 40-multiple-choice item questionnaire

covering 10 areas of knowledge: program orientation, nature of heart disease, risk factors,

physical activity, diet, cardiopulmonary resuscitation, psychological factors associated with

CAD, type A and B behavior, stress management, and problems related to home and family. A

sample from this scale is “A risk factor of CAD that cannot change is”. Each item has 4 options

as answer, only 1 correct. Smith, Hicks & Heyward (1991) examined the psychometric

properties of this scale in a sample of 93 male subjects diagnosed with CAD, 48 (52%)

participating in CR programs. Cronbach’s alpha was 0.84 and construct validation indicated that

the average test score of CR participants was significantly higher than that of non-participants

(p≤0.01). Firstly, while Coronary Heart Disease Knowledge Test showed a valid difficulty rating

(DR=63%) of the questions, information about time to completion and clarity index is missing.

Secondly, despite the incorporation of relevant topics to CR education, the dimensional structure

was not tested. Finally, the criterion validity of this scale is questionable due to the lack of a

large and broad sample of cardiac patients.

The Knowledge Inventory is a 50-item scale (46 multiple-choice items and 4 open-answer ones),

described by the authors as a “criterion-referenced mastery test”, which means that each learner

should attain a certain score level to be successful. Items covered the following areas of

knowledge: coronary disease, cardiac surgery, diagnostic, physical exercise guidelines, smoking,

diet, drugs and stress. A sample from this scale is “Angina and chest pain is caused by”. The

scale was validated in a sample of 10 post-bypass surgery patients and pilot-tested in 54 patients,

either following home or structured CR at a single medical center in Ohio (Schuster, Wright &

13

Tomich, 1995). Cronbach’s alpha was 0.84. Subgroups analysis of total scores showed male

patients in structured CR programs with higher knowledge than their female counterparts

(P<0.001). Further details or an independent assessment of content and criterion validity is

needed, as well as factorial analysis. Thus, testing on a larger and more diverse population of

patients is necessary.

The Maugeri Cardiac Prevention Questionnaire (MICRO-Q) is a 26-item self-report

questionnaire, which asks patients to indicate for each statement the response “true”, “false”, or

“don’t know”. The questionnaire covers four areas of knowledge: 1) risk factors and lifestyle; 2)

diet; 3) pre-admission avoidable delay; and, 4) cardiac disease. A sample item from this scale is

“People who feel under stress cannot do anything to change this”. The scale was validated in a

sample of 250 MI patients at an in-hospital CR in Italy (Sommaruga et al, 2003). Preliminary

psychometric validation of this scale has been established: spearman Rho correlation coefficient

of 0.72, and a Cronbach’s alpha value of 0.68. Subgroup analysis of total scores showed patients

with higher education had significantly higher scores on the correct scale (p≤0.0001), while

patients with a lower level of education showed a higher score for misconceptions (p≤0.0001).

Overall, while this scale incorporates important topics related to CR (e.g. risk factors), it was

psychometrically-validated in a sample of MI inpatients only, and therefore its generalizability to

CR programs is unknown. Additionally, statistical evidence of a multifactorial structure was not

found and the subdivision into 4 areas is of clinical relevance only.

The Coronary Artery Disease Education Questionnaire (CADE-Q) is a 19- multiple-choice item,

self-administered questionnaire, which assesses patients’ knowledge about their disease and CR

related factors. A sample item from this scale is “Which description below is a typical symptom

of CAD?”. Each item has 4 alternatives or statements, that correspond to a knowledge level: a

14

correct statement showing “complete knowledge”; a correct statement showing “incomplete

knowledge”; an incorrect statement showing “wrong knowledge”; and, a ‘don’t know’ statement

showing a “lack of knowledge”. Each alternative has a score and the sum of final scores leads to

a classification of knowledge (excellent, good, acceptable, poor, and insufficient). This scale was

developed through a comprehensive review of the literature and feedback from a CR

multidisciplinary team and patients (Ghisi et al., 2010).

The CADE-Q was originally developed in Brazil by Ghisi et al (2010) in Portuguese, and

psychometrically-validated in a sample of 155 CR patients. It was later translated, and culturally-

adapted to English by De Melo Ghisi et al (2012). The latter version was then psychometrically-

validated in a sample of 200 Canadian patients enrolled in CR (Ghisi et al, 2012). In the

Brazilian version of the CADE-Q, Cronbach’s alpha was 0.68, intraclass correlation coefficient

(ICC) was 0.78, and factorial analysis revealed 6-internally-consistent factors related to CADE-

Q’s 4 areas of knowledge: 1) pathophysiology and signs and symptoms of the disease, 2) risk

factors and lifestyle habits, 3) diagnosis, treatment and medicines, and 4) exercise. In the English

version, Cronbach's alpha was 0.809, ICC was 0.846, and factorial analysis revealed five factors,

all internally-consistent and well-defined by the items. Thus, criterion validity was supported by

significant differences in mean scores by family income (p=0.02) and educational level

(p<0.001). Although both versions demonstrated good reliability and validity, the CADE-Q

presented lack of detailed assessment of all core components of cardiac rehabilitation (CR), such

as nutrition and psychosocial risk. Besides that, the development of CADE-Q started in 2004,

needing update. The availability of a more comprehensive and updated CADE-Q is important to

assess patients’ knowledge and to tailor the educational component of CR programs (Ghisi et al.,

2013a). Therefore, the second version of this instrument (called CADE-Q II) was developed and

psychometrically validated and this process is described in chapter 6 of this thesis.

15

3 Theoretical Orientation

Theories are a generalized set of rules, and according to Hochbaum, Sorenson, & Lorig, (1992)

they become important instruments to help understand, influence and assess patient learning and

motivation. A number of studies have shown that using theory in crafting interventions can lead

to more powerful effects than interventions developed without theory (Ammerman et al, 2002;

Legler et al, 2002; Glanz, Rimer, & Viswanath, 2008). In the context of patient education,

theories can provide us with a workable basis for an education action we wish to undertake. This

is especially important when teaching patients whose educational needs are less predictable or

more diverse (Doak, Doak, & Root, 2007).

The theoretical basis of chronic disease management (CDM) models typically involves

components of the medical and behavioral/lifestyle approaches to health promotion. The medical

approach is used to eliminate or treat disease and illness through the use of scientific and

technological innovation (Laverack, 2004). The behavioral and lifestyle approach often works

within this medical model framework. The underlying assumption to this approach is that

individuals, once educated about healthy lifestyle choices and risk of disease or illness, will

avoid high-risk behaviors and adopt health behaviors to reduce their disease risk. This approach

often uses the Transtheoretical Model of Behavior Change (TTM) in conjunction with health

education to assess and increase individuals’ readiness to change and capacity to adopt health

promoting behaviors (Prochaska & DiClemente, 1983). The TTM uses stages of change to

integrate processes and principles of change across major theories of intervention. The major

weakness in this approach is that it fails to recognize the broader contextual and structural issues

that may affect individual’s ability to adopt healthy behaviors (Betancourt & Quinlan, 2007).

TTM is also unable to address a number of issues beyond personal motivation for health

16

promoting behavior.

Offering a more comprehensive approach to health promotion that takes into account social and

structural impediments for behavior change, the Social Cognitive Theory (SCT) posits a

multifaceted causal structure in which self-efficacy beliefs operate together with goals, outcome

expectations, and perceived environmental impediments and facilitates the regulation of human

motivation, behavior, and well-being (Bandura, 2004). However, because this theory is so broad

and ambitious, it has not been tested comprehensively in the same way that other health behavior

theories have been tested. Thus, to test the theory more fully, different concepts and principles in

SCT need to be measured, and manipulated in systematic experiments replicated over diverse

behaviors and populations (Glanz, Rimer, & Viswanath, 2008). This could determine whether

some of SCT’s concepts and principles are more or less useful or feasible for particular

behaviors or types of behavior change.

According to Schwarzer (2008), changing health-related behaviors requires two separate

processes that involve motivation and volition, respectively. First, an intention to change is

developed, in part on the basis of self-beliefs. Second, the change must be planned, initiated, and

maintained, and relapses must be managed. In addition, self-regulation plays a critical role in

these processes. Social-cognition models of health behavior change should address these two

processes. One such model, the Health Action Process Approach (HAPA), is explicitly based on

the assumption that two distinct phases need to be studied longitudinally: one phase that leads to

a behavioral intention and the other one that leads to the actual behavior. Particular social-

cognitive variables may play different roles in the two stages; perceived self-efficacy is the only

predictor that seems to be equally important in the two phases (Schwarzer, 1992). A recent

overview covering seven empirical studies (Schwarzer, 2008), has demonstrated the universal

17

applicability of the HAPA for a number of health behaviors and for diverse samples from various

cultures, including physical exercise adherence after a CR program (Scholz, Sniehotta, &

Schwarzer, 2005).

Choosing a structural theoretical model to fit your objectives, however, does not prove that the

chosen model is the only one or the best one that fits your research. The question is whether this

model appears to be empirically superior to alternative models. According to Glanz, Rimer, &

Viswanath (2008) finding the best model for a particular research context requires consideration

of several questions, such as: Which model accounts for most of the criterion variance? Which

one provides the best insight into the causal mechanism of health behavior change? Is the model

that makes the best prediction also the best one for the design of interventions? Which is the

most parsimonious one?

Three different theories and models influenced the development of this thesis: the SCT, the

Mediating Variable Model (MVM), and the HAPA. The SCT was valuable to understand what is

needed for a patient to make a behavior change. Thus, this thesis investigates self-efficacy as a

focal determinant of patient knowledge, affecting behavior both directly and by its influence on

the other determinants. As will be discussed further, self-efficacy plays a crucial role at all stages

of the health behavior change process. The MVM is helpful to understand the importance of

mediators in predicting health-promoting behavior. Finally, the HAPA was used to design the

new educational curriculum, as well as to identify which variables should be measured and

compared. All three models are described below. In addition, Adult Education Theories are also

briefly described in order to provide the foundation of adult education practice.

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3.1 Social Cognitive Theory

Social Cognitive Theory (SCG) was presented by Bandura (1986) and specifies “a core set of

determinants, the mechanism through which they work, and the optimal ways of translating this

knowledge into effective health practices”. The basic organizing principle of behavior change

proposed by this theory is reciprocal determinism in which there is a continuous, dynamic

interaction between the individual, the environment and behavior (Redding et al, 2000). The core

determinants of this theory include: knowledge of health risks and benefits of different health

practices, perceived self-efficacy that one can control one’s health habits, health goals people set

for themselves and the concrete plans and strategies for realizing them, and the perceived

facilitators and social and structural impediments to the change they seek (Bandura, 2004).

In this model, knowledge of health risks and benefits creates the precondition for change. If

people lack knowledge about how their lifestyle habits affect their health, they have little reason

to put themselves through the process of changing their habits. But additional self-influences are

needed for most people to overcome the barriers to adopting and maintaining new lifestyle

habits. Self-efficacy plays a central role in personal change, being the foundation of human

motivation and action (Bandura, 2004). In addition, health behavior is affected by the outcomes

people expect their actions to produce, and health goals they want to achieve in a short and long-

term (Bandura, 2004). In other words, SCT suggests that while knowledge of health risks and

benefits are a prerequisite to change, additional self-influences are necessary for change to occur.

Behavior change would be easy if there were no impediments to surmount. The perceived

facilitators and obstacles are another determinant of health habits. Some of these factors are

19

personal ones, and others are related to external sources (health systems, culture, health

providers) (Bandura, 2002; 2004).

An example of SCT’s use is the self-management model, which has been shown to be effective

in cardiac patients (Clark et al, 1991; 1992; Haskell et al, 1994). This model operates through a

set of psychological subfunctions where people have to learn to monitor their health behavior

and the circumstances under which it occurs, including identifying proximal goals to motivate

themselves and to enlist social supports to sustain their efforts (DeBusk et al, 1994). Haskell et al

(1994) used the self-management system to promote lifestyle changes in patients suffering from

coronary artery disease. At the end of 4 years in self-management, patients achieved big

reductions in risk factors: decreased intake of saturated fat, weight lost, decrease of LDL

cholesterol, increase of HDL cholesterol, increase of exercise, and increase of cardiovascular

capacity. In contrast, those receiving regular medical care by their physicians showed no change

or they got worse.

Insights provided from this theory were helpful to understand what is needed for the patient to

make a behavior change. Using SCT it was understood that knowledge alone is not sufficient to

change and maintain behavior; but additional self-influence is needed for most people to

overcome the barriers to adopting and maintaining new lifestyle habits. Self-efficacy – a critical

determinant of behavior change – is described below.

3.1.1 Self-Efficacy

Self-efficacy is a fundamental component of the SCT and addresses the role of people’s

confidence that they could carry out the behavior asked of them. According to Bandura (1986),

all behavioral changes are mediated by self-efficacy. A person with low self-efficacy is less

20

likely to try to carry out a new health care behavior, or to change an ingrained behavior. Self-

efficacy influence goals and aspirations shape the outcomes people expect their efforts to

produce, and determine how obstacles and impediments are viewed (Bandura, 2004). A review

reported that self-efficacy could explain between 4% and 26% of variance in behavior (Keller et

al, 1999). Figure 1.1 shows the paths of influence posited in the sociocognitive causal model,

according to Bandura’s statement that “beliefs of personal efficacy affect behavior both directly

and by their impact on goals, outcome expectations, and perceived sociostructural facilitators and

impediments”.

Figure 1.1 – Structural paths of influence wherein perceived self-efficacy affects health habits

(Bandura, 2004; p.146).

Doak, Doak, and Root (2007) describe factors that help build patients’ self-efficacy and are

under control of the health care provider. First, initial perception of self-confidence that patients

can do a task is influenced by the way the topic is introduced and presented. This may be a

deciding factor in whether or not patients will pay attention and try to learn from the education

intervention. Second, the task, especially a complex task or behavior, is partitioned into smaller

easier-to-do subtasks. This allows many small successes to be experienced during the learning

21

process. Third, there is repetition of the task or behavior, which builds self-confidence and skill,

and hence, self-efficacy. Finally, there is recognition, reward and reinforcement for doing the

task, which can build self-esteem and self-confidence.

3.2 Mediating Variable Framework

According to Baranowski, Anderson & Carmack (1998) interventions work by means of

mediating variables, such as: self-efficacy, self-motivation, knowledge, attitudes, expectations,

perceived barriers, positive/negative outcomes, benefits and barriers, processes of change and

social support. A mediating variable would account for the effect of an intervention if a positive

relationship between the intervention and outcome were rendered nonsignificant after

statistically controlling for the mediator (Baron & Kenny, 1986; MacKinnon & Dwyer, 1993).

Current theoretical models from which mediating variables are obtained often do not account for

substantial variability in the targeted outcomes. In addition, interventions have not been shown to

effect substantial change in the mediating variables (Baranowski, Anderson & Carmack, 1998).

These factors impose limits on the effectiveness of the interventions. As a result, the mediating

variable model can be applied to this thesis since it highlights the importance of theory in

understanding community intervention results, since the mediating mechanisms are the

theoretical variables used to design the interventions (see Figure 1.2 below).

Figure 1.2 – Mediating variable model of behavior (Baranowski, Anderson & Carmack, 1998;

p.282).

22

As shown, the independent variable (intervention) has its effects on the outcome (behavior) via

the mediator. Because of that, interventions can target change in critical antecedents of

behavioral engagement and these will follow a causal chain to ensuing behavior change. Thus,

Figure 1.2 is simplified, since there can be many mediating processes or cascading sequences of

mediating processes (Baranowski, Anderson & Carmack, 1998).

Reviews have identified that few studies have reported mediators’ analysis in experimental trials

(Baranowski et al, 1997; Baranowski, Anderson & Carmack, 1998). The MVM was helpful to

understand the importance of mediators to predict behavior, showing that studies aiming to

demonstrate the intervention effects on behavior should identify mediators, and test mediating

effects, not only outcomes.

3.3 The Health Action Process Approach

As described elsewhere, interventions need to be theory-guided to allow for meaningful

interpretations of empirical findings and to draw valid conclusions. Moreover, recommendations

for successful practice need a theory base. Studies of exercise behaviour of people with chronic

illness have been criticized for lacking a theoretical basis (Tulloch et al, 2009), leading to the

current interest in applying health behaviour change theories to improve our understanding of

exercise behaviour.

The traditional continuum models have been mainly criticized because of the intention–behavior

gap (i.e. the gap between wanting to make a behavior change and actually doing it). A model that

explicitly includes post-intentional factors to overcome this gap is the Health Action Process

23

Approach (HAPA), which integrates the health self-efficacy theory, the planned behaviour

theory, and stages of change to predict engagement in health behaviour (Schwarzer, Lippke &

Luszczynska, 2011). Thus, the HAPA model appears to have great potential as a motivational

model for physical activity self-management for people with chronic problems in a variety of

settings, in particular rehabilitation settings (Schwarzer, Lippke & Luszczynska, 2011).

The HAPA is designed as an open architecture that is based on principles rather than on specific

testable assumptions. It was developed in 1988 (Schwarzer, 1992) as an attempt to integrate the

model of action phases (Heckhausen & Gollwitzer, 1987) with social-cognitive theory (Bandura,

1986). It has 5 major principles that make it a distinct from other models and that help to apply

the HAPA to research and interventions

Principle 1: Motivation and volition. The first principle suggests that the health behaviour

change process should be divided into two phases: a motivational phase and a volitional phase.

The motivational phase is the one where people develop their intentions. Afterward, they enter

the volition phase.

Principle 2: Two volitional phases. In the volition phase, there are two groups of people: those

who have not yet translated their intentions into action, and those who have. There are inactive as

well as active persons in this phase. In other words, in the volitional phase one finds intenders as

well as actors who are characterized by different psychological states. Thus, in addition to health

behaviour change as a continuous process, one can also create 3 categories of people, depending

on their current location within the course of health behaviour change: preintenders, intenders

and actors.

24

Principle 3: Postintentional planning. Intenders who are in the volitional preactional stage are

motivated to change, but do not act because they may lack the right skills to translate their

intention into action. Planning is a key strategy at this point. It serves as an operative mediator

between intentions and behaviour.

Principle 4: Two kinds of mental simulation. Planning can be divided into action planning and

coping planning. Action planning pertains to the when, where, and how of intended action.

Coping planning includes the anticipation of barriers and the design of alternative actions that

help to attain one’s goal despite the impediments.

Principle 5: Phase-specific self-efficacy. Perceived self-efficacy is required throughout the entire

process; however, the nature of self-efficacy differs from phase to phase. This is because there

are different challenges that are not of the same nature. Therefore, it is important to distinguish

preactional self-efficacy (also called talk self-efficacy), coping self-efficacy (maintenance self-

efficacy), and recovery self-efficacy.

In addition to the five principles, the model suggests a distinction between (a) preintentional

motivation processes that lead to a behavioral intention, and (b) postintentional volition

processes that lead to the actual health behavior (Schwarzer, 1992). Thus, the model constitutes

an implicit stage model. Within the two phases or “stages”, different patterns of social-cognitive

predictors may emerge (see Figure 1.3, which appears on the next page).

25

Figure 1.3 – Health action process approach (Schwarzer, 1992; retrieved from http://userpage.fu-

berlin.de/~health/hapa_figures.pdf).

According to Schwarzer (1992), in the initial motivation phase, a person develops an intention to

act. In this phase, risk perception is seen as a distal antecedent (e.g. “I am at risk for

cardiovascular disease”). Risk perception in itself is insufficient to enable a person to form an

intention. Rather, it sets the stage for a contemplation process and further elaboration of thoughts

about consequences and competencies. Similarly, positive outcome expectancies (e.g. “If I

exercise five times per week, I will reduce my cardiovascular risk”) are chiefly seen as being

important in the motivation phase, when a person balances the pros and cons of certain

behavioral outcomes. Further, one needs to believe in one’s capability of performing a desired

action (perceived self-efficacy, e.g. “I am capable of adhering to my exercise schedule in spite of

26

the temptation to watch TV”). Perceived self-efficacy and outcome expectancies are seen as the

major predictors of intentions. Both beliefs are needed for forming intentions to adopt behaviors.

It is common knowledge that good intentions do not necessarily guarantee corresponding

actions. After a person develops an inclination towards a particular health behavior, the “good

intention” has to be transformed into detailed instructions on how to perform the desired action.

Once an action has been initiated, it has to be maintained. This is not achieved through a single

act of will, but involves self-regulatory skills and strategies. Thus, the postintentional phase

should be further broken down into more proximal factors, such as planning and recovery self-

efficacy (Schwarzer, 1992).

According to HAPA (Schwarzer, 1992), once an action has been initiated, it has to be controlled

by cognitions in order to be maintained. In this stage, self-efficacy determined the amount of

effort invested and the perseverance. People with self-doubts are more inclined to anticipate

failure scenarios, worry about possible performance deficiencies, and abort their attempts

prematurely. People with an optimistic sense of self-efficacy, however, visualize success

scenarios that guide the action and let them persevere in face of obstacles. Finally, barriers and

resources have to be considered, since actions are not only a function of intentions and cognitive

control, but are also influenced by the perceived and the actual environment.

3.4 Adult Education Theories

According to Cranton (1989): “no unified theory of instruction for adult learners exists”. It can

also be argued that no one theory of instruction is possible, given the diverse activities that are,

together, called adult education (Greenhalgh, 2000). However, several theoretical writers have

provided the foundations for adult education practice, even though they may not have been

27

writing directly about adult education. In this section, the foundations for adult education will be

provided briefly.

One of the earliest descriptions of adult education was provided by Dewey (1916, 1938) and

Lindeman (1926). Dewey argued that education must be thought of as a lifelong process, and

viewed learning as being based on life experience, emphasizing the importance of the scientific

method in learning. That is, an individual faced with a problem will develop hypotheses about it,

and then collect evidence to confirm or deny these hypotheses. The ways of describing learning

by Dewey and Lindemans’ works lead to a model of instruction in which the teacher’s role is one

of guide and facilitator rather than expert or formal authority.

Described as a critical theory, Freire’s (1973) work describes how things should or could be

rather than how things are. Freire worked in Brazil, in the area of health literacy, and believed

that lack of education, particularly literacy education, is a form of oppression. In order to

overcome this barrier, the educator becomes a learner, listening to and understanding the needs

of the individual. In this context, learners participate actively in the learning process, through

dialogue with the instructor. According to Freire (1973), educator and learner are mutually

responsible for the teaching and learning process.

The strongest influence on the practice of adult education has been the work done by Knowles

(1973,1980,1984). Although the term “andragogy” was used prior to Knowles work, he is

credited with popularizing the term, which is defined as “art and science of helping adults learn”.

Androgogy is based on five assumptions about how adults learn, and their attitude towards and

motivation for learning.

28

Most theorists agree that andragogy is not really a theory of adult learning, but they regard

Knowles’ principles as guidelines on how to teach learners who tend to be at least somewhat

independent and self directed (Kaufman, 2003). Knowles’s principles can be summarized as

follows:

- Establish an effective learning climate, both physical and psychological, where learners feel

safe and comfortable to express themselves;

- Involve learners in mutual planning of relevant methods and curriculum content;

- Involve learners in diagnosing their own needs, with the instructor acting as a guide and

resource person;

- Encourage learners to formulate their own learning objectives;

- Encourage learners to identify resources and devise strategies for using the resources to

achieve their objectives;

- Support learners in carrying out their learning plans; and,

- Involve learners in evaluating their own learning.

Despite the list presented above, Cranton (1989) warns about the over-simplification to

summarize the andragogy model. According to the author, “it must be remembered that the

teaching and learning process is a complex one and that individual learners and groups of

learners are very different from each other” (Cranton, 1989; page 34). In summary, there is no

single rule or principle of adult education, which could be applied in every situation.

In the context of adult education it is important to describe studies from theorists who have

contributed to the understanding of how adults learn, but not writing exclusively about adults.

Among them, Gagné (1977), Mezirow (1981), Rogers (1969), and Brundage & Mackeracher’s

(1980).

29

First, Gagné (1977) described a model of learning relevant to individuals of all ages. He

proposed that there are types of learning which form a hierarchy; that is, some types of learning

must precede others. The problem-solving cycle – proposed by this author – is related to the

design of educational curriculum for adult learning and includes: (1) the perception of the

problem; (2) collection of observations, thoughts, and ideas about the problem; (3) formulation

of hypothesis; (4) testing of hypothesis until the solution is found; (5) assimilation of the

solution; and (6) the situation no longer perceived as a problem. Second, Mezirow (1981)

described learning as “reflecting on experience” and proposes in her theoretical model of

learning that an individual learns during a life “crisis” or dilemma (i.e. divorce, promotion,

disease). The learning cycle described by the author includes: self-orientation, exploring options,

building confidence, planning a course of action, acquiring knowledge, experimenting with new

roles, and reintegration into society. Third, Rogers (1969) has provided useful insights into the

learning process, emphasizing the self-actualization of the learner as a goal of education. Finally,

Brundage & Mackeracher (1980) undertook the integration of the research and writing on adult

learning into a set of “learning principles” and their implications for educators. Examples of

some of these principles are listed below.

- Adults enter learning activities with an organized set of descriptions about themselves (self-

concept, self-esteem, self-efficacy), which influence their learning processes.

- Adult learning is facilitated when the learner's representation and interpretation of his own

experience are accepted as valid, acknowledged as an essential aspect influencing change,

and respected as a potential resource for learning.

- A certain degree of arousal is necessary for learning to occur, whereas stress acts as a major

block to learning.

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- Adult learning is facilitated when teaching activities do not demand finalized, correct

answers and closure; express a tolerance for uncertainty, inconsistency, and diversity; and

promote question-asking and -answering, problem-finding and problem-solving.

- Adult skill learning is facilitated when individual learners can assess their own skills and

strategies to discover inadequacies or limitations for themselves.

- Adult learning is facilitated when the teacher can give up some control over teaching

processes and planning activities and can share these with learners.

Brundage & Mackeracher’s (1980) learning principles described above demonstrate the

complexity of the adult learning phenomenon. According to Cranton (1989) no set of adult

learning principles or guidelines can be regarded as definitive due to this complexity. Each

instructional situation should be adapted to the reality of the learners and instructors (Cranton,

1989).

4 Study Purpose, Objectives and Hypothesis

The purposes of this thesis were to investigate the relationship between patient education and

behavior change in CR and secondly examine the role of knowledge on behavior change and its

mediators in the context of the Health Action Process Approach.

This thesis combines five papers with specific objectives, as described below:

Paper 1: A systematic review of patient education in cardiac patients: do they

increase knowledge and promote health behavior change?

(1) To assess the published research which investigates the impact of education on patients’

knowledge about health and disease;

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(2) To determine if the published evidence supports a relationship between educational

interventions and health behavior change in CAD patients; and,

(3) To describe the nature of the educational interventions offered to CAD patients.

Hypothesis: It was hypothesized that education significantly increased patients’ knowledge and

would be significantly correlated to behaviour change (physical exercise, medication adherence,

diet, smoking, response to symptoms, and psychosocial well-being).

Paper 2: Development and psychometric validation of a scale to assess

information needs in cardiac rehabilitation: The INCR tool

(1) To develop and psychometrically validate a new tool to assess information needs in CR

(INCR) patients.

Hypothesis: It was hypothesized that the INCR would have good psychometric properties (test-

retest reliability, internal consistency, criterion validity) and could be used to assess information

needs in CR patients.

Paper 3: Healthcare providers’ awareness of the information needs of their

cardiac rehabilitation patients throughout the program continuum

(1) To describe CR participant information needs;

(2) To investigate whether CR providers are cognizant of patient’s information needs and

preferred delivery formats; and,

(3) To investigate whether patient information needs change over the course of CR.

Hypothesis: It was hypothesized that CR providers were cognizant with patients’ information

needs and that these needs change over the course of CR.

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Paper 4: Development and psychometric validation of the second version of

the Coronary Artery Disease Questionnaire (CADE-Q II)

(1) To develop and psychometrically validate the second version of the CADE-Q (CADE-Q

II).

Hypothesis: It was hypothesized that the CADE-Q II would have good psychometric properties

(internal consistency, criterion validity, factor structure, and content validity) and could be used

to assess CADE- related knowledge in CR patients.

Paper 5: Behavior determinants among cardiac rehabilitation patients

receiving educational interventions: an application of the health action

process approach

(1) To investigate changes in knowledge and related theoretical constructs (i.e., self-

efficacy, outcomes expectancies, risk awareness, intention, and planning) among CR

patients following exposure to a traditional or theoretically-informed educational

curriculum; and,

(2) To investigate the theoretical correlates of exercise behavior change among CR patients

receiving educational interventions.

Hypothesis: It was hypothesized that both groups of CR patients increased their knowledge of

cardiovascular health with education interventions and knowledge was correlated to intentions to

change behavior.

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Chapter 2 OVERALL RESEARCH DESIGN AND METHODOLOGY

The proposed thesis involves five studies in order to understand the role of knowledge on

behavior change. To provide the reader with an overview of the proposal research, the overall

research design and how these studies are combined in a logical and interconnected sequence is

presented in this chapter, as well as a brief description of each phase. The appropriate methods

that are used in each study are described under each chapter. Furthermore, it is described in

detail the development of the new education curriculum for CR patients and their families, which

is an important piece of all studies described here.

1 Design and Procedure

All studies were reviewed and approved by the University Health Network Research Ethics

Board, in accordance with CNS’s resolution 196/96. All five papers presented in this thesis are

related as described below in four steps. The reader can also visualize this interaction through an

infographic at the end of this chapter (figure 2.1).

Step one: The initial step was to review systematically the literature in order to assess the state of

knowledge regarding the impact of education on patients’ knowledge about health and disease, to

determine if educational interventions are related to health behavior change in CAD patients, and

to describe the nature of the educational interventions offered to CAD patients. This step was

important to gain a clear picture of how these interventions are structured and how they impact

not only behaviour, but disease-related knowledge. To our knowledge, such a synthesis had not

been published previously. A literature search of five electronic databases was conducted for

published articles from database inception to August 2012. Eligible articles included cardiac

34

patients, and described delivery of educational interventions by a healthcare provider. Outcomes

were knowledge, smoking, physical activity, dietary habits, response to symptoms, medication

adherence, and psychosocial well-being. Articles were reviewed by two authors independently.

Results as well as a more detailed methodology are presented in chapter 3.

Step two: In this step the author as well as a group of researches and experts in CR (called

Patient and Family Education Committee) conducted a comprehensive review of existing

documents related to adult learning and patient education in order to develop a new education

curriculum for cardiac patients participating in the largest academic CR centre of Toronto. One

of the findings was that, within the context of CR, educational interventions based on patients’

needs are likely to be more effective. Therefore, a needs analysis was one of the first phases

included in the development of the education curriculum. Since a previous literature review

failed to identify any available and validated tool to assess information needs in coronary

patients in CR programs a new questionnaire was developed and psychometrically validated.

This questionnaire was called INCR and its development and validation are described in chapter

4. In addition, chapter 5 presents a study using the INCR to describe CR participant information

needs, investigate whether CR providers are cognizant of patient’s information needs and

preferred delivery formats, and whether patient information needs change over the course of CR.

Results from this study were important in the development of the new education curriculum for

CR patients.

Step Three: In this step a more comprehensive and updated questionnaire to assess CR patients’

knowledge was developed and psychometric validated. This questionnaire was called CADE-Q

II and the process of development involved a literature search, analysis of the information needs

assessment study results (chapter 5), focus group discussions with 15 CR experts, and a pilot

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study with a convenience sample of 30 coronary patients who finished their CR programs. A

final version was generated and psychometrically tested in 307 CR patients. A detailed

methodology and results are described in chapter 6.

Step Four: After the development of the new education curriculum and the tool to assess

patients’ knowledge, the final step was to investigate changes in knowledge and behavior change

mediators pre and post CR in two groups of patients: one receiving a traditional education

curriculum and one receiving a new education curriculum. Another objective of this step was to

test the extent to which knowledge can predict behavior change mediators in the context of

education interventions. In summary, a sample of CR patients was divided into two groups based

on the type of education they were receiving (current or new education curriculum). Patients’

knowledge and behavior change mediators were assessed in the beginning of their CR program

and 6 months after discharge. A detailed methodology and results are described in chapter 7 of

this thesis.

2 Setting

All studies described in this thesis included participants recruited from the largest academic CR

centre of Toronto: Toronto Rehabilitation Institute (TRI). The cardiac rehabilitation and

secondary prevention program at TRI is a national leader in the provision of comprehensive,

long-term outpatient services involving medical evaluation, prescribed exercise training, cardiac

risk factor modification, education and counseling. These services are designed to limit the

physiological and psychological effects of cardiac illness, reduce the risk of sudden death, re-

infarction or new cardiovascular events, control or improve cardiac symptoms, stabilize or

36

reverse the atherosclerotic process, and enhance the psychosocial and vocational status of

patients (TRI, 2011).

The CR program in this location is 6-months in duration. The program benefits more than 1,650

patients each year, with a new cohort of 80 patients starting every third Monday of the month.

Upon starting CR, each patient undergoes a comprehensive assessment, they are provided a CR

education workbook and pamphlets as applicable to their educational needs. Participants then

come to the center for weekly classes that include exercise, education, counseling and support.

In addition they are encouraged to exercise on their own at home 4 other times and read an

applicable chapter in their education workbook. In conjunction with these weekly visits, an

interprofessional team provides approximately 15 hours of patient education over the course of

the 6-month program. This is delivered in large and small group education session.

A new educational curriculum was developed for these patients and it is described below. An

infographic illustrating these steps is presented in Figure 2.2, in the end of this chapter.

2.1 Development of the New Education Curriculum

This section describes the development of an education curriculum for CR patients and their

families, called in this thesis the “New Education Curriculum”. This development was based on

two education curriculum frameworks: the University Health Network (UHN) curriculum

framework (UHN, 2003) that guides the delivery of health education for patients and the Eastern

Region Community College ABC program (Eastern Region Community College, 2012) that

guides education delivery in public colleges within Ontario. A committee of 16 CR and patient

education experts – called Patient Education Committee (PEC) – was organized in order to

develop the education curriculum. The responsibilities of this committee are described below.

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Table 2.1 – Responsibilities of the committee of CR and patient education experts

Responsibilities

1. Developing educational strategies to accelerate the translation of scientific discovery and knowledge to improve patient and family knowledge and skill about the prevention and treatment of cardiovascular disease. This includes a focus on areas that might improve clinician knowledge, attitudes for enhancing communication with patients and families including topics such as health literacy, cultural competence, group facilitation, motivational interviewing and the development and use of patient/family educational materials.

2. Providing oversight for the design, implementation, and evaluation of the new education curriculum activities and products.

3. Performing ongoing evaluations of the education curriculum for patients and families, as well as the general public, to determine that they are relevant, current, effective and cost-effective.

4. Overseeing the periodic development, updating and modification of the program’s educational portfolio for patients and families and conducts periodic strategic planning aimed at continued improvement.

5. Exploring ways to ensure that the patient and family perspective is incorporated into educational activities.

6. Ensuring that staff is best equipped to provide patient and family education and have the opportunity to provide education to other rehabilitation settings within the organization.

Although the word curriculum has its roots in the Latin word for “track” or “race course” its

definition is much wider and represents the expression of educational ideas in practice, including

all the planned learning experiences of an institution. Successful education curriculums are in a

form that can be communicated to those associated with the health learning (i.e. clinicians,

patients, family), are open to critique and are readily transformed into practice (Cranton, 1989).

The development of the curriculum involved a rigorous 3-year process with multiple stages of

research, analysis, and revision as following: (1) problem definition, (2) theoretical foundation,

(3) needs analysis, (4) program goals & educational objectives, (5) sequencing instruction, (6)

instructional strategy/design, (7) instructional methods/materials, (8) evaluation of

instruction/materials, and (9) evaluation of learning for health outcomes.

