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The Cardiac Rehabilitation Inventory: A New Method of Tailoring Patient Support

Micklewright, Dominic PhD; Northeast, Laura MSc; Parker, Penny MSc; Jermy, Michelle MSc; Hardcastle, Jane PhD; Davison, Ruth BSc; Sandercock, Gavin PhD; Shearman, Jeremy PhD

The Journal of Cardiovascular Nursing: March/April 2016 - Volume 31 - Issue 2 - p 175–185
doi: 10.1097/JCN.0000000000000220
ARTICLES
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Background: Uptake and adherence to cardiac rehabilitation (CR) are low, and a contributing factor to this may be the practical difficulties of providing a tailored CR environment suited to individual preferences and needs.

Objective: The aim of this study was to develop and test a short questionnaire that CR practitioners can use to understand individual patient need and tailor support accordingly.

Methods: A conceptual framework of engagement in CR was derived from a comprehensive literature review and the content analysis of semistructured interviews with 15 CR patients. The conceptual framework was used to construct the first version of the Cardiac Rehabilitation Inventory (CRI), which comprised 42 items. Responses on the CRI were measured using a 5-point Likert scale. The CRI was administered to 380 phase III and IV CR patients, and factor analysis (FA) was used to identify salient CR engagement factors.

Results: The simplest structure found using FA was three 6-item subscales that all had good levels of internal consistency (Cronbach’s α) and were labeled (a) outcome anxiety, α = .726; (2) process anxiety, α = .724; and (3) autonomy, α = .653. The 3-factor CRI model was verified using confirmatory FA (CMin/df = 3.2, root-mean-square error of approximation = 0.073). Attenders were found to have higher levels of outcome anxiety than nonattenders (P < .001), and precontemplator nonattenders were found to have lower autonomy compared with attenders (P < .001). Standard multiple regression analysis indicated outcome anxiety was a strong predictor of CR intentions (r2 = 0.716), followed by autonomy (r2 = 0.110) and process anxiety (r2 = 0.031).

Conclusions: The CRI is a reliable method of measuring CR outcome anxiety, process anxiety, and autonomy. These CRI measurements provide rehabilitation practitioners with valuable information that can help provide individual tailored support.

Dominic Micklewright, PhD Dean of