How important are individual counselling,expectancy beliefs and autonomy for the maintenance of exercise after cardiac rehabilitation?

Abstract

Aims: We examined whether autonomy supportive and self-efficacy enhancing individual lifestyle counselling was associated with improved maintenance of exercise and physical capacity compared with group based counselling. We also tested whether self-efficacy beliefs and autonomous motivation was associated with improved maintenance of exercise over time. Methods: Randomised controlled trial and longitudinal study of predictor variables. One hundred and seventy six (38 female) patients mainly with coronary heart disease were randomized to either have standard group based rehabilitation or to additionally receive the intervention. Patients were recruited from a 4-week cardiac rehabilitation programme with two years follow-up at Krokeide Centre in Bergen, Norway. Results: We found no statistically significant between-group differences. The groups showed an overall improvement of their self-evaluated physical capacity during the two years of the study, corresponding 7% change of score (p<0.001). The composite exercise score improved 6% during follow-up (p<0.001). Intensity of exercise activities improved 17% from inclusion to 24 months' follow-up (p<0.001). Self-efficacy for increased exercise, general expectancy and autonomous motivation were significant predictors of increased exercise and physical capacity. Controlled motivation hampered physical capacity improvement. Conclusions: Among this self-selected and motivated group of rehabilitation patients we found no additional effect of adding individual counselling to group-based interventions. Based on longitudinal documentation this cardiac rehabilitation programme improves long-term maintenance of exercise and physical capacity and this maintenance is related to autonomous motivation, general expectancy and self-efficacy.

Keywords

Cardiac rehabilitation coronary heart disease motivation physical activity change randomized controlled trial secondary prevention

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References

Jolliffe JA , Rees K. , Taylor RS , Thompson D. , Oldridge N. , Ebrahim S. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2001:CD001800.

Iestra JA , Kromhout D. , van der Schouw YT , Grobbee DE , Boshuizen HC , van Staveren WA Effect size estimates of lifestyle and dietary changes on all-cause mortality in coronary artery disease patients: a systematic review. Circulation 2005;112:924-34.

Giannuzzi P. , Saner H. , Bjornstad H. , Fioretti P. , Mendes M. , Cohen-Solal A. , et al. Secondary prevention through cardiac rehabilitation - position paper of the working group on cardiac rehabilitation and exercise physiology of the European Society of Cardiology. Eur Heart J 2003;24: 1273-8.

Balady GJ , Ades PA , Comoss P. , Limacher M. , Pina IL , Southard D. , et al. Core components of cardiac rehabilitation/secondary prevention programs: a statement for healthcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Circulation 2000;102: 1069-73.

Dusseldorp E. , van Elderen T. , Maes S. , Meulman J. , Kraaij V. A meta-analysis of psychoeduational programs for coronary heart disease patients. Health Psychol 1999;18:506-19.

Graves KD , Miller PM Behavioral medicine in the prevention and treatment of cardiovascular disease . Behav Modification 2003;27:3-25.

Anderssen SA , Stromme SB Fysisk aktivitet og helseanbefalinger [Physical activity and health-recommendations]. Tidsskr Nor Laegeforen 2001;121:2037-41.

Stephens T. Physical activity and mental health in the United States and Canada: Evidence from four population surveys. Prev Med 1988;17:35-47.

Deci EL , Ryan RM Intrinsic motivation and self-determination in human behavior. New York: Plenum; 1985.

10.

Deci EL , Ryan RM Handbook of self-determination research. Rochester, NY : University of Rochester Press; 2002.

11.

Williams GC , Rodin GC , Ryan RM , Grolnick WS , Deci EL Autonomous regulation and long-term medication adherence in adult outpatients. Health Psychol 1998;17:269-76.

12.

Bandura A. Self-efficacy: the exercise of control. New York: Freeman; 1997.

13.

T. Mildestvedt et al.

14.

Oldridge NB , Stoedefalke KG Compliance and motivation in cardiac exercise programs. Clin Sports Med 1984;3:443-54.

15.

Willich SN , Muller-Nordhorn J. , Kulig M. , Binting S. , Gohlke H. , Hahmann H. , et al. Cardiac risk factors, medication, and recurrent clinical events after acute coronary disease; a prospective cohort study. Eur Heart J 2001;22:307-13.