2.1.1 Problem Definition

According to literature and guidelines, health education should be delivered not only to increase

patients’ knowledge but to also achieve health behavior change (Mullen et al., 1992; Dusseldorp

38

et al., 1999; Thomas et al., 2007; Aldcroft et al., 2011; Schadewaldt & Schultz, 2011; Canadian

Cardiovascular Society [CCS], 2013; Ghisi et al., 2014a). Although studies have shown that

knowledge is insufficient for generating sustained behaviour change (Brown et al., 2011),

knowledge is an essential component of behaviour change because it informs patients of the

probable consequences and outcomes of their choices. PEC members identified a gap between

knowledge and behaviour change, so the new education curriculum was developed to

consciously improve knowledge to influence behaviour change.

2.1.2 Theoretical Foundation

Three different theories guided the committee to meet their objectives of developing an

education curriculum that increased knowledge and promoted and supported behaviour change:

constructivist learning theory, adult learning theory, and the HAPA model. Constructivist

learning theory and adult learning theory guided the education curriculum and the HAPA model

supported their efforts of incorporating behaviour change into the curriculum. Self-management

skills were incorporated to support the behaviour component of the new curriculum and

prescriptive model to support curriculum design.

Adult learning theory and the HAPA model were described on chapter 1 of this thesis. In regards

to constructivist learning theory, constructivism refers to the idea that learners construct

knowledge for themselves – each learner individually (and socially) constructs meaning – as he

or she learns. In this context, learning is active, constructive, social, and contextual. The learner

is an information constructor. People actively construct or create their own subjective

representations of objective reality. New information is linked to prior knowledge and

motivation is a key component in learning (Cole & Griffin, 1987).

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In regards to self-management (SM) theory, current evidence indicates that individuals and

families who engage in self-management behaviours improve their health outcomes (Ryan &

Sawin, 2009). SM is a multidimensional, complex phenomenon that can be conceptualized as

affecting individuals or families across all the learning process. The SM theory consists of three

dimensions: context, process, and outcomes. In summary, the SM theory says that improvement

of individual and family outcomes translate to improved outcomes for health care practitioners

and systems (Meleis, 1997; Fawcett et al., 2001). Self-management strategies mediate self-

efficacy, which is an important component of patient education as described in chapter 1.

Finally, one other concept was useful in the development of the new curriculum: the prescriptive

model. Prescriptive models are concerned with the ends rather than the means of a curriculum.

The “outcomes based education” model is recent and starts from a simple premise: the

curriculum should be defined by the outcomes to be obtained by learners. Curriculum design

proceeds by working “backwards” from outcomes to the other elements (e.g. content, teaching

and learning experiences, assessment and evaluation) (Harden, Crosby, & Davis, 1991).

2.1.3 Needs Analysis

In order to plan and deliver an effective CR educational intervention, it is important to have

precise information about the educational needs of the patients (i.e. how patients want their

education to be structured and delivered) (Scott & Thompson, 2003; Ghisi et al., 2013a). Indeed,

the literature highlights the importance of a comprehensive understanding of patients’ health

information needs as one of the first steps in developing education curriculums (Cranton, 1989).

The needs analysis as part of the new curriculum development process included the following

five steps: (1) development of a tool to access CR patient information needs; (2) assessment of

CR patients’ information needs and CR clinical staff awareness of patients’ information needs;

40

(3) environmental scan of other CR programs; (4) literature review of best practice on CR patient

education; and, (5) patient focus group. Steps 1 and 2 are described in detail on chapters 4 and 5

of this thesis, respectively.

2.1.3.1 Environmental Scan of other CR programs

In order to understand how education is delivered in similar CR programs, an environmental

scan was performed. From 12 possible sources for this scan, 3 (25%) responded. Together, the

programs provide a variety of education topics including exercise, medical, risk factor

identification and modification and goal setting. Group and individual education is offered as

well as workshops in smoking cessation, stress and weight management. Two of the CR

programs involve patients in the process of developing the curriculum for their education

program (via feedback surveys). A patient needs assessment done in one CR program resulted in

their team revamping the content, amount of detail and comprehension level of the education

offered to their patients and family. Modes of delivery consist of power point presentations,

handouts, workbook and e-learning (for those with internet access). Nutrition education includes

use of food models, real packaging and grocery store demonstrations. Finally, evaluation of the

education programs includes some or all of the following: knowledge uptake, patient satisfaction

and change in behaviour. One program provides “game days” consisting of review of the

patients’ understanding of the educational material. Immediate feedback is given to the patients

and incorrect responses are then reviewed with the group.

2.1.3.2 Literature review of best practice on CR patient education

A literature search of CR guidelines was conducted for information regarding patient education.

Six guidelines were included (Globle & Worcester, 1999; Queensland Health, 2000; National

41

Heart Foundation of Australia [NHFA] & Australian Cardiac Rehabilitation Association

[ACRA], 2004; Ries et al., 2007; Stone et al., 2009; British Association for Cardiovascular

Prevention and Rehabilitation, [BACPR], 2012). Data was extracted and combined into 5

categories: content (educational topics and materials), special considerations (groups which

education should be adjusted), effectiveness (principles for effective teaching and learning),

mode (delivery format), and evaluation. Table 2.2 summarizes the results from this literature

review.

2.1.3.3 Patient focus group

Focus groups are collective discussions that are designed to explore a specific set of issues. They

are a qualitative technique appropriate for exploring patients’ knowledge and experiences,

examining not only what they think but why they hold a particular opinion. They can reveal

dimensions of understanding that often remain untapped by quantitative data methods. Thus,

focus groups explore people's understanding of issues by encouraging interaction between

research participants (Kitzinger, 1999).

Focus groups were used to determine patients’ experience with the education they were receiving

in the CR program prior to any changes made to the curriculum. Analysis of 9 CR patients’

narratives – composing 1 focus group – identified key themes and issues about previous patient

education. Using qualitative framework approach, participants’ narratives were coded and

grouped together under themes (Kitzinger, 1999). Main themes that emerged are described in

Table 2.3.

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Table 2.2 – Summary of the Literature review of best practice on CR patient education

Source Content Special Considerations To be Effective Mode Evaluation

CACR (Canada)

Topics: − Risk factor target and risk factor

modification (weight reduction, smoking cessation, dietary and nutrition habits)

− Dietary habits to increase fibre, alpha-linolenic acid, fruits, nuts, vegetables, whole grains, monounsaturated fats, polyunsaturated fats, omega 3s, plant-based proteins and reduce saturated fats, simple carbohydrates and sodium)

− Adherence to life-enhancing and/or life-prolonging prescription and non-prescription drugs. (e.g. aspirin, clopidogrel, beta blockers, statins, ACE inhibitors and/or angiotensin receptor blockers)

− Health behaviour interventions including optimal dietary, physical activity strategies and weight control

− Develop self-management techniques (problem solving, decision making, resource utilization, partnership formation, action planning (SMART goal setting) and self-tailoring)

Elderly-cognitive function may be impaired; instructions need to be clear, concise and may need to be written down and frequently reviewed (often with family members) Hearing impaired-clear description by video Visually impaired-clear description by audio Heart failure-education (and counselling) to help them adjust to the psychological, physical and social effects of living with heart failure. Importance of weighing themselves daily and how to adjust diuretic usage in response to weight gain. Diabetes-foot care, proper footwear, medication adherence to diabetes meds, blood sugar monitoring and prevention/treatment of hypo and hyperglycemia. Sexual health- expert education and counselling in patients with congenital heart disease, heart failure or patients who have received information about their sexual health in relation to their cardiovascular condition.

− Voluntary participants − Mutual respect − Time for critical

reflection of material − Empowered to become

self-directed learners − Discuss specific health

goals − Is personalized − Explains the risks of not

changing, the benefits of changing

− Seeks to influence outcome beliefs regarding the outcome efficacy of interventions or behavioural changes

− Often emphasizes proximal risks and benefits over distal ones

− Seeks to heighten self-efficacy concerning possible effective self-regulation of specific behaviours

− May seek to elicit positive emotions, to increase optimism about the possibility of change and to heighten the salience of personal experience or other evidence supporting self-efficacy.

− Individual or group

− Collaborative learning activities

− Internet-based cardiac rehab education

− Efficacious dietary interventions include case management and group interventions combined with individual counselling

− Education outcomes are considered a core component of cardiac rehab

− Documentatio

n of the education plan and progress.

43

AACVPR

(USA)

Topics: − Improving cardiac risk (through a low-

fat diet, blood pressure management, lipid management, smoking cessation, diabetes management, depression/stress management and physical activity habits)

− Managing cardiac emergencies (angina, possible heart attack, pain or discomfort during exercise

− Understanding the disease process (atherosclerosis, high blood pressure, diabetes)

− Maintaining psychosocial health (addressing sexual function, social relationships, depression, anger, hostility

− Adapting to limitations imposed by the disease process (changing roles in the family, jobs at work, hobbies and recreational activities)

Materials should be: − Consistent with national guidelines − Developed by health care professionals − Developed from behaviour and

education programs with documented success

− Reviewed and commented on by patients and families

− Approved by the appropriate institutional administrative structure

− Dependent upon the needs and preferences of patient and families

− At appropriate reading level of patient and family

− Large print on nonglossy paper is more readable

− Translated into different languages

Elderly-address impaired senses(e.g., printed instruction for hearing impaired large-type print for poor vision), offer daylight times, small amounts of information repeated often and individualized to each person, involve family/care givers to reduce social isolation, emphasize nutrition principles adapted for this age group, identify barriers to learning) Multicultural-plan education sessions to last longer than usual, use simple sentences when giving instruction, speak clearly and avoid technical terms, sequence the material, have patient give a return demonstration on any skill you teach, include one or more significant family members, partner with faith-based organizations whenever possible, use health care providers from the patient’s culture where possible, respect the patient’s health beliefs or practices Transplant patients-medications, symptoms, specific diet changes (diet low in fat, cholesterol and sodium to prevent weight gain and hypertension), importance of regular exercise Diabetes-medications, exercise safety, diet, complications, blood sugar monitoring, prevention/treatment of hypoglycemia, foot care.

− Should be dependent upon the needs and preferences of the patient and family

− Individual or group

− Telephone,

internet based, books, audiotapes, videotapes, CD-ROMs, interactive computer programs (computer assisted instruction)

All programs should have written plans for providing education and a method for documenting implementation and patient progress.

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The Heart Research Centre (Australia).

Medical topics: − Anatomy, physiology and pathology of

cardiovascular disease − Coronary heart disease/ischemic heart

disease − Acute cardiac events − Investigation and procedures − Symptoms and their management − Cardiac medications Modifiable risk factors: − Smoking, raised lipids, nutrition and

dietary fat, high blood pressure, overweight, obesity and diabetes, physical inactivity, other risk factors

Non modifiable risk factors: − Older age, male sex, positive family

history Behavioural and psychosocial topics: − Behaviour change and adherence to

medication and advice − Mood and emotions − Psychosocial risk factors and social

support − Impact upon the spouse and family − Sexual activity and activities of daily

living − Return to work (this is considered a

major aim of cardiac rehab. This is not consistently done in USA and Canada)

Low education levels, increasing age, and heightened anxiety all negatively impacts the cardiac patients’ ability to learn and retain information.

− The patients’ specific needs and their receptivity to information should be considered.

− Joint setting of priorities for educational content by the patient and educator is recommended to maximize learning.

− Information given needs to be repeated reinforced and be consistent amongst the healthcare providers.

Individual or group

Number (%) of patients whose knowledge level is assessed. Number (%) of patients with improved knowledge.

BACPR

(England)

Topics: − Attention to the common unhelpful

beliefs and misconceptions about cardiac illness that lead to increased disability

− Pathophysiology and symptoms − Physical activity, smoking, diet, blood

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pressure, lipids, weight management and glucose

− Psychological issues − Occupational issues − Sexual dysfunction − Cardioprotective drug therapy, surgical

interventions and devices − Cardiopulmonary resuscitation

NHFA & ACRA

(Australia)

Topics: − Basic anatomy and physiology of the

heart, effects of heart disease, the healing process, recovery and prognosis, symptom management, medications, investigations and procedures, cardiac health beliefs and misconceptions,

− Risk factors for heart disease and their modification for secondary prevention (e.g. smoking cessation, physical activity, healthy eating, control of blood lipids, weight, blood pressure and diabetes)

− Supporting skill development to enable behaviour change and maintenance

− Resumption of physical, sexual and daily living activities including driving and return to work (emphasized),

− Psychological issues e.g. mood (depression), emotions, sleep disturbance, social factors e.g. family and personal relationships, social support/isolation

Queensland Health

(Australia)

Heart disease: − How the heart works, atherosclerosis,

angina, conduction disorders, valvular disease, diseases of the heart muscle, heart attack and the healing process

− Employ adult learning principles

− Encourage group disclosure and sharing of experiences

“Education involves more than the transfer of information. It is not confined

Regularly conduct process, impact and outcome evaluations

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(causes and symptoms, difference between heart attack and cardiac arrest, myths and misconceptions), cardiac symptoms and their management, what to expect during recovery

Risk Factors: − Modifiable risk factors (smoking,

raised lipids, nutrition and diet, high blood pressure, overweight and obesity, management of type 2 diabetes, physical inactivity alcohol intake, stress)

− Non-modifiable risk factors (age, sex, diabetes, positive family history

Physical Activity/Exercise: − Definition of physical activity,

definition of exercise, type, durations, frequency, intensity, how to monitor the level of exertion, benefits, how to manage angina while doing activity, appropriate clothing and footwear, orthopedic and musculoskeletal problem avoidance-acute and chronic, barriers to exercise, co-morbidity impact on exercise (e.g. CVA, congenital heart disease, very low level of exercise capacity)

Activities of Daily Living: − Outline of recovery process and

anticipated timeframes, general principles regarding resumption of activity, self-monitoring of exertion and symptoms, how to resume general activities using (principles of energy conservation, principles of work simplification), guidelines for return to self-care, home, work and leisure

− Understand group work principles (group dynamics and participant behaviour to foster a positive learning environment for all)

− Encourage the group to generate their own solutions to encourage ownership of knowledge

− Use theories and strategies for behaviour change

− Tailor the education mode to suit individual needs

− Assess knowledge and learning style/preferences

− Address misconceptions − Establish/provide a

supportive learning environment

− Address knowledge, attitude, beliefs and skills of the individual

− Develop client-set, client- focussed learning objectives in collaboration with the health professional

− Provide written confirmation of information provided

to formal education sessions, but is an integral component of physical activity and exercise prescriptions, counselling sessions and informal gatherings such as morning teas. Individuals can benefit from the experiences of others in similar situations so time should be allowed for group members to share their experiences either in a formal or informal way.”

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activities, use of assistive equipment Nutrition: − Healthy weight range, healthy eating,

modification of diet to achieve appropriate body weight and maintain micronutrient adequacy, dietary fats-types, role in heart disease, salt, fibre, other nutrients in food, cholesterol, food selection/shopping, eating habits/meal patterns, food preparation/cooking, eating out/takeaway, food labelling, recipe modification, hydration during exercise

Smoking Cessation: − Association of smoking and heart

disease, benefits of quitting, nicotine dependence, methods of quitting (behaviour change), resources available, medications available for nicotine addiction

Medications: − Knowledge and understanding of

medications, cost, method of administration, strategies for compliance with medications

Psychosocial Issues: − Mood and emotions (anxiety, denial,

depression, grief and loss), normalization of event, address areas of concern (job security, sexual activity), psychosocial risk factors, return to normal activities, financial concerns, social support, social isolation, impact on family

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Stress Management: − Link between stress and heart disease,

resources available, stress management strategies (relaxation techniques, time management, setting priorities, balancing work, family and leisure, resources available)

Cardiac Investigations and Procedures: − Explanation of test they have had (e.g.

ECG, echocardiogram, stress test, blood tests, angiogram). Explanation of management (medical or intervention) e.g. thrombolytic therapy, heart surgery, angioplasty, pacemaker implantation. Address and discuss anxieties associated with the above.

CPR: − See heart disease topics, emergency

procedures, community resources

CR indicates cardiac rehabilitation; CACR Canadian Association of Cardiac Rehabilitation; AACVPR American Association of Cardiovascular and Pulmonary Rehabilitation; BACPR British Association of Cardiovascular Prevention & Rehabilitation; NHFA National Heart Foundation of Australia; ACRA Australian Cardiac Rehabilitation Association; ACE angiotensin-converting-enzyme; CVA cerebrovascular accident; ECG electrocardiogram; CPR cardiopulmonary resuscitation.

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Table 2.3 – Main themes that emerged from patient’s focus group

Main Themes

The workbook is a valuable resource for patients.

The group setting for education delivery is an important part of the CR program. A greater number of participants could benefit from this aspect of the program if more opportunities for peer support and discussion were woven into the curriculum.

There was great value seen in the additional learning groups provided within the program including; the Eating Behaviours, Chronic Disease Self Management, Stress Management, and Post-Surgical clinic.

− The importance of promoting cardiac rehab program throughout the community to increase patient access.

− The CR program is holistic and customized for individuals within a group setting.

− More attention to goals, including follow-up throughout rehabilitation.

− The importance of the facilitator.

2.1.4 Program Goals & Educational Objectives

Program learning outcomes are statements that reflect what learners will know and be able to do

when they graduate from a program. In the development of an education curriculum, it is

important to ensure that program learning outcomes are clearly identified, which described what

graduates of the program will be able to do. This aligns well with the Prescriptive Model,

described earlier. After the previously described steps were completed, the results enabled the

development of the education curriculum’s 5 program learning outcomes, described in Table 2.4.

Table 2.4 – Education Curriculum’s 5 program learning outcomes

By the end of their 6-month CR program, patients will be able to:

1. Take charge of their medical condition and respond appropriately to changes in their health status;

2. Maintain an exercise program to improve their health and well-being;

3. Identify and develop strategies to decrease their risk factors for heart disease;

− 4. Incorporate healthy food choices and practices to manage their health and well-being; and,

− 5. Identify and develop strategies to manage their psychosocial risks for heart disease and improve their well-being.

CR indicates Cardiac Rehabilitation

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2.1.5 Sequencing Instruction

Sequencing instruction is the order in which topics or objectives will be taught. The process of

determining which learning must precede which other learning is called instructional analysis

(Cranton, 1989). To summarize briefly, instructional analysis is simply a systematic procedure

for sequencing instruction in order to optimize learning. To develop this education curriculum a

type of instructional analysis called task analysis was used, which is based on the assumption

that learning is hierarchical in nature, and learners should be taught from simplest to most

complex topics. In addition, results from the needs assessment study described in chapter 5 were

important to determine in which stage of treatment patients wanted to know about a certain topic.

The education curriculum developed has 3 sections, which are described in Table 2.5.

Table 2.5 – Sections of the new education curriculum for CR patients

Period (weeks)* Section Description

Beginning (1–5 weeks)

Safety and Foundation Information about the CR program, their aerobic exercise prescription and safety, managing angina, irregular heartbeats, diabetes, exercising in cold and hot weather, the heart (anatomy, pathophysiology, diagnoses and treatment) and cardiac medications.

Middle (6-12 weeks)

Skill Development Information about the patient’s risk factor profile, goal setting and action planning, resistance training, nutrition (fats, fiber, reading food labels, sodium), psychosocial risk, and sexual intimacy

End (18-26 weeks) Preparing for Graduation

Information about how much physical activity is good, aerobic and resistance training progression, relapse planning, and graduation.

CR indicates Cardiac Rehabilitation.

* The CR program is 26 weeks long.

2.1.6 Instructional Strategy and Design

Once the content of the course was described in terms of expected learning and once that

learning has been sequenced, the next step in the curriculum development was the instructional

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strategy and design, or the activities around the learner, which will facilitate his/her learning. In

this context, learning activities, learning assessments, and learning resources and materials were

developed.

Learning activities are designed, grouped and sequenced activities that help learners achieve the

course learning outcomes. Through these learning activities learners also receive feedback about

their progress and are prepared for evaluation where they can demonstrate their achievement of

the course learning outcomes (ERCC, 2012). In the end of each lesson, learning activities are

available for patients within their education workbook as well as in their group education class.

Activities included practical ones like taking their pulse, cognitive ones like reflecting on their

own thoughts and experiences depending on the topic and self-regulatory activities like action

planning and problem solving around a desired behaviour.

Learning assessments should be aligned with learning outcomes. Thus, well-planned assessments

allow learners to demonstrate that they have achieved the learning outcome or provide feedback

that identified the progress they are making towards their achievement (ERCC, 2012). Each

educational topic of the curriculum has learning assessments and assessments of patients’

motivation and confidence level to incorporate change into their lifestyle pertaining to the topic.

Finally, when developing an education curriculum it is important to ensure that learning

resources and materials support the learning activities and assessments. They also need to align

with the needs, interests and abilities of the learners (ERCC, 2012). In this context, the resources

and materials of the new education curriculum are:

- 24 educational weekly group education sessions strategically mapped and sequenced

to support the program learning outcomes. Education sessions are given by an

interprofessional team of CR experts and are usually 30 minutes in duration.

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- A comprehensive education workbook for people living & thriving with

cardiovascular disease containing 22 chapters. Clinicians and patients reviewed the

material and a plain language and clear design review was completed. The

workbook’s chapters were mapped to correspond to the three topics of the education

curriculum described in Table 2.5.

2.1.7 Instructional Methods and Materials

2.1.7.1 Instructional Methods

For the new education curriculum a combination of four teaching methods were used: (1)

instructor-centered, (2) interactive, (3) individualized techniques, and (4) experiential learning.

Although in this curriculum lectures are included in each CR session, instead of learners being

passive receivers of information, interactive methods are used to promote communication among

learners, as well as between learners and the instructor (e.g. class discussion, peer-to-peer

learning and discussion groups). Individualized learning techniques are also included in the new

curriculum, based on the assumptions that individuals learn at different speeds and that regular

immediate feedback facilitates the learning process (Cranton, 1989). In this context, patients

have the opportunity to have a one-on-one consultation with health providers, including a

dietician, a social worker and a psychologist. Finally, experiential learning methods – learners

performing tasks – are also used in this curriculum, such as creating action plans.

2.1.7.2 Instructional Materials

Instructional materials are the tools used by the educator to help the learner retain, compare,

visualize and reinforce learning (UHN, 2003). As described elsewhere, the materials of the new

education curriculum are an education workbook and educational weekly lectures. Both

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resources were strategically mapped and sequenced to support the program learning outcomes.

While the workbook comprises the full comprehensive explanation, the weekly lectures highlight

the important ideas of each topic, as well as check patients’ progress (assessments). Besides that,

there are individual care plans, in which patients can interact with staff while they are exercising.

In the future this educational curriculum will be multicultural (to ensure that information is

understood by patients from different cultures) and multimedia (internet and mobile resources

will be added in order to achieve a broader group of patients, in different countries).

2.1.8 Evaluating Instruction and Materials

2.1.8.1 Evaluating Instruction

Capacity building involves increasing knowledge, skills and resources of existing structures to

disseminate an idea (Jackson et al., 1994). During the development of the new education

curriculum each instructor participated in building capacity sessions, which involved information

about the new curriculum, including learning activities, assessments and outcomes in order to

enhance instructors’ skills essential to implementation of the new educational curriculum. In

these sessions, instructors met in small groups of 4-6 on a weekly basis over a course of 6

months. They had the opportunity to learn the new curriculum and the skills for group

facilitation. Furthermore, instructors also expressed their learning needs and used the time to

support one another during this implementation phase. The experience with the new education

curriculum indicates that building capacity sessions are a viable method for instruction

assessment, since an informal feedback is provided to instructor about their instruction.

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2.1.8.1 Evaluating Materials

Three groups evaluated the new education workbook: patients, staff, and experts. In regards to

patients’ feedback, 8 focus groups (total of 24 patients and 1 spouse) were held. Sessions were

45 minutes long and a 21-item discussion guide was developed by the PEC to guide the

discussion. Positive features of the workbook identified by patients included: content covers their

needs, appropriate amount of information, and appropriate language and content. Negative

features included binding and weight. Overall, patients were very satisfied with the workbook.

Staff’s feedback was also collected during a focus group (n=10), and 13-item discussion guide

was developed by the PEC to guide the discussion. Staff identified that the workbook promotes a

better interaction with patients, and that it is a good resource for them too. However, they point

out that finding information is not always easy.

Finally, experts (editors, volunteers, patients with a medical or educational background) assessed

the content and outcomes of the workbook. Results were positive and reinforced the use of this

tool to educate patients.

2.1.9 Evaluating Learning for Health Outcomes

Chapter 7 of this thesis describes a study aimed to investigate the effects of patient education on

behavior change and its mediators in CR patients, before and after their participation in this new

education curriculum. CR patients were assessed at the beginning of their program and at the

end, through questionnaires. A cohort of CR patients participating in a traditional version of the

education curriculum was also assessed for comparison.

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2.1.10 Discussion

This section described the 9 phases of the development of an education curriculum for CR

patients and their families. The new curriculum consists of 24 educational weekly lectures

strategically mapped and sequenced to support the program learning outcomes and an

educational workbook with 22 chapters matching the weekly lectures. Individual care plans are

also provided. Each educational topic contains a background educational content, learning

activities, learning assessments, behavioral-based action planning related to the topic, and

assessment of patients’ motivation and confidence level to incorporate change into their lifestyle

pertaining to the educational topic. Positive aspects of the education curriculum include the

following: topics structured from simplest to most complex; instructional strategy and design

comprising learning activities, learning assessments and learning resources and materials; all 4

categories of teaching methods included (instructor-centered, interactive, individualized

techniques and experiential learning); capacity building sessions to increase knowledge, skills

and resources of instructors as well as to assess them; and evaluation of the materials by multiple

groups (patients, staff, and experts).

A key strength of the new curriculum is that it is empirically derived and conceptually congruent.

The new education intervention was developed on the principles of the following theories:

constructivist learning theory, the HAPA model, adult learning theory and prescriptive model. In

addition, because CAD is considered a chronic condition, the intervention was designed to

promote self-management, which is an important element for the management of chronic disease.

Reviews of effectiveness of chronic disease management interventions indicate that interventions

based on behavioral change models are more likely to be effective than those that are not (Jordan

& Osborne, 2007).

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Another strength in the new curriculum was the needs analysis phase, with information gathered

from five activities to allow the CR expert committee to develop a vision for a patient and family

education curriculum and five program learning outcomes. These activities were very

comprehensive including information derived from patients (assessment of patient information

needs and patient focus group), health providers (staff survey of patient information needs), other

CR programs (environmental scan of other CR programs), and national guidelines (literature

review of best practice). Synthesizing the information gathered from the needs analysis allowed

the development of a vision for a patient and family education curriculum that includes: a variety

of topics and modes of delivery that are relevant to CR patients; information that help CR

patients to make informed decisions about their health; and information that is also consistent

across the team members and is supported by best evidence. In addition, based on results from

this phase the new curriculum is sensitive to potential barriers to learning, culture specific for

both patients and staff, and designed for special populations.

One of the greatest challenges of delivering educational interventions to cardiac patients is to

integrate multiple characteristics and cultures into clinical practice. In the future, the education

curriculum will be translated to different languages to address this issue. Besides being

multicultural, a multimedia set will be build, so patients can assess information in their mobile

and at home. Whether a software version of the curriculum would have similar efficacy in

delivering the message is unknown, but is worth investigated.

In conclusion, the new education curriculum developed in this study is a sequential and

theoretical strategy that could reach CR programs in order to support cardiac patients’ education.

This intervention may be a powerful tool to promote behaviour change in CR patients. CR

programs can use this model to implement education components into their practice.

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Figure 2.1 - Infographic of the papers that comprise this thesis

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Figure 2.2 – Development of the new education curriculum - Infographic

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Chapter 3 PAPER ONE: A systematic review of patient education in cardiac

patients: do they increase knowledge and promote health behavior change?

In this chapter are presented results from a systematic literature search of several electronic

databases from database inception to August 2012 in order to: (1) investigate the impact of

education on patients’ knowledge; (2) determine if educational interventions are related to health

behavior change in cardiac patients; and (3) describe the nature of educational interventions.

Overall, 42 articles were included, of which 23(55%) were randomized controlled trials. This

paper was published in Patient and Education Counseling Journal, in 2014 (Ghisi et al., 2014a).

1 Introduction

Cardiovascular Diseases (CVDs) are the leading cause of mortality worldwide (WHO, 2012),

and are a significant contributor to morbidity and health-related costs (Cardiac Care Network

[CCN], 2002). Coronary Artery Disease (CAD) – the most common type of CVDs – is

considered a chronic condition and, therefore, requires a careful medical management with

multiple recommendations for patients to achieve optimal secondary prevention (Stone, Arthur,

& Suskin, 2009; Clark et al., 2005; Heran et al., 2011). As a consequence, patient education is a

necessary first step to promote patient understanding of the recommended therapies and behavior

changes, as well as to follow them (Alm-Roijer et al., 2006; Kayaniyil et al., 2009; Boyde,

Turnet, Thompson, & Stewart, 2011; Brown et al., 2011).



status” (as cited in Koongstvedt, 2001, p. 788). Research is beginning to demonstrate a positive

60

effect of cardiac patient education on behavior change, including 4 reviews (Mullen, Mains, &

Velez, 1992; Dusseldorp et al., 1999; Aldcroft, Taylor, Blackstock, & O’Halloran, 2011;

Schadewaldt & Schultz, 2011). Of these, 3 demonstrated that educational interventions produce a

positive effect on behavior change. Although these reviews may be less subject to bias as they

included only randomized controlled trials, they included a small number of trials and focus on

outcomes, failing to describe the interventions in depth and aiming only to assess psycho-

educational strategies. It is important to gain a clear picture of how these interventions are

structured and how they impact not only behavior, but knowledge. To our understanding , such a

synthesis has not been published previously.

Cardiac rehabilitation (CR) is a comprehensive risk reduction program, of which patient

education is considered a core component (Buckley et al., 2013). Thus, American and Canadian

Cardiovascular Societies include education as a quality indicator of CR (Thomas et al., 2007;

Canadian Cardiovascular Society, 2013). According to the Canadian Association of CR

Guidelines (Stone et al., 2009), patient education should: be personalized; be led by a

professional staff, with regular contact between staff and patients; be delivered in individual or

group settings; discuss specific health goals; and seek to influence outcomes beliefs, to elicit

positive emotions, to increase optimism about the possibility of change, and to heighten the

salience of personal experience or other evidence supporting self-efficacy. However, the nature

of education delivery is not fully specified, and the impact of the education has not been often

considered.

The first objective of this systematic review was to investigate the impact of education on

patients’ knowledge about health and disease. The second objective was to determine if

educational interventions are related to health behavior change in CAD patients, namely

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smoking, physical activity, dietary habits, response to cardiac symptoms, and medication

adherence, as well as psychosocial well-being. Finally, the third objective was to describe the

nature of the educational interventions offered, as per the Workgroup for Intervention

Development and Evaluation Research (WIDER) reporting guideline (Workgroup for

Intervention Development and Evaluation Research [WIDER], 2008).

2 Methods

2.1 Search Methods for Identification of Studies

Literature published from database inception until August 2012 was searched using the

MEDLINE, PsycINFO, CINAHL, EMBASE and EBM computerized databases, in conjunction

with a subject librarian. Search results were downloaded into bibliographic software. The search

strategy incorporated 3 concepts: (1) condition, which was divided into cardiac and rehabilitation

aspects (e.g. coronary disease, myocardial infarction, and rehabilitation); (2) education (e.g.

health education or patient education); and (3) outcomes (e.g. knowledge, health behavior,

lifestyle, and attitude toward health). Search terms were specific to each database. The search

strategy for 2 databases is shown in Table 3.1. A snowball hand-search was undertaken after the

first selection of articles.

2.2 Inclusion and Exclusion Criteria

The criteria for considering studies for this review were:

(1) Design: peer-reviewed studies were considered for inclusion. Primary or secondary studies

were included, whether they were observational or interventional in design. Qualitative studies

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were not included, however they served to inform interpretation of quantitative findings.

Reviews were identified as a source of additional primary studies.

(2) Participants: cardiac patients with primary diagnosis of CAD, myocardial infarction, or who

have undergone coronary artery bypass graft surgery, or percutaneous coronary intervention.

These patients are indicated for CR in clinical practice guidelines (Stone et al., 2009). Heart

failure patients were excluded from this review as these patients require additional education

when compared to CAD patients.

(3) Education: any educational interventions about CAD and its management, delivered by a

healthcare provider. In order for the article to be included, the educational intervention had to be

described in accordance with the reporting guidelines for behavior change interventions

developed by WIDER (WIDER, 2008). Specifically, at least 3 of the 8 recommended elements

for intervention description had to be detailed: characteristics of those delivering the intervention

(i.e. type of healthcare professional), characteristics of the recipients, the setting (i.e. time and

place of intervention), mode of delivery, the intensity (i.e. contact time), the duration (i.e.

number of sessions), adherence to delivery protocols, and a detailed description of the

intervention content.

(4) Outcomes: Studies had to either report the impact on knowledge, behavior, or psychosocial

indicators (e.g., stress). The five behaviors were: smoking, physical activity, dietary habits,

response to cardiac symptoms, and medication adherence. These behavioral outcomes were

chosen because they are related to better health outcomes in cardiac patients (Clark et al., 2005;

Stone et al., 2009; Verril et al., 2009; Heran et al., 2011).

(5) Published in the English language.

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Table 3.1 – Search Strategy

Concept Search Terms - MEDLINE Search Terms - EMBASE

1. Condition Aspect Coronary disease Coronary artery disease 1.1 Cardiac Aspect Heart disease Heart disease

1.2 Rehabilitation Aspect Cardiovascular disease Cardiovascular disease Coronary artery disease Heart infarction Myocardial infarction Myocardial infarction

Rehabilitation Rehabilitation Physical therapy modalities Rehabilitation research/

medicine/patient Rehabilitation Centers Rehabilitation Centers Physical medicine Physical Medicine Cardiac Rehabilitation Cardiac Rehabilitation

2. Education Aspects Health education Health education Educational status Educational status Education Education Education session/program/

support/target/patient/intervention Education session/program/ support/target/patient/intervention

Patient education as topic Teaching Health literacy Nurses role Teaching session Nurse-patient relations Nurse patient relationship

3. Outcomes Health behavior Health behavior Patient knowledge Patient knowledge Self care Self care Disease management Disease management Treatment outcome Treatment outcome Life style Lifestyle Self-efficacy Self concept Attitude to health Attitude to health Outcome assessment Outcome assessment Effect behavior change Effect behavior change Behavior modification Behavior modification Behavior change Behavior change Lifestyle modification Lifestyle modification Diet Diet Blood glucose Glucose blood level Sodium dietary Sodium intake Smoking Smoking Alcohol drinking Drinking behavior Exercise Exercise Physical fitness Fitness Vital signs Vital sign Body weights and measures Morphometrics Health attitudes, practice Attitude Lipids Lipid blood level Adherence Adherence Medication Medication Psychosocial Psychosocial Stress Stress Symptoms Symptoms

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2.3 Data Collection and Analysis

Two reviewers independently screened the references identified by the search strategy by title

and abstract. In order to be selected, abstracts had to clearly identify cardiac participants,

educational interventions and one of the outcomes described previously. The full-text reports of

all remaining citations were obtained and assessed independently for eligibility by these 2

reviewers, based on the defined inclusion criteria. Any disagreements were resolved through

discussion between the two investigators and, if needed, consultation with a third author.

Data extraction was undertaken by a single reviewer and checked by a second reviewer. The

Downs and Black scale (Downs & Black, 1998) - a checklist used to assess the methodological

quality not only of randomized controlled trials but also non-randomized studies - was selected

to assess the quality of the studies, as it contained the highest number of relevant items for the

needs of this review. Given not all items were relevant to all study types included in this review,

2 modified versions of the checklist were created. The one for cohort / cross-sectional studies

consisted of 18 items with a maximum score of 18 points. The one for randomized controlled

trials (RCT) consisted of 25 items. This tool was used to rate article quality in 4 areas: reporting,

external validity, internal validity (bias), and internal validity (confounding). The total points for

each article were categorized as “good”, “fair”, or “poor” based on the United States Preventive

Services Task Force approach (Harris et al., 2001).

