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A Behavior Change Intervention for Women in Cardiac Rehabilitation

Beckie, Theresa M. PhD, RN, FAHA

The Journal of Cardiovascular Nursing: March-April 2006 - Volume 21 - Issue 2 - p 146-153
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There is undeniable evidence for physical and psychosocial benefits of cardiac rehabilitation programs for individuals suffering from coronary heart disease. Yet, fewer women than men are referred to, begin, or complete cardiac rehabilitation programs. The numerous logistical, economic, and motivational barriers to healthy behavior change place women at risk for subsequent CHD events. To close this gender gap and improve outcomes, novel, efficacious, and individualized rehabilitative approaches for women with coronary heart disease are needed. The purpose of this article is to describe a theory-driven behavioral intervention designed exclusively for women with coronary heart disease. The 12-week intervention is being tested in a randomized controlled trial involving women referred to a cardiac rehabilitation program. The tenets of the Transtheoretical Model of behavior change and motivational interviewing guided the development and implementation of the stage-matched, individualized intervention to promote healthy behavior change for women with coronary heart disease. The ongoing trial will examine the efficacy of the intervention on physiological and psychosocial outcomes.

Theresa M. Beckie, PhD, RN, FAHA College of Nursing, University of South Florida, Tampa, Fla.

The Women's-Only Phase II Cardiac Rehabilitation Program was funded by the National Institute of Nursing Research Grant RO1-07678-01A2. Members of the research team are acknowledged for their expertise and commitment.

Corresponding author Theresa M. Beckie, PhD, RN, FAHA, is an Associate Professor and Principal Investigator, College of Nursing, University of South Florida, MDC Box 22, 12901 Bruce B. Downs Boulevard, Tampa, FL 33612-4766 (e-mail: tbeckie@hsc.usf.edu).

Coronary heart disease (CHD) remains the leading cause of death and disability in North American women. Cardiovascular diseases (CVDs) claim the lives of more than half a million women each year-about 1 death per minute.1 Yet, most women have difficulty recognizing and modifying their risk for CVD.2 Only 13% of women cite heart disease as their greatest health threat and a mere 38% of women report their physicians ever discussing heart disease with them.3 Although at significant risk, women tend to be underserved in the area of cardiovascular health. Healthcare providers have important opportunities to educate women about CVD risks and provide efficacious interventions to reduce these risks.3

Cardiac rehabilitation (CR) programs play a significant role in reducing mortality, improving risk factors, meeting informational needs, and improving exercise capacity and psychosocial wellbeing.4-6 Of the millions of patients with CHD who are candidates for CR, only 5% to 20% typically participate, and most are men.7-14 Women often face overwhelming psychosocial and physical rehabilitative hurdles, yet fewer women than men are referred to, begin, or complete CR programs.6 The attendance of women who are referred is often sporadic because of family responsibilities or other logistical and economic barriers.15-21 Low participation in CR prevents women from attaining the multiple health benefits of these programs.5,22

To close this gender gap, and improve health outcomes, novel, efficacious, and individualized rehabilitative approaches for women with CHD are needed.14,23 These approaches include addressing the logistical barriers to attendance; redesigning rehabilitative services that are stage-matched, gender-sensitive, and reflect women's roles; attending to their unique health and interpersonal needs. The purpose of this article is to describe a theoretically based behavior change intervention designed exclusively for women that is currently being tested in a randomized controlled trial of women at one CR site.

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Background

Almost 3 million American women have a history of myocardial infarction and more than 400,000 are undergoing coronary artery bypass graft surgery or percutaneous coronary interventions each year.1 Yet, women continue to have more anginal symptoms and depression than do men after coronary interventions, with resultant limitations on their activities and quality of life.24 Compared to men, women's cardiac symptoms, risk factors, and recovery from acute cardiac events are more likely to result in adverse outcomes.24-27 The themes woven throughout the studies of women with CHD are powerlessness, role conflict, fear, depression, anxiety, guilt, denial, and anger.28-37 Additional themes include failure to recognize symptoms, lack of emotional support, and the importance of maintaining their caregiver and home management roles. Murray et al37 found that women with CHD had difficulties recognizing their cardiac symptoms and 35% reported they were initially misdiagnosed by their medical provider.