16.

Kjellgren KI , Ahlner J. , Saljo R.

Taking antihypertensive medication-controlling or co-operating with patients?

Int J Cardiol 1995;47:257-68.

17.

Clark P. , Noreen M. Dodge M. , Julia A. Exploring self-efficacy as a predictor of disease management. Health Educ Behav 1999;26:72-98.

18.

Meland E. , Maeland JG , Laerum E. The importance of self-efficacy in cardiovascular risk factor change. Scand J Public Health 1999;27:11-7.

19.

Bandura A. The primacy of self-regulation in health promotion . Applied Psychol 2005;54:245-54.

20.

Jackson L. , Leclerc J. , Erskine Y. , Linden W. Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors 10.1136/hrt.2004.045559. Heart 2005;91: 10-4.

21.

Senecal C. , Nouwen A. , White D.

Motivation and dietary self-care in adults with diabetes: are self-efficacy and autonomous self-regulation complementary or competing constructs?

Health Psychol 2000 ;19:452-7.

22.

Mildestvedt T ME , Eide GE No difference in lifestyle changes by adding individual counselling to group-based rehabilitation RCT among coronary heart disease patients. In. Scand J Public Health 2007;35:591-8.

23.

Beck A. , Rush AJ , Shaw B. , Emery G. Cognitive therapy of depression. New York: The Guilford Press; 1979.

24.

Mildestvedt T. , Meland E. Examining the ``Matthew effect'' on the motivation and ability to make lifestyle changes in 217 heart rehabilitation patients . Scand J Public Health 2007;35: 140-7.

25.

Maeland JG , Havik OE Self-assessment of health before and after a myocardial infarction. Soc Sci Med 1988;27: 597-605.

26.

Ryan RM , Connell JP Perceived locus of causality and internalization: examining reasons for acting in two domains. J Pers Soc Psychol 1989;57:749-61.

27.

Havik OE , Maeland JG Patterns of emotional reactions after a myocardial infarction. J Psychosom Res 1990;34 (3):271-85.

28.

Cortes O. , Arthur HM Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review. Am Heart J 2006;151:249-56.

29.

Beswick AD , Rees K. , West RR , Taylor FC , Burke M. , Griebsch I. , et al. Improving uptake and adherence in cardiac rehabilitation: literature review. J Adv Nurs 2005;49: 538-55.

30.

Williams GC , McGregor HA , Sharp D. , Levesque C. , Kouides RW , Ryan RM , et al. Testing a self-determination theory intervention for motivating tobacco cessation: supporting autonomy and competence in a clinical trial. Health Psychol 2006;25:91-101.

31.

Isaacs AJ , Critchley JA , Tai SS , Buckingham K. , Westley D. , Harridge SD , et al. Exercise evaluation randomised trial (EXERT): a randomised trial comparing GP referral for leisure centre-based exercise, community-based walking and advice only. Health Technol Assess 2007;11:1-165iii-iv.

32.

Moore SM , Charvat JM , Gordon NH , Pashkow F. , Ribisl P. , Roberts BL , et al. Effects of a CHANGE intervention to increase exercise maintenance following cardiac events. Ann Behav Med 2006 ;31:53-62.

33.

Marks R. , Allegrante JP , Lorig K. A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: implications for health education practice (part I). Health Promot Pract 2005;6: 37-43.

34.

Williams GC , Gagne M. , Ryan RM , Deci EL Facilitating autonomous motivation for smoking cessation. Health Psychol 2002;21:40-50.

35.

Williams GC , Grow VM , Freedman ZR , Ryan RM , Deci EL Motivational predictors of weight loss and weight-loss maintenance. J Pers Soc Psychol 1996;70:115-26.

36.

Baranowski T. , Anderson C. , Carmack C.

Mediating variable framework in physical activity interventions. How are we doing? How might we do better?

Am J Prev Med 1998;15:266-97.

37.

Bach Nielsen KD , Dyhr L. , Lauritzen T. , Malterud K. Long-term impact of elevated cardiovascular risk detected by screening. A qualitative interview study. Scand J Prim Health Care 2005;23:233-8.