Given the nature of the literature, quantitative synthesis of data was not possible. The multiple

sources of heterogeneity observed across studies (in terms of interventions and outcomes) meant

that undertaking a formal meta-analysis was not considered appropriate. Heterogeneity amongst

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included studies was explored qualitatively. Studies were grouped accordingly to intervention

characteristics (e.g., delivery format and education content) and the outcomes of interest.

3 Results

Initial searching yielded 6476 records, and 3 records were identified through the snowball hand-

search. After the screen, 343 full-articles were assessed for eligibility. Overall, 42 articles were

included in this systematic review. A flow diagram depicting the search results, reasons for

exclusion, and study selection is presented in Figure 3.1.

3.1 Characteristics of Included Studies

Table 3.2 summarizes the methodological characteristics of the 42 included studies. Thirty

(71.4%) were experimental: 23 (55%) RCTs (Horlick et al., 1984; van Elderen-van et al., 1994;

van Elderen et al., 1994; Oldenburg et al., 1995; Lidell & Fridlund, 1996; Moore & Dolansky,

2001; Jeong et al., 2002; Mayou et al., 2002; Otterstad, 2003; Leslie et al., 2004; Buckley et al.,

2007; Heidal et al., 2007; Jiang, Sit, & Wong, 2007; Giannuzzi et al., 2008; Kummel et al., 2008;

Cordasco et al., 2009; Lindsay et al., 2009; McKinley et al., 2009; Smith & Burgess, 2009;

Carlson et al., 2011; Wolkanin-Bartnik, Pogorzelska, & Bartnik, 2011; Chan et al., 2012;

Eckman et al., 2012) and 7 (16.7%) quasi-experimental (Linde & Janz, 1979; Dracup et al.,

1984; Marshall, Penckofer, & Llewellyn, 1986; Verges et al., 1998; Yoshida et al., 1999; Van

Elderen & Dusseldorp, 2001; Irmac & Fesci, 2010); and 11 (26.2%) observational: 6 (14.3%)

cross-sectional in design (Fletcher, 1986; Song & Lee, 2001; Frame et al., 2003; Pelletier,

Kundrat, & Hasler, 2003; Oliveira, Ribeiro, & Gomes, 2008; Froger-Bompas et al., 2009) and 5

(12%) were cohort studies - 4 prospective (Lisspers et al., 1999; Palomaki et al., 2002; Timlim,

66

Shores, & Reicks, 2002; Jensen, 2003) and 1 retrospective (Bellman et al., 2009). One (2.5%)

study used a mixed-methods design (Davidson et al., 2008).

The included studies involved 16,079 participants from 187 centers. Thirteen (35%) studies were

undertaken in the United States, 5 (12%) in the United Kingdom, 3 (7%) each in the Netherlands,

Sweden, Australia and Canada, 2 (5%) each in China, France, Korea and Finland, and 1 (2.5%)

each in Japan, Italy, Turkey and Portugal.

The quality ratings of the studies are also shown in Table 3.2. Overall, 16 (38%) studies were

considered “good”, 24 (57%) studies “fair”, and 2 (5%) studies were considered “poor” quality.

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Figure 3.1: Flow Diagram of Study Selection Process.

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Table 3.2 – Characteristics of the included studies describing the relationship between education knowledge and behavior change, N=42!

Study Study Design Centers Sample Size

Quality Assessment Score (Classification)*

Primary outcome Follow up (months)

Knowledge Assessment Results

Bellman et al 2009 Sweden

Cohort Retrospective 32 centers 2822 cardiac patients

16 (Good) Physical activity Smoking

12 No Physical activity habits: no statistical difference between groups (p=.052) at 1-year follow-up. Smoking cessation: among the patients who were smokers at admission for their AMI, 68.8% of the participants in the educational program had managed to stop smoking, compared with 51.9% of the non-participants (p<.001), at the 1-year follow-up.

Buckley et al 2007 Australia

RCT 1 center 200 people with CAD

19 (Good) Response to symptoms 12 Response Questionnaire [64], adapted for this study

Response to symptoms: the intervention had no effect on participants’ response to AMI symptoms Knowledge: both groups increased the knowledge scores. The INT had higher scores than CON (p<.001).

Carlson et al 2001 USA

RCT 1 center 80 CR patients

19 (Good) Physical activity Social support

6 No Physical activity habits: patients in INT demonstrated higher rates of exercise (p=.005) compared to CON. Social support: both groups had a high level of social support; no statistical differences.

Chan et al 2012 China

RCT 10 centers 1860 cardiac outpatients

21 (Good) Smoking 12 No Smoking cessation: INT had higher smoking cessation rates (p<.002) compared to CON.

Cordasco et al 2009 USA

RCT 1 center 210 cardiac inpatients

20 (Good) Medication adherence 1 Medication Knowledge and Compliance Scale [65], adapted for this study

Medication adherence: no statistical differences found between groups; however INT self-reported their medication more accurately. Knowledge: no statistical differences between groups.

Davidson et al 2008 Australia

Mixed-methods 2 centers 54 cardiac women

14 (Good) Depression and anxiety Stress

6 No Depression, anxiety and stress: no statistical differences between groups.

Dracup et al 1984 USA

Quasi-experimental 4 centers 58 CR outpatients

7 (Fair) Physical activity Smoking

6 No Physical activity habits: no statistical differences between groups (p=.08). Smoking cessation: no statistical differences between groups.

Eckman et al RCT 17 (Fair) Physical activity 6 A 12-item Physical activity habits: the INT had a significant

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2012 USA

3 centers 170 cardiac patients

Dietary habits Smoking

questionnaire developed and pilot tested for this study

improvement (p=.05). Dietary habits: significant improvement in diet, in both groups (p<.001). Smoking cessation: significant improvement in both groups (p<.001) Knowledge: significantly higher in INT (p<.001).

Fletcher 1986 USA

Cross-sectional, longitudinal 1 center 30 cardiac patients

4 (Poor) Physical activity Dietary habits Smoking

6 No Physical activity habits: 16 of 30 patients started exercising regularly. Dietary habits: 18 of 30 patients adhere to a fat-controlled diet. Smoking cessation: 18 of 30 patients stopped smoking.

Frame et al 2003 USA

Cross-sectional, longitudinal 1 center 118 CR patients

10 (Fair) Dietary habits 24 No Dietary habits: the reduction of dietary fat intake was sustained by patients 2 years after CR; and, little progress was observed in the increase intake of fruits and vegetables.

Froger-Bompas et al 2009 France

Cross-sectional 1 center 136 cardiac patients

11(Fair) Dietary habits 36 No Dietary habits: intervention patients had significantly higher consumption of fruits and vegetables (p<.001), global cardiovascular protective diet score (p<.001) and lower consumption of saturated fatty acids (p<.001).

Giannuzzi et al 2008 Italy

RCT 78 centers 3241 CR patients

20 (Good) Physical activity Dietary habits Smoking Stress

12 No Physical activity habits: significant differences between groups (p=.01) and time effect (p<.001). Dietary habits: significant differences between groups (p<.001) and time effect (p<.001). Smoking cessation: at 6 months after intervention, patients were more likely to stop smoking than control (p=.02). Stress: significant differences between groups (p<.001) and time effect (p<.001).

Heidal et al 2007 USA

RCT 1 center 36 cardiac patients

12 (Fair) Dietary habits 2 No Dietary habits: both groups increased n-3 FA intakes from baseline to 1 month (p<.001) and from baseline to 2 months (p<.014). No significant differences between groups after 2 months.

Horlick et al 1984 Canada

RCT 3 centers 116 MI patients


6 No Physical activity habits: no statistical differences between groups. Smoking cessation: no statistical differences between groups.

Irmak & Fesci Quasi- 12 (Fair) Physical activity 3.5 No Physical activity habits: the proportion of patients

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2010 Turkey

experimental 1 center 36 MI patients

Dietary habits Smoking Medication adherence

exercising regularly increased significantly (p<.001). Dietary habits: the proportion of patients who were careful about their nutritional intake before and after the program increased significantly (p<.001). Smoking cessation: the proportion of smokers decreased significantly (p<.001). Medication adherence: no statistical differences.

Jensen 2003 Canada

Cohort 3 centers 350 cardiac inpatients

12 (Fair) Medication adherence 4 Medication Knowledge Questionnaire, developed and validated for this study

Medication adherence: no statistical differences. Knowledge: significantly increased from admission to 16 weeks after discharge (p<.001). Medication knowledge scores were found to be significantly higher for subjects in the INT compared to CON (p=.003).

Jeong et al 2002 Korea

RCT 3 centers 45 MI patients


12 No Physical activity habits: the number of subjects exercising at the INT was significantly higher (p=.001) compared to CON. Smoking cessation: after the education, the number of non-smokers had significantly increased, in both groups (INT p=.014, and CON p=.001). The number of non-smokers was significantly higher in the INT (p=.019).

Jiang et al 2007 China

RCT 3 centers 167 CAD patients

18 (Good) Physical activity Dietary habits Smoking Medication adherence

6 No Physical activity habits: compared with baseline, the INT demonstrated a significantly greater increase in the mean scores of walking performance, both at 3 months (p=.001) and 6 months (p=.002), compared to CON. Dietary habits: compared with baseline, the INT demonstrated a significantly greater increase in the mean scores of diet adherence, both at 3 months (p=.001) and 6 months (p=.002), compared to CON. Smoking cessation: no significant differences between the percentages of quitters in the INT and CON. Medication adherence: significant differences were found only at 3 months between groups (p=.029). The mean scores for medication adherence of both groups were decreased, but to a significantly lesser extent in INT.

Kummel et al 2008

RCT 1 center

15 (Fair) Physical activity Dietary habits

12 No Physical activity habits: the reported frequency of PE increased more among men in INT than in CON

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Finland 117 CABG patients

(p<.001). A similar result was found, when men and women were analyzed together. At 3 months following operation, the change in PE was more favourable among women in CON than women in INT. At 6 months, the change was more favourable in INT, whereas at 12 months, women in CON exercise even more regularly than women in INT. These differences were significant between groups (p=.024). Dietary habits: in the 3-month follow-up, men in CON reported decreased frequency of eating fresh greens and vegetables, but they increased it by 12-month measurement. At 6 months, the frequency of eating vegetables increased among men in INT. Differences between groups were significant (p<.001).

Leslie et al 2004 UK

RCT 2 centers 85 CR patients

16 (Fair) Dietary habits 12 No Dietary habits: differences between groups were significant at 3 months on portions of fruits and vegetables (p=.006), and macronutrients composition (p<.001). Differences in food intakes between groups observed at 3 months were no longer evident at 12 months.

Lidell & Fridlund 1996 Sweden

RCT 1 center 97 MI patients

18 (Good) Physical activity Dietary habits

60 The Cardiac Health Knowledge Questionnaire [66]

Physical activity habits: differences between groups favouring the INT after 1 year (p<.001) and after 5 years (p<.001). Dietary habits: differences between groups favouring the INT after 5 years (p<.04). Knowledge: INT group presented statistical higher knowledge compared to CON 5 years after MI (misconceptions; p<.04 and basic cardiac knowledge; p<.005).

Linde & Janz 1979 USA

Quasi-experimental 1 center 48 cardiac patients

9 (Fair) Dietary habits 4 A 10-item questionnaire developed for this study

Dietary habits: significant differences were found pre and post education in both groups (p=.01). Knowledge: general cardiac knowledge increased significantly (p=.0038). No significant differences observed in knowledge on medication.

Lindsay et al 2009 UK


11 (Fair) Physical activity Dietary habits Smoking

12 No Physical activity habits: patients in INT spent significantly more days per week exercising CON (p<.001). The CON also experienced a significant reduction in the number of days per week spent in

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moderate exercise comparing 6 and 9 months (p=.03). Dietary habits: no significant changes between groups. Smoking cessation: no significant changes between groups.

Lisspers et al 1999 Sweden

Cohort 1 center 292 cardiac patients


12 Tool developed for this study

Physical activity habits: subjects exercised at the 12-months follow-up on average more than 4 times per week with a low to high intensity, which was a significant increase compared to baseline (p<.001). Dietary habits: significant changes in diet (healthy habits) were observed after 12 months (p<.0001). Smoking cessation: the number of nosmokers decreased significantly (p<.05) at the 12-months follow-up. Knowledge: knowledge about healthy diet increased at 12 months (p<.0001).

Marshall et al 1986 USA

Quasi-experimental 1 center 60 CABG patients

6 (Poor) Physical activity Smoking

6 A tool based on the format devise by Rahe et al [67]

Physical activity habits: INT patients had better compliance to physical activity compared to CON (p<.05). Smoking cessation: INT patients had better compliance to smoking cessation compared to CON (p<.05). Knowledge: a significant difference of knowledge was found between groups (p<.05) and time periods (p<.01). Knowledge was found to have increased significantly (p<.01) in all subtests.

Mayou et al 2002 UK



12 No Physical activity habits: at 3 months, INT patients had significantly better activity levels compared to CON (p=.028). Dietary habits: at 1 month, INT patients were significantly more willing to have tried to change their diet compared to CON (p=.017).

McKinley et al 2009 USA

RCT 6 centers 3519 cardiac patients

21 (Good) Response to symptoms Depression and anxiety

12 The ACS Response Index, adapted from [68]

Response to symptoms: increased significantly (p=.0005) in the INT at 3 months and remained higher than CON at 12 months. Depression and anxiety: CON were less likely to have anxiety symptoms compared to INT (p=.029). There was no other statistically significant difference between groups on patients in the 12-month follow-

73

up. Knowledge: knowledge increased significantly (p=.0005) in the INT at 3 months and remained higher than CON at 12 months.

Moore & Dolansky 2001 USA

RCT 1 center 180 CABG patients

18 (Good) Distress 1 No Distress: no differences between groups over time.

Oldenburg et al 1995 Australia

RCT 1 center 86 CABG patients


12 No Physical activity habits: both groups level of activity generally changed over time (p<.001). Activity increased sharply from baseline to 4 months to a level that patients maintained over the rest of the follow-up period. Dietary habits: both groups presented a reduction in self-reported dietary fat intake over time (p<.001). However, no differences between groups were identified. Smoking cessation: rates for smoking differed at 4 months and at 12 months. However, these differences were not significant.

Oliveira et al 2008 Portugal

Cross-sectional 1 center 30 MI patients

10 (Fair) Physical activity 3 No Physical activity habits: INT significantly increased daily PA index (p<.05) and time spent in moderate-intensity PA (p<.05). No changes were observed in CON.

Otterstad 2003 UK

RCT 3 centers 191 cardiac patients

21 (Good) Physical activity Dietary habits Smoking

24 No Physical activity habits: there was no difference in the amount of exercise in the 2 groups at baseline. At 6 months, 93% of INT and 72% of CON exercised for more than 1 hour per week (p<.001). At 2 years, 7% of INT and 22% of CON had no exercise at all (p<.01). Dietary habits: after 6 months, INT patients had a significantly lower intake of saturated and monounsaturated fat, sugar and cholesterol combined with a higher intake of fibre when compared with CON (p<.001 for all). These differences tended to diminish after 2 years, but were still highly significant in favour to INT (p<.001 for fat; p<.01 for sugar and p<.001 for cholesterol. Smoking cessation: at baseline, 50% of patients in INT and 42% in CON were smokers. At 6 months,

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55% of smokers in INT and 33% in CON had stopped smoking (p<.05). At 2 years, 45% in INT and 23% in CON were non-smokers (p<.05).

Palomaki et al 2002 Finland

Cohort 3 centers 72 cardiac patients

16 (Good) Physical activity Dietary habits

12 No

Physical activity habits: the weekly leisure time increased significantly during 8 months in the INT (p=.002) without any change in the CON. At 12 months, the physical activity remained at a higher level in the INT, compared to baseline (p=.017). The total amount of physical activity in leisure time was significantly higher at 8 months compared to baseline (p=.046) in the INT. In the CON this variable remained unchanged. Dietary habits: did not change significantly during the 1-yeaqr follow-up.

Pelletier et al 2003 USA

Cross-sectional 2 centers 69 CR patients

9 (Fair) Dietary habits 2 No Dietary habits: all 4 functional foods consumption increased significantly from survey 1 and 2 (p<.001).

Smith & Burgess 2009 Canada


22 (Good) Smoking 12 No Smoking cessation: more patients at INT than in CON reported not smoking at 3 months (p=.009), 6 months (p=.003), and 12 months (p=.007). The odds of quitting were 2 times greater for patients who received INT compared to CON in all endpoints. More patients at INT than in CON were confirmed nonsmokers at 12 months (p=.002).

Song & Lee 2001 South Korea

Cross-sectional 1 center 86 MI outpatients


2 No Physical activity habits: after the INT, participants tend to significantly be more active than before (p<.001). Dietary habits: after the INT, participants tend to significantly eat better (p=.025) than before.

Timlin et al 2002 USA

Cohort study 2 centers 104 cardiac patients

16 (Good) Dietary habits 3 No Dietary habits: significantly improved in both groups from entry to discharge from the program (p=.0001), indicating overall dietary changes, but there was no effect related to group by time.

Van Elderen & Dusseldorp 2001 The Netherlands

Quasi-experimental 3 centers 339 CAD patients

15 (Good) Physical activity Dietary habits Smoking

12 No Physical activity habits: at the first follow-up, patients in INT had a higher risk of maintaining a sedentary lifestyle than patients in CON. Dietary habits: participants in INT decrease the odds of maintaining unhealthy eating habits by a factor 0.30 than patients in CON. Smoking cessation: at the first follow-up treatment

75

was not a significant predictor for smoking cessation. At the second follow-up, patients in INT1 had a higher risk of continuing smoking than patients in CON.

Van Elderen-van et al 1994 The Netherlands


11 (Fair) Physical activity Dietary habits Smoking Depression and anxiety

12 No Physical activity habits: in the short term (8 weeks after discharge; p<.05) the INT resulted in an increase in physical exercise. Dietary habits: in the short term (8 weeks after discharge; p<.001) and long term (1-year after discharge; p<.05) the INT resulted in an increase in healthy eating habits. Smoking cessation: no statistical differences were found. Depression and anxiety: no statistical differences were found.

Van Elderen et al 1994 The Netherlands

RCT 1 center 217 CAD patients


12 The Knowledge Questionnaire for Heart Patients [69]

Physical activity habits: no statistical differences were found between patients in CON and INT in both short and long term. Dietary habits: a significantly higher number of patients in INT compared to CON decreased their salt intake in the short-term (p=.009). In the long-term patients in INT maintained a tendency to consume less salt than CON (p=.107). In the short-term, there is a tendency of INT patients to consume less fat than CON (p=.08); however, this did not persist in the long term. Smoking cessation: the number of smokers who quit smoking was significantly higher in INT than in CON, in the short-term (p=.007) and in the long-term (p=.011). Knowledge: Patients in INT showed a higher knowledge than patients in CON in the short-term (4- month assessment) (p=.005). In the long term (1-year assessment) this difference was not maintained (p=.0704).

Verges et al 1998 France

Quasi-Experimental 1 center 52 CAD men

10 (Fair) Dietary habits Smoking

2 A 16-item questionnaire developed for this study

Dietary habits: consumption of fat and fried food reduced in 82% and 52%, respectively, in the INT. Smoking cessation: 12 patients in INT and 11 in CON quit smoking. Knowledge: pre and post analysis showed a

76

significant higher knowledge on the fat-content of the nutriments in 82% of the INT.

Wolkanin-Bartnik et al 2011 UK


11 (Fair) Physical activity 12 No Physical activity habits: at baseline, self-reported physical activity did not differ significantly between CON and INT. At 3 months, it was observed a significantly increase in INT (p<.001). The improvement is leisure PA was maintained for the 12-month period for the INT.

Yoshida et al 1999 Japan

Quasi-Experimental 1 center 63 MI patients

11 (Fair) Physical activity Depression and anxiety

6 No Physical activity habits: there was no significant difference in the frequency of exercise between groups before the onset of MI. At the 6-month follow-up, the percentage of patients was: in the INT 74% had good physical activity, 4% had low, and 22% had very low, and in the CON, 31%, 24% and 45%, respectively (no p values reported). Depression status: before entry the program, the depression score in INT was significantly higher than CON (p=.02). At the 6-month follow-up, the score significantly decreased in INT (p=.02). In contrast, the depression score increased numerically in the CON, but it was not significant. At 6-months, there were no significant differences in SRQ-D score between the 2 groups (p=.75). Anxiety status: in INT, the anxiety scores improved significantly after the completion of the CR (p=.04). In the CON scores showed no change at the 6-month follow-up. However, there were no significant differences between groups (p=.59).

RCT: randomized controlled trial; CABG: coronary artery bypass grafting; CAD: coronary artery disease; MI: myocardial infarction; CR: cardiac rehabilitation; INT:

intervention or intervention group; CON: control or control group; PA: physical activity; MI: myocardial infarction.

* For RCT scores ranged from 0-25 (Poor: 0-8; Fair: 9-17; Good: 18-25). Other types of study, scores ranged from 0-18 (Poor: 0-6; Fair: 7-12; Good: 13-18).

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3.2 Nature of Education Interventions

Table 3.3 summarizes the nature of educational interventions. The educational interventions

were categorised based on WIDER reporting guidelines (WIDER, 2008), and no study reported

complete characteristics. Seventeen studies (40.5%) reported 6 of the 8 WIDER intervention

description elements. None of the studies reported on fidelity or adherence to delivery protocols.

With regard to those delivering the intervention, nurses delivered the education in 15 (35.7%)

studies (Marshall et al., 1986; van Elderen-van et al., 1994; Lisspers et al., 1999; Moore &

Dolansky, 2001; Mayou et al., 2002; Jensen, 2003; Buckley et al., 2007; Jiang et al., 2007;

Davidson et al., 2008; Kummel et al., 2008; Cordasco et al., 2009; McKinley et al., 2009; Smith

& Burgess, 2009; Irmak & Fesci, 2010; Chan et al., 2012), a multidisciplinary team in 13 (31%)

studies (Horlick et al., 1984; Fletcher, 1986; van Elderen et al., 1994; Olderburg et al., 1995;

Lidell & Fridlund, 1996; Yoshida et al., 1999; Song & Lee, 2001; Van Elderen & Dusseldorp,

2001; Palomaki et al., 2002; Timlin et al., 2002; Otterstad, 2003; Bellman et al., 2009; Carlson et

al., 2011), dietitians in 6 (14.3%) studies (Verges et al., 1998; Frame et al., 2003; Pelletier et al.,

2003; Leslie et al., 2004; Heidal et al., 2007; Froger-Bompas et al., 2009), and a cardiologist in 1

(2.4%) study (Giannuzzi et al., 2008).

With regard to setting, most studies (n=22; 52.4%) delivered the educational intervention after

hospital discharge; of these, 11 (26.2%) were interventions in CR (Verges et al., 1998; Yoshida

et al., 1999; Timlin et al., 2002; Frame et al., 2003; Pelletier et al., 2003; Leslie et al., 2004;

Davidson et al., 2008; Giannuzzi et al., 2008; Oliveira et al., 2008; Carlson et al., 2011;

Wolkanin-Bartnik et al., 2011). Six (14.3%) studies provided the education intervention before

hospital discharge (Fletcher, 1986; Marshall et al., 1986; Jeong et al., 2002; Mayou et al., 2002;

78

Jensen, 2003; Smith & Burgess, 2009). A total of 8 (19%) studies (Linde & Janz, 1979; Lidell &

Fridlund, 1996; Lisspers et al., 1999; Horlick et al., 2007; Jiang et al., 2007; Kummel et al.,

2008; Froger-Bompas et al., 2009; Irmak & Fesci, 2010) delivered education interventions both

before and after hospital discharge, whereas 2 (4.8%) studies provided education only at

discharge (Moore & Dolansky, 2001; Cordasco et al., 2009). Four studies reported providing

education to ambulatory patients (Heidal et al., 2007; Lindsay et al., 2009; McKinley et al.,

2009; Eckman et al., 2012).

With regard to mode of delivery, group (n=37 studies; 88.1%) education was delivered by

lectures in 17 (40.5%) studies (Horlick et al., 1984; van Elderen-van et al., 1994; van Elderen et

al.,1994; Oldenburg et al., 1995; Verges et al., 1998; Lisspers et al., 1999; Yoshida et al., 1999;

Song & Lee, 2001; Palomaki et al., 2002; Timlin et al., 2002; Pelletier et al., 2003; Leslie et al.,

2004; Heidal et al., 2007; Kummel et al., 2008; Oliveira et al., 2008; Bellman et al., 2009;

Froger-Bompas et al., 2009), group discussions in 17 (40.5%) studies (Dracup et al., 1984;

Horlick et al., 1984; van Elderen-van et al., 1994; van Elderen et al., 1994; Oldenburg et al.,

1995; Lisspers et al., 1999; Song & Lee, 2001; Van Elderen & Dusseldorp, 2001; Frame et al.,

2003; Otterstad, 2003; Davidson et al., 2008; Kummel et al., 2008; Oliveira et al., 2008; Bellman

et al., 2009; Lindsay et al., 2009; Irmak & Fesci, 2010; Carlson et al., 2011), and question and

answer periods in 3 (7.1%) studies (Song & Lee, 2001; Frame et al., 2003; Bellman et al., 2009).

Individual education was used in 37 (88.1%) studies, including individual counselling in 21

(50%) studies (Linde & Janz, 1979; Fletcher, 1986; Marshall et al., 1986; Lidell & Fridlund,

1986; van Elderen-van et al., 1994; Verges et al., 1998; Lisspers et al., 1999; Yoshida et al.,

1999; Moore & Dolansky, 2001; Timlin et al., 2002; Frame et al., 2003; Leslie et al., 2004;

Buckley et al., 2007; Heidal et al., 2007; Jiang et al., 2007; Gianuzzi et al., 2008; Lindsay et al.,

2009; McKinley et al., 2009; Smith & Burgess, 2009; Carlson et al., 2011; Chan et al., 2012),

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follow-up telephone contacts in 13 (31%) studies (Lidell & Fridlund, 1986; Marshall et al., 1986;

van Elderen-van et al., 1994; Lisspers et al., 1999; Van Elderen & Dusseldorp, 2001; Jeong et

al., 2002; Buckley et al., 2007; Heidal et al., 2007; Oliveira et al., 2008; McKinley et al., 2009;

Smith & Burgess, 2009; Wolkanin-Bartnik et al., 2011; Chan et al., 2012) and home visits in 3

(7.1%) studies (Jiang et al., 2007; Oliveira et al., 2008; Irmak & Fesci, 2010).

Few studies provided information regarding intensity. The contact time varied from 5-10 minutes

(Smith & Burgess, 2009) to 3 hours (Oldenburg et al., 1995) as well as a full day of education

(Song & Lee, 2001); 15 (35.7%) studies provided no duration information (Fletcher, 1986;

Marshall et al., 1986; Lisspers et al., 1999; Yoshida, 1999; Moore & Dolansky, 2001; Mayou et

al., 2002; Jensen, 2003; Jiang et al., 2007; Kummel et al., 2008; Oliveira et al., 2008; Bellman et

al., 2009; Cordasco et al., 2009; Lindsay et al., 2009; Carlson et al., 2011; Wolkanin-Bartnik et

al., 2011; Chan et al., 2012). With regard to duration, the average number of educational sessions

offered was 6 – range 1 (Moore et al., 2001; Cordasco et al., 2009) to 24 (Lidell & Fridlund,

1996; Van Elderen & Dusseldorp, 2001; Otterstad, 2003), however this was not described in 5

(12%) studies (Fletcher, 1986; Marshall et al., 1986; Lisspers et al., 1999; Lindsay et al., 2009;

Wolkanin-Bartnik et al., 2011). The frequency of contact varied from daily education (Jensen,

2003) to every 6 months (Gianuzzi et al., 2008); most studies (n=17; 40.5%) described weekly

education (Horlick et al., 1984; Dracup et al., 1984; van Elderen et al., 1994; Oldenburg et al.,

1995; Lidell & Fridlund, 1996; Verges et al., 1998; Van Elderen & Dusseldorp, 2001; Palomaki

et al., 2002; Frame et al., 2003; Leslie et al., 2004; Buckley et al., 2007; Heidal et al., 2007;

Davidson et al., 2008; Gianuzzi et al., 2008; Bellman et al., 2009; McKinley et al., 2009; Carlson

et al., 2011) and 12 (28.6%) studies provided no frequency information (Linde & Janz, 1979;

Fletcher, 1986; Marshall et al., 1986; van Elderen-van et al., 1994; Lisspers et al., 1999; Yoshida

et al., 1999; Mayou et al., 2002; Timlin et al., 2002; Gianuzzi et al., 2008; Lindsay et al., 2009;

80

Smith & Burgess, 2009; Wolkanin-Bartnik et al., 2011).

With regard to intervention content, the educational interventions described in the 42 studies

included 19 different topics, with an average of 3.3 topics per study (range from 1 to 7 topics).

One study did not describe the educational content of its intervention (Bellman et al., 2009).

Education content most-often concerned nutrition (n=26; 62%: Linde & Janz, 1979; Horlick et

al., 1984; Fletcher, 1986; Marshall et al., 1986; van Elderen-van et al., 1994; van Elderen et al.,

1994; Verges et al., 1998; Lisspers et al., 1999; Yoshida et al., 1999; Song & Lee, 2001; Van

Elderen & Dusseldorp, 2001; Jeong et al., 2002; Palomaki et al., 2002; Timlin et al., 2002;

Frame et al., 2003; Pelletier et al., 2003; Otterstad, 2003; Leslie et al., 2004; Heidal et al., 2007;

Jiang et al., 2007; Giannuzzi et al., 2008; Froger-Bompas et al., 2009; Lindsay et al., 2009; Irmak

& Fesci, 2010; Carlson et al., 2011; Eckman et al., 2012), exercise (n=19; 45.2%: Linde & Janz,

1979; Fletcher, 1986; Marshall et al., 1986; van Elderen-van et al., 1994; Verges et al., 1998;

Lisspers et al., 1999; Yoshida et al., 1999; Song & Lee, 2001; Jeong et al., 2002; Palomaki et al.,

2002; Otterstad, 2003; Jiang et al., 2007; Giannuzzi et al., 2008; Oliveira et al., 2008; Lindsay et

al., 2009; Irmak & Fesci, 2010; Carlson et al., 2011; Wolkanin-Bartnik et al., 2011; Eckman et

al., 2012), risk factors (n=17; 40.5%; Horlick et al., 1984; Fletcher, 1986; Marshall et al., 1986;

van Elderen-van et al., 1994; Oldenburg et al., 1995; Lidell & Fridlund, 1996; Verges et al.,

1998; Yoshida et al., 1999; Van Elderen & Dusseldorp, 2001; Jeong et al., 2002; Palomaki et al.,

2002; Otterstad, 2003; Giannuzzi et al., 2008; Oliveira et al., 2008; Irmak & Fesci, 2010; Carlson

et al., 2011; Eckman et al., 2012), psychosocial education (i.e. stress, anxiety, social support,

emotions, relaxation techniques and self-management; n=16; 38.1%: Dracup et al., 1984; Horlick

et al., 1984; van Elderen-van et al., 1994; van Elderen et al., 1994; Lidell & Fridlund, 1996;

Lisspers et al., 1999; Yoshida et al., 1999; Moore & Dolansky, 2001; Song & Lee, 2001; Van

Elderen & Dusseldorp, 2001; Otterstad, 2003; Buckley et al., 2007; Jiang et al., 2007; Giannuzzi

81

et al., 2008; McKinley et al., 2009; Carlson et al., 2011), and medications (n=13; 31%: Linde &

Janz, 1979; van Elderen-van et al., 1994; van Elderen et al., 1994; Song & Lee, 2001; Van

Elderen & Dusseldorp, 2001; Jeong et al., 2002; Jensen, 2003; Otterstad, 2003; Leslie et al.,

2004; Cordasco et al., 2009; Irmak & Fesci, 2010; Carlson et al., 2011; Eckman et al., 2012).

Other content topics were smoking cessation (n=8; 19%: Lisspers et al., 1999; Otterstad, 2003;

Jiang et al., 2007; Gianuzzi et al., 2008; Lindsay et al., 2009; Smith & Burgess, 2009; Irmak &

Fesci, 2010; Chan et al., 2012), responding to cardiac symptoms (n=7; 16.7%: Fletcher, 1986;

Lidell & Fridlund, 1996; Moore & Dolansly, 2001; Buckley et al., 2007; Jiang et al., 2007;

McKinley et al., 2009; Irmak & Fesci, 2010), behavior change strategies (n=6; 14.3%:

Oldenburg et al., 1995; Lisspers et al., 1999; Jiang et al., 2007; Davidson et al., 2008; Irmak &

Fesci, 2010; Carlson et al., 2011), surgical procedures (n=5; 11.9%: Linde & Janz, 1979;

Fletcher, 1986; Marshall et al., 1986; Moore & Dolansky, 2001; Kummel et al., 2008), return to

activities (n=4; 9.5%: van Elderen-van et al., 1994; van Elderen et al., 1994; Yoshida et al.,

1999; Mayou et al., 2002), management of CAD (n=4; 9.5%: Van Elderen & Dusseldorp, 2001;

Otterstad, 2003; Lindsay et al., 2009; Eckman et al., 2012), physiology of the heart (n=3; 7.1%:

Horlick et al., 1984; Marshall et al., 1986; Song & Lee, 2001), and nature of the disease (n=2;

4.8%: Fletcher, 1986; Jeong et al., 2002). Other topics were described only by 1 study: secondary

prevention (Mayou et al., 2002), quality of life (Oldenburg et al., 1995), metabolic syndrome

(Palomaki et al., 2002), sexual activity (van Elderen et al., 1994), health beliefs (van Elderen et

al., 1994), and shared decision-making (Eckman et al., 2012).

Finally, educational materials provided to patients included: teaching booklets in 11 (26.2%)

studies (Linde & Janz, 1979; Fletcher, 1986; Marshall et al., 1986; Moore & Dolansky, 2001;

Van Elderen & Dusseldorp, 2001; Jeong et al., 2002; Jiang et al., 2007; Giannuzzi et al., 2008;

Oliveira et al., 2008; Smith & Burgess, 2009; Eckman et al., 2012), cookbooks in 3 (7.1%)

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(Verges et al., 1998; Leslie et al., 2004; Heidal et al., 2007), educational videos in 5 (11.9%)

(Fletcher, 1986; Yoshida et al., 1999; Smith & Burgess, 2009; Carlson et al., 2011; Eckman et

al., 2012), educational audio-recordings in 2 (4.8%) studies (Moore & Dolansky, 2001; Smith &

Burgess, 2009), medication education kits in 2 (4.8%) studies (Jensen, 2003; Cordasco et al.,

2009) and in 1 study (2.4%) medication and illustration cards (Linde & Janz, 1979), a checklist

(Marshall et al., 1986), heart models (Fletcher, 1986). Verbal orientation to educational materials

was described in 6 (14.3%) studies (Jeong et al., 2002; Jensen, 2003; Cordasco et al., 2009;

Lindsay et al., 2009; Smith & Burgess, 2009; Wolkanin-Bartnik et al., 2011).

3.3 Knowledge

Eleven studies (26%) reported the assessment of knowledge about their condition and 11

different tools were used to assess this knowledge. Six studies used tools developed by other

authors – Response Questionnaire (used by Buckley et al., 2007, and developed by BACPR,

2008), Medication Knowledge and Compliance Scale (used by Cordasco et al., 2009, and

developed by Brown, 1992), the Cardiac Health Knowledge Questionnaire (used by Lidell &

Fridlund, 1996, and developed by Lane & Evans, 1979), the Rahe et al. format model (used by

Marshall et al., 1986, and developed by Kirkland et al., 1999), the Acute Coronary Syndrome

Response Index (used by (McKinley et al., 2009, and adapted from Stewart et al., 2004), and the

Knowledge Questionnaire for Heart Patients (used by van Elderen et al., 1994, and developed by

Sui et al., 2008). In 3 studies the authors developed a questionnaire (Linde & Janz, 1979; Verges

et al., 1998; Lisspers et al., 1999), in 1 study the authors developed and pilot-tested a tool

(Eckman et al., 2012), and in 1 study the authors developed and psychometrically-validated their

tool (Jensen, 2003).