Efficacy research has demonstrated that CR produces multiple improvements in the short term, and reduces morbidity and mortality in the long term. It improves functional capacity, modifies CVD risk factors, slows the progression of the disease, and improves psychosocial functioning in men and women.4,5 Despite undeniable evidence for clinical, psychosocial, and economic benefits, referral and attendance rates are low, particularly for elderly and minority women.5,13,21 Women eligible for CR often live alone, receive little social support, endure multiple role strain, have significant financial concerns, have limited healthcare access, and perceive a limited choice of enjoyable activities.11-13,38 Women have poorer attendance related to comorbidities such as arthritis, anxiety and depression, and guilt related to family responsibilities. In addition, they often believe that CR programs are unnecessary or fail to meet their needs.37-43 The literature supports women's difficulties in initiating and maintaining exercise programs.44-47 Researchers found that despite experiencing a recent life-threatening cardiac event and having attended a CR program, some women never exercised again and only 50% were still exercising at the end of 3 months.46,47 For many women with CHD, a discussion of CR is never offered by their healthcare providers.3,28,31,48 Women's low participation in CR and poor representation in clinical trials have led to a paucity of data related to older women in CR.

The literature has largely focused on recovery from acute cardiac events from an androcentric perspective. Medically supervised exercise training has been the cornerstone of CR programs and the treatment protocols have traditionally been based on a male model of medicine, with women's health issues viewed as deviations from a male-defined norm. CR programs that are responsive to the social and cultural norms important to women with CHD and their need for individualized behavioral interventions may lead to improved physiological and psychosocial profiles than are currently evident in traditional CR programs.

It has been suggested that women with CHD require effective gender-sensitive rehabilitation programs individually tailored to their psychosocial needs with an emphasis on alleviating depression, meeting their physical needs to improve long-term adherence to positive lifestyle changes as well as increasing social supports by sharing their experiences exclusively with other women.23,29 A CR program that offers women individualized, theory-driven, behavior change interventions within a group setting may increase their self-efficacy to sustain healthy behaviors. Despite the growing evidence of psychosocial morbidity such as depression, anxiety, and poor social support, increased mortality, and suboptimal participation in CR programs, there is a paucity of evidence on effective gender-sensitive behavior change interventions that address the unique issues women with CHD encounter in their recovery.

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A Women's-Only Phase II Cardiac Rehabilitation Program: Conceptual Frameworks

The behavioral intervention designed for the ongoing randomized controlled trial of a women's-only CR program was based on the techniques of the Transtheoretical Model (TTM) and motivational interviewing (MI) (see Fig 1). TTM was chosen to guide the intervention because it utilizes stages of change or readiness as the central organizing construct. TTM has played an integral role in the development of MI,49 which is particularly beneficial for individuals who are ambivalent about behavior change.

FIGURE 1

FIGURE 1

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The Transtheoretical Model

The TTM is useful for explaining and predicting how and when individuals end high-risk behaviors and adopt healthy ones.50 TTM has been applied to, and demonstrated empirical support for, a number of health behaviors including smoking cessation,51 diabetes self-management,52 exercise adoption,53-58 and dietary fat intake reduction.58-60 It offers a promising approach to behavior change in CR, although it has not been formally tested for women in a randomized controlled trial. The model integrates 4 concepts central to change: (1) stages of change or readiness to act; (2) decision balance (pros and cons of changing); (3) self-efficacy (confidence to make changes in difficult situations); and (4) processes of change, which refers to 10 cognitive and behavioral strategies that facilitate change.61

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Stages of Change

In the first stage, precontemplation, individuals either deny they need to change their behavior, are unaware of the negative consequences of their behavior, believe the consequences are insignificant, or have given up the thought of changing because they are demoralized. These individuals are often unaware of the importance of healthy behaviors, such as the importance of physical activity in the secondary prevention of CHD. They often become defensive and resistant if pressured to take action in the next 6 months.