83

Of these 11 studies assessing knowledge, 6 (14.3%) were RCTs and 3 (7.1%) quasi-

experimental. The majority (n=10; 91%: Linde & Janz, 1979; Marshall et al., 1986; van Elderen

et al., 1994; Lidell & Fridlund, 1996; Verges et al., 1998; Lisspers et al., 1999; Buckley et al.,

2007; Jensen, 2003; McKinley et al., 2009; Eckman et al., 2012) reported a significant increase

in knowledge associated with the educational interventions. Results are shown in Table 3.2.

3.4 Behavior Change and Psychosocial Well-Being

Behavior change and psychosocial well-being were assessed via self-report in all (n=42; 100%)

studies. In regards to behavior change, physical activity was measured in 26 studies (62%:

Dracup et al., 1984; Horlick et al., 1984; Fletcher, 1986; Marshall et al., 1986; van Elderen-van

et al., 1994; van Elderen et al., 1994; Oldenburg et al., 1995; Lidell & Fridlund, 1996; Lisspers et

al., 1999; Yoshida et al., 1999; Song & Lee, 2001; Van Elderen & Dusseldorp, 2001; Jeong et

al., 2002; Mayou et al., 2002; Palomaki et al., 2002; Otterstad, 2003; Jiang et al., 2007;

Giannuzzi et al., 2008; Kummel et al., 2008; Oliveira et al., 2008; Bellman et al., 2009; Lindsay

et al., 2009; Irmac & Fesci, 2010; Carlson et al., 2011; Wolkanin-Bartnik et al., 2011; Eckman et

al., 2012), while dietary habits were measured in 25 studies (60%: Linde & Janz, 1979; Fletcher,

1986; van Elderen-van et al., 1994; van Elderen et al., 1994; Oldenburg et al., 1995; Lidell &

Fridlund, 1996; Verges et al., 1998; Lisspers et al., 1999; Song & Lee, 2001; Van Elderen &

Dusseldorp, 2001; Mayou et al., 2002; Palomaki et al., 2002; Timlin et al., 2002; Frame et al.,

2003; Otterstad, 2003; Pelletier et al., 2003; Leslie et al., 2004; Heidal et al., 2007; Jiang et al.,

2007; Giannuzzi et al., 2008; Kummel et al., 2008; Froger-Bompas et al., 2009; Lindsay et al.,

2009; Smith & Burgess, 2009; Irmac & Fesci, 2010; Eckman et al., 2012). Twenty (48%) studies

measured smoking (Dracup et al., 1984; Horlick et al., 1984; Fletcher, 1986; Marshall et al.,

1986; van Elderen-van et al., 1994; van Elderen et al., 1994; Oldenburg et al., 1995; Verges et

84

al., 1998; Lisspers et al., 1999; Van Elderen & Dusseldorp, 2001; Jeong et al., 2002; Otterstad,

2003; Jiang et al., 2007; Giannuzzi et al., 2008; Kummel et al., 2008; Bellman et al., 2009;

Lindsay et al., 2009; Irmac & Fesci, 2010; Chan et al., 2012; Eckman et al., 2012) measured

smoking, 4 (9.5%) studies measured medication adherence (Jensen, 2003; Jiang et al., 2007;

Cordasco et al., 2009; Irmac & Fesci, 2010), and 2 (5%) studies measured response to symptoms

(Buckley et al., 2007; McKinley et al., 2009). Results are described in Table 3.2.

Of the 26 studies measuring physical activity, 20 (77%) reported a significant positive

relationship between education and physical activity, 5 (19%) reported no differences, and 1

(4%) reported a negative relationship. Of the 25 studies assessing dietary habits, 21 (84%)

reported a significant positive relationship between education and dietary habits. No negative

associations were found between dietary habits and educational strategies. Twenty studies

assessed the influence of educational strategies on smoking and 13 studies (65%) reported

significant and positive associations. No negative associations were found. With regard to

response to symptoms, 1 (50%) study reported a significant positive association to education,

and 1 (50%) study found no significant association. With regard to medication adherence, only 1

(25%) study reported a significant difference between educational and non-educational groups;

however, significant differences were only demonstrated at the 3-month assessment point (the

association did not persist).

Finally, 7 (16%) studies examined psychosocial well-being: 4 depression and anxiety (van

Elderen-van et al., 1994; Yoshida et al., 1999; Davidson et al., 2008; McKinley et al., 2009), 2

stress (Davidson et al., 2008; Giannuzzi et al., 2008), and 1 each general distress (Moore &

Dolansky, 2001) and social support (Carlson et al., 2011). Three (43%) studies reported

significant and positive associations; and the other studies presented null results.

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Table 3.3 - Characteristics of educational interventions (n=42)

Study Health provider delivering the intervention

Setting Delivery Format

Intensity - Contact time - Frequency of each educational session

Mean number of educational sessions*

Education Content

Bellman et al 2009 Sweden

Multidisciplinary team

After D/C Lectures Group discussions Q and A

NR Weekly

5 Not described

Buckley et al 2007 Australia

Nurse After D/C Individual counselling Follow-up telephone contacts

45 minutes Weekly

5 Psychosocial education Symptoms

Carlson et al 2001 USA


After D/C, CR Group discussions Individual counselling Educational videos

NR Weekly

4 Behavior change strategies Exercise Medications Nutrition Psychosocial education Risk factors

Chan et al 2012 China

Nurse After D/C Individual counselling Follow-up telephone contacts

1 hour Baseline, 1 week and 1 month

3 Smoking cessation counselling

Cordasco et al 2009 USA

Nurse At D/C Medication education kit Verbal orientation

NR NA

1 Medications

Davidson et al 2008 Australia

Nurse CR Group discussions 1 hour Weekly

6 Behavior change strategies

Dracup et al 1984 USA

Not provided After D/C Group discussions

90 minutes Weekly

10 Psychosocial education

Eckman et al 2012 USA

Not provided Ambulatory patients

Teaching booklet Educational videos

NR NA

NA Exercise Management of CAD Medications Nutrition Risk factors Shared decision making

Fletcher 1986 USA


Before D/C Individual counselling Teaching booklet Educational videos Heart models

NR NR

NR Exercise Nutrition Risk factors Surgical procedures Symptoms

86

Frame et al 2003 USA

Dietician CR Group discussions Q and A Individual counselling

1 hour Weekly

12 Nutrition

Froger-Bompas et al 2009 France

Dietician Before D/C, After D/C

Lectures NR 2x/week

6 Nutrition

Giannuzzi et al 2008 Italy

Cardiologist CR Individual counselling Teaching booklet

NR Monthly and every 6 months

12 Exercise Nutrition Psychosocial education Risk factors Smoking cessation

Heidal et al 2007 USA

Dietician Ambulatory patients

Lectures Teaching booklet (cookbook) Follow-up telephone contacts Individual counselling

1 hour Weekly

5 Nutrition

Horlick et al 1984 Canada


Before D/C, After D/C

Lectures Group discussions

30-45 minutes Weekly

6 Nutrition Physiology of the heart Psychosocial education Risk factors

Irmak & Fesci 2010 Turkey

Nurse Before D/C, After D/C

Group discussions Home visits

30-40 minutes Monthly

5 Behavior change strategies Exercise Medications Nutrition Risk factors Smoking cessation Symptoms

Jensen 2003 Canada

Nurse Before D/C Medication education kit Verbal orientation

NR Daily

2 Medications

Jeong et al 2002 Korea

Not provided Before D/C Verbal orientation Teaching booklet Follow-up telephone contacts

20-25 min 3rd and 5th days hospitalization

3 Exercise Medications Nature of the disease Nutrition Risk factors

Jiang et al 2007 China


Individual counselling Teaching booklet Home visits

NR Weekly

12 Behavior change strategies Exercise Medications Nutrition Psychosocial education Symptoms

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Smoking cessation Kummel et al 2008 Finland


Lectures Group discussions

NR Every 2 months

5 Surgical procedures

Leslie et al 2004 UK

Dietician CR Lectures Teaching booklet Individual counselling

1 hour Every 2 weeks

4 Nutrition

Lidell & Fridlund 1996 Sweden


Before D/C, After D/C

Individual counselling Follow-up telephone contacts

2 hours Weekly

24 Psychosocial education Risk factors Symptoms

Linde & Janz 1979 USA

Not provided Before D/C, After D/C

Individual counselling Teaching booklets Medication education cards Illustration models

20-25 min NR

6 Exercise Medications Nature of the disease Nutrition Surgical procedures

Lindsay et al 2009 UK

Not provided Ambulatory patients

Computer-based: Individual counselling Group discussions Verbal orientation

NR NR

NR Exercise Management of CAD Nutrition Smoking cessation

Lisspers et al 1999 Sweden


Lectures Group discussions Individual counselling Follow-up telephone contacts

NR NR

NR Behavior change strategies Exercise Nutrition Psychosocial education Smoking cessation

Marshall et al 1986 USA

Nurse Before D/C Teaching booklet Checklist

NR NR

NR Exercise Nutrition Physiology of the heart Risk factors Surgical procedures

Mayou et al 2002 UK

Nurse Before D/C Individual counselling Follow-up telephone contacts

NR NR

4 Return to activities Secondary prevention

McKinley et al 2009 USA

Nurse Ambulatory patients

Individual counselling Follow-up telephone contacts

40 min Monthly

2 Psychosocial education Symptoms

Moore & Dolansky 2001

Nurse At discharge Individual counselling Educational audios Teaching booklets

NR NA

1 Psychosocial education Symptoms Surgical procedures

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USA Oldenburg et al 1995 Australia


After D/C Lectures Group discussion

3 hours Weekly

8 Behavior change strategies Quality of life Risk factors

Oliveira et al 2008 Portugal

Not provided CR Lectures Group discussions Teaching booklet Home visits Follow-up telephone contacts

NR NR

4 Exercise Risk factors

Otterstad 2003 UK


After D/C Group discussions 2 hours 2x/week

12 Exercise Management of CAD Medications Nutrition Psychosocial education Risk factors Smoking cessation

Palomaki et al 2002 Finland


After D/C Lectures

2 hours Weekly

6 Exercise Metabolic syndrome Nutrition Risk factors

Pelletier et al 2003 USA

Dietician CR Lectures 90 minutes Every 2 months

2 Nutrition

Smith & Burgess 2009 Canada

Nurse Before D/C Teaching booklets Verbal orientation Individual counselling Educational videos Educational audios Follow-up telephone contacts

1 (45-60 min) and 7 (5-10 min) NR

8 Smoking cessation

Song & Lee 2001 South Korea


After D/C Q and A Lectures Group discussions

Daily activity Every 2 months

2 Exercise Medications Nutrition Physiology of the heart Psychosocial education

Timlin et al 2002 USA


CR Lectures Individual counselling

1 hour NR

3 Nutrition

Van Elderen & Dusseldorp


After D/C Group discussions Follow-up telephone contacts

5 (2 hours) and 7 (NR)

12 Management of CAD Medications

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2001 The Netherlands

Weekly Nutrition Psychosocial education Risk factors

Van Elderen-van et al 1994 The Netherlands

Nurse CR Individual counselling Lectures Group discussions Follow-up telephone contacts

90 minutes NR

2 Exercise Medications Nutrition Psychosocial education Risk factors Return to activities

Van Elderen et al 1994 The Netherlands


After D/C Lectures Group discussions

2 hours 8 weekly and 1 2 months after the 8th session

9 Healthy beliefs Medications Nutrition Psychosocial education Return to activities Sexual activity

Verges et al 1998 France

Dietician CR Lectures Individual counselling Teaching booklets

NR Weekly

8 Exercise Nutrition Risk factors

Wolkanin-Bartnik et al 2011 UK

Not provided CR Teaching booklets Verbal orientation Follow-up telephone contacts

NR NR

NR Exercise

Yoshida et al 1999 Japan


CR Lectures Educational videos Individual counselling

NR NR

7 Exercise Nature of the disease Nutrition Psychosocial education Return to activities Risk factors

* Including all types of intervention strategies

NA: not applicable (Only one intervention or no formal intervention – e.g., printed or audio/visual materials only); Q and A: Questions and answers; CAD: Coronary

Artery Disease; D/C: discharge; CR: cardiac rehabilitation; NR: not reported.

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4 Discussion and Conclusion

4.1 Discussion

This systematic review investigated the impact of education on CAD patients’ knowledge and

health behavior change and described the nature of educational interventions delivered. Overall

results of this review suggest that educational interventions within cardiac care increase patients’

knowledge and facilitate behavior change. All studies assessing knowledge but one reported an

increase in patients’ knowledge, in areas including appropriate responses to cardiac symptoms

and medications. Analysis showed that educational interventions were related to increases in

physical activity, healthier dietary habits and smoking cessation, but revealed equivocal relation

to response to cardiac symptoms, medication adherence and psychosocial well-being.

Although the results were mainly positive, studies varied significantly with regard to educational

interventions characteristics. This can be considered a significant gap as no data exists to guide

healthcare providers on the optimal setting, mode of delivery, intensity, duration and content for

provision of patient education for cardiac patients. Indeed, no study described all 8

characteristics according to the WIDER reporting guidelines (WIDER, 2008), and less than half

of the studies reported 6 characteristics. WIDER also makes the recommendation that authors

articulate the assumed change process and design principles underlying their intervention, and

also that they provide access to manuals and protocols to enable reproducibility.

This review demonstrated that on average: nurses were the most frequent educator; most education

was delivered post-discharge; lectures and group discussions were the most common delivery

formats; most interventions also incorporated some form of follow-up telephone contact and

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individual counseling; the average number of educational sessions delivered was 6; and, an average

of 3.3 topics per intervention were covered, with the most common ones being nutrition, exercise,

risk factors, psychosocial well-being, and medications. Few studies provided information regarding

education duration, but when reported it varied from 5-10 minutes to a day of education.

An underlying principle of patient education is that knowledge is necessary, but not sufficient to

change health behaviours. Patient education involves more than telling people what to do or

giving them instructional materials to read; age (Lane & Evans, 1979; Brown, 1992; Kirkland et

al., 1999), gender (Stewart et al., 2004; Kayaniyil et al., 2009), social and economic (Rathore et

al., 2006; Sui et al., 2008; Loucks et al., 2009), cognitive factors (Schwarz, Schoberberger,

Rieder, & Kunze, 1994; Dracup & Moser, 1997), and environmental factors (Stern, 2000) are

also important considerations. Studies suggest that younger patients learn more than older ones,

and women may be better informed and more active in the decision-making process than men.

Furthermore, economically-challenged patients will face additional barriers to learning. Even

with good access to providers, patients with cognitive impairments and low literacy will need

interventions tailored to their needs (Berckman et al., 2011). Different factors may affect

patients’ ability to learn or engage in interventions, and these factors should be addressed in

educational programs as well as studies assessing educational interventions (Michie et al., 2009).

The findings presented in this review should be interpreted with caution. First, the broad variety of

outcomes parameters across many time periods, and the variety of interventions mitigated the use of

meta-analysis. Indeed, it was impossible to compare the effects of the interventions based on their

characteristics as they were so poorly described. Second, the majority of the trials utilized self-

reported outcome measures, which can be subject to expectation bias. Third, multiple and

simultaneous interventions were often implemented, and thus it is difficult to ascertain what

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components contribute to the outcomes. Fourth, generalizability is limited as only English articles

were included. Finally, studies in CR setting offer multiple interventions and so we cannot rule out

explanation of effect by these other interventions in uncontrolled studies. Potential biases in the

review process were minimal.

4.2 Conclusion

In conclusion, I was unable to identify the nature of effective educational interventions to cardiac

patients because it was poorly described in the studies. Yet, this systematic review supports the

benefits of educational interventions in CAD, through increases in patients’ knowledge, physical

activity, nutrition behavior and smoking cessation. It is recommended that future reporting of

education interventions should be more explicitly characterized.

4.3 Practice Implications

The weight of evidence suggests the need for comprehensive multidisciplinary education

programs offered in-hospital and post-discharge, through individual and group educational

activities delivered in discursive rather than didactic fashion (BACPR, 2008; Kayaniyil et al.,

2009; Stone et al., 2009; Boyde et al., 2011; Heran et al., 2011). Ensuring CAD patient have

access to comprehensive, evidence-based and manualized education programs may optimize the

benefits observed in relation to physical activity, diet and smoking cessation.

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Chapter 4 PAPER TWO: Development and psychometric validation of a

scale to assess information needs in cardiac rehabilitation: The INCR tool

In this chapter the development and psychometric validation of a scale to assess information

needs in cardiac rehabilitation (CR) are described. This tool was called INCR (Information

Needs in Cardiac Rehabilitation), has 55 items and asks respondents to rate the importance of

each item to increase their knowledge about coronary artery disease. The INCR was tested in 203

CR patients. This paper was published at Patient and Education Counseling Journal, in 2013

(Ghisi et al., 2013a).

1 Introduction

Cardiovascular Diseases (CVDs) are the leading cause of mortality worldwide (WHO, 2001) and

are a significant contributor to morbidity and health-related costs (CCN, 2002). Moreover, up to

90% of risk for a myocardial infarction (MI) for instance, is due to modifiable behaviours (Yusuf

et al., 2004). A key aim to cardiac rehabilitation (CR), a comprehensive risk reduction program,

is not only to improve physical health and quality of life but to equip and support people to

develop the necessary skills to successfully self-manage (Stone, et al., 2009; BACPR, 2012).

According to the British Association of Cardiovascular Prevention and Rehabilitation, there are

seven core components of CR: health behaviour change and education; lifestyle risk factor

management; psychosocial health; medical risk factor management; cardioprotective therapies;

long-term management; and audit and evaluation (BACPR, 2012). Studies have shown that when

all core components of CR programs are applied in a comprehensive and systematic fashion,

including patient education, it has a significant impact on mortality, improved functional

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capacity, and decreased re-hospitalization and overall medical costs (Clark et al., 2005; Heran et

al., 2011).

Knowledge of health and disease is necessary, although not sufficient, for successful patient self-

management of coronary artery disease (Potvin, Richard, & Edwards, 2000; Karner, Goransson,

& Bergdahl, 2003; Gazmararian et al., 2003). Studies have shown that patient education is

related to healthier patient choices in daily life, and to better management of cardiac disease. It

has also been shown to relate to fewer adverse outcomes, and even to regression of coronary

disease (Roter, Stashefsky-Margalit, & Rudd, 2001; Karner et al., 2003; Alm-Roijet et al., 2004;

Khan et al., 2006; Osborne, Elsworth, & Whitfield, 2007; Williams, Lindsell, Rue, & Blomkalns,

2007; Krannich et al., 2008; Michie et al., 2008; Kayaniyil et al., 2009).

In the CR population, it has been reported that some patients understand little of what has

happened to them or how to manage their lives in the aftermath of their treatments (Alm-Roijet

et al., 2004). Unfortunately, some patients also report that they would want and need more

information than they usually receive in the course of CR (Kayaniyil et al., 2009). In order to

plan and deliver an effective CR educational intervention, it is important to have precise

information about what patients know regarding cardiac disease and secondary prevention, and

also to identify their information needs (Scott & Thompson, 2003). Indeed, the literature

highlights the importance of a comprehensive understanding of patients’ health information

needs as a logical first step in developing educational programs.

Despite existing studies assessing information needs of patients following revascularization

(Goodman, 1997; Brezynskin, Pendon, Lindsay, & Adam, 1998; Astin et al., 2008), acute

coronary syndrome (Czar & Engler, 1997; Nakano, Mainz, & Lomborg, 2008), MI (Casey,

O’Connel, & Price, 1984; Moynihan, 1984; Orzeck & Staniloff, 1987; Bubela et al., 1990; Chan,

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1990; Wingate, 1990; Moser, Dracup, & Marsden, 1993; Mirka, 1994; Larson, Nelson,

Gustafson, & Batalden, 1996; Ashton, 1997; Hughes, 2000; Timmins & Kaliszer, 2003; Decker

et al., 2007; Smith & Liles, 2007), and heart failure (Wehby & Brenner, 1999; Lile, Buhmann, &

Roders, 1999), to our knowledge, there are no validated tools to assess information needs in CR

patients. Given wait times to start CR are often upwards of two months (Russel et al., 2011),

patient information needs are likely very different at program inception than they were at the

time of hospitalization. In addition, a previous literature review failed to identify any available

and validated tool to assess information needs in coronary patients in cardiac rehabilitation

programs (Scott & Thompson, 2003). The objective of this study was to develop and

psychometrically validate a new tool to assess information needs in CR (INCR) patients.

2 Methods

2.1 Design and Procedure

This study was reviewed and approved by the Toronto Rehabilitation Institute Research Ethics

Board. The design consisted of a series of cross-sectional, observational studies.

First, a broad search of research in articles and books was performed to identify the most

important areas of information that coronary patients need to know about their disease and its’

management. A literature review of studies and tools examining information needs of coronary

patients was also undertaken. Based on this review, an inventory of these elements was

developed into a first version of the questionnaire and areas of information needs were identified.

This was then emailed to 20 healthcare professionals who were experts in CR. They performed a

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content analysis, verifying if the new instrument was appropriate for administration in a CR

population and evaluating clarity of the questions. Items were refined based on the findings.

Second was a pilot study to verify the applicability of the INCR instrument, and to evaluate

patient understanding of the items (clarity). Here a convenience sample of coronary patients that

finished their CR programs and had previously-agreed to be contacted about research

opportunities were recruited. Results were used to further refine the INCR tool.

Third, a psychometric validation was performed. The refined tool was administered to a larger

sample of current CR participants from 2 CR programs. The questionnaire was re-administered

two weeks after the first application in 25 randomly selected participants to assess test-retest

reliability. Data were collected between January and April of 2012.

2.2 Participants

For the pilot test, graduates of the Toronto Rehabilitation Institute CR program were surveyed.

For the psychometric-validation of the INCR Tool, a convenience sample of current CR patients

from two institutions were recruited: Toronto Western Hospital and the Toronto Rehabilitation

Institute, both of the University Health Network in Toronto, Ontario, Canada. These programs

are 4-6 months in duration. The inclusion criteria were the following: confirmed coronary artery

disease diagnosis or multiple cardiovascular risk factors (such as hypertension and diabetes). The

exclusion criteria were the following: younger than 18 years old, lack of English-language

proficiency, any significant visual or cognitive condition or serious mental illness which would

preclude the participant’s ability to answer the questionnaire.

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2.3 Measures

To assess clarity, the expert panel and pilot study patients were asked to rate each information

item Likert-type scale (Pasquali, 2003) ranging from 1 (not clear) to 10 (very clear). CR

participants from the pilot study and psychometric-validation were characterized according to

sex, age, educational level and family income, comorbidities, cardiac risk factors and history,

and duration of participation in CR. All characteristics were self-reported.

2.4 Statistical Analysis

To test the psychometric properties of the new tool, I investigated reliable measures of each one

of the areas of information needs. The first analysis was test-retest reliability, assessed through

the intraclass correlation coefficient (ICC). Since bad items were found they were eliminated. I

then proceed to internal consistency analysis of each area by Cronbach’s alpha. For this analysis,

values higher than 0.70 were considered acceptable, reflecting the internal correlation between

items of the same area (Hair & Anderson, 1998). The factor structure was an option of

assessment if the internal correlation between items in the areas was not confirmed.

Criterion validity was also assessed by comparing INCR scores by participant’s level of

education and duration in CR, using t-tests and Pearson’s correlation respectively. Item

completion rates were also described. As subjects are rating importance, ceiling and floor effects

are likely not applicable (Terwee et al., 2007).

Finally, a descriptive analysis of the INCR Tool was performed. A mean total score was

computed to reflect total information needs. T-tests, one-way analysis of variance and chi-square

tests were used as appropriate to assess differences in INCR scores based on patient’s socio-

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demographic and clinical characteristics. SPSS Version 21.0 (IBM Corp, 2012) was used for

entering, cleaning and analyzing the data and the level of significance was set at 0.05 for all tests.

Where more than 10% of the items were missing, the data were excluded from further analysis.

3 Results

3.1 Participants Characteristics

For the content validation, there were 10 (50%) clinicians, and 10 (50%) researchers who

reviewed the items. For the pilot test, 50 CR graduates who agreed to be contacted were

contacted. Thirty-four (68%) responded, of which 15 (44%) were female. Respondents had a

mean age of 69.4±8.4, and had participated in a mean of 11±6.5 months of CR.

For the psychometric validation study, 290 coronary patients participating in CR (representing

approximately 25% of total annual CR patients) were approached to participate in this study

during the recruitment phase. Two hundred and three (70%) participants signed the consent form

and completed the INCR tool. The characteristics of these participants are presented in Table 4.1.

To assess test-retest reliability, 25 of these participants were randomly selected and ask to

complete the INCR.

3.2 Development of the Tool

Through the literature review, 11 areas of information needs – a total of 60 items - were

identified and comprised the first version of the INCR Tool. These areas are: the heart

(physiology, symptoms, surgical treatments), nutrition, exercise/physical activity, medication,

work/vocational/social, stress/psychological factors, general/social concerns, emergency/safety,

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diagnosis and treatment, risk factors, and barriers/goal setting. The mean clarity rating by the

experts was 8.56±1.99. Item ratings are shown in Table 4.2. No changes were made in the scale

at this phase.

After this review, the items were formatted for patient administration with Likert-type response

options as follows: 1 = really not important; 2 = not important; 3 = neutral; 4 = important; and 5

= very important. On the top of the page, patients were asked to report their current educational

needs about each item following the Likert scale.

3.3 Pilot Testing

The 34 participants took a mean of 11.45±4.8 minutes to complete the INCR. Regarding the

evaluation of clarity, mean clarity of the items was 8.21 and no items had mean clarity scores

lower than 6 (ratings are shown in Table 4.2). These results indicated that the questionnaire was

understood by the target population.

3.4 Psychometric Validation

The INCR was administered to the CR participants from 2 programs, and the mean scores are

shown in Table 4.2. Item completion rates are also shown in Table 4.2.

The test-retest reliability was evaluated through the intraclass correlation coefficient (ICC) for

each area, and the ICCs for items 15, 25, 59, and 60 did not meet the minimum recommended

standard (Nunnally & Bernstein, 1994) and were eliminated. Since items 59 and 60 contribute to

the scale barriers/goal setting and this scale has 3 items, I could not compute the scale based on 1

item; therefore, item 58 also dropped.

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After that, the reliability of each area was assessed by Cronbach’s alpha. All areas were

considered internally consistent (α > 0.7). Table 4.2 displays Cronbach’s alpha of each area.

With regard to criterion validity, total INCR scores were compared by education level and by

duration in CR. As shown in Table 4.2, patients with lower educational level had significantly

greater information needs than those with higher education (p<0.05). Regarding duration in CR,

there was a correlation between this characteristic and total needs (r=0.15; p<0.001): patients in

the first 4 months of the program had significantly higher needs compared to patients finishing

the program (5-6 months of duration). In addition, patients participating in the program for more

than 6 months had significantly higher needs compared to regular participants (at most 6

months).

3.5 Information Needs

The mean total score was 4.08±0.53. Forty-seven percent of patients identified all items as very

important. Analyses (t-tests, one-way analysis of variance and chi-square tests as appropriate)

were performed to evaluate differences in mean INCR scores by patients’ socio-demographic

and clinical characteristics. As shown in Table 4.1, scores were only related to gender (p=0.02),

educational level (p=0.03) and duration in CR (p<0.001).

Means and standard deviations of each item are reported in details in Table 4.2.

Regarding the 10 subject areas of the tool, participants rated emergency/safety

(mean=4.53±0.71), the heart (mean=4.32±0.63), and stress/psychological factors

(mean=4.29±0.7) as the areas with the greatest information needs; and work/vocational/social

(mean=3.61±1.09), general/social concerns (mean=3.83±1.13) and risk factors

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(mean=3.83±0.79) as their lowest information needs. Mean and standard deviation of each area

is reported in Table 4.3.

Table 4.1 – Sociodemographic/Clinical Characteristics of the Participants for the Psychometric

Validation and INCR mean scores and differences among subgroups (N=203)

Characteristic INCR Score Sociodemographic (mean±SD) p Age (mean±SD) 64.2±11.8 Sex n(%) Male 154 (75.9) 4.04±0.53 0.02† Female 49 (24.1) 4.23±0.50 Educational Level n(%) Elementary School 2 (1.0) 3.30±0.36 0.03† High School 53 (26.1) 4.03±0.56 College 52 (25.6) 4.16±0.46 University 55 (27.1) 3.65±0.57 Postgraduate 40 (19.7) 4.29±0.45 Missing 1 (0.5) - Family Income per year n(%) Under $10.000 6 (3.0) 4.52±0.45 0.24

between $11.000 and $50.000 59 (29.1) 4.07±0.61 between $50.001 and $100.000 70 (34.5) 4.01±0.53 between $100.001 and $150.000 38 (18.7) 4.06±0.39 above $150.000 15 (7.4) 4.03±0.39 Missing 15 (7.4) - Clinical Risk Factors n(%) Hypertension 48 (23.9) 4.03±0.50 0.42 Dyslipidemia 5 (2.5) 4.74±0.24 0.50 Smoking History 41 (20.2) 4.12±0.72 0.80 Comorbidities n(%) Heart Failure 8 (3.9) 4.03±0.80 0.77 Diabetes Mellitus type I 6 (3.0) 4.24±0.75 0.48 Diabetes Mellitus type II 33 (16.3) 3.99±0.71 0.27 Peripheral Arterial Disease 12 (5.9) 4.11±0.91 0.86

Chronic Obstructive Pulmonary Disease 3 (1.5) 3.92±0.68 0.85

Acute Cardiac Event n(%) Acute Myocardial Infarction 39 (19.2) 4.18±0.51 0.20 Revascularization Coronary Bypass 1 (0.5) 3.95±0.59 0.10 Procedures n(%) Angioplasty 90 (44.3) 4.16±0.53 0.06 Duration in CR (mean±SD) 3.8±3.9 At most 2 months 66 (32.5) 4.04±0.51 <0.001†††

3 – 4 months 72 (35.5) 4.10±0.60 5 – 6 months 42 (20.7) 3.90±0.41 More than 6 months 10 (4.7) 4.68±0.18 Missing 13 (6.4) -

SD=standard deviation. Significant differences between groups: †p<.05; ††p<.01; †††p<.001. Note: Income shown in Canadian dollar

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Table 4.2 – Mean and Standard Deviation of Clarity Rating by Experts (N=20) and Pilot Study Patients (N=20), INCR Score (N=203),

INCR Item Completion Rates and Cronbach’s alpha per area.

Clarity Rating by Expert Panela

Clarity Rating by Pilot Study Patientsa

INCR Scoreb

INCR Item Completion Rates

Cronbach’s alpha per area

Areas Item Mean±SD Mean±SD Mean±SD % The Heart 1. How does a healthy heart works? 8.17±2.17 7.44±2.58 4.32±0.74 100% 0.88 (physiology, 2. What is “coronary artery disease”? 9.00±2.33 8.44±2.28 4.41±0.75 100% symptoms, surgical 3. What is angina? 8.92±2.31 8.00±2.25 4.41±0.77 100% treatments) 4. What happens when someone has a heart attack? 9.33±1.50 8.06±2.24 4.55±0.65 98% 5. What is “bypass surgery”? 8.33±2.39 8.31±2.09 4.14±0.82 100% 6. What is an angioplasty 8.67±2.10 8.75±2.14 4.24±0.86 97.5% Nutrition 7. What foods should I eat for a healthy heart? 8.58±2.57 8.31±1.58 4.40±0.76 100% 0.87 8. How can I choose healthy foods at the grocery

store? 9.42±1.08 8.31±1.85 4.21±0.82 98.5%

9. How can I choose healthy foods when dining out? 9.25±1.42 8.50±1.46 3.99±0.80 100% 10. How do I read food labels? 8.75±2.14 8.25±1.98 4.18±0.75 99.5% Exercise/ Physical 11. How will exercise help my heart condition? 8.17±2.17 9.13±1.02 4.58±0.59 100% 0.88 Activity 12. What are the components of a safe exercise

program? 7.58±2.97 8.25±1.81 4.54±0.67 97%

13. What is cardiovascular or aerobic exercise? 8.42±2.75 8.31±1.54 4.27±0.83 99.5% 14. What can I do to improve of maintain flexibility? 7.92±2.35 8.00±2.00 4.19±0.76 100% *15. How do I check my heart rate (pulse)? 9.75±0.62 9.25±1.34 16. How should I exercise in hot or cold weather? 8.17±2.08 9.13±1.15 4.07±0.94 100% 17. If I have diabetes, how do I prevent low blood

sugar with exercise? 7.83±2.41 6.69±3.70 3.66±1.12 88.2%

18. How do I take care for my feet when in an exercise program?

8.33±2.42 6.75±3.24 3.72±0.99 99%

19. What is resistance training (i.e. exercise for strengthen)?

8.50±3.00 8.81±1.28 3.88±1.08 98.5%

20. What types of exercise equipment are available? (where?)

8.17±2.69 8.44±1.63 3.77±0.98 100%

21. How can I exercise at home safety? 9.92±0.29 8.69±1.35 3.94±1.00 100% 22. When should I stop physical exercise? 7.17±3.07 8.38±1.41 4.14±0.99 100% 23. Is sexual activity safe for me? 6.92±3.40 8.56±2.00 3.70±1.15 99% Medication 24. What medications do I need to help my heart? 9.42±1.00 8.69±1.62 4.28±0.99 100% 0.92

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*25. What is the purpose of each of my medications? 8.00±2.04 7.69±2.36 26. How do I take my medication in the right way? 7.75±3.05 7.94±1.88 4.30±0.91 100% 27. What side effects are possible with my

medication? 9.58±0.90 7.06±2.98 4.22±0.95 98.5%

28. Do the medications I am taking interfere with each other?

8.58±2.61 7.44±2.55 4.23±0.99 98%

29. Are there foods I should avoid while taking these medications?

8.58±2.79 7.63±2.06 4.42±0.83 100%

30. What are the effects of complementary and alternative medications?

6.67±4.05 6.69±2.44 4.17±0.95 100%

Work/Vocational/ Social

31. When can I return to work and my old activities? 8.83±2.12 8.19±1.80 3.80±1.08 97% 0.85

32. Can I go back to my same job? 9.50±0.80 8.50±1.46 3.59±1.21 94.1% 33. When can I start driving again? 9.33±2.31 8.75±1.65 3.86±1.16 97.5% Stress/Psychological Factors

34. What feelings are common after a heart attack? 8.92±1.62 8.25±2.14 4.26±0.92 99.5% 0.87

35. How does stress affect my heart? 9.67±0.89 8.69±1.58 4.52±0.70 100% 36. How can I cope with stress? 8.83±1.99 8.31±1.58 4.42±0.75 97.5% 37. What can I do to reduce stress in my life? 8.50±2.07 8.44±1.63 4.36±0.87 98.5% 38. Do sleep problems affect my heart? 9.75±0.62 8.25±1.61 4.15±1.01 99.5% General/Social Concerns

39. What services, support organizations and groups are available?

8.17±1.9 8.63±1.26 4.04±0.94 97% 0.84

40. What support services are available to my family?

9.08±1.00 8.56±1.46 3.84±1.05 97%

Emergency/Safety 41. How do I recognize angina symptoms? 7.92±1.59 8.50±1.86 4.54±0.70 98.5% 0.90 42. What should I do if I feel angina or chest pain? 9.58±0.79 8.88±1.41 4.54±0.78 98.5% 43. When should I call the doctor? 9.17±1.47 8.50±1.37 4.61±0.65 99.5% 44. When should I call 911 or go to emergency

room? 7.58±2.97 8.13±1.67 4.61±0.79 100%

Diagnosis and treatment

45. What are the tests used to diagnosis my heart condition?

9.08±1.44 8.25±1.29 4.32±0.92 99.5% 0.86

46. What treatments are available for my condition? 8.50±2.28 8.44±1.67 4.50±0.89 99.5% Risk Factors 47. What are the risk factors for heart disease? 8.08±2.27 7.88±1.89 4.36±0.97 99.5% 0.87 48. What are the risk factors that I cannot control? 8.25±2.34 8.25±1.65 4.17±0.90 100% 49. What are the risk factors I can control? 8.08±2.57 7.88±1.86 4.63±0.60 100% 50. What can I do to bring my risk factors under

control? 9.42±1.44 8.88±1.15 4.60±0.70 98.5%

51. How does cholesterol affect my heart? 9.67±0.65 7.44±2.76 4.27±0.97 99.5% 52. How does diabetes affect my heart? 8.42±2.11 8.56±1.50 3.93±1.07 93.1% 53. How does physical inactivity affect my heart? 9.83±0.39 9.25±1.12 4.35±0.85 99.5%

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54. How does smoking affect my heart? 9.58±0.79 8.94±1.47 3.33±1.45 93.6% 55. What are the benefits of quitting smoking? 9.50±1.17 9.13±1.26 3.28±1.52 92.6% 56. What supports are available to help me quit

smoking? 9.92±0.29 8.38±1.75 3.00±1.43 92.6%

57. How does alcohol affect my heart? 6.25±2.77 6.13±1.96 3.35±1.41 98% **Barriers/Goal Setting

*58. How do I identify and overdue barriers to start and maintain a healthy lifestyle?

7.92±2.94 8.19±1.33

*59. How can setting goals help me to be successful in my rehab program?

6.25±3.33 7.75±1.61

*60. How do I establish effective goals for my rehab program?

6.25±3.72 6.63±2.85

Total 8.56±1.99 8.21±1.82 4.08±0.53 98% - SD=standard deviation. aClarity rating out of 10 were 1 = not clear and 10 = very clear. bINCR response options were 1 = really not important; 2 = not important; 3 = neutral; 4 = important; and 5 = very important. *items dropped due to low ICC. **area excluded due to test-retest analysis

Table 4.3 – Mean and Standard Deviation of educational needs per subject area, N=203

Subject Mean±SD 1 – The Heart (physiology, symptoms, surgical treatments)

4.32±0.63

2 – Nutrition 4.18±0.67 3 – Exercise/ Physical Activity 3.99±0.63 4 - Medication 4.28±0.77 5- Work/Vocational/Social 3.61±1.09 6 – Stress/Psychological Factors 4.30±0.70 7-General/Social Concerns 3.83±1.13 8-Emergency/Safety 4.54±0.72 9-Diagnosis and treatment 4.39±0.90 10-Risk Factors 3.84±0.79 Total 4.08±0.53

SD=standard deviation

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4.1 Discussion

Education is a core component of CR, and is necessary to promote patient understanding of

secondary prevention strategies and adherence to these strategies. Herein, a new tool to assess

CR participant’s information needs has been developed and psychometrically-validated through

a rigorous process. Internal reliability, test-retest reliability, content and criterion validity as well

as factor structure were all established, and demonstrate the utility of this tool. In particular,

results should inform review of educational programs provided to patients within CR.

The overall mean, as well as many of the 10 subject areas means were all quite high,

demonstrating that CR participants consider most of the 55 information items to be “important”.

This also highlights the importance of CR, where patients have repeated contacts with the

program, so there is sufficient opportunity to provide such comprehensive education. Clearly, it

would be difficult to convey all the information patients deemed important in a clinic visit,

although written patient education materials can be provided.

Although the provision of education to patients with acute cardiac disorders has been a

predominant theme in the literature over the past 20 years, to our knowledge, there is no

available tool in the literature that addresses information needs during CR. Studies have being

assessed information needs of cardiac patients following different conditions; however timing is

an important framework in this context, and information needs may vary from when the patient

is at home, after discharge and during rehabilitation (Scott & Thompson, 2003; Decker et al.,

2007).

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Results of the present study are generally consistent with those reported previously in MI

patients. In particular, the emergency/safety (Casey et al., 1984; Larson et al., 1996; Timmins &

Kaliszer, 2003) and medication (Casey et al., 1984; Chan, 1990; Timmins & Kaliszer, 2003;

Smith & Liles, 2007) subject areas were highly concordant. However, there are differences in the

present study compared to literature. Firstly, the present study revealed a stress/psychological

factor as a subject area, which is not well documented as a need in some studies (Timmins &

Kaliszer, 2003). Thus, knowing about risk factors is described as the highest information need in

different studies (Casey et al., 1984; Chan, 1990; Wingate, 1990) but, surprisingly, not in this

study.

There are some limitations to this study, which should be stated. First, a sample size of at least

50 patients is generally considered adequate for the assessment of test-retest reliability (Altman,

1991), yet only 25 were tested in the current study. There are some elements of the scale, which

require further assessment. Construct validity was not tested, and this should form the basis for

future study. Moreover, future research is needed to assess whether the scale is sensitive to

change, such as following participation in the education components of CR, or to test

implementation of new education materials. Finally, whether the INCR is a valuable and valid

tool to identify information needs in individual patients should be explored.

4.2 Conclusion

In conclusion, the INCR Tool proved to have strong psychometric properties, providing

preliminary evidence of the reliability and validity of the INCR Tool to assess information needs

in CR patients. It is hoped this tool can support CR evaluation of their program’s education

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component, and promote greater provision of information consistent with patient’s identified

needs.


Good patient education involves assessing needs (Kayaniyil et al., 2009; Roter et al., 2001; Scott

& Thompson, 2003; Timmins & Kaliszer, 2003), setting goals and objectives, implementing a

teaching plan, and evaluating outcomes (Cranton, 1989). Before implementing patient education

programs, it is prudent to evaluate what information is needed. The availability of this valid

needs assessment tool is essential to evaluate the information needs of CR patients and to tailor

the information component of these programs. Then tools such as the CADE-Q (Coronary Artery

Disease Educational Questionnaire) (Ghisi et al., 2010; de Melo Ghisi et al., 2013) can be

administered to determine whether patients have the learned the information they perceived as

important.

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Chapter 5 PAPER THREE: Healthcare providers’ awareness of the information needs of their cardiac rehabilitation patients

throughout the program continuum

Results are presented from a cross-sectional study aimed to: (1) describe cardiac rehabilitation

(CR) participant information needs, (2) investigate whether CR providers are cognizant of

patient’s information needs and preferred delivery formats, and (3) whether patient information

needs change over the course of CR. The tool used to assess information needs was the INCR,

which development and validation was described in Chapter 4. This paper was published in

Patient and Education Counseling Journal, in 2014 (Ghisi et al., 2014b).

1 Introduction

Patient participation in cardiac rehabilitation (CR), a comprehensive outpatient risk reduction

program, mitigates the burden of cardiovascular diseases (Clark et al., 2005; Heran et al., 2011;

Lawler, Filion, & Eisenberg, 2011), the leading cause of mortality worldwide (WHO, 2011), and

a significant contributor to morbidity and health-related costs (CCN, 2002). Given the

complexity of CVD management, including physical activity, nutrition, medication adherence

and smoking cessation, education is necessary to support patients in achieving risk reduction and

ultimately secondary prevention (Alm-Roijer et al., 2006; Kayaniyil et al., 2009; Boyde et al.,

2011; Brown et al., 2011). Indeed, a core component of CR programs is patient education (Stone

et al., 2009; 2012).



status” (Koongstvedt, 2001, p. 788). As a facilitator of behavior change, patient education

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therefore plays a key role in the management of CVD (Brown et al., 2011). The effectiveness of

patient education has been demonstrated, such that patient CVD knowledge has been shown to

strongly influence their symptom recognition (Zalesskaya, Noruzbaeva, Lunegova, &

Mirrakhimov, 2005; DeVon, Rankin, Paul, & Ochs, 2010), advocacy for physician screening

(Bolman et al., 2005), attitudes toward their disease (Bellmanet al., 2009), promote their

motivation for self-care and ultimate behavior change (Dickson, Tkas, & Riegel, 2008; Bellman

et al., 2009), improve health-related quality of life, and decrease costs through reductions in

downstream healthcare utilization (Brown et al., 2011). Conversely, inadequate patient

understanding of their disease may cause unwarranted emotional distress, inappropriate coping

behavior, non-compliance with medical advice (Monane et al., 1994; Blyth et al., 1997), and

unnecessary disease progression (Sui et al., 2008; Zalesskaya et al., 2005).

To deliver effective patient education, educators need to address patients’ information needs. The

information needs of cardiac patients immediately following revascularization (Goodman et al.,

1997; Brezynskin et al., 1998; Astin et al., 2008), acute coronary syndrome (Czar & Engler,

1997; Nakano et al., 2008), myocardial infarction (MI) (Casey et al., 1984; Moynihan et al.,

1984; Ashton, 1997; Timmins & Kaliszer, 2003; Decker et al., 2007; Smith & Liles, 2007), and

heart failure (Wehby & Brenner, 1999; Lile et al., 1999), have been previously described, and

include knowing how to manage signs and symptoms, knowing how to modify or change risk

factors, and knowing the names, dosages and side-effects of medications. However, the

information needs of CR participants have only recently been described (Ghisi et al., 2013a).

This is a major gap, considering many CR participants understand or recall little of what

happened in hospital (due to anxiety and sedation for example), they would have received

information primarily related to acute recovery from their therapies (Kayaniyil et al., 2009; Alm-

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Roijer et al., 2006; Boyde et al., 2011; Brown et al.,2011; de Melo Ghisi et al., 2013), and that

information needs change across the continuum of care (Cameron & Gignac, 2008).

To be effective, patient education should be comprehensive, planned, supportive and, in

particular, patient-centered (Koongstvedt, 2001; Su, Herron, & Osisek, 2001; Furze et al., 2002;

Brown et al., 2011). Unfortunately, much previous literature on cardiac and non-cardiac patient

education has demonstrated that healthcare providers’ are often unaware or inaccurately-perceive

patients’ educational needs (Casey et al., 1984; Moynihan, 1984; Gerard & Peterson, 1984;

Karlik & Yarcheski, 1987; Hagenhoff et al., 1994). Clearly, this can result in less engaged and

informed patients, and thus potentially negatively impact their health outcomes. Accordingly,

understanding what patients identify as information needs and concerns, especially early in CR,

can ensure that education provided is relevant to the learner. Thus, the objectives of this study

were to: (1) describe CR patient information needs and their relation to patient sociodemographic

and clinical characteristics, (2) investigate whether CR providers are cognizant of patient’s

information needs and preferred delivery formats, and (3) investigate whether patient

information needs change over the course of CR.

2 Methods

The framework for this study was based on Knowles’s assumptions regarding the nature of the

adult learning process (Knowles, 1973). Specifically, it was assumed that adults are able to

identify their own learning needs, and that they are motivated to learn when they see the content

as relevant.

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This was a cross-sectional study. Ethics approval was obtained from the local review board, and

written consent to participate was provided by all respondents. Data was collected between

January and August, 2012.

CR patients were approached by a research team member at the beginning of their group classes

to participate in the study. They were provided the option to complete the survey while in the CR

center, or to take it home to complete, and bring it back at their next visit. The survey included

sociodemographic items, the Information Needs in CR (INCR) instrument (Ghisi et al., 2013a),

and items assessing patient preferences for educational delivery formats. Clinical data were

extracted from their medical charts. CR providers were asked to complete an adapted version of

the same survey.

2.2 Participants

This study included CR patients and healthcare providers recruited from a large academic CR

centre in Toronto, Canada. The CR program is 6-months in duration. Upon starting CR, each

patient undergoes a comprehensive assessment, they are provided a CR book, and are provided

pamphlets as applicable to their needs. Participants then come to the center for weekly exercise

classes, in addition to their home exercise. In conjunction with these weekly visits, an

interdisciplinary team provides approximately 15 hours of patient education including

information on exercise safety, nutrition, risk management, medications, stress management, and

lifestyle management. This is delivered in large and small group lectures.

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A convenience sample of 500 CR patients was approached to participate in this study. Patients

from all CR classes were approached to solicit responses across all months of the program. The

exclusion criteria for patients were: age less than 18 years, lack of English language proficiency,

and any visual, cognitive or psychiatric condition that would preclude the participant from

completing the survey. All 59 healthcare providers from the CR centre were emailed the survey

to complete, including nurses, registered dietitians, exercise physiologists, kinesiologists,

physicians, physiotherapists, social workers, and psychologists. Administrative and exercise

testing staff were excluded from participation.

2.3 Measures

Patients’ clinical characteristics were obtained from the medical chart, and included cardiac

history, comorbidities, risk factors and months in CR. Patients and CR providers’

sociodemographic characteristics were also assessed: age, sex, educational level and family

income for patients; and age, sex and years working in CR for providers.

The INCR assessed CR patients’ information needs in 10 areas: the heart (physiology,

symptoms, and surgical treatments), nutrition, exercise/physical activity, medication,

work/vocational/social, stress/psychological factors, general/social concerns, emergency/safety,

diagnosis and treatment, and risk factors. Participants were asked to rate the importance of each

of the 55 information items in increasing their knowledge about CVD. Items were rated on a 5-

point Likert-type scale, that ranged from 1 = really not important to 5 = very important, and

accordingly higher scores indicated greater information needs. The INCR has been

psychometrically-validated in the CR setting, and demonstrated good reliability and validity

(Ghisi et al., 2013a). The INCR was adapted to be administered to CR providers, through minor

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revision to the instructions. Providers were asked to rate the importance of each item to their

patients on the same 5-point scale.

Next, patients were asked to report their preferences for educational delivery formats, checking

their preferences from a list of options. There was also space to report “other” preferred formats,

in open-ended fashion. CR providers were similarly asked to denote their perceptions of their

patients preferred delivery formats. Finally, providers were also asked to describe the most

common questions asked by patients, to describe perceived education gaps in the program, in

open-ended fashion.


SPSS Version 21.0 was used (IBM Corp, 2012). Descriptive statistics were used to describe

sociodemographic and clinical characteristics of patients and CR providers. To test the first

objective, INCR scores were explored. Pearson’s correlation, t-tests and ANOVAs (as

applicable) were computed to test for significant differences INCR scores based on patient and

provider characteristics. To determine whether outliers in the dataset influenced responses they

were removed and analyses repeated. If no difference is found between results excluding or

including these cases, all subsequent analyses will include outliers.

To test the second objective, a descriptive examination of mean total information needs scores

and mean item scores by sample (patients vs. CR providers) was performed. To test for

differences between samples, non-parametric tests (Mann-Whitney U) were applied, due to

difference in size between samples. A similar approach was also undertaken for preferred

delivery formats.

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Open-ended questions (preferences for educational delivery formats, the most common questions

patients asked, and gaps in CR education curriculum) were coded (Silverman, 2000) and

described by sample. Responses from all open-ended questions were analyzed using the

following steps (Pope, Ziebland, & Mays, 1999): (1) consider the quality of the data; (2) focus

the analysis by topic; (3) categorize information, identifying themes or patterns and organize

them into coherent categories; (4) identify patterns and connections within and between

categories; and, (5) interpretation. Two researchers independently reviewed the data and met to

compare results. Any discrepancies in meaning were resolved by a third researcher.

Finally, to test the third objective, patients were categorized based on their month in the program,

as beginning (1-2 months), middle (3-4 months) and end (5 or more). INCR subscale scores were

compared across each time point using ANOVA.

3 Results

3.1 Respondent Characteristics

With regard to patients, 306 (response rate = 61.2%) returned and fully completed the INCR tool.

On average, patients had been in the program just over 4 of the 6 months. Table 5.1 displays

their sociodemographic and clinical characteristics, and how these characteristics were related to

their information needs. As shown, patients with lower income had significantly higher

information needs than those with higher income, despite outliers. When five individuals with an

income below CAD$10,000 that have disproportionally high information needs score were

excluded from the analysis, there is still a significant impact of income on information needs

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scores (F=2.54). So all subsequent analyses included these outliers. There was no significant

relationship between information needs and any other characteristic.

Table 5.1 – Sociodemographic and Clinical Characteristics of Patient Respondents (N=306), and

Mean and Standard Deviation of Total Information Needs Scores by these Characteristics.

Characteristic Mean±SD /

n (%)

Information Needs

(Mean±SD)

test statistic*

Sociodemographic† Age, years (mean±SD) 66.33±11.11 - 0.02

Less than or equal to 65 years old 139 (45.4%) 4.22±0.54 0.09 Older than 65 years old 165 (54.6%) 4.12±0.53

Sex, n (%) 1.06 Female 85 (27.8%) 4.22±0.54 Male 219 (72.2%) 4.15±0.53 Highest Educational Level, n (%) 1.49

Elementary School 4 (1.3%) 4.18±0.75 High School 70 (22.9%) 4.05±0.54 College 71 (23.2%) 4.22±0.46 University 86 (28.1%) 4.15±0.58 Graduate School 67 (21.9%) 4.26±0.52 Did not answer 8 (2.6%) -

Annual Family Income in CAD, n (%) 2.62§ Under $10,000 5 (1.6%) 4.68±0.30 $10,000 - $50,000 77 (25.2%) 4.15±0.58 $50,001 - $100,000 108 (35.3%) 4.17±0.49 $100,001 - $150,000 55 (18.0%) 4.02±0.50 Above $150,000 29 (9.5%) 4.05±0.59 Did not answer 32 (10.5%) -

Clinical,‡n (% yes) Hypertension 104 (34.0%) 4.19±0.54 0.26 Dyslipidemia 59 (19.3%) 4.22±0.54 0.98 Smoking History 55 (18.0%) 4.25±0.55 1.30 Diabetes Type I 4 (1.3%) 4.64±0.16 1.55 Diabetes Type II 48 (15.7%) 4.27±0.52 1.46 Previous MI 79 (25.8%) 4.29±0.50 1.46 Prior CABG 94 (30.7%) 4.04±0.58 1.48 Prior PCI 125 (40.8%) 4.24±0.51 1.59 Heart Failure 11 (3.6%) 4.25±0.65 0.14 Peripheral Vascular Disease 14 (4.6%) 4.27±0.73 0.78 Chronic Obstructive Pulmonary Disease 5 (1.6%) 4.36±0.50 0.81

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CABG indicates coronary bypass artery graft surgery, CAD Canadian dollars, CR cardiac rehabilitation, MI myocardial infarction, PCI percutaneous coronary intervention, SD standard deviation. *F test, t-test or Pearson’s correlation, as appropriate. Significant differences between samples: §p<.05 †self-reported ‡extracted from medical chart Note. INCR scores range from 1-5, with greater scores denoting greater information needs.

With regard to CR providers, 28 (response rate = 47.5%) completed the survey. CR providers

were on average 43.64±13.56 years of age, and were primarily female (n=23, 82.1%). With

regard to tenure, 19 (68%) providers reported working in CR for more than 6 years, 7 (25%)

between 1 and 5 years, and 2 (7%) less than 1 year. There was no significant relationship

between total INCR scores and sex (p=0.30), age (p=0.25), or years working in CR (p=0.30).

3.2 Information Needs

The INCR performed reliably in both samples, with Cronbach’s alpha for the patients’ and CR

providers’ respondents being 0.98 and 0.89, respectively. Cronbach’s alpha for the subscales

ranged from .83 to .93 for the patients’ version, and from .75 to .91 for the CR providers’

version.

The mean total INCR for both samples was 4.38±0.44. Table 5.2 displays the mean total,

subscale and item needs scores for patients and CR providers. Both patients and CR providers

rated all items as “important” to learn (i.e., all item means above 3.0). The items where the mean

score was below 4 would generally not be applicable to all participants (i.e., diabetes, smoking,

return to work, driving); an observation which is supported by the generally higher standard

deviations for these items.

As shown in Table 5.2, CR providers rated the total information needs of patients significantly

greater than patients overall. Similarly, for 30 of 55 items and for 5 of 10 subscales, CR

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providers rated the information needs significantly higher than patients did. There were only 2

items where patients scored the information importance as significantly higher than providers

rated them, specifically with respect to diagnosis and treatment. The greatest disparities in mean

item score between patients and providers were for again for specific items, which may not

pertain to all patients such as smoking (0.86 – 1.47) and diabetes (0.71-0.96).

CR providers were asked to report the topics that they perceived patients have more difficulty

learning. Using content analysis, responses were grouped into 9 categories: goal-setting and self-

care (identified by 12 providers; 43%), exercise (n=7; 25%), nutrition (n=6; 21%), the heart

(physiology, symptoms, surgical treatments; n=5; 18%), medication (n=5; 18%),

stress/psychological factors (n=3; 11%), risk factors (n=3; 11%), work/vocational/social (n=1;

4%), and diagnosis and tests (n=1; 4%).

Finally, based on their experiences with patients and their perceived information needs, providers

were asked to identify gaps in the education curriculum. They noted gaps in information related

to the heart (i.e., physiology, symptoms, surgical treatments), exercise, medication, sexual

activity, stress/psychological factors, sleep problems, different forms of physical activity (e.g. tai

chi, relaxation techniques), and risk factors. In addition, providers identified “other” topics,

including fall prevention, problem solving, and self-management.

Table 5.2 – Mean and Standard Deviation of Total Information Needs by Sample, and Mean

Differences.

Patients

(n=306; 91.6%) CR Providers (n=28; 8.4%)

Difference (CR providers needs –

patients needs) Subscale Item Mean±SD Mean±SD The Heart 1. How does a healthy heart work? 4.41±0.79 4.43±0.72 0.02 (physiology, 2. What is “coronary artery disease”? 4.46±0.79 4.79±0.57 0.33* symptoms, surgical

3. What is angina? 4.46±0.78 4.79±0.42 0.33*

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treatments) 4. What happens when someone has a heart attack? 4.55±0.77 4.64±0.62 0.09 5. What is “bypass surgery”? 4.16±0.85 4.39±0.74 0.23 6. What is an angioplasty 4.28±0.85 4.46±0.69 0.18 Total Mean 4.39±0.65 4.58±0.50 0.19*** Nutrition 7. What foods should I eat for a healthy heart? 4.49±0.80 4.68±0.48 0.19 8. How can I choose healthy foods at the grocery

store? 4.32±0.87 4.54±0.58 0.22

9. How can I choose healthy foods when dining out?

4.16±0.85 4.50±0.51 0.34*

10. How do I read food labels? 4.32±0.78 4.64±0.56 0.32* Total Mean 4.32±0.68 4.59±0.50 0.27 Exercise/ Physical

11. How will exercise help my heart condition? 4.62±0.67 4.93±0.26 0.31*

Activity 12. What are the components of a safe exercise program?

4.54±0.69 4.86±0.36 0.32*

13. What is cardiovascular or aerobic exercise? 4.35±0.72 4.43±0.84 0.08 14. What can I do to improve or maintain

flexibility? 4.22±0.81 3.96±0.79 -0.26

15. How should I exercise in hot or cold weather? 4.20±0.85 4.61±0.57 0.41* 16. If I have diabetes, how do I prevent low blood

sugar with exercise? 3.83±1.13 4.79±0.42 0.96***

17. How do I take care for my feet when in an exercise program?

3.85±0.97 4.56±0.51 0.44***

18. What is resistance training (i.e. exercise for strengthening muscles)?

4.12±0.93 4.56±0.51 0.44*

19. What types of exercise equipment are available? (where?)

3.82±0.94 3.96±0.74 0.14

20. How can I exercise at home safely? 4.11±0.88 4.61±0.57 0.5*** 21. When should I stop physical exercise? 4.27±0.91 4.64±0.56 0.37* 22. Is sexual activity safe for me? 3.72±1.15 4.46±0.58 0.74*** Total Mean 4.09±0.59 4.51±0.41 0.42*** Medication 23. What medications do I need to help my heart? 4.41±0.93 4.75±0.52 0.34 24. How do I take my medication in the right way? 4.41±0.84 4.67±0.56 0.26 25. What side effects are possible with my

medication? 4.35±0.87 4.39±0.63 0.04

26. Do the medications I am taking interfere with each other?

4.41±0.87 4.39±0.69 -0.02

27. Are there foods I should avoid while taking these medications?

4.44±0.81 4.50±0.69 0.06

28. What are the effects of complementary and alternative medications?

4.24±0.89 4.25±0.80 0.01

Total Mean 4.37±0.69 4.51±0.55 0.14 Work/Vocational/ Social

29. When can I return to work and my old activities?

3.89±1.01 4.64±0.49 0.75***

30. Can I go back to my same job? 3.65±1.18 4.39±0.74 0.74** 31. When can I start driving again? 3.91±1.17 4.36±0.87 0.45 Total Mean 3.65±1.10 4.46±0.63 0.81*** Stress/Psychological Factors

32. What feelings are common after a heart attack? 4.24±0.95 4.68±0.48 0.44*

33. How does stress affect my heart? 4.50±0.76 4.75±0.44 0.25 34. How can I cope with stress? 4.41±0.80 4.75±0.44 0.34* 35. What can I do to reduce stress in my life? 4.39±0.86 4.79±0.42 0.40* 36. Do sleep problems affect my heart? 4.20±0.91 4.75±0.44 0.55** Total Mean 4.31±0.72 4.74±0.36 0.43

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General/Social Concerns

37. What services, support organizations and groups are available?

4.04±0.92 4.54±0.58 0.50**

38. What support services are available to my family?

3.87±1.06 4.50±0.58 0.63**

Total Mean 3.92±0.99 4.52±0.54 0.60*** Emergency/Safety

39. How do I recognize angina symptoms? 4.57±0.75 4.93±0.26 0.36*

40. What should I do if I feel angina or chest pain? 4.59±0.80 4.89±0.32 0.30* 41. When should I call the doctor? 4.58±0.76 4.86±0.36 0.28 42. When should I call 911 or go to emergency

room? 4.63±0.80 4.79±0.42 0.16

Total Mean 4.58±0.70 4.87±0.26 0.29 Diagnosis and treatment

43. What are the tests used to diagnose my heart condition?

4.36±0.84 4.21±0.79 -0.15

44. What treatments are available for my condition? 4.48±0.80 4.44±0.75 -0.04 Total Mean 4.42±0.74 4.25±0.88 -0.17** Risk Factors 45. What are the risk factors for heart disease? 4.47±0.84 4.89±0.32 0.42* 46. What are the risk factors that I cannot control? 4.26±0.88 4.46±0.64 0.20 47. What are the risk factors I can control? 4.64±0.63 4.82±0.39 0.18 48. What can I do to bring my risk factors under

control? 4.64±0.70 4.86±0.36 0.22

49. How does cholesterol affect my heart? 4.40±0.90 4.75±0.44 0.35* 50. How does diabetes affect my heart? 3.97±1.12 4.79±0.42 0.82*** 51. How does physical inactivity affect my heart? 4.41±0.83 4.86±0.36 0.45** 52. How does smoking affect my heart? 3.46±1.46 4.93±0.27 1.47*** 53. What are the benefits of quitting smoking? 3.41±1.53 4.68±0.55 1.27*** 54. What supports are available to help me quit

smoking? 3.17±1.45 4.54±0.58 1.37***

55. How does alcohol affect my heart? 3.68±1.26 4.50±0.64 0.82** Total Mean 3.93±0.79 4.73±0.38 0.80** Total 4.17±0.53 4.59±0.34 0.42***

SD indicates standard deviation. Significant differences between samples: *p<.05; **p<.01; ***p<.001.

3.3 Education Delivery Formats and Gaps

Table 5.3 displays the preferences for education delivery formats by patients and CR provider’s

perceptions of patients’ preferences. Lecture, book and discussion with healthcare providers

were identified as the preferred formats by patients, and were also correctly perceived by CR

providers as patients’ preference. As with the information needs, providers endorsed each

delivery format more strongly than patients did. But contrarily, providers significantly under-

estimated patient preference for education delivered by their physician. However, this was the

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least preferred format among patients. In addition, 10 (3.3%) patients reported as important the

inclusion of family or spouse during education delivery.

Table 5.3 – Preferences for Educational Delivery Formats by Sample

Format Patients (N=306)

CR Providers (N=28) p

Lectures 211 (69.0%) 25 (89.3%) 0.04 Book 206 (67.3%) 27 (96.4%) 0.004 Discussions with CR providers 198 (64.7%) 26 (92.9%) 0.004 Internet 162 (52.9%) 24 (85.7%) 0.001 Movies/videos 90 (29.4%) 11 (39.3%) 0.322 E-learning 71 (23.2%) 18 (64.3%) <.001 Audio 64 (20.9%) 10 (35.7%) 0.08 Peer 8 (2.6%) 6 (21.4%) 0.09 Physician only 13 (4.3%) 3 (1.0%) 0.04

3.4 Information Needs over the Course of CR

Table 5.4 displays patient’s information needs by area and by time in CR. Specifically, at the

beginning of the program, patients were most interested in learning about medications and

emergency/safety. Mid-program their greatest information needs related to diagnosis and

treatment, as well as nutrition. At the end of the program, participants reported their greatest

information needs related to emergency/safety, diagnosis/treatment and the heart. There was a

significant difference in information needs by time in program in the following areas:

general/social concerns (greatest mid-program), emergency/safety (greatest beginning of

program), and risk factors (greatest mid-program).

CR providers were asked to describe the most common questions patients asked them, when

during the program, and where (location inside the CR center) these were generally asked.

Content analysis revealed these questions corresponded to 9 of the 10 areas of the INCR, plus

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questions related to the CR program itself. Questions related to the heart (physiology, symptoms,

and surgical treatments), work, vocational and social aspects of CR, and general and social

concerns were commonly asked in the beginning of the program, and usually on a one-on-one

basis. Questions related to exercise and physical activities were also usually asked in the

beginning of the program, in several places such as: in the exercise testing lab, on the exercise

track, during lectures, and one-on-one, among others. Furthermore, in the beginning of the

program overall questions about CR were mostly asked, in several locations inside the CR

center.

Table 5.4 – Mean and Standard Deviation of Patient Information Needs by Subscale and Time in

CR Program, N=306

Area of Information Need Beginning

Months 1 and 2 (n=86; 28.1%)

Middle Months 3 and 4 (n=93; 30.4%)

End More than 5 Months

(n=96; 26.8%) F

The heart 4.29±0.80 4.41±0.50 4.36±0.63 0.81

Nutrition 4.26±0.61 4.43±0.65 4.22±0.78 2.34

Exercise/Physical activity 3.98±0.65 4.12±0.60 4.10±0.52 1.59

Medication 4.47±0.58 4.36±0.75 4.30±0.75 1.26

Work/Vocational/Social 3.60±1.14 3.67±1.13 3.67±0.94 1.51

Stress/Psychological factors 4.22±0.70 4.38±0.71 4.35±0.72 1.19

General/social concerns 3.57±1.20 4.11±0.81 3.94±0.93 6.96***†‡

Emergency/safety 4.40±0.88 4.26±0.65 4.22±0.53 3.61*†

Diagnosis and treatment 4.32±0.69 4.53±0.75 4.38±0.80 1.92

Risk factors 3.81±0.83 4.08±0.82 3.86±0.74 2.90**†

SD indicates standard deviation. Significant differences by time: *p<.05; **p<.01; ***p<.001. † Significant differences between Beginning and Middle ‡ Significant differences between Beginning and End

Questions related to nutrition were asked in the beginning and middle of the program, mostly

during educational lectures or one-on-one. Questions about risk factors were most-commonly

asked in the middle of the program, in several places such as: the exercise testing lab, on the

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exercise track, during lectures, and one-on-one, among others. Question regarding medication

were asked throughout the program and usually during lectures or during a one-on-one

consultation. Questions regarding diagnosis and tests were also asked throughout the program,

usually in the exercise testing laboratory, on the exercise track and during one-on-one

consultations. Although identified by CR providers, questions about stress and psychological

factors were not perceived to be common, and were usually asked to allied health professionals

and peers.


4.1 Discussion

Both patients and CR providers generally reported all 55 informational items as “important” to

learn, suggesting that CR, which affords repeated contacts over time between patients and

providers, must play an important role in ensuring all patients’ information needs are met.

Overall, CR providers rated the total needs of patients significantly greater than patients, which

may be related to the fact that perhaps the providers were also considering the needs of those

who did not volunteer for this study. The greatest information needs identified by patients were

related to medication, emergency/safety, and diagnosis and treatment, and were perceived as

stress/psychological factors, emergency/safety, and risk factors by CR providers. CR providers

were quite aware of patient’s information needs, except in regard to diagnosis and treatment.

Finally, most additional questions CR providers reported they received by patients are included

in the INCR tool, supporting its validity and comprehensiveness.

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Overall, patient’s desired information in areas that are vital to patient survival and ongoing

control of symptoms, and CR providers were quite aware of these information needs. In this

study, there was agreement between patients and CR providers that emergency/safety was one of

the highest information needs, which has also been observed in previous studies (Gerard &

Peterson, 1984; Czar & Engler, 1997; Ghisi et al., 2013a; de Melo Ghisi et al., 2013). Most of

the previous studies that compared patients and CR providers views of information needs, found

that providers considered medication information as a greater need than patients (Gerard &

Peterson, 1984; Ghisi et al., 2013a; de Melo Ghisi et al., 2013); however, this study did not

corroborate this, which may reflect an increasing awareness and interest of patients in their

pharmacological treatment. Moreover, in contrast to other studies (Gerard & Peterson, 1984;

Czar & Engler, 1997; Ghisi et al., 2013a; de Melo Ghisi et al., 2013), patients identified ‘risk

factors’ as one of their lowest information needs. Finally, providers should focus on educating

patients of lower income, as they identified significantly greater educational needs than their

high income counterparts (Kaplan & Keil, 1993).

In regards to delivery formats, lectures, books and discussions with healthcare providers were

identified as the preferred formats by patients, and were also correctly perceived by CR

providers as patients’ preference. These desired formats are congruent with what is offered in the

CR program evaluated. Surprisingly, patients did not desire to learn through electronic media

resources such as the internet, and e-learning. Despite patients’ preferences for non-electronic

resources, the effectiveness of this type of technology in patient education has been described in

the literature (Kuhn, Sears, & Conti, 2006). Moreover, there are some randomized controlled

trials of web-based CR currently underway (Lear, 2010). It will be important to test the user-

friendliness of the education modules, and the impact on patient knowledge, and subsequently

behavior. Indeed, the current research was intended to inform the development of online

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education videos, to enable a broader reach to cardiac patients, and “on-demand” access right

when patients want particular information. Clearly, further consideration and assessment will be

needed prior to video development, to ensure the education content is learner-centered.

To our knowledge, this is the first study to have tested differences in patient information needs

over the course of CR. There were significant differences in information needs by time related to

general/social concerns, emergency/safety, and risk factors. Specifically, patients were

significantly most interested in learning about emergency/safety at the beginning of the program,

and about general/social concerns and risk factors mid-program. While replication is warranted,

these findings could inform efforts to “time it right” in CR education delivery.

Needs Assessment is considered an ongoing process of gathering data to determine what

information needs exist so that education can be developed to help the institution to accomplish

its patients’ goals. In this context, personal aspects, background, beliefs, previous knowledge

influence results. Thus, individual and group learning needs are different. The approach used by

this study is the group learning needs, which produce an average picture that fails to address

important needs and interests of individual members of the group—so a balance is required.

Individual learning needs assessment is best used in the context of learning that occurs on an

individual basis— which is not the case for most of the CR Programs, where the education is

delivered in group settings.

Caution is warranted when interpreting results. First, the generalizability of these finding to other

CR populations is somewhat limited, considering recruitment stemmed from a single centre.

Replication is warranted. Second, this was a convenience sample, and as such may be biased. For

instance, the sample could have been composed of patients with higher information needs than

the average CR participant. Third, the response rate for both samples (patients and providers)

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was lower than 75%, which can also introduce bias. Finally, the design was cross-sectional and

therefore causal conclusions cannot be drawn. In particular, a longitudinal study of change in

patients’ information needs through the course of CR is warranted, to ascertain whether the

differences in information needs identified herein are robust.

4.2 Conclusion

CR patients desire information in many areas, but in particular they desire information regarding

emergency / safety and diagnosis / treatment. CR providers were highly cognizant of patient

information needs. Patients preferred information to be delivered via lectures, books or

discussions with CR providers. This is concordant with healthcare provider perceptions, and with

CR delivery in most instances. This is the first study to our knowledge to have documented

differences in patient information needs over the course of CR programs.