Those in the contemplation stage are more likely to recognize the benefits of changing unhealthy behaviors in the next 6 months, yet they continue to overestimate the costs of changing, and thus, are ambivalent and not ready to take action. Contemplators can remain stuck in this stage for long periods, substituting thinking for action. Indecision, low self-efficacy, and lack of commitment are characteristics of the contemplation stage.

Individuals in the preparation stage have decided to make a change in the next 30 days and have begun to take steps toward that goal. Those in the action stage are overtly engaged in modifying their behaviors or acquiring new behaviors and those in the maintenance stage have been able to sustain change for at least 6 months and are actively striving to prevent relapse.51

Few people progress linearly through the stages of change for problem behaviors.51 A cyclical pattern is more common: individuals reaching the action stage, relapse, and then recycle to an earlier stage of change. Relapse is common but the gains made before the relapse are preserved and subsequent action attempts are more likely to be successful.62 Relapse is viewed not as failure but as an opportunity to learn from previous mistakes and try new more successful strategies.

Stages of change also represent a temporal dimension reflecting how change unfolds over time. Without stage-matched, client-centered guidance in CR programs, women in the precontemplation stage can remain stuck as they overestimate the barriers of reducing their risk factors and underestimate the benefits. Although individuals in contemplation are intending to take action, their ambivalence can lead to putting off such action. Their rule of thought is "when in doubt, don't act."61 Those in the preparation stage are ready to take more immediate action. The better prepared they are, the more likely they are to reach their goal. The action stage is particularly demanding as individuals work hard for about 6 months to successfully reach their goal. After about 6 months, they progress into the maintenance stage and become more confident about reaching their goals.

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Decisional Balance

The decision to move toward action is based on the relative weight given to the pros and cons of changing. In precontemplation, the cons always outweigh the pros. From precontemplation to contemplation, the pros increase and the cons decrease from contemplation to action. The pros begin to outweigh the cons of changing prior to action being taken.50 For women not ready to begin eating healthy or increasing physical activity, enhancing the pros and decreasing the cons can help increase intentions to take the steps to be ready.

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Self-efficacy

Self-efficacy, or the degree to which one believes they have the capacity to make changes in difficult situations, can influence motivation.63 Self-efficacy in the TTM has 2 distinct but related components: confidence to make and sustain changes and temptation to relapse to an earlier stage. Like decision balance, levels of self-efficacy differ systematically across the stages of change, with those further along in the stages generally experiencing greater confidence. Self-efficacy has consistently been found to bean important correlate of physical activity.55,64 To increase self-efficacy, women are encouraged to set realistic goals, take small steps, and use stage-appropriate strategies.

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Processes of Change

Ten experiential and behavioral processes of change underlie the modification of problem behaviors and support the transition from stage to stage.50,51 The 5 experiential processes are internally focused on emotions, values, and cognitions, whereas the 5 behavioral processes are overtly focused on behavioral changes. Experiential processes include consciousness-raising, dramatic relief, environmental reevaluation, social liberation, and self-reevaluation. Behavioral processes include counterconditioning, helping relationships, reinforcement management, stimulus control, and self-liberation. The processes of change and the stages of change are integrally related; use of the experiential processes of change tends to peak in the contemplation or preparation stages, whereas use of the behavioral processes tends to peak in the action or maintenance stages.

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Motivational Interviewing

Motivational interviewing (MI) is defined as "a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence."49(p25) MI was developed within the context of alcohol-dependence treatment as an alternative to the classic addiction model of directly confronting patients and framing their resistance to change as denial. MI has since been shown to be effective across a range of health-related behaviors.65,66 For women with CHD, moving through the stages of change requires significant cognitive and behavioral effort; motivation provides the impetus for this effort and plays an important role in recognizing the need for and achieving successful behavior change.