The identification of needs using an instrument like the INCR could serve as a mechanism for

understanding patient information gaps. Moreover, CR staff could use the INCR to assess the

comprehensiveness of their education programming, and to consider whether the main focus of

their programming relates to the key information needs of patients at different stages of the

program. Programs should also consider whether the delivery format of their education program

is concordant with patient preferences.

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Chapter 6 PAPER FOUR: Development and psychometric validation of the

second version of the Coronary Artery Disease Questionnaire (CADE-Q II)

The phases of development and psychometric validation of the second version of the Coronary

Artery Disease Education Questionnaire (CADE-Q II) are described in this chapter. CADE-Q

was originally developed and psychometrically validated to assess patients’ knowledge about

CAD in Brazil. It was later translated, cross-culturally adapted, and validated to English.

Although both versions demonstrated good reliability and validity, the CADE-Q presented lack

of detailed assessment of all core components of cardiac rehabilitation. In order to be used in the

study described on chapter 7, CADE-Q needed to be redesigned and updated. This paper was

submitted to Patient and Education Counseling Journal in May 2014 and is currently under

revision.

1 Introduction

Coronary Artery Disease (CAD) is a leading cause of morbidity worldwide (WHO, 2011). It is a

chronic condition that carries a high risk of recurrent events and, therefore, a significant

contributor to health-related costs. Secondary prevention strategies are highly effective, but

multi-factorial, necessitating patient awareness and adherence to optimize health outcomes

(Clark et al., 2005; Stone et al., 2009; Heran et al., 2011; Ghisi et al., 2014a). Indeed, findings

from a recent systematic review demonstrate the importance of patient education in CAD

patients, in improving self-management behaviors (Ghisi et al., 2014a), health-related quality of

life and potentially reducing healthcare costs (Brown et al., 2011). While most CAD patients will

receive some education if hospitalized, it is often forgotten, too brief, and focused appropriately

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on acute recovery (which leaves no time to educate on chronic self-management) (Mullen et al.,

1992; Stone et al., 2009; Aldcroft et al., 2011; Berra, Miller, & Jenning, 2011).

Cardiac rehabilitation (CR) is a comprehensive secondary prevention program, delivered by a

multi-disciplinary team of healthcare providers. Patient education is considered a core

component of CR (Buckley et al., 2013). Programs are offered over several months permitting

repeated patient contact with these providers, enabling fulsome education regarding the

numerous lifestyle changes and treatments shown to reduce risk over time (Berra et al., 2011).

While the important role of patient education has been well-recognized in CR practice (e.g.,

clinical practice guidelines and quality indicators), patient knowledge in CR has only scantly

been investigated.


precise information of what cardiac patients know about their condition (Kayaniyil et al., 2009;

Brown et al., 2011). Patients’ knowledge of heart disease can strongly influence symptom

recognition, advocacy for physician screening, attitude towards the disease, and provide

motivation for individual behaviour changes. Likewise, inadequate understanding of the disease

may cause unwarranted emotional distress, inappropriate coping behaviour, non-compliance with

medical advice, and unnecessary disease progression (Alm-Roijer et al., 2006; Kayaniyil et al.,

2009; Brown et al., 2011).

In this context, the Coronary Artery Disease Education Questionnaire (CADE-Q) was previously

developed and psychometrically validated to assess patients’ knowledge about CAD in a

Portuguese speaking population of CR patients in Brazil (Ghisi et al., 2010). It was later

translated, cross-culturally adapted, and psychometrically validated to English (de Melo Ghisi et

al., 2013). It has been used to compare knowledge between a developed and a developing

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country (Ghisi et al., 2013b). Although both versions demonstrated good reliability and validity,

the CADE-Q lacked detailed assessment of all core components of cardiac rehabilitation (CR),

such as nutrition and psychosocial risk. Besides that, the development of CADE-Q started in

2004, needing update based on new researches involving CR. The availability of a more

comprehensive and updated CADE-Q is important to assess patients’ knowledge and to tailor the

educational component of CR programs (Ghisi et al., 2013a). The aim of this study was to

develop and psychometrically validate the second version of the CADE-Q (CADE-Q II).

2 Methods


This study was reviewed and approved by the Toronto Rehabilitation Institute (TRI) Research

Ethics Board. The design consisted of a series of cross-sectional, observational studies.

First, results from a study using the Information Needs in Cardiac Rehabilitation tool (INCR)

(Ghisi et al., 2014b) were used to assess what information cardiac patients want to know and to

investigate whether CR providers are cognizant of patient’s information needs (Ghisi et al.,

2013a). In addition, a literature search on broad components of patient education in CR and

guidelines was performed to identify the most important information that coronary patients need

to know about their disease and its’ management. Based on an inventory of the results from these

studies, the review, and the development of a new education curriculum at the TRI, the first

version of the questionnaire was developed. This was then reviewed by a committee of 15 CR

experts (a multidisciplinary group of CR professionals with expertise in clinical and research

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areas). They performed a content analysis, verifying if the new instrument was appropriate for

administration in a CR population. Items were refined based on the findings.

Second step was a pilot study to verify the applicability of the instrument, and to evaluate patient

understanding of the items (clarity). A convenience sample of coronary patients that finished

their CR programs (called graduates) and had previously-agreed to be contacted about research

opportunities were recruited. Results were used to further refine the CADE-Q II.

Third, a psychometric validation was performed. The refined tool was administered to a larger

sample of cardiac patients from a CR program in Toronto, Canada. Data were collected between

May and December 2013.

2.2 Participants

For the pilot test, graduate patients of the CR program were surveyed. For the psychometric-

validation, a convenience sample of cardiac patients from this institution was recruited before

their participation in CR or during their first week in the program. The inclusion criteria were the

following: confirmed CAD diagnosis or multiple cardiovascular risk factors (such as

hypertension and diabetes). The exclusion criteria were the following: younger than 18 years old,

lack of English-language proficiency, any significant visual or cognitive condition or serious

mental illness which would preclude the participant’s ability to answer the questionnaire.

2.3 Measures

To assess clarity, the pilot study patients were asked to rate each information item Likert-type

scale (Pasquali, 2003) ranging from 1 (not clear) to 10 (very clear).

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CR participants from the psychometric-validation were characterized according to sex, age,

educational level, comorbidities, cardiac risk factors and history. All characteristics were

extracted from medical chart except educational level, which was self-reported.


The sample size calculation for the psychometric analysis was based on Hair & Anderson (1998)

recommendation of a sample size of 10 subjects per item, and/or at least 100 participants. Since

the questionnaire has 31 items, a sample size of 307 is considered valid.

To investigate the psychometric properties of the new tool, the internal consistency, criterion

validity and the factor structure were assessed. The internal consistency was assessed by

Cronbach's alpha. Values higher than 0.60 were considered acceptable, reflecting the internal

correlation between items and factors (Hair & Anderson, 1998). Criterion validity was assessed

through t-tests, comparing CADE-Q II scores and participant’s level of education. Item

completion rates were also described.

The dimensional structure was analyzed through exploratory factor analysis. The main

component method for factor extraction was used, considering only those that presented

eigenvalues > 1.0. After the selection of the factors, a correlation matrix was generated, where

the associations between items and factors were observed through factor loadings greater than

0.30 on only one factor. The varimax method with Kaiser normalization was used to interpret the

matrix (Kaiser, 1960).

Finally, a descriptive analysis of the CADE-Q II was performed. A mean total score was

computed to reflect total knowledge. T-tests, one-way analysis of variance and chi-square tests

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were used as appropriate to assess differences in CADE-Q II scores based on patient’s socio-

demographic and clinical characteristics.

SPSS Version 21 (IBM 2012) was used for entering, cleaning and analyzing the data and the

level of significance was set at 0.05 for all tests. Where more than 10% of the items were

missing, the data were excluded from further analysis.

3 Results

3.1 Participants Characteristics

For the content validation, there were 10 (75%) clinicians, and 5 (25%) researchers who

reviewed the items. For the pilot test, 50 CR graduates were contacted and 30 (60%) responded,

of which 8 (27%) were female. Respondents had a mean age of 68.7±8.4, and had participated in

a mean of 15±20.8 months of CR.

For the psychometric validation study, 307 coronary patients (representing approximately 26%

of total annual CR patients) were approached to participate in this study before starting CR,

signed the consent form and completed the CADE-Q II. The characteristics of these participants

are presented in Table 6.1.

3.2 Development of the Tool

First, results from a study using the INCR tool (Ghisi et al., 2014b) showed that CR participants

rated emergency/safety, the heart, and stress/psychological factors as the areas with the greatest

information needs. So, questions related to these needs were incorporated in the CADE-Q II. A

literature review on core content for a patient education program was performed and presented

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consistency across sources, including the following topics: medical, risk factor target and

modification, nutrition, exercise, smoking cessation, and psychosocial risk. The best practice

guidelines’ review also provided suggestions for adapting an education program for special

populations attending CR programs, such as patients with diabetes and elderly and patients from

other nationalities and cultures.

Through these studies, 5 areas of knowledge – a total of 31 questions – were identified and

comprised the first version of the CADE-Q II. These areas were: medical condition, risk factors,

exercise, nutrition, and psychosocial risk. Overall, three items from the CADE-Q were retained.

As stated in the CADE-Q, each one of the questions had 4 alternatives, which generated a score.

The sum of scores was used to represent a mean total knowledge. The experts concluded that all

items were appropriate for administration in a CR population and no changes were made in the

scale at this phase.

3.3 Pilot Test

The 30 participants took a mean of 20±7 minutes to complete the CADE-Q II. Regarding the

evaluation of clarity, mean clarity of the items was 8.2 and no items had mean clarity scores

lower than 7 (ratings are shown in Table 6.2). These results indicated that the target population

understood the questionnaire.

3.4 Psychometric Validation

The CADE-Q II was administered to the CR participants from one CR program, and the mean

scores are shown in Table 6.2. Item completion rates are also shown in Table 6.2.

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The reliability of each area was assessed by Cronbach’s alpha. All areas were considered

internally consistent (α > 0.7). Table 6.2 displays Cronbach’s alpha of each area.

With regard to criterion validity, total CADE-Q II scores were compared by education level. As

shown in Table 6.2, patients with lower educational level had significantly greater information

needs than those with higher education (p<.001).

Table 6.1 – Sociodemographic and Clinical Characteristics of Patient Respondents (N=307), and

Mean and Standard Deviation of CADE-Q II Scores by these Characteristics.

MI indicates myocardial infarction, CABG coronary bypass artery graft surgery, PCI percutaneous coronary intervention, SD standard deviation. aself-reported Significant differences between samples: *p<.05, **p<.01, ***p=<.001 Note. The maximum CADE-Q II score is 91, with higher scores indicating greater knowledge.

Characteristic CADE-Q II scores Sociodemographic (mean±SD) P Age (mean±SD) 63.78±11.9 - 0.72 Sex n (%) 0.24 Male 239 (77.9%) 63.87±18.6 Female 68 (22.1%) 65.50±15.9 Educational Levela n (%) <.001*** Less than high school 20 (6.5%) 53.45±18.8 High school/graduation certificate 40 (13%) 60.35±17.8 Trades certificate 11 (3.6%) 57.09±18.2 College certificate or diploma 61 (19.9%) 66.26±18.0 University 166 (54.1%) 67.39±16.0 Missing 9 (2.9%) - Clinical, n (% yes) Hypertension 143 (46.9%) 64.17±17.22 0.17 Smoking History 103 (33.6%) 63/67±18.2 0.90 Diabetes Type I 21 (6.8%) 57.57±21.5 0.35 Diabetes Type II 50 (16.3%) 63.58±16.1 0.34 Depression 9 (2.9%) 67.78±18.3 0.75 Sleep Apnea 26 (8.5%) 67.50±14.86 0.07 Fibrilation 28 (9.1%) 67.79±17.3 0.69 Angina 10 (3.3%) 60.10±15.9 0.97 Previous MI 114 (37.1%) 64.97±18.4 0.72 Transient Ischaemic Attack 8 (2.6%) 69.50±11.4 0.30 Prior CABG 71 (23.1%) 66.51±15.8 0.13 Prior PCI 118 (38.4%) 64.09±20.1 0.04* Heart Failure 18 (5.9%) 67.39±8.6 0.01* Cardiomyopathy 14 (4.6%) 71.79±9.2 0.04* Valvular Heart Disease 39 (12.5%) 58.79±18.4 0.98 Peripheral Vascular Disease 11 (3.6%) 65.55±13.4 0.25 Chronic Obstructive Coronary Disease 16 (5.2%) 63.75±16.8 0.51 Cerebral Vascular Accident 21 (6.8%) 57.52±20.4 0.72

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Table 6.2 – Mean and Standard Deviation of Clarity Rating by Pilot Study Patients (N=30), CADE-Q II Score (N=307), CADE-Q II

Item Completion Rates, Cronbach’s alpha per area, and Mean Score per area.

Clarity Rating by Pilot Study Patientsa

CADE-Q II Scoreb

CADE-QII Item Completion Rate

Cronbach’s alpha per area

CADE-Q II Mean Score per Areac

Areas Question Mean±SD Mean±SD % α Mean±SD Medical condition 1. Coronary Artery Disease is: 8.6±2.4 2.92±0.7 96.7% 0.71 15.12±4.9

2. Angina (chest pain of discomfort) occurs: 8.9±2.1 2.12±0.6 97.7%

3. In a person with coronary artery disease, which of the following is a usual description of angina?

8.5±2.2 2.31±0.7 97.4%

4. A heart attack occurs: 8.8±1.6 2.78±0.8 98%

5. The best resources available to help someone understand his/her medications are:

8.5±2.2 1.72±1.1 99%

6. Medications such as aspirin (ASA) and clopidogrel (PlavixTM) are important because:

8.6±1.7 2.65±0.6 98%

7. The “statin” medications, such as atorvastatin (LipitorTM), rosuvastatin (CrestorTM), or simvastatin (ZocorTM), have a beneficial effect in the body by:

8.0±3.6 2.13±1.1 96.4%

Risk factors 1. The risk factors for heart disease that can be changed are: 8.7±3.2 2.55±0.9 96.7% 0.65 9.41±3.4

2. The actions that can be taken to control cholesterol levels include: 8.9±2.6 2.26±0.6 97.1%

3. The actions that can be taken to control blood pressure include: 8.7±2.2 2.91±0.5 98%

4. The first step towards controlling a risk factor (such as blood pressure or cholesterol) is:

7.4±4.2 2.51±1.0 97.7%

5. The actions to prevent developing diabetes include: 7.4±3.0 1.94±1.2 96.1%

Exercise 1. What are the important parts of an exercise prescription? 8.3±3.2 1.83±1.1 98.4% 0.77 15.59±5.3

2. For a person living with heart disease, it is important to do a cardiovascular warm-up before exercising because:

7.9±2.5 2.17±0.6 97.7%

3. The pulse can be found: 8.1±2.7 2.70±0.8 97.4%

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4. Three things that one can do to exercise safely outdoors in the winter are:

7.8±2.2 2.21±1.0 98%

5. The benefits of doing resistance training (lift weights or elastic bands) include:

7.9±2.1 2.72±0.9 97.4%

6. If a person gets chest discomfort during a walking exercise session, he or she should:

8.2±2.1 2.87±0.5 98%

7. How does a person know if he/she is exercising at the right level? 8.6±1.9 1.64±1.1 98%

Nutrition 1. What is the best source of omega 3 fats in food? 8.6±4.2 3.03±0.7 98.4% 0.66 13.96±4.8

2. Trans fat are: 7.8±2.5 2.57±1.0 97.1%

3. What is one good way to add more fibre to your diet: 7.7±2.2 2.66±0.9 96.4%

4. Which of the following foods has the most salt: 8.2±3.8 2.12±0.6 99%

5. What combination of foods can help lower blood pressure? 8.3±2.2 2.93±0.5 98%

6. When reading food labels, what should one look at first? 8.3±3.2 1.76±1.1 98.4%

7. How many servings of fruits and vegetables should adults consume?

7.8±1.1 2.08±1.1 98%

Psychosocial risk 1. Which of the below are effective stress management techniques? 8.4±2.5 2.82±0.7 97.7% 0.67 10.15±3.7

2. What stresses have been related to increased risk for heart attacks? 8.1±0.28 1.93±1.2 97.4%

3. Which of the following describes your best option for reducing your risk from depression:

7.8±1.6 2.13±0.6 98.7%

4. It is important to recognize “sleep apnea” because: 7.9±0.29 2.61±0.9 98.4%

5. “Chronic stress” is defined as: 7.3±0.69 2.15±1.0 95.8%

Total 8.2±1.90 64.23±18.1 97.7% 0.91 - SD=standard deviation. aClarity rating out of 10 were 1 = not clear and 10 = very clear. bCADE-Q scores range from 0 to 3 in each question. The maximum total CADE-Q II score is 91. cThe maximum score for medical condition, exercise and nutrition’ areas is 21 and for risk factors and psychosocial risk.

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With regard to criterion validity, total CADE-Q II scores were compared by education level. As

shown in Table 6.2, patients with lower educational level had significantly greater information

needs than those with higher education (p<.001).

The dimensional structure was evaluated through exploratory factor analysis. The results from

the Kaiser-Meyer-Olkin index (KMO=0.859) and Bartlett’s Sphericity tests (X²=2073.98;

p<0.001) indicated that the data were suitable for factor analysis. Four factors were extracted,

representing 62.2% of the total variance. Table 6.3 shows the factor loadings for each item.

Factor 1 reflected medical condition items, factor 2 risk factors and exercise, factor 3 nutrition,

and factor 4 psychosocial risk.

3.5 Knowledge Assessment

The mean total score was 64.23±18.1. Forty-seven percent of patients scored higher than 68,

which indicates a knowledge of 75% or higher. Analyses (t-tests, one-way analysis of variance

and chi-square tests as appropriate) were performed to evaluate differences in mean CADE-Q II

scores by patients’ socio-demographic and clinical characteristics. As shown in Table 6.1, scores

were only related to educational level (p<.001), heart failure (p=0.01), cardiomyopathy (p=0.04)

and history of PTCA (p=0.04). In this context, patients with higher educational level, history of

heart failure, cardiomyopathy and PTCA presented significantly higher knowledge compared

with their counterparts.

Means and standard deviations of each item are reported in details in Table 6.2. The questions

with higher scores were the following: “What combination of foods can help lower blood

pressure?” (2.93±0.5), “Coronary Artery Disease is:” (2.92±0.7), “The actions that can be taken

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to control blood pressure include:” (2.91±0.5), and “If a person gets chest discomfort during a

walking exercise session, he or she should:” (2.87±0.5).

Regarding the 5 areas of the questionnaire, exercise and medical condition are the areas with the

greatest knowledge; and risk factors’ area is the one with the lowest knowledge. Mean and

standard deviation of each area are also reported in Table 6.1.

Table 6.3 – Factor Structure of the CADE-Q II, sorted by loading

Areas Items Factor 1 Medical

Condition

Factor 2 Risk factors/ Exercise

Factor 3 Nutrition

Factor 4 Psychosocial risk

Medical Q1 .454 Condition Q2 .425 Q3 .499 Q4 .573 Q5 .399 Q6 .506 Q7 .559 Risk Factors Q1 .534 Q2 .638 Q3 .637 Q4 .499 Q5 .549 Exercise Q1 .626 Q2 .582 Q3 .442 Q4 .566 Q5 .642 Q6 .541 Q7 .595 Nutrition Q1 .570 Q2 .518 Q3 .447 Q4 .433 Q5 .537 Q6 .330 Q7 .307 Psychosocial Q1 .584 Risk Q2 .491 Q3 .412 Q4 .610 Q5 .538

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4.1 Discussion

This study sought to develop and validate the CADE-Q II. Since patient education is a core

component of CR programs, this tool can be useful to help healthcare providers to understand

what information cardiac patients know about their condition, as well as to promote educational

strategies to these patients. The psychometric validation of the CADE-Q II followed strict rules,

since the development of the instrument required a greater effort including a needs assessment

study (Ghisi et al., 2013a), and a literature search on broad components of patient education in

CR and guidelines.

When a new version of a questionnaire is developed it should not only be updated, and better on

theoretical basis, but must also be shown to be at least as good as the original instrument in terms

of validity and reliability. In this context, results of the CADE-Q II were consistent with those

presented in the original instrument (Ghisi et al., 2010) and the English adapted version of the

CADE-Q (de Melo Ghisi et al., 2013), particularly in relation to criterion validity (correlation to

educational level) and all areas being considered internally consisted (α > 0.70). The overall

mean, as well as the means of the areas were high, reinforcing the idea that CR patients are

knowledgeable of the information that is important for them. It may also suggest that individuals

with low socioeconomic levels are not participating in these programs and strategies to eliminate

barriers to access CR should be implemented (Daly et al., 2002; Grace et al., 2008).

There are some limitations to this study, which should be stated. There are some elements of the

scale, which require further assessment. First, test-retest reliability was not evaluated, and this

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should form the basis for future study. A sample size of at least 50 patients should be considered

to promote adequate assessment of this psychometric property (Altman, 1991). Second, future

research is needed to assess whether the scale is sensitive to change, such as following

participation in CR, or to test implementation of new education materials. Finally, whether the

CADE-Q II is a valuable and valid tool to identify knowledge differences in non-CR patients

should be explored.

4.2 Conclusion

In this study I have proved the CADE-Q II has strong psychometric properties, providing

preliminary evidence of its reliability and validity to assess patients’ knowledge about CAD in a

more comprehensive format. It is hoped this tool can support CR evaluation of their program’s

education component, and promote greater provision of information consistent with patient’s

educational needs.


Good patient education involves assessing needs and knowledge, setting goals and objectives,

implementing a teaching plan, and evaluating outcomes (Cranton, 1989). Before implementing

patient education programs it is prudent to evaluate what patients know about their condition.

The assessment of CR patients’ knowledge is, therefore, relevant. The CADE-Q II can be

especially useful in the evaluation of comprehensive educational interventions, and can provide

valuable information to clinicians, and researchers regarding the content of educational

programming in CR.

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Chapter 7 PAPER FIVE: Behavior determinants among cardiac rehabilitation patients receiving educational interventions: an application of the

health action process approach

This chapter presents the results from paper five, an observational prospective study assessing

knowledge, behavior and theory-driven constructs pre- and post-CR in two groups of patients

receiving different educational interventions. One of these interventions is the new educational

curriculum, which development was described in chapter 2 and its content was strategically

sequenced based on the needs assessment study described in chapters 5. Knowledge was

assessed in this study using the CADE-Q 2 questionnaire, which development is also described

in this thesis (chapter 6).

1 Introduction

For people with chronic conditions, behavior change can be an effective strategy to prevent

further morbidity and mortality (Schwarzer et al., 2011). When people are enrolled in secondary

prevention programs (e.g. cardiac rehabilitation), there is a good chance that these patients can

learn how to improve their health behaviors and maintain them after discharge. For persons with

Coronary Artery Disease (CAD), secondary prevention strategies are highly effective to promote

behavior change, but multi-factorial, necessitating patient awareness and adherence to optimize

health outcomes (Clark et al., 2005; Stone et al., 2009; Heran et al., 2011; Ghisi et al., 2014a).

Therefore, patient education is an essential part of the rehabilitation of CAD patients targeting

self-management behavior to reduce risk factors and subsequent cardiac events (Dusseldorp et

al., 1999; Balady et al., 2007; Stone et al., 2009).

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Cardiac rehabilitation (CR) is a comprehensive risk reduction program, of which patient

education is considered a core component (Buckley et al., 2013). Thus, American and Canadian

Cardiovascular Societies include education as a quality indicator of CR (Thomas et al., 2007;

Grace et al., 2014). Findings from meta-analyses provide evidence of the effectiveness of patient

education in CAD patients, in improving self-management behaviors (Mullen et al., 1992;

Dusseldorp et al., 1999; Aldcroft et al., 2011), health-related quality of life, and potentially

reducing healthcare costs (Brown et al., 2011) and recurrence of acute events (Dusseldorp et al.,

1999). Furthermore, a recent systematic review demonstrates the benefits of educational

intervention in CAD, through increase in patients’ knowledge and behavior change (physical

activity, dietary habits, and smoking cessation) (Ghisi et al., 2014a). However, patient

knowledge in CR has only scantly been investigated, and the impact of the education on behavior

change has not been often considered.

To explain, predict, and effectively improve behavior change of individuals and to optimize

treatment, theories of health behavior change are needed (Noar, Benac, & Harris, 2007; Dunn &

Elliot, 2008). In this context, the Health Action Process Approach (HAPA) has received attention

from researchers, because it is considered as a useful integration of the basic concepts of current

social cognitive health behavior models and as a valuable theoretical framework for identifying

postintentional factors leading to behavior adoption (Schwarzer, 1992; Lippke, Ziegelmann, &

Schwarzer, 2004; Renner & Schwarzer, 2005; Schwarzer et al., 2011).

According to this model, changing health-related behaviors requires two separate processes that

involve motivation and volition, respectively. First, an intention to change is developed, in part

on the basis of self-beliefs. Second, the change must be planned, initiated, and maintained, and

relapses must be managed. In addition, self-regulation plays a critical role in these processes

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(Schwarzer, 1992). A recent overview covering seven empirical studies (Schwarzer, 2008), has

demonstrated the universal applicability of the HAPA for a number of health behaviors and for

diverse samples from various cultures, including physical exercise adherence after a CR program

(Scholz, Sniehotta, & Schwarzer, 2005).

For CR patients, no standardized and evaluated educational program has so far been available for

routine use. Moreover, many CR education programs still lack certain quality requirements, such

as the use of manuals, patient-oriented didactics, small-group format and evaluation of

effectiveness (Ghisi et al., 2014a). To date, theory-based techniques to foster health behavior are

only rarely employed and, although the HAPA model has proven to be a valid framework for the

prediction of behavior change, existing studies within this framework have focused on

heterogeneous sample and no studies have specifically considered its predictive value among CR

patients in educational programs. In addition, few studies have compared different educational

approaches applied within a multidisciplinary rehabilitation program in an outpatient CR setting.

Therefore, the present study draws upon the HAPA model to investigate: (1) changes in

knowledge and related theoretical constructs (i.e., self-efficacy, outcomes expectancies, risk

awareness, intention, and planning) among CR patients following exposure to a traditional or

theoretically-informed educational curriculum; and, (2) the theoretical correlates of exercise

behavior change among CR patients receiving educational interventions. The chosen behavior

was exercise, which is associated with lower mortality, lower recurrence rates and reduced

symptoms in cardiac patients (Blair et al., 1995; Thompson et al., 2003; Taylor et al., 2004;

Nocon et al., 2008; Lawler, Filion, & Eisenberg, 2011).

To specifically analyze the second objective, theory-implied constructs of the HAPA model were

investigated. In the pre-intentional motivational phase, it was hypothesized that risk awareness,

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outcome expectancies and task self-efficacy are determinants of intention formation. According

to Sniehotta, Scholz, & Schwarzer (2006) the starting point for the motivational phase is some

level of risk awareness, for example feeling vulnerable to a (recurring) cardiac event. Positive

and negative outcome expectancies are deliberated: if the pros outweigh the cons of a behavior

change, one prerequisite for an intention is accomplished. Task self-efficacy – the perceived

capability to implement successfully alternative behaviors – is recognized as the major

determinant of intention formation (Renner & Schwarzer, 2003; Ziegelmann & Lippke, 2007).

Finally, it was also hypothesized that knowledge would be positively correlated with intention,

which is reported in previous studies with cardiac patients (Meischke et al., 2002; Clark et al.,

2005; Petter et al., 2009).

A second set of hypothesis concerned the post-intentional volition phase. Social-cognitive

models of behavior propose that intention is the most proximal and powerful predictor of

subsequent behavior (Ajzen, 1991; Conner & Armitage, 1998; Sheeran, 2002). However, good

intention does not necessarily guarantee corresponding actions and is seldom successful alone

(Sutton, 1994). In the current study it was hypothesized that intention would be correlated with

planning, which may lead to behavior change. Planning was divided into two sub-constructs:

action planning and coping planning (Sniehotta, Scholz, & Schwarzer, 2006). It was also

hypothesized that task and scheduling self-efficacy could influence planning, and maintenance

self-efficacy could influence directly behavior. Figure 7.1 presents the proposed model under

investigation, illustrating the relationships described above.

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2 Methods

2.1 New Educational Curriculum Development

The new education curriculum was developed by a multi-disciplinary committee of 16 experts

from the CR program. The aim of this curriculum was to enable patients to take charge of their

medical condition and respond appropriately to changes in their health, and in developing

strategies to improve their risk factors.

The development of the curriculum consisted of the following phases: problem definition,

theoretical foundation, needs analysis (including a literature search and environmental scan),

program goals/educational objectives, sequencing instruction, instructional strategy/design and

methods/materials development, and evaluation of instruction/materials and learning for health

outcomes (which is presented in this study). Constructive theory (Cole & Griffin, 1987) and

adult learning principles (Knowles, 1980;1984) were the foundations for curriculum

development and delivery. The HAPA model (Schwarzer, 1992) was embedded in the

curriculum to promote behavior change.

The curriculum includes: 24 educational weekly group education sessions strategically

sequenced in accordance with the CR program learning outcomes, a comprehensive education

workbook, and individual care plans. Each topic contains educational content, learning activities,

learning assessments, behavioral-based action planning, and assessment of patients’ motivation

and confidence to incorporate change into their lifestyle. It was provided by an interdisciplinary

team of on-site exercise leaders, nurses, nutritionist, psychologist, psychiatrist and physicians.

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This study was quasi-experimental in design, with assessments undertaken pre and post-CR.

Random assignment of study participants was not possible, because patients were allocated to

educational curriculum based on their choice of class (i.e. the class they choose based on their

preferences). Ethics approval was obtained from the review board at the hospital where the CR

program was located. Data was collected between April 2013 and May 2014.

Patients were informed about the study during their first cardiopulmonary exercise stress test by

a technician. They were also provided with information to take home and consider if desired.

Consenting patients were then allocated to an education curriculum based on their choice of class

(i.e. the class they choose based on their preferences).

Participants were invited to complete a self-administered confidential survey in paper format

(pre-CR survey). The survey included sociodemographic items, and psychometrically-validated

scales to assess exercise and related theoretical constructs (self-efficacy, outcomes expectancies,

risk awareness, intention, and planning), and a knowledge scale, namely the Coronary Artery

Disease Education Questionnaire II (CADE-Q II) (Ghisi et al., 2014c). Clinical data were

extracted from electronic patient records.

CR participants are offered weekly supervised exercise classes for 24 weeks, and provided a

home exercise prescription for the other days of the week. The traditional educational program

was provided by another interdisciplinary team of on-site health providers. Topics covered

include exercise safety, nutrition, risk management, medications, stress management, and

lifestyle management, presented in a less comprehensive way when compared to the new

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curriculum. Education was delivered in large and small group sessions, lectures, a workbook,

online videos, and in pamphlet form.

Between the 22nd and 24th weeks of CR, patients were approached during their CR class to

complete the post-CR survey. It again assessed exercise, HAPA constructs, and knowledge as

per the initial survey. Electronic patient records were reviewed to ascertain degree of CR

participation and completion.

2.3 Participants

This study included CR patients (with heart disease or multiple cardiovascular risk factors)

recruited from the largest CR program in Toronto, Canada. The exclusion criteria were: lack of

English-language proficiency, and any visual, cognitive or psychiatric condition that would

preclude the participant from completing the surveys.

Sample size was based on the Ding, Velicer & Harlow (1995)’s rule of a minimum of 100

participants to run structural equation modeling. Anticipating a retention rate of 70%, a

minimum of 145 participants per group were required to achieve a final sample size of 100 per

group. Patients were approached consecutively until the required sample size was achieved.

2.4 Measures

Clinical characteristics extracted from medical records included: CR referral indication,

comorbid conditions, and cardiac risk factors. Patients self-reported their sociodemographic

characteristics, which included highest educational attainment.

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Health literacy – which is the ability to obtain, read, understand and use healthcare information

to make appropriate health decisions and follow instructions for treatment – was measured pre-

CR using two questionnaires: the Medical Term Recognition Test (METER; Rawson et al, 2009)

and the Newest Vital Sign (NVS; Weiss et al, 2005). The METER consists of 40 medical terms

and 30 non-words. Respondents are instructed to mark which words they recognize as actual

words. Scores are based on the number of “true hits”, or actual medical terms the respondent

correctly identified, and can range from 0-40. Score ranges from 0-20, 21-34, and 35-40 indicate

low, marginal and functional health literacy, respectively. The METER was shown to have good

reliability (Cronbach’s alpha = 0.93), and strong construct and predictive validity (Rawson et al,

2009). The NVS consists of six questions regarding the information found on an accompanying

nutrition label. Each correct response is worth one point. Scores greater than four are considered

to be evidence of adequate health literacy. In initial validation studies, the NVS was shown to be

internally consistent (Cronbach’s alpha = 0.76).

Knowledge was assessed at pre- and post-CR using the CADE-Q II (development described on

chapter 4), which assesses patients’ knowledge about CAD in 5 domains: (1) medical condition,

(2) risk factors, (3) exercise, (4) nutrition, and (5) psychosocial risk. Each of the 31 items has 4

alternative response options, of which 1 is most correct (scored 3), 1 is somewhat accurate

(scored 1), and 2 are incorrect (scored 0). These scores are summed, with a maximum score of

93.

The target behavior was exercise, measured at pre- and post-CR. Exercise behavior was self-

reported by 2 questions: “How often do you usually walk in a week?” (never, less than 3-4 times,

more than 3-4), and “How much time do you spend exercising per week? (in hours)”. Guidelines

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recommend cardiac patients engage in exercise most days of the week, and accumulate 150

minutes (or 2.5 hours) (Stone et al., 2009).

2.4.1. HAPA constructs

All constructs from the HAPA model were assessed pre- and post-CR using the

psychometrically-validated scales outlined below.

Risk awareness. Risk awareness refers to the quality and quantity of an individual’s perceived

susceptibility to a health threat; it is usually assessed along the dimensions of vulnerability and

severity (Schwarzer, 1992). Accordingly, risk awareness was measured as follows: 4 items

assessing vulnerability with the stem of “If I keep my lifestyle the way it was prior to my heart

problem”; and, 4 items assessing severity with the stem of “How severe (serious) are the

following health-related problems if I don’t exercise regularly?”. For the vulnerability items,

response ranges from 1= “very unlikely” to 7= “very likely”. For the severity items, response

ranges from 1= “not severe at all” to 7= “very severe”.

Outcome expectancies. Outcome expectancies are subjective beliefs about contingencies of an

individual’s behavioral consequences. These outcomes were evaluated with regard to their

favorableness for the individual, as positive or negative. Outcomes expectancies were considered

in 3 domains (social, psychological, and physical), assessed by a total of 15 items. All items had

the stem “If I exercise regularly…”, followed by positive consequences such as “I will simply

feel better afterwards”, or “my cholesterol level will improve”. Response options ranged from 1=

“very unlikely” to 7= “very likely” (Renner & Schwarzer, 2005).

Intentions. Intention is the person’s motivationtowards a goal or target behavior in terms if

direction and intensity. Intentions related to physical exercise were assessed with 2 questions

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starting with “I will try” and “I intend”, which was followed by “to do my exercise prescription

over the next 6 months”. Response options ranged from 1= “definitely false” to 7= “definitely

true” (Renner & Schwarzer, 2005).

Self-efficacy. Three types of self-efficacy were measured: task, scheduling, and maintenance.

Task self-efficacy is the perceived capability of a person to implement a certain behavior and

facilitates goal-setting. The stem of a task self-efficacy item contains a statement about the target

behavior or the behavior change. In this study, task self-efficacy was measured by asking

patients “Assuming you were very motivated, how confident are you that you could physically

do the following amounts of exercise in one session without stopping over the next 6 months”?