The core philosophy of MI is the counselor style with collaboration as the key characteristic. The intent of MI is to diminish resistance to behavior change and increase intrinsic motivation. Communicating an attitude of acceptance and expressing empathy encompass the first principle of MI. The second principle emphasizes the importance of creating a discrepancy between an individual's current maladaptive behavior and a more adaptive behavior with the individual, not the counselor, identifying the reasons for and advantages of change. Rolling with resistance is the essence of the third principle. Argumentation or direct persuasion is considered counterproductive and is to be avoided, as it is likely to produce defensiveness or resistance. This principle directly opposes the more action-oriented, prescriptive strategies of behavior change often implemented in CR programs. The final principle is to support self-efficacy. The individual is seen as the responsible party for choosing and carrying out personal change.49

DiClemente and Velasquez67 argue that the TTM and MI are a natural fit with similar goals and strategies for behavior change. The most obvious connection between them is that the MI philosophy, approach, and methods are uniquely suited to addressing the tasks and emotional reactions of individuals who are moving through the first 2 stages of change.65,66 Precontemplators and contemplators are not ready to make a commitment, and are resistant to or ambivalent about more traditional behavior change approaches that encourage them to make changes for which they are not ready.68 MI offers women in CR an atmosphere that is conducive rather than coercive to healthy behavior change.

Burke et al65 conducted a meta-analysis and reported medium effect sizes for MI interventions for diet and exercise problem behaviors. A more recent meta-analysis of 72 randomized controlled studies, assessing the effectiveness of MI on such outcomes as blood cholesterol and blood pressure, found a significant effect in 74% of the trials.66 MI outperformed traditional advice-giving in about 80% of the studies. MI was designed to assist behavior change through brief encounters of only 15 minutes. There is reason to believe that MI has the potential to demonstrate a dose-response relationship66 and the extended contact with CR participants may reveal even greater effect sizes. MI might be particularly effective in increasing physical activity and healthy eating in women with CHD because these behaviors do not involve a physiological addiction that may complicate the change process.

Cardiac rehabilitation has historically been delivered as an action-oriented program with the assumption that all participants are ready and willing to act on reducing their risk factors. Applying the action paradigm to multiple behaviors, as is typical in CR, can overwhelm participants. The literature suggests that less than 10% of individuals with 4 health behavior risks, such as smoking and sedentary lifestyles, are ready to take action on even 2.50 Giving advice and prescribing behavior change are likely to produce resistance either passively through inaction or actively through argument or rationalization in the individual. Action is the most demanding stage of change and taking action on several behaviors at once may be too demanding for many women.

Traditional action-oriented CR programs may not be the most appropriate format for women, many of whom are not prepared to take action, as evidenced by the low uptake and completion rates. Stage-matched, client-centered interventions can have greater impact than one-size-fits-all programs by increasing participation and increasing the likelihood that individuals will take action. Stage-matched interventions allow all individuals to participate in the change process, even if they are not prepared to take action and can increase the likelihood that they will get to action. Stage-matched interventions have outperformed one-size-fits-all interventions for exercise acquisition, dietary behavior, and other health behaviors in population-based studies. Individualized, stage-matched interventions for women in CR may reduce resistance and the time needed to implement the change by accelerating movement toward the action stage. This stage-matched approach can benefit women who are ready to change a problem behavior as well as the majority of women who are neither prepared nor motivated to change.

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A Women's-Only Cardiac Rehabilitation Program

The women's-only CR program is being evaluated with women with CHD randomly assigned to either the women's-only, stage-matched intervention group or to a traditional mixed-gender CR program. The experimental intervention involves 10 psychoeducational sessions utilizing the TTM and MI strategies, social support, and 36 ECG-monitored exercise sessions over the course of 12 weeks.

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TTM Staging Assessment

Before implementing the intervention, the experimental group participants are assessed for their stages of change and they undergo their first face-to-face MI with a cardiovascular clinical nurse specialist trained in the behavioral intervention. The TTM expert system assessment69 involves a series of 3 computer reports generated at 0, 3, and 9 months for each of 3 behaviors (healthy eating, physical activity, and stress management). The 3- to 5-page report (for each behavior) is divided into 5 sections: The first section focuses on the stage of change and readiness to change behavior. The second section addresses pros and cons of changing, with feedback when necessary about underevaluating the pros of changing and/or overevaluating the cons. The third section provides feedback on the participants' use of change processes relevant to their stage of change. Participants are compared normatively on each change process with the most successful self-changers. For the 2 follow-up assessments, they are also compared to their prior assessment. The fourth section offers feedback on how to enhance self-efficacy in the most tempting situations. The last section consists of strategies for taking small steps to progress to the next stage. The expert system reports facilitate the match between the intervention strategies used and the participants' stage of change.

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Motivational Interviewing Sessions

The clinical nurse specialist conducts three 1-hour individualized MI sessions with each participant. The first occurs before beginning the group psychoeducational sessions, the second is implemented midway through the study, and the third at the end of the study. The participant's risk behaviors are explored with the nurse in terms of confidence, importance, and readiness to change. The nurse elicits the participant's arguments for change, affirms the right and capacity for self-directed goals setting, and confidence to cope with obstacles and succeed in change.

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The Psychoeducational Intervention

A 280-page psychoeducational manual based on TTM and MI was developed with the assistance of expert consultants and field tested in a pilot study of 13 women with CHD. The manual, divided into 8 sections, offers detailed information on the stages of change, and the processes of change with numerous homework exercises that personalize the strategies of change for the participants. Table 1 provides a brief summary of the TTM strategies the participants are taught in the first 2 sections of the manual. The 6 remaining sections of the manual provide evidence-based guidelines that are used as the vehicle for introducing and practicing the strategies of behavior change. Topics include CVD risk factors, medications, communication skills, stress management, and dietary and exercise guidelines.

TABLE 1

TABLE 1

The 10 psychoeducational group sessions attended by 8 participants at one time are facilitated by a clinical psychologist and the clinical nurse specialist trained in TTM and MI. The group format provides opportunities for social support, role playing, and group comment and reflection on motivation and importance for change emerging from group members in higher stages of behavior change. The participants' motivation and readiness are enhanced vicariously by listening to the challenges and successes of others. Stress-reducing strategies, such as progressive muscle relaxation, guided imagery, and deep breathing, are implemented at the beginning of each session.

The participants are guided in their progress toward self-selected goals for behavior change using MI (see Table 2). Advice is not given without the participants' permission, and when given, is accompanied by actively encouraging women to make their own choices. Participants are guided to make self-motivating statements, including the disadvantages of current behaviors, optimism for and advantages of healthy behavior change, and intention or commitment to change. The psychologist and the nurse selectively reinforce the participant's self-motivational statements, monitor readiness to change, ensure that resistance is not generated by jumping ahead of the individual, and affirm the individual's freedom of choice and self-determination. The goal is to increase women's intrinsic motivation so that change arises from within rather than being imposed from without.

TABLE 2

TABLE 2

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Summary

Evidence from the literature indicates that CHD in women is a major public health concern. Numerous published reports establish the underutilization and less than desirable health outcomes for women attending CR programs to reduce risk factors and improve healthy lifestyles. Several authors suggest the merits of designing and implementing CR programs designed exclusively for women to better meet their unique behavioral, psychosocial, and physical needs. Beyond gender sensitivity, women may benefit from a supportive, client-centered, and individualized intervention based on their level of motivation, self-efficacy, and commitment for behavior change. The aim of the women's-only CR program is to foster positive and sustained behavior change for women with CHD who are ready, willing, and able to change their behavior as well as those who are not yet. Guided by the change strategies of TTM and techniques of MI, the intent is to scientifically examine the efficacy of this approach given that few previous strategies have been successful in sustained behavior change in this subset of the population. To provide scientifically rigorous and theoretically based gender-sensitive interventions targeted to improving the heart health of women, there is an urgent need for studies that identify effective strategies that increase the intrinsic motivation for women most at risk for dying.

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Keywords:

cardiac rehabilitation; coronary heart disease; motivational interviewing; stages of change; women

© 2006 Lippincott Williams & Wilkins, Inc.