The alternatives varied from 10 to 60 minutes and response options ranged from 1= “not

confident at all” to 7= “very confident”. Scheduling self-efficacy relates to managing one’s

schedule to accommodate the behavior. The scale that measured scheduling self-efficacy asked

patients “Assuming that you are very motivated, in the next 6 months, how confident are you that

you can fit your exercise prescription into your weekly schedule”? The alternatives varied from

once per week to more than 5 times per week and response options ranged from 1= “not

confident at all” to 7= “very confident”. Finally, maintenance self-efficacy describes optimistic

beliefs about one’s capability to deal with barriers that arise while continuing exercise.

Maintenance self-efficacy was measured by 13 items identifying barriers to adherence to

exercise with the stem “Assuming you were very motivated, how confident are you that you will

do your exercise prescription over the next 6 weeks”. Response options also ranged from 1= “not

confident at all” to 7= “very confident” (Maddux, 1995; Bandura, 1997; Rodgers & Sullivan,

2001; Rodgers et al, 2002; Blanchard et al, 2003; Schwarzer, 2008).

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Planning. Action planning and coping planning were assessed. Action planning refers to

concrete plans about when, where, and how to implement the intended behavior and has be

proven to be a useful strategy in health behavior change (Scholz, Sniehotta and Schwarzer,

2005). For action planning, the item stem “I already have concrete plans…” was followed by the

items (a) “where to exercise”, (b)”when to exercise”, (c)”how to exercise”, (d)”how often to

exercise”, (e)”with whom to exercise”, and (f) what types of activities to do. Coping planning

includes the anticipation of barriers and the design of alternative actions that help to attain one’s

goal despite impediments (Renner & Schwarzer, 2005). For coping planning, the item stem “I

already have concrete plans regarding…” was followed by the items (a)”what to do if someone

interferes with my exercise schedule”, (b)”what to do if I miss an exercise session”, (c)”what to

do in difficult situations in order to stick to my exercise schedule”, and (d)”if something gets in

the way of my plans to exercise”. Both scales had response options that ranged from 1=

“strongly disagree” to 7= “strongly agree”.


SPSS Version 21.0 (IBM Corp, 2012) was used for entering, cleaning and analyzing the data,

and the level of significance was set at 0.05 for all tests. Firstly, descriptive statistics were used

to describe participants’ sociodemographic and clinical characteristics by educational curriculum

type, to ascertain if there were any differences which may impact the subsequent findings.

Frequency tables were used for categorical variables and descriptives (mean, standard deviation,

minimum and maximum) for continuous variables.

To test the first objective, the mean CADE-Q II scores were examined by item, subscale and

overall. Next, paired sample t-tests and ANOVA were computed to investigate changes in all

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overall knowledge before and after exposure to each educational curriculum. Where significant,

changes in subscales and individual items were tested. Pre- and post-CR scores for each variable

were considered as a within-factor and groups as a between-factor.

Finally, to test the second objective, the exercise variable was examined. Outliers were identified

and excluded from the descriptive and path analysis. The program IBM SPSS AMOS 20

(Arbuckle, 2011) was used to conduct the path (regression) analysis, to establish the best-fitting

model for the relationship among the HAPA variables under study. A maximum likelihood

estimation procedure was used to generate the parameter estimates (e.g. regression weights).

Model fit was evaluated by consulting various indices: chi-square (χ²); root mean square error of

approximation (RMSEA); comparative fit index (CFI); and goodness-of-fit index (GFI).

According to Hu & Bentley (1999) CFI and TLI values above .90 and RMSEA values less than

.08 indicate an adequate fit. Where the fit indices indicated that the hypothesized model did not

provide an adequate fit to the data, the modification indices (MI) were consulted to identify any

areas of misfit in the model. The value of a modification index represents the expected drop in

chi-square value if a fixed parameter were to be freely estimated. The parameter with the largest

MI value was freed only if it made substantive sense; if it was not meaningful then the parameter

with the next largest MI value was considered. The regression coefficients were examined only

after a good-fitting model was identified.

The path analysis was used as a full structural equation model (SEM) (measurement + structural

model). The use of a SEM including a measurement model would have required a substantial

increase in the number of parameters to be estimated, and hence to an insufficient ratio of

participants : parameters.

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Figure 7.1 – Model of the relationship between HAPA constructs, knowledge and exercise

behavior. SE indicates self-efficacy, OE outcome expectancies, e- errors.

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3 Results

3.1 Respondents Characteristics

A flow diagram of study participation is presented in Figure 7.2. Overall, significantly more

males (77.8%) agreed to participate in this study than females (22.2%; p<.001), as well as

subjects with a university degree compared to other educational status (p<.001).

Three hundred and six patients consented to participate in this study, of which 146 (47.7 %) were

exposed to the new curriculum. Sociodemographic and clinical characteristics of the sample

overall and by curriculum are shown in Table 7.1. There were no significant differences in

participant characteristics by curriculum. METER and NVS mean scores showed that both

groups presented functional and adequate health literacy, respectively.

Overall, 173 (56.5%) participants completed the post-CR survey. Participants who completed the

post-CR survey were significantly older than the ones who completed only the pre-CR survey

(p=0.002). Reasons for not completing the post-CR survey are also presented in Figure 7.2.

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Figure 7.2 – Flow diagram of study participants

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Table 7.1 – Sociodemographic and Clinical Characteristics of Participants, and by Educational Curriculum.

Characteristic Overall (N=306)

Traditional (n=160; 52.3%)

New (n=146; 47.7%)

p*

Sociodemographic Age, years (mean±SD) 63.92±11.83 63.58±11.66 64.30±12.04 0.23

Sex, n (%) 0.51

Female 68 (22.2%) 37 (23.1%) 31 (21.2%)

Male 238 (77.8%) 123 (76.9%) 115 (78.8%)

Highest Educational Attainment, n (%)§ 0.31

Less than high school 20 (6.5%) 14 (8.8%) 6 (4.1%)

High School 40 (13.1%) 24 (15.0%) 16 (11.0%)

Trades Certificate 11 (3.6%) 5 (3.1%) 6 (4.1%)

College 62 (20.3%) 32 (20.0%) 30 (20.5%)

University 166 (54.2%) 80 (50.0%) 86 (58.9%)

Health Literacy, (mean±SD)†

METER 35.19±5.83 35.64±5.31 34.69±6.35 0.42

NVS 4.50±1.72 4.29±1.81 4.74±1.58 0.26

Clinical,!n (% yes)‡

Referral Indication

Heart Failure 18 (5.9%) 9 (5.6%) 9 (6.2%) 0.84

Cardiomyopathy 14 (4.6%) 8 (5.0%) 6 (4.1%) 0.71

Stroke/Transient Ischemic Attack 29 (9.5%) 16 (10.0%) 13 (8.9%) 0.38

Valvular Heart Disease 39 (12.7%) 21 (13.1%) 18 (12.3%) 0.84

Peripheral Vascular Disease 11 (3.6%) 5 (3.1%) 6 (4.1%) 0.65

Chronic Obstructive Pulmonary Disease 16 (5.2%) 8 (5.0%) 8 (5.5%) 0.85

Angina 10 (3.3%) 3 (1.9%) 7 (4.8%) 0.16

Arrhythmia 28 (9.2%) 14 (8.8%) 14 (9.6%) 0.80

Myocardial Infarction 113 (36.9%) 60 (37.5%) 53 (36.3%) 0.83

Coronary Artery Bypass Graft Surgery 71 (23.2%) 43 (26.9%) 28 (19.2%) 0.11

Percutaneous Coronary Intervention 117 (38.2%) 56 (35.0%) 61 (41.8%) 0.23

Risk factors

Hypertension 144 (47.1%) 72 (45.0%) 72 (49.3%) 0.45

Type I Diabetes 21 (6.9%) 13 (8.1%) 8 (5.5%) 0.68

Type II Diabetes 51 (16.7%) 24 (15%) 27 (18.5%) 0.42

Depression 9 (2.9%) 5 (3.1%) 4 (2.7%) 0.85

Sleep Apnea 26 (8.5%) 15 (9.4%) 11 (7.5%) 0.56

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Smoking history 104 (34.0%) 54 (33.8%) 50 (34.2%) 0.93

Smoking, years (mean±SD) 7.95±13.92 7.90±14.2 8.01±13.6 0.31

SD indicates standard deviation, METER Medical Term Recognition Test (maximum = 40), NVS Newest Vital Sign (maximum = 5). *Chi-square or t-tests as appropriate for differences between groups (p<.05 for significant differences between traditional and new educational curriculum, if any). §Self-reported. †Assessed via pre-survey (pre-CR). ‡Extracted from electronic patients records.

3.2 Knowledge

Knowledge pre-CR did not differ significantly by curriculum. There was a significant increase

(p<.001) in overall knowledge from pre- to post-CR in the overall sample, as well as in

participants exposed to both curricula. As shown in Table 7.2, the increase in knowledge

appeared on all subscales overall and by curriculum. There were no significant differences by

curricula in any type of knowledge (overall, domains or items).

In regards to individual items, knowledge scores improved on 22 items in the overall sample (6

items from medical condition, 6 from exercise, 4 from risk factors, 3 from nutrition, and 3 from

the psychosocial risk subscale). Participants exposed to the traditional curriculum improved their

knowledge significantly on 16 items, particularly related to exercise (6 items), risk factors and

medical condition (3 items each). Finally, participants exposed to the new curriculum improved

their knowledge significantly on 17 items, particularly related to risk factors, nutrition, and

exercise (4 items each).

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3.3 HAPA constructs

Table 7.3 displays mean HAPA theoretical constructs scores at pre- and post-CR, overall and by

curriculum. Results show significant increases in risk awareness, psychological and physical

outcomes expectancies, task self-efficacy, and action and coping planning, overall and

curriculum from pre to post-CR. Patients exposed to the traditional curriculum also significantly

improved scheduling self-efficacy and patients exposed to the new curriculum improved social

outcome expectancies. Significant differences among groups at post-CR were observed in social

outcome expectancies, with patients exposed to the new curriculum showing significant higher

scores.

3.4 Exercise behavior

As described elsewhere, the chosen behaviour for this study was physical exercise, which was

self-reported by 2 questions at pre- and post-CR. Results are presented in Table 7.3. Participants

reported a significant increase in hours of physical exercise per week from pre- to post-CR,

overall and by groups. In addition, the frequency of walking per week increased significantly

from pre- to post-CR, again overall and by groups.

3.5 Knowledge and theoretical determinants of exercise behavior

3.5.1 Preliminary Analysis

The means and standard deviations of the theoretical variables in the study are presented in Table

7.3. Overall, Pearson correlations confirmed the expected pattern of associations as proposed in

Figure 1. Specifically, risk awareness (r=0.20, p<0.05), psychological outcome expectancies

(r=0.21; p<0.05), task self-efficacy (r=0.27, p<0.01), and total knowledge (r=0.28, p<0.01) were

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positively related to intention. Task self-efficacy (r=0.46, p<0.01), scheduling self-efficacy

(r=0.43, p<0.01), intention (r=0.48, p<0.01) and total knowledge (r=0.26, p<0.01) were

positively related to action planning. Task self-efficacy (r=0.33, p<0.01), scheduling self-

efficacy (r=0.44, p<0.01), and intention (r=0.43, p<0.01) were positively related to coping

planning. Scheduling self-efficacy (r=0.27, p<0.01), maintenance self-efficacy (r=0.20, p<0.01),

and action planning (r=0.20, p<0.05) were positively correlated to behavior. A correlation matrix

is presented in Table 7.4.

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Table 7.2 – Total, subscale and item knowledge scores at pre- and post-CR in overall sample, and by curriculum

Knowledge scores (mean±SD)

Overall (N=306) Traditional (n=160) New (n=146)

Maximum possible

score

Pre-CR Post-CR p* Pre-CR Post-CR p* Pre-CR Post-CR p* p§

Total Knowledge 93 64.72±17.35 75.68±12.27 <.001 65.14±17.65 75.29±13.27 <.001 64.25±17.08 76.12±11.11 <.001 0.90

Subscales

Medical Condition 21 15.24±4.77 17.12±3.98 <.001 15.31±4.89 17.09±4.09 <.001 15.15±4.65 17.15±3.88 0.001 0.77

Risk Factors 15 9.49±3.32 11.26±2.66 <.001 9.43±3.43 11.08±2.87 <.001 9.56±3.20 11.47±2.41 <.001 0.73

Exercise 21 15.70±5.18 18.57±3.05 <.001 15.79±5.21 18.63±2.93 <.001 15.60±5.14 18.51±3.20 <.001 0.75

Nutrition 21 14.07±4.66 16.84±3.39 <.001 14.27±4.66 16.69±3.42 <.001 13.84±4.65 17.01±3.37 <.001 0.43

Psychosocial Risk 15 10.23±3.64 11.86±2.56 <.001 10.34±3.70 11.80±2.69 <.001 10.10±3.60 11.93±2.42 0.001 0.25

Items

Medical Condition

1. Coronary Artery Disease is: 3 2.17±1.27 2.49±1.07 0.004 2.13±1.28 2.54±1.06 0.01 2.22±1.27 2.43±1.10 0.14 0.52

2. Angina (chest pain or discomfort) occurs:

3 2.58±1.00 2.75±0.77 0.02 2.62±0.95 2.87±0.16 0.007 2.53±1.05 2.62±0.94 0.31 0.46

3. In a person with coronary artery disease, which of the following is a usual description of angina?

3 2.42±1.09 2.53±0.95 0.53 2.49±1.02 2.46±1.01 0.33 2.33±1.16 2.62±0.94 0.06 0.19

4. A heart attack occurs: 3 2.36±1.10 2.66±0.82 0.001 2.38±1.10 2.58±0.90 0.07 2.35±1.11 2.75±0.72 0.007 0.84

5. The best resources available to help someone understand his/her medications are:

3 2.29±1.06 2.45±0.93 0.02 2.32±1.09 2.42±0.97 0.15 2.27±1.04 2.49±0.90 0.09 0.67

6. Medications such as aspirin (ASA) and clopidogrel (PlavixTM) are important because:

3 1.90±1.13 2.18±1.06 0.01 1.79±1.15 2.07±1.05 0.06 2.02±1.09 2.31±1.07 0.09 0.08

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7. The “statin” medications, such as atorvastatin (LipitorTM), rosuvastatin (CrestorTM), or simvastatin (ZocorTM), have a beneficial effect in the body by:

3 1.51±1.27 2.08±1.19 <.001 1.59±1.25 2.15±1.16 <.001† 1.43±1.29 1.99±1.21 0.02 0.28

Risk Factors

1. The risk factors for heart disease that can be changed are:

3 2.30±1.08 2.55±0.91 0.03 2.24±1.09 2.42±1.00 0.42 2.36±1.06 2.70±0.77 0.009 0.36

2. The actions that can be taken to control cholesterol levels include:

3 2.45±1.05 2.77±0.74 0.003 2.40±1.09 2.71±0.83 0.02 2.51±1.00 2.83±0.63 0.07 0.37

3. The actions that can be taken to control blood pressure include:

3 2.48±1.01 2.73±0.76 <.001 2.51±1.02 2.73±0.80 0.01 2.45±1.00 2.74±0.70 0.02 0.60

4. The first step towards controlling a risk factor (such as blood pressure or cholesterol) is:

3 0.55±0.94 0.78±1.11 0.07 0.59±0.94 0.81±1.11 0.22 0.49±0.93 0.75±1.11 0.19 0.35

5. The actions to prevent developing diabetes include:

3 1.72±1.34 2.42±1.11 <.001 1.69±1.35 2.41±1.12 <.001 1.76±1.33 2.44±1.11 <.001 0.63

Exercise

1. What are the important parts of an exercise prescription?

3 2.63±0.95 2.85±0.62 0.01 2.63±0.94 2.86±0.61 0.02 2.62±0.96 2.84±0.64 0.33 0.94

2. For a person living with heart disease, it is important to do a cardiovascular warm-up before exercising because:

3 2.12±1.16 2.44±0.95 <.001 2.09±1.20 2.41±0.95 0.003 2.15±1.11 2.47±0.95 0.04 0.67

3. The pulse can be found: 3 2.32±1.12 2.49±0.97 0.25 2.28±1.16 2.56±0.91 0.05 2.37±1.08 2.41±1.03 0.67 0.46

4. Three things that one can do to exercise safely outdoors in the winter are:

3 1.94±1.30 2.73±0.73 <.001 1.99±1.28 2.71±0.75 <.001 1.89±1.32 2.75±0.72 <.001 0.49

5. The benefits of doing resistance training (lift weights or elastic bands) include:

3 2.17±1.19 2.59±0.87 <.001 2.21±1.16 2.59±0.91 0.002 2.13±1.23 2.59±0.83 0.04 0.55

6. If a person gets chest discomfort during a walking

3 2.35±1.08 2.77±0.68 <.001 2.31±1.11 2.88±0.51 <.001 2.40±1.05 2.65±0.81 0.29 0.46

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exercise session, he or she should:

7. How does a person know if he/she is exercising at the right level?

3 2.16±1.24 2.70±0.81 <.001 2.28±1.18 2.62±0.93 0.02 2.03±1.30 2.79±0.65 <.001 0.09

Nutrition

1. What is the best source of omega 3 fats in food?

3 2.33±1.20 2.51±1.03 0.18 2.34±1.19 2.53±1.05 0.11 2.32±1.22 2.49±1.01 0.74 0.87

2. Trans fat are: 3 1.67±1.41 2.41±1.12 <.001 1.73±1.41 2.43±1.11 <.001 1.61±1.41 2.38±1.15 0.004 0.48

3. What is one good way to add more fibre to your diet:

3 2.19±1.17 2.47±0.95 0.10 2.26±1.13 2.42±1.00 0.69 2.11±1.20 2.53±0.90 0.04 0.25

4. Which of the following foods has the most salt:

3 2.66±0.91 2.82±0.65 0.40 2.66±0.91 2.82±0.63 0.14 2.66±0.91 2.81±0.67 0.58 0.99

5. What combination of foods can help lower blood pressure?

3 2.55±0.96 2.77±0.72 0.09 2.58±0.96 2.77±0.72 0.05 2.52±0.97 2.77±0.73 0.90 0.58

6. When reading food labels, what should one look at first?

3 1.48±0.99 2.22±1.01 <.001 1.47±0.98 2.18±1.05 <.001 1.50±0.99 2.26±0.97 <.001 0.78

7. How many servings of fruits and vegetables should adults consume?

3 1.18±1.40 1.62±1.40 0.02 1.23±1.42 1.49±1.41 0.70 1.12±1.37 1.77±1.39 0.006 0.50

Psychosocial Risk

1. Which of the below are effective stress management techniques?

3 2.48±1.03 2.66±0.84 0.16 2.42±1.07 2.69±0.81 0.08 2.55±0.98 2.63±0.87 0.85 0.25

2. What stresses have been related to increased risk for heart attacks?

3 1.79±1.40 2.29±1.22 0.001 1.86±1.38 2.26±1.23 0.02 1.71±1.43 2.32±1.21 0.02 0.33

3. Which of the following describes your best option for reducing your risk from depression:

3 2.67±0.91 2.84±0.62 0.04 2.69±0.89 2.81±0.71 0.34 2.66±0.93 2.88±0.48 0.04 0.77

4. It is important to recognize “sleep apnea” because:

3 2.01±1.37 2.63±0.91 <.001 2.06±1.35 2.60±0.95 <.001 1.95±1.40 2.67±0.87 <.001 0.46

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5. “Chronic stress” is defined as: 3 1.27±1.26 1.43±1.22 0.46 1.31±1.29 1.43±1.26 0.71 1.23±1.22 1.43±1.18 0.48 0.58

SD indicates standard deviation.

* Paired t-test

§ Independent sample t-test (between groups at post-CR)

Table 7.3 – HAPA constructs and exercise behavior at pre- and post-CR in overall sample, and by curriculum

Overall (n=306) Traditional (n=160) New (n=146)

Maximum possible

score

Pre-CR Post-CR p* Pre-CR Post-CR p* Pre-CR Post-CR p* p§

Constructs (mean±SD)

Risk Awareness 7 5.16±1.36 5.62±1.17 <.001 5.16±1.41 5.62±1.23 0.001 5.15±1.31 5.63±1.10 0.003 0.95

Outcome Expectancies

Social 7 4.45±1.51 4.65±1.48 0.13 4.48±1.55 4.34±1.58 0.94 4.42±1.47 4.95±1.30 0.005 0.006

Psychological 7 5.68±1.32 6.07±1.03 <.001 5.70±1.44 6.01±1.14 0.01 5.66±1.18 6.13±0.88 0.009 0.41

Physical 7 5.14±1.32 5.58±1.81 0.001 5.16±1.44 5.39±1.36 0.05 5.12±1.18 5.79±2.19 0.008 0.16

Self-efficacy

Task 7 5.09±1.72 5.75±1.49 <.001 4.97±1.80 5.67±1.56 <.001 5.21±1.64 5.84±1.42 0.002 0.46

Scheduling 7 5.20±1.68 5.61±1.48 0.02 5.13±1.70 5.63±1.46 0.02 5.27±1.65 5.58±1.51 0.35 0.80

Maintenance 7 5.20±1.26 5.44±1.27 0.31 5.15±1.37 5.30±1.28 0.77 5.25±1.14 5.60±1.24 0.13 0.12

Intention 7 6.30±1.17 6.34±1.08 0.60 6.35±1.24 6.26±1.19 0.74 6.32±1.09 6.42±0.93 0.64 0.33

Planning

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Action 7 4.81±1.57 6.03±1.00 <.001 4.68±1.60 6.00±0.88 <.001 4.96±1.45 6.07±1.04 <.001 0.61

Coping 7 4.27±1.62 5.18±1.42 <.001 4.27±1.73 5.10±1.58 <.001 4.27±1.50 5.27±1.21 <.001 0.43

Behavior

Weekly physical exercise, hours (mean±SD)

- 4.91±5.90 8.05±13.24 <.001 5.26±6.97 7.45±6.01 0.03 4.55±4.52 8.73±13.35 <.001

Walking 3-4 times per week or more, n(%)

- 204 (68.7%) 147 (85.5%) <.001 104 (67.5%) 82 (89.1%) 0.001 100 (69.9%) 65 (81.3%) 0.04 0.15

SD indicates standard deviation.

* Paired t-test

§ Independent sample t-test (between groups at post-CR)

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Table 7.4 - Pearson’s correlation matrix for HAPA constructs and exercise behavior post-CR (n=173)

Constructs 1 2 3 4 5 6 7 8 9 10 11 12

1. Risk Awareness 1 0.32** 0.33** 0.37** 0.27** 0.20*§ 0.17*

2. Outcome

Expectancies Social 1 0.38** 0.40** 0.18* 0.23** 0.18*

3. Outcome

Expectancies

Psychological

1 0.47** 0.21* 0.30** 0.22**§ 0.26** 0.20** 0.19*

4. Outcome

Expectancies Physical 1 0.17* 0.20* 0.17*

5. Task Self-efficacy 1 0.44** 0.41** 0.27**§ 0.46**§ 0.33**§ 0.37** 0.27**

6. Scheduling Self-

efficacy 1 0.45** 0.44** 0.43**§ 0.44**§ 0.27**§

7. Maintenance Self-

efficacy 1 0.52** 0.58** 0.53** 0.19*§ 0.32**

8. Intention 1 0.48**§ 0.43**§ 0.28**§

9. Action Planning 1 0.61** 0.20*§ 0.26**§

10. Coping Planning 1

11. Behavior 1

12. Total Knowledge 1

Only significant correlations are shown: *p<0.05 **p<0.01

§ Correlation included in our hypothesis model

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3.5.2 Path Analysis

The proposed model illustrated in Figure 7.1 was tested, and results demonstrated unsatisfactory

fit (chi-square = 323.14, df = 50, CFI = 0.31, GFI = 0.68, RMSEA = 0.20 [0.18, 0.22]. The

model was then modified, guided by theory and modification indices. All types of self-efficacy

and outcome expectancies, and action and coping planning were correlated with each other,

which has been previously described as a way to simplify the model (Schwarzer, 1992). In

addition, knowledge was correlated to task and maintenance self-efficacy, since self-efficacy has

emerged as a highly effective mediator of motivation and learning (Zimmerman, 2000).

Knowledge was also correlated to action planning (Sniehotta et al., 2006) since the educational

programs assessed in this study had a strong action planning component. As self-efficacy is a key

factor influencing intention, the other factors from the motivational phase – risk awareness and

all types of outcome expectancies – were correlated.

This modified model (see Figure 7.3) yielded satisfactory fit across indices (chi-square = 66.98,

df = 34, CFI = 0.92, GFI = 0.93, RMSEA = 0.084 [0.05, 0.11]). All new correlations were

significant (p<.001): task self-efficacy with knowledge (r=0.20), scheduling self-efficacy

(r=0.41), and maintenance self-efficacy (r=0.39); scheduling self-efficacy with maintenance

self-efficacy (r=0.42); maintenance self-efficacy with knowledge (r=0.26), risk perception with

social (r=0.32), psychological (r=0.33), and physical (r=0.40) outcome expectancies, physical

outcome expectancies with psychological (r=0.47) and social (r=0.40), psychological and social

(r=0.38), and action and coping planning (r=0.45).

In the modified model the following associations were significant: knowledge was positively

related to intention (β=0.23, p=0.04), task self-efficacy to action planning (β=0.30, p<0.001) and

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behavior (β=0.30, p=0.002), intention to action planning (β=0.32, p<0.001) and coping planning

(β=0.28, p<0.001), and scheduling self-efficacy to coping planning (β=0.25, p=0.003).

Figure 7.3 – Modified model of the relationship between HAPA constructs, knowledge and

exercise behavior. SE indicates self-efficacy, OE outcome expectancies, e- errors.

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4.1 Discussion

The present study provides evidence that education interventions in CR are effective strategies to

improve knowledge, change theory-implied constructs of behavior and enhance physical

exercise. Despite the fact that the sample was highly educated and health-literate, there was a

significant increase in patients’ overall knowledge from pre- to post-CR in the overall sample.

Knowledge improved significantly across all domains. However, contrary to expectation, the

revised educational curriculum did not result in improvements in knowledge, HAPA-related

constructs or behavior when compared to the traditional curriculum. This may be related to the

fact that patients were already knowledgeable, and the traditional curriculum was effective.

In the pre-intentional motivation phase it was hypothesized that, among CR patients receiving

educational interventions, task self-efficacy, followed to a lesser extent by risk awareness and

outcome expectancies would be positive predictors of intention. None of these associations were

supported. Although this analysis failed to identify these relations, positive correlations were

found between all these mediators and intention formation. This predictive pattern differs from

the one observed by Renner et al., (2007), on which was observed that middle-aged and older

adults are motivated to engage in physical activity only due to task self-efficacy. Results from

our study are similar to those reported by Caudroit, Stephan, & Le Scanff (2011) who identify

risk awareness as a determinant of intention formation to exercise among older adults. According

to these authors, older adults become motivated to engage in physical activity because they feel

at risk for future health problems and disease. This can be translated to our sample of CR patients

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receiving educational interventions, who are strongly driven by a secondary prevention program,

aimed to decrease health risks and avoid new events.

A second and complementary set of hypothesis concerned the post-intentional volition phase. It

was hypothesized that, intention would be correlated to planning (action and coping), which may

lead to behavior change. It was also hypothesized that task and scheduling self-efficacy could

influence planning and maintenance self-efficacy could influence directly behavior. The results

partially confirmed this hypothesis and revealed that intention was positively related to action

and coping planning, which was correlated to behavior. These findings suggest that when CR

patients become motivated to engage in physical exercise, their intentions are not directly

translated into action. This result is in line with Reuter et al. (2010) who found that planning is

necessary to bridge the intention-behavior gap, but stands in contrast with research conducted by

Renner et al. (2007) and Caudroit et al. (2011) among older individuals where intentions directly

translated into action without preparatory strategies of approaching the activity.

Furthermore, it was hypothesized that knowledge was related to intentions. This hypothesis was

confirmed via regression analysis and knowledge was also positively correlated to action

planning, task and maintenance self-efficacy. According to health behavior models, knowledge

of the negative health consequences of a behavior is a necessary condition for behavior change

(Janz & Becker, 1984; Rosenstock, 1990). However, knowledge alone is not sufficient to

promote behavior change. It is generally thought that individuals who perceive themselves to

have an increased risk of CVD are more like to change their intentions and adopt behaviors that

reduce their risk (Dishman et al., 2004; Segan, Borland, & Greenwood, 2004; Lynch et al.,

2006).

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Caution is warranted when interpreting these results. The chief limitation is potential selection

bias. The results are specific to a small, well-educated sample of cardiac patients who attend a

comprehensive CR program at a single-centre. They do not apply to cardiac patients with lower

educational status, which raises doubt about the possibility of generalizing the results. Low

retention was also observed (however, not compared to other CR programs). Future research

should examine the interplay of theory-implied constructs described in the HAPA in a larger

cohort of cardiac patients with lower educational levels to confirm results obtained in the present

study. Moreover, given the fairly low rate of program completion observed, it is not likely the

sample was biased towards highly-adherent patients. Second, results are only generalizable to

patients who are referred and attend CR programs, which are a low proportion of cardiac

outpatients (Suaya et al., 2007). Third, because both educational programs assessed were similar,

and usually educational programs for cardiac patients are not highly standardized (Ghisi et al.,

2014), whether the relationship between program completion and knowledge would be replicated

in other communities of practice is not known. Fourth, the behavior used in the model was self-

reported, which can introduce social desirability bias and over-reporting. The use of objective

assessment tools such as accelerometers should be undertaken. In addition, there are other

behavior that should be changed are not included in this study (e.g. diet, medication use,

smoking habits). Fifth, multiple comparisons were undertaken, which inflates error rates. Finally,

a study assessing CR patients not receiving education is warranted, to ascertain whether the

differences in knowledge identified herein are robust.

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4.2 Conclusion

Knowledge, behavior, and theory-implied constructs of behavior improve in post-CR programs

with educational interventions. Although it was found positive correlations based on our

hypothesis, path analysis revealed that only knowledge was a significant motivational construct

leading to intention formation, and intentions to engage in physical activity were not directly

translated into behavior, needing especially action planning, which is related to self-efficacy.

The present study contributes to existing knowledge as the first to apply the HAPA for the

prediction of behavior among CR patients receiving educational interventions. It confirms that it

provides a useful framework for the understanding of the social cognitive processes underlying

this behaviour for this group of patients.


Innovative educational strategies are needed for cardiac patients not only to increase knowledge

but also enhance intentions, self-efficacy, and action planning. This included the provision of

education and skill training for CVD prevention based on a better understanding of the

individuals’ social and cultural characteristics.

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Chapter 8 SUMMARY OF THE RESEARCH AND GENERAL DISCUSSION

This chapter presents a summary of the 5 studies that composed this thesis, plus general

discussion, implications, future directions and limitations.

1 Summary of the Research

As described elsewhere, this thesis involved 5 studies divided into 4 steps: (1) a systematic

review; (2) information needs assessment; (3) knowledge assessment; and (4) assessment of

behavior determinants.

The initial step was to review systematically the literature in order to: (1) investigate the impact

of education on patients’ knowledge about health and disease, (2) determine if educational

interventions are related to health behavior change in CAD patients, and (3) describe the nature

of the educational interventions offered to CAD patients. This step was important to gain a clear

picture of how these interventions are structured and how they impact not only behaviour, but

disease-related knowledge. To our knowledge, such a synthesis had not been published

previously. A literature search of several electronic databases was conducted for published

articles from database inception to August 2012. Eligible articles included cardiac patients, and

described delivery of educational interventions by a healthcare provider. Measures were

knowledge, smoking, physical activity, dietary habits, response to symptoms, medication

adherence, and psychosocial well-being. Articles were reviewed by 2 authors independently.

Overall, 42 articles were included, of which 23 (55%) were randomized controlled trials, and 16

(38%) were considered “good” quality. Eleven studies (26%) assessed knowledge, and 10

showed a significant increase with education. With regard to measures, educational interventions

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were significantly and positively related to physical activity, dietary habits, and smoking

cessation. The nature of interventions were poorly described and most frequently delivered post-

discharge, by a nurse, and in groups. In conclusion, findings from this study support the benefits

of educational interventions in CAD, though increase in patients’ knowledge and behavior

change. Furthermore, future reporting of education interventions should be more explicitly

characterized, in order to be reproducible and assessed.

Step two refers to the information needs assessment. In this step the author as well as a group of

researches and experts in CR conducted a comprehensive review of existing documents related

to adult learning and patient education in order to develop a new education curriculum for

cardiac patients participants in the largest academic CR centre of Toronto. One of the findings

was that, within the context of CR, educational interventions based on patients’ needs are likely

to be more effective. Therefore, needs analysis was one of the first phases included in the

development of the education curriculum. Since a previous literature review failed to identify

any available and validated tool to assess information needs in coronary patients in CR programs

a new questionnaire was developed and psychometrically validated. This questionnaire was

called INCR (Information Needs in Cardiac Rehabilitation). After a literature search, 60

information items divided into 11 areas of needs were identified. To establish content validity,

they were reviewed by an expert panel (N=10). Refined items were pilot-tested in 34 CR patients

on a 5-point Likert-scale from 1 “really not helpful” to 5 “very important”. A final version was

generated and psychometrically-tested in 203 CR patients. Test-retest reliability was assessed via

the intraclass correlation coefficient (ICC), the internal consistency using Cronbach's alpha, and

criterion validity was assessed with regard to patient’s education and duration in CR. Results

showed that 5 items were excluded after ICC analysis as well as one area of needs. All 10 areas

were considered internally consistent (Cronbach's alpha > 0.7). Criterion validity was supported

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by significant differences in mean scores by educational level (p<0.05) and duration in CR

(p<0.001). The mean total score was 4.08±0.53. Patients rated safety as their greatest information

need. In conclusion, the INCR Tool was demonstrated to have good reliability and validity. This

is an appropriate tool for application in clinical and research settings, assessing patients’ needs

during CR and as part of education programming.

In addition to step two, another study was conducted using the INCR to describe CR participant

information needs, investigate whether CR providers are cognizant of patient’s information

needs and preferred delivery formats, and whether patient information needs change over the

course of CR. In this cross-sectional study, 306 CR patients and 28 CR providers completed a

survey. The survey consisted of the INCR questionnaire, and items about preferred education

delivery formats. Results showed that low-income CR participants had significantly greater

information needs than high-income participants. CR providers were cognizant of patient

information needs, except patients did desire more information on diagnosis and treatment than

providers perceived (p<.01). Books, lectures and discussion were identified as the preferred

delivery formats by both patients and providers. There were significant differences in patient

information needs over the course of the program, particularly in relation to exercise safety

concerns and risk factors. In conclusion, CR patients desire information in many areas,

particularly regarding emergency/safety and diagnosis/treatment. CR providers were highly

cognizant of patient information needs; however, these do change over time. These findings

could inform evaluation and improvement of CR education programming, to ensure programs

are meeting patient information needs across all stages of recovery. In addition, results from this

study where important in the development of the new education curriculum for CR patients.

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Step three refers to knowledge assessment and the development and psychometric validation of a

more comprehensive and updated questionnaire to assess CR patients knowledge, called

Coronary Artery Disease Education Questionnaire version II (CADE-Q II). After an information

needs assessment study, a literature search and a focus group discussions with CR experts (n=15)

a 31-item pilot questionnaire was developed. Overall, three items from the CADE-Q were

retained. The questionnaire underwent pilot testing in 30 patients, in which clarity was provided.

A final version was generated and psychometrically tested in 307 CR patients. The internal

consistency was assessed using Cronbach's alpha, the dimensional structure through an

exploratory factor analysis, and criterion validity was assessed with regard to educational level.

Results showed a Cronbach's alpha of 0.91. Criterion validity was supported by significant

differences in mean scores by educational level (p<.001). Factor analysis revealed four factors,

which were all internally-consistent and well-defined by the items. The mean total score was

64.23±18.1. Patients with history heart failure (p=0.01), cardiomyopathy (p=0.04) and history of

PTCA (p=0.04) presented significantly higher knowledge compared with their counterparts.

Knowledge about exercise and medical condition was significantly higher than knowledge about

risk factors, nutrition and psychosocial risk. In conclusion, the CADE-Q II was demonstrated to

have good reliability and validity. This tool will provide valuable information to clinicians and

researchers about the value of patient education in CR.

Finally, step four refers to the assessment of behavior determinants among CR patients receiving

educational interventions. This final step draws upon the HAPA model to investigate: (1)

changes in knowledge and related theoretical constructs (i.e., self-efficacy, outcomes

expectancies, risk awareness, intention, and planning) among CR patients following participation

in one of two educational programs; and, (2) the theoretical correlates of exercise behavior

change among CR patients receiving educational interventions. This quasi-experimental study

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assessed CR patients before and after exposure to an existing or new HAPA and evidence-based

education curriculum. Patients were allocated to an educational program based on their

preferences of time and day of the week, not knowing which type of education they would be

receiving. Consenting patients were invited to complete a self-administered survey assessing

sociodemographic characteristics, and including scales to assess exercise and HAPA constructs

(e.g., self-efficacy, outcome expectancies, risk awareness, intention, and planning), and

knowledge, namely the Coronary Artery Disease Education Questionnaire II (CADE-Q II).

Clinical data were extracted from charts. In the last weeks of their 6 month program, patients

were asked to complete a similar post-test survey. Three hundred and six patients consented to

participate, of which 146 (47.7%) were exposed to the new educational curriculum. There was a

significant improvement in patients’ overall knowledge from pre- to post-CR regardless of

curriculum (p<.001). With regard to the HAPA constructs, significant increases in risk

awareness, psychological and physical outcomes expectancies, task self-efficacy, and action and

coping planning were observed (p<0.05), regardless of curriculum. With regard to objective 2,

participants reported a significant increase in exercise from pre- to post-CR, again regardless of

curriculum. Path analysis revealed that knowledge was a significant motivational construct

leading to intention formation, and intentions to engage in physical activity were not directly

related to behavior, needing especially action planning, which was related to self-efficacy. In

conclusion this step showed that educational interventions in CR effectively improve knowledge,

change HAPA constructs and enhance physical exercise. Educational strategies are needed for

cardiac patients not only to increase knowledge but also enhance intentions, self-efficacy, and

action planning.

176

2 General Discussion

Patient education is a core component of CR (Buckley et al., 2013). Thus, Canadian

Cardiovascular Societies include education as a quality indicator of this practice (Grace et al.,

2014). According to the Guidelines of the Canadian Association of Cardiac Rehabilitation

(CACR; Stone et al., 2009) patient education should: be personalized; be led by a professional

staff, with regular contact between staff and patients; be delivered in individual or group settings;

discuss specific health goals; and seek to influence health beliefs, to elicit positive emotions, to

increase optimism about the possibility of change, and to heighten the salience of personal

experience or other evidence supporting self-efficacy. In addition, the problem of educating low-

literate patients cannot be ignored: health organizations should provide instruction

understandable to patients, assess patients' knowledge based on their literacy, and document such

educational efforts (Weiss et al., 1995; Williams et al., 1995; Doak, Doak, & Root, 2007). To

achieve this, a coordinated approach to developing an educational curriculum for patient

education is recommended and some “rules” should be followed.

In this thesis I have explored some of these rules, including needs and knowledge assessments,

and the need of CR educational interventions to be theory-driven and to aim behavior change. In

fact, two of our studies (the systematic review and the assessment of behavior determinants)

identify a positive relationship between education and behavior change. The systematic review

(study 1) supports the benefits of educational interventions in CAD, through increases in

patients’ knowledge, physical activity, nutrition behavior and smoking cessation. Furthermore,

the assessment of behavior change in study five showed that participants reported a significant

increase in hours of physical exercise per week from pre- to post-CR, overall and by groups. In

177

addition, the frequency of walking per week increased significantly from pre- to post-CR, again

overall and by groups.

The literature highlights the importance of a comprehensive understanding of patients’ health

information needs as a logical first step in developing and implementing educational programs

(Cranton, 1989; Scott & Thomspon, 2003; Timmins & Kaliszer, 2003). The availability of a

valid needs assessment tool is essential to evaluate the information needs of CR patients and to

tailor the information component of these programs. In this context, the Information Needs in CR

(INCR) scale was developed and psychometrically validated to assess information needs in CR

patients. Furthermore, we’ve also investigated whether CR providers are cognizant of patient’s

information needs using the INCR tool. Results showed that CR patients desire information in

many areas, particularly regarding emergency/safety and diagnosis/treatment, and that CR

providers are highly cognizant of patient information needs. However, patients’ information

needs change over time and healthcare providers should be aware of these change and

accurately-perceive patients’ needs in order to have engaged and informed patients, which can

positively impact their health outcomes (Karlik & Yarchesk, 1987; Hagenhoff et al., 1994; Ghisi

et al., 2014b).


precise information of what cardiac patients know about their condition (Kayaniyil et al., 2009;

Brown et al., 2011). Patients’ knowledge of heart disease can strongly influence symptom

recognition, advocacy for physician screening, attitude towards the disease, and provide

motivational for individual behaviour changes. In this context, the Coronary Artery Disease

Education Questionnaire (CADE-Q) was previously developed and psychometrically validated

to assess patients’ knowledge about CAD in a Portuguese speaking population of CR patients in

178

Brazil (Ghisi et al., 2010). It was later translated, cross-culturally adapted, and psychometrically

validated to English (de Melo Ghisi et al., 2013). It has also being used to compare knowledge

between a developed and a developing country (Ghisi et al., 2013b). Although both versions

demonstrated good reliability and validity, the CADE-Q presented lack of detailed assessment of

all core components of cardiac rehabilitation (CR), such as nutrition and psychosocial risk.

Therefore, a new version – CADE-Q II – was developed and psychometrically tested in this

thesis.

According to literature and guidelines, health education should be delivered not only to increase

patients’ knowledge but to also achieve health behavior change (Mullen et al., 1992; Dusseldorp

et al., 1999; Aldcroft et al., 2011, Schadewaldt & Schultz, 2011; Ghisi et al., 2014a). A number

of studies have shown that using theory in crafting interventions can lead to more powerful

effects than interventions developed without theory (Ammerman et al., 2002; Legler et al., 2002;

Glanz et al., 2008). In the context of patient education, theories can provide us with a workable

basis for an education action we wish to undertake. This is especially important when teaching

patients whose educational needs are less predictable or more diverse (Laverack, 2004; Doak,

Doak, & Root, 2007). Theories such as the HAPA model (Schwarzer, 1992; Schwarzer, Lippke,

& Luszynska, 2011), social cognitive theory (Bandura, 1986), and adult learning principles

(Knowles, 1978; 1980; 1984) are examples of useful theories that may be incorporated in

educational interventions to CR patients. In particular, the use of HAPA framework for

predicting physical exercise change after a comprehensive educational intervention in cardiac

rehabilitation patients was tested in Study 5, and results reinforce the use of HAPA model as an

important theory to guide development, delivery and assessment of patient education strategies.

179

Finally, it is important to describe how the term patient education was used throughout my

thesis. As described previously, patient education is defined as the process by which health

professionals or others impart information to patients with the purpose to improve their

knowledge, and consequently promote behavior change or improve outcomes. Although many of

the educational efforts described in my thesis incorporated strategies derived from psychosocial

and psycho-educational interventions (i.e. education offered to individuals to help empower them

and deal with a certain condition in an optimal way) I’ve decided to use the term patient

education because this is the term used in cardiac rehabilitation guidelines as a core component

and usually in clinical practice. I see psycho-education as a subtype of patient education, and in

my opinion patient education is a broader concept which involves not only social and

psychological aspects, but also learning principles and knowledge. Psychosocial or psycho-

educational interventions may affect rehabilitation outcomes in two ways. First, they can

facilitate psychosocial recovery, including the patient's return to everyday activities. Second,

they can play an important role in secondary prevention, by encouraging compliance with

medical advice and behavior change related to risk factor modification. Most interventions of the

first type can be characterized as stress management (SM) programs, and interventions of the

second type focus on behavior modification and health education (HE). Patient education can

incorporate these strategies but is a broader term, reflecting all types of learning that leads to

behavior change (increase in knowledge regarding different topics) (Dusseldorp et al., 1999).

Both patient education and psychosocial interventions may influence mediators. Studies should

be performed to find a way to usefully distinguish the two interventions.

180

3 Limitations

Caution is warranted when interpreting results from this thesis. Limitations from each study are

described in each chapter. Overall, the generalizability of these findings to other CR populations

is somewhat limited, considering recruitment stemmed from a single-centre, which has a strong

educational component in CR programs (impact of setting on findings and generalizability is

warranted). Results from these studies were not compared to people that do not attend formal CR

or populations, such as patients with low general or health literacy. I limited my studies to those

of the coronary artery disease population, which may have eliminated unique methods that could

be conducted in other populations such as patients with heart failure. Replication is warranted.

In regards to the instruments used to assess HAPA construct at study 5, HAPA creator

recommends these instruments; however, only partial descriptions of the methods used to

develop these tools are available.

4 Implications and Future Directions

Results from all 5 papers are valuable in the area of patient education in CR. Firstly, the weight

of evidence in the systematic review suggests the need for comprehensive multidisciplinary

education programs offered in-hospital and post-discharge, through individual and group

educational activities delivered in discursive rather than didactic fashion. Ensuring CAD patient

access to comprehensive, evidence-based and education programs may optimize the benefits

observed in relation to physical activity, diet and smoking cessation. Furthermore, this review

suggested that there was a need for valid and reliable tools to assess patients’ knowledge, since

few studies assess this measure. This gap was addressed in chapter 6, in which a new tool to

181

assess CR patients’ knowledge was developed and tested. Secondly, this thesis showed that good

patient education involves assessing needs, setting goals and objectives, implementing a teaching

plan, and evaluating outcomes. Before implementing patient education programs, it is prudent to

evaluate what information is needed and what patients know about their condition. The

availability of valid tools (such as the INCR and CADE-Q II) is essential to not only evaluate

these measures, but to tailor educational programs. Thus, these tools can be administered to

determine whether patients have changed their information needs or learned the information they

perceived as important. Furthermore, the identification of needs using an instrument like the

INCR could serve as a mechanism for understanding patient information gaps. CR staff could

use the INCR to assess the comprehensiveness of their education programming, and to consider

whether the main focus of their programming relates to the key information needs of patients at

different stages of the program. Programs should also consider whether the delivery format of

their education program is concordant with patient preferences. Finally, innovative educational

strategies are needed not only to increase knowledge but also enhance intentions, self-efficacy,

and action planning. This included the provision of education and skill training for CVD

prevention based on a better understanding of the individuals’ social and cultural characteristics.

Of the current health promotion models, the HAPA model appears to hold the most promise in

predicting health-related outcomes and informing subsequent interventions. It possesses an

integrative framework that addresses the variables associated with motivation, intention, and

action toward engaging in health-promoting behaviors (Schwarzer et al., 2011). In regards this

model, results from this dissertation support the usefulness of this model for prediction of

behavior change in CR patients. Although testing the HAPA model was not an objective of the

fifth study, results showed that the distinction of preintentional and intentional stages was

confirmed (principles 1 and 2 of the theory), as well as the importance of action planning to

182

change exercise behavior in this population. Results also showed that CR patients require

educational interventions targeting specific HAPA-constructs (e.g. intentions, action planning).

Future directions include: assess educational needs, knowledge and behavior determinants in

multicultural settings, and compare these measures to those who are not in CR programs or are in

non-comprehensive CR programs. In addition, due to the lack of evidence demonstrating benefit

of comprehensive CR programs in lower-resource settings future directions will include the

investigation of whether participation in educational programs CR in middle-income countries

results in better disease-related knowledge, behavior determinants and behavior in cardiac

patients when compared to usual care. A single-blinded pragmatic RCT with 3 parallel arms:

comprehensive CR vs. usual care vs. control group (no CR) is planned to occur in Brazil, where

CVDs are also a leading cause of death and responsible for 29% of total mortality in 2010

(approximately 37,000 deaths/year) (Brazil, 2010). Considering that most of these deaths occur

prematurely, the economic impact is devastating. To lessen the impact of CVDs on individuals

and societies, a comprehensive approach is needed.

In addition, future research should focus on developing guidelines on patient education for

special cardiac populations (e.g. low health literacy subjects, older patients, patients with

psychological impairments). As described in my thesis, guidelines usually mention that patient

education should be designed based on the characteristics of the recipients (including special

populations); however, there is no data to guide on how this education should be structured,

delivered, tested and which outcomes should be evaluated. Another future research direction

might focus on cost-effectiveness of comprehensive cardiac rehabilitation. Including patient

education in cardiac rehabilitation programs involves time, training, efforts and, consequently,

money. Although studies have shown that cardiac rehabilitation is more cost-effective than other

183

post-MI treatments (Ades, Pashkow & Nestor, 1997; Briffa et al., 2005) (e.g. thrombolytic

therapy, coronary bypass surgery and cholesterol lowering drugs), there are no studies comparing

cardiac rehabilitation programs versus comprehensive cardiac rehabilitation programs (i.e. with a

structured education intervention).

184

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Appendices

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Appendix 1: The INCR Scale

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Appendix 2: The CADE-Q II Questionnaire

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Domain: Medical Condition

Question 1 Coronary Artery Disease is:

a) A disease of the heart’s arteries that occurs only in older age and is mainly caused by deposits of calcium in the arteries.

b) A disease of the arteries of the heart which occurs in older age in people with high cholesterol or who smoke.

c) A disease of the arteries of the heart that starts silently at a young age. It is influenced by poor life style habits, genetics, and involves inflammation in the arteries.

d) I don’t know. Question 2 Angina (chest pain of discomfort) occurs:

a) When the heart muscle is working too hard. b) When the heart muscle is not getting enough blood and oxygen to work properly. c) When the brain is not getting enough oxygen. d) I don’t know.

Question 3 In a person with coronary artery disease, which of the following is a usual description of angina?

a) Headache after meals. b) Chest pain or discomfort, at rest or during physical activity, which can also be felt

in the arm and/or back and/or neck. c) Chest pain or discomfort during physical activity. d) I don’t know.

Question 4 A heart attack occurs:

a) If an artery in the heart becomes blocked. b) If the heart suddenly races in response to stress. c) If the flow of oxygen-rich blood to an area of heart muscle suddenly becomes

blocked. If blood flow is not restored quickly, the area of heart muscle begins to die. d) I don’t know.

Question 5

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The best resources available to help someone understand his/her medications are:

a) The doctor, the cardiac rehab team, the pharmacist and recommended resources on the internet.

b) What someone reads on the internet. c) The doctor and the cardiac rehab team. d) I don’t know.

Question 6 Medications such as aspirin (ASA) and clopidogrel (PlavixTM) are important because:

a) They lower blood pressure. b) They “thin” the blood. c) They reduce the “stickiness” of platelets in the blood so that blood flows more

easily through coronary arteries and past coronary stents. d) I don’t know.

Question 7 The “statin” medications, such as atorvastatin (LipitorTM), rosuvastatin (CrestorTM), or simvastatin (ZocorTM), have a beneficial effect in the body by:

a) Lowering LDL cholesterol in the blood stream. b) Blocking the production of LDL cholesterol in the liver, lowering LDL cholesterol

in the blood stream, and encouraging cholesterol to move out of plaques from the arteries.

c) Reducing the absorption of cholesterol from food. d) I don’t know.

Domain: Risk Factors

Question 1 The risk factors for heart disease that can be changed are:

a) Blood pressure, cholesterol, and smoking. b) Age, family history of heart disease, ethnicity and sex. c) Blood pressure (systolic and diastolic), LDL + HDL cholesterol, smoking and

second hand smoking, waist size, and reaction to stress. d) I don’t know.

Question 2

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The actions that can be taken to control cholesterol levels include:

a) Knowing the total cholesterol level, becoming a vegetarian and avoiding eggs. b) Knowing the LDL and HDL levels, taking cholesterol medication as prescribed,

increasing soluble fibre intake and reducing saturated fat in the diet, and participating in aerobic exercise 5 times per week.

c) Knowing the cholesterol levels and taking cholesterol medication as prescribed. d) I don’t know.

Question 3 The actions that can be taken to control blood pressure include:

a) Increasing calcium in the diet. b) Reducing the amount of salt in the diet, and taking blood pressure medication. c) Reducing the amount of sodium in the diet to <2000 mg per day, exercising,

taking blood pressure medication regularly and learning relaxation techniques. d) I don’t know.

Question 4 The first step towards controlling a risk factor (such as blood pressure or cholesterol) is:

a) Knowing if someone has the risk factor. b) Knowing the level of the risk factor. c) Setting a goal or action plan to control the risk factor. d) I don’t know.

Question 5 The actions to prevent developing diabetes include:

a) Follow a heart healthy diet, do 150 minutes of aerobic exercise weekly and twice weekly resistance exercises with weights and therabands.

b) Reduce the amount of fats and carbs in the diet. c) With a family history of diabetes, a person is bound to develop diabetes because

diabetes is not a preventable disease. d) I don’t know.

Domain: Exercise

Question 1

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What are the important parts of an exercise prescription?

a) Replacing calories and salt during a light workout. b) How hard to exercise, how long to exercise, how often to exercise and what type

of exercise to do. c) How hard to exercise, and how long to exercise. d) I don’t know.

Question 2 For a person living with heart disease, it is important to do a cardiovascular warm-up before exercising because:

a) It gradually increases the heart rate, it may reduce muscle soreness and can reduce the risk of developing angina.

b) It adds more time to the total amount of minutes of exercise. c) It prepares the body for exercise. d) I don’t know.

Question 3 The pulse can be found:

a) In the wrist below the base of the thumb. b) In the wrist below the base of the pinky finger or on the neck on the Adam’s

apple. c) At the radial artery (wrist) or at the carotid artery (neck). d) I don’t know.

Question 4 Three things that one can do to exercise safely outdoors in the winter are:

a) Check the temperature and wind-chill, and wear layers of clothing. b) Check the temperature and wind-chill and make sure it is not below -10 degrees

C, wear 3-4 layers of clothing and adjust the pace of walking so that the level of exertion and heart rate are on target.

c) Check the temperature and wind-chill and make sure it is not below -15 degrees C, wear a winter coat and jog if one gets too cold.

d) I don’t know. Question 5 The benefits of doing resistance training (lift weights or elastic bands) include:

a) Builds up strength and muscles.

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b) Lowers resting heart rate. c) Increases strength, improves the ability to carry out day to day activities,

improves blood sugar levels and increases muscle. d) I don’t know.

Question 6 If a person gets chest discomfort during a walking exercise session, he or she should:

a) Speed up to see if the discomfort goes away. b) Slow down and stop exercising. c) Slow the walk pace and if it does not go away within 1 minute, stop exercising. If

it still does not go away within the next 1 minute, take nitro-glycerine as prescribed. If the pain continues, get help.

d) I don’t know. Question 7 How does a person know if he/she is exercising at the right level?

a) The heart rate is in the target zone, the exertion level is no higher than “some-what hard”, and the person can exercise and talk.

b) The heart rate is in the target zone. c) Working up a sweat, breathing heavy and the heart rate is going fast. d) I don’t know.

Domain: Nutrition

Question 1 What is the best source of omega 3 fats in food?

a) Ground flaxseed. b) Pasta. c) Fatty fish (e.g. trout, salmon). d) I don’t know.

Question 2 Trans fat are:

a) Found in nuts and seeds.

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b) Partially hydrogenated vegetable oils (e.g. vegetable shortening). c) Margarine. d) I don’t know.

Question 3 What is one good way to add more fibre to your diet:

a) Add nuts and seeds to a salad. b) Drink juice. c) Eat plant proteins (e.g. legumes/beans, lentils). d) I don’t know.

Question 4 Which of the following foods has the most salt:

a) Bread. b) Frozen dinners. c) Fruits and vegetables. d) I don’t know.

Question 5 What combination of foods can help lower blood pressure?

a) Red meat, poultry, fish. b) Vegetables and fruits. c) Vegetables and fruits, whole grains, low fat dairy, nuts and seeds. d) I don’t know.

Question 6 When reading food labels, what should one look at first?

a) Fat content. b) Brand name. c) Serving size. d) I don’t know.

Question 7 How many servings of fruits and vegetables should adults consume?

a) 7 to 10 servings a day. b) 5 servings a day.

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c) As many as possible. d) I don’t know.

Domain: Psychosocial Risk

Question 1 Which of the below are effective stress management techniques?

a) Deep breathing. b) Avoid communication. c) Meditation, progressive muscle relaxation, making social connections,

stretching/exercise, deep breathing. d) I don’t know.

Question 2

What stresses have been related to increased risk for heart attacks?

a) Chronic stresses, major life events, disrupted sleep, and feelings of distress. b) Chronic stress at home or at work and feeling depressed. c) Stresses that you do not feel in control of. d) I don’t know.

Question 3 Which of the following describes your best option for reducing your risk from depression:

a) Take an antidepressant, and do your exercise prescription. b) Do your exercises, take better care of yourself, and if required take medications. c) The risk of heart attack due to depression cannot be reduced. d) I don’t know.

Question 4

It is important to recognize “sleep apnea” because:

a) It leads to long term lung disease. b) It is associated with high blood pressure, abnormal heart rhythms, and higher

risk of future heart attack.

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c) It leads to further heart problems. d) I don’t know.

Question 5 “Chronic stress” is defined as:

a) Ongoing persistent stressful events in one area of your life. b) Events at work or at home that make you feel irritable, anxious, or sleepless. c) The stresses that are out of a person’s control. d) I don’t know.

Thanks for your participation!

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Appendix 3: Assessment Booklet for Paper 5

236

Initial Survey

Instructions for completing the survey questions appear at the beginning of each section.

Please seal your completed questionnaire in the envelope provided and return it to the TRI

Version #2: 22 April 2013

Participant #_______

!!

Patient

Education Study

237

General Instructions

We need your help to make our study a success. Your candid answers to the items in this survey

are very important to us. The survey will take about 30 minutes to complete.

REMEMBER:

• We want to know what you think. • There are no right or wrong answers. • Everything you tell us will be kept strictly confidential. • Please provide only one answer for each item.

SESSIONS:

This survey has 3 sessions.

• Session A - About you: information needed to understand the characteristics of the people participating in this study. In this session you will be asked to provide your educational level, and we will assess health literacy and physical activity.

• Session B - Assessment of Mediators: mediators are characteristics that may influence your behaviour change

• Session C - Knowledge Assessment: CADE-Q 2 Questionnaire will be used to assess your knowledge about heart disease and related factors.

If, at any time, you have questions as you complete this questionnaire, or regarding your

participation in this study, please call:

Gabriela L. Melo Ghisi, PhD Candidate

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Please answer the questions about physical activity, physical exercise and exercise prescription with the following definitions in mind: Physical Activity: any type of activity/movement produced by muscles that results in energy expenditure. Physical Exercise: physical activity that is planned, structured, and repetitive for the purpose of conditioning any part of the body. Exercise Prescription: physical exercise based on your medical history, your current level of fitness, the results from your cardiopulmonary assessment, and your specific goals.

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Instructions: The information within this session is needed to help understand the characteristics of the people participating in this study. For this reason, it is very important information. Be assured that it will remain confidential.

1. Educational Level

What is the highest level of education you have completed?

2. Physical Activity

How often do you usually carry out the following physical activities?

(Almost) every day

3-4 times a week

Once a week

1-3 times a month

Less or never

Bicycling (also stationary exercise bike) 1 2 3 4 5

Walking, hiking, running 1 2 3 4 5

Calisthenics, gymnastics, aerobics, dancing 1 2 3 4 5

Endurance sports (swimming, rowing, skiing) 1 2 3 4 5

Resistance training (weight training) 1 2 3 4 5

(Almost) every day

3-4 times a week

Once a week

1-3 times a month

Less or never

1 Less than high school (no certificates, diplomas or degrees)

2 High school graduation certificate

3 Trades certificate

4 College certificate or diploma

5 University: a certificate below the bachelor’s level, bachelor’s degree, certificate above the bachelor’s level, master’s level, earned doctorate or a professional degree.

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Martial arts 1 2 3 4 5

Team sport games (baseball, soccer, volleyball, etc) 1 2 3 4 5

Other? Please specify: ________________________ 1 2 3 4 5

How much time do you spend on the above mentioned activities? __________________ hours per week. Have you been exercising on a regular basis during the last 6 months?

3. Health Literacy

3.1.The Medical Term Recognition Test (METER)1

The following list (see next page) contains some real medical words. For example, some of the words have to do with body parts or functions, kinds of diseases, or things that can make your health better or worse. The list also contains some items that may look or sound like medical words but that are not actually real words.

As you read through the list, put an “X” next to the items that you know are real words.

You should not guess. Only put an “X” next to an item if you’re sure it’s a real word.

_______ Irrity _______ Astiringe _______ Infarth

_______ Arthritis _______ Nutral _______ Dose

1 No

2 Yes, with longer interruptions

3 Yes, with short interruptions

4 Yes, without interruptions

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_______ Obesity _______ Asthma _______ Hemorrhoids

_______ Flu _______ Inflammatory _______ Testicle

_______ Behaviose _______ Anemia _______ Eye

_______ Syphilis _______ Allagren _______ Midlocation

_______ Potassium _______ Prognincy _______ Insomniate

_______ Hormones _______ Stress _______ Bloodgatten

_______ Nerves _______ Ellargic _______ Sexually

_______ Pilk _______ Inlest _______ Pelvince

_______ Rection _______ Pollent _______ Vaccilly

_______ Blout _______ Malories _______ Prescription

_______ Boweling _______ Cancer _______ Germs

_______ Exercise _______ Alcoheliose _______ Gonorrhea

_______ Pustule _______ Antibiotics _______ Tumic

_______ Cerpes _______ Antiregressant _______ Fatigue

_______ Kidney _______ Colitis _______ Osteoporosis

_______ Emergency _______ Diabetes _______ Constipation

_______ Potient _______ Occipitent _______ Hepatitis

_______ Menopause _______ Nausion _______ Fam

_______ Diagnosis _______ Impetigo

_______ Depretion _______ Menstrual

_______ Jaundice _______ Abghorral

_______ Gallbladder _______ Seizure

_______ Miscarriage _______ Appendix

3.2.The Newest Vital Sign (NVS)2

242

See the food label below and answer the questions on next page.

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Based on the information in the nutritional label (see last page), please answer the following questions: a. If you eat the entire container of ice cream, how many calories will you eat? b. If you are allowed to eat 60 grams of carbohydrates as a snack, how much ice cream could you have? c. Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 grams of saturated fat each day, which includes 1 serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day? d. If you usually eat 2500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving? e. Pretend that you are allergic to the following substances: penicillin, peanuts, latex gloves, and bee stings. Is it safe for you to eat this ice cream? YES NO f. If you answered 'no' to the last question, explain why it would not be safe to eat this ice cream. 1 Rawson, K. A., Gunstad, J., Hughes, J., Spitznagel, M.B., Potter, V., Waechter, D., et al. (2009). The METER: A

brief, self-administered measure of health literacy. Journal of General Internal Medicine, 25(1), 67-71.

2 Weiss, B. D., Mays, M. Z., Martz, W., Castro, K. M., DeWalt, D. A. , Pignone, M. P., et al. (2005). Quick Assessment of Literacy in Primary Care: The Newest Vital Sign. Annals of Family Medicine, 3(6), 514-522.

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Section B: Mediators

Instructions: Mediators are characteristics that may influence your behaviour change and how

your knowledge can influence this behaviour. We are assessing 8 types of mediators (M1-M8).

M1: Risk Awareness

1. Using the scales provided, please circle the most appropriate response (from 1 to 7) to show

your agreement with each statement.

a) If I keep my lifestyle the way it was prior to my heart problem I will suffer from an elevated cholesterol level.

1 2 3 4 5 6 7 Very

unlikely Moderately

likely Very likely

b) If I keep my lifestyle the way it was prior to my heart problem I will suffer from a heart attack.

1 2 3 4 5 6 7 Very

unlikely Moderately

likely Very likely

c) If I keep my lifestyle the way it was prior to my heart problem I will suffer from high blood pressure.

1 2 3 4 5 6 7 Very

unlikely Moderately

likely Very likely

d) If I keep my lifestyle the way it was prior to my heart problem I will suffer from cardiovascular disease.

1 2 3 4 5 6 7 Very

unlikely Moderately

likely Very likely

2. Using the scales provided, please circle the most appropriate response (from 1 to 7) for each question.

a) How severe (serious) is obesity if I don’t exercise regularly? 1 2 3 4 5 6 7

Not severe at all

Moderately severe

Very severe

(can be ignored) (as if someone has the flu) (life threatening)

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b) How severe (serious) is heart attack if I don’t exercise regularly?

1 2 3 4 5 6 7 Not severe

at all

Moderately severe

Very severe


c) How severe (serious) is high blood pressure if I don’t exercise regularly? 1 2 3 4 5 6 7

Not severe at all

Moderately severe

Very severe


d) How severe (serious) is cardiovascular disease if I don’t exercise regularly? 1 2 3 4 5 6 7

Not severe at all

Moderately severe

Very severe

(can be ignored) (as if someone has the flu) (life threatening) M2: Outcomes Expectancies 1. Using the scale provided below, please circle the most appropriate response (from 1 to 7) for the question: What do you think will be the consequences if you exercise regularly?

1 2 3 4 5 6 7 Very

unlikely Moderately

likely Very likely

a) Social Outcomes: If I exercise regularly… …I will be able to socialize with others. 1 2 3 4 5 6 7

…others will appreciate my willpower. 1 2 3 4 5 6 7

…I will take a lot of my time. 1 2 3 4 5 6 7

... I will spend time with others. 1 2 3 4 5 6 7

b) Psychological Outcomes:

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If I exercise regularly… …I will reduce my stress. 1 2 3 4 5 6 7

…I will feel more energized. 1 2 3 4 5 6 7

…I will be more balanced in my daily life 1 2 3 4 5 6 7

... my quality of life will increase. 1 2 3 4 5 6 7

… I will look more attractive. 1 2 3 4 5 6 7

c) Physical Outcomes:

If I exercise regularly… …I will simply feel better afterwards. 1 2 3 4 5 6 7

…I won’t have weight problems (anymore). 1 2 3 4 5 6 7

…my cholesterol level will improve. 1 2 3 4 5 6 7

…I will prevent a heart attack. 1 2 3 4 5 6 7

… it will be good for my blood pressure. 1 2 3 4 5 6 7

... it will help me cope with medication side effects.

1 2 3 4 5 6 7

M3: Task Self-efficacy 1. For the following questions, please indicate how confident you are on a scale from 1 (not confident at all) to 7 (completely confident). Assuming you were very motivated, how confident are you that you could physically do the following amounts of physical activity in one session without stopping over the next 6 months. Please answer for each amount of time.

Not Confident At All Neutral Completely

Confident

10 minutes 1 2 3 4 5 6 7

20 minutes 1 2 3 4 5 6 7

Not Confident At Neutral Completely

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All Confident

30 minutes 1 2 3 4 5 6 7

40 minutes 1 2 3 4 5 6 7

50 minutes 1 2 3 4 5 6 7

60 minutes 1 2 3 4 5 6 7

M4: Intention 1. Using the scales provided, please circle what extent (from 1 to 7) is the following statement true for you. a) “I will try to do my exercise prescription over the next 6 months.”

1 2 3 4 5 6 7 Definitely

False Definitely

True

2. Using the scales provided, please circle what extent (from 1 to 7) is the following statement likely for you. b) “I intend to do my exercise prescription over the next 6 months.”

1 2 3 4 5 6 7 Extremely Unlikely

Extremely Likely

M5: Action Planning 1. Using the scales provided, please rate the extent to which you agree with each statement. Do you already have concrete plans with regard to exercising?

a) I already have concrete plans about WHERE to exercise.

1 2 3 4 5 6 7 Strongly Disagree

Neutral Strongly Agree

b) I already have concrete plans about WHEN to exercise.

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c) I already have concrete plans about HOW to exercise.



d) I already have concrete plans about HOW OFTEN to exercise.



e) I already have concrete plans about WITH WHOM to exercise.



f) I already have concrete plans about WHAT TYPES OF ACTIVITIES I will do.

1 2 3 4 5 6 7

Strongly Disagree


M6: Coping Planning 1. Using the scales provided, please rate the extent to which you agree with each statement. Do you already have concrete plans for your new exercise schedule (habits)?

a) I already have concrete plans about what to do if something interferes with my exercise schedule.

1 2 3 4 5 6 7

Strongly Disagree


b) I already have concrete plans about what to do if I miss an exercise session.

1 2 3 4 5 6 7

Strongly Disagree


c) I already have concrete plans about what to do in difficult situations in order to stick

to my exercise schedule.

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d) I already have concrete plans if something gets in the way of my plans to exercise.

1 2 3 4 5 6 7

Strongly Disagree


M7: Scheduling Self-Efficacy 1. Using the scales provided, please answer each statement. Assuming that you are very motivated, in the next 6 months, how confident are you that you can fit your exercise prescription into your weekly schedule…

Please answer for each frequency

Not Confident At All

Neutral Completely Confident

…Once per week? 1 2 3 4 5 6 7

…Twice per week? 1 2 3 4 5 6 7

…Three times per week? 1 2 3 4 5 6 7

…Four times per week? 1 2 3 4 5 6 7

…Five times per week? 1 2 3 4 5 6 7

…More than 5 times per week? 1 2 3 4 5 6 7

M8: Maintenance Self-Efficacy 1. Using the scales provided, please answer each statement. Assuming you were very motivated, how confident are you that you will do your exercise prescription over the next 6 months…

Please answer for each frequency Not Confident At All

Neutral Completely Confident

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…even if it takes you a long time to make it a habit? 1 2 3 4 5 6 7

…even if you are worried and troubled? 1 2 3 4 5 6 7

…even if you don’t see success at once? 1 2 3 4 5 6 7

…even if you are tired? 1 2 3 4 5 6 7

…even if you are stressed out? 1 2 3 4 5 6 7

…even if you feel tense? 1 2 3 4 5 6 7

…even if you do not have the support of others around you? 1 2 3 4 5 6 7

…even if you feel slow? 1 2 3 4 5 6 7

…even if your partner or family isn’t physically active? 1 2 3 4 5 6 7

…even if you don't feel well? 1 2 3 4 5 6 7

…even if you don't know where to go to engage in physical activity? 1 2 3 4 5 6 7

…even if you don't know what types of physical activity to do? 1 2 3 4 5 6 7

…even if you are physically sore or in pain? 1 2 3 4 5 6 7

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Section C: CADE-Q 2 Questionnaire

CADE-Q 2

Coronary Artery Disease Education Questionnaire

You are being invited to fill out this questionnaire because you are in a cardiac

rehabilitation program. Knowledge about your condition, treatments and risk factors is

an important component about management. We would like to have a sense of the

information that you have acquired thus far as you have been treating your heart

problem or risk factor.

About the questionnaire:

The purpose of this questionnaire is:

• to assess patients’ overall knowledge about heart disease and related factors; and,

• to assess specific areas/domains of knowledge (medical condition, risk factors, exercise, nutrition, and psychosocial risk,).

Questions are structured as followed:

• multiple choice

• each question has 4 possible answers/alternatives

• each answer corresponds to a knowledge level:

- a correct statement showing “complete knowledge”

- a correct statement showing “incomplete knowledge”

- an incorrect statement showing “wrong knowledge”

- a don’t know statement showing “lack of knowledge”

• each alternative has a score and the sum of final scores lead to a classification on knowledge.

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Instructions for completing this survey:

• Questions are grouped in domains (areas of knowledge);

• Please answer as many questions as you can;

• Check the alternative you think that is the most correct one;

• If you don’t know the answer, mark the “don’t know” statement (do not leave the question blank);

• After completing the questionnaire, please return to the researcher or to the reception;

This questionnaire is confidential and completely voluntary.

It should take around 20 minutes to complete.

Thanks for your time!

CADE-Q 2’s Version (April 9 2013)

For CADE-Q 2 please refer to Appendix 2

Patient Education in Cardiac Rehabilitation - TSpace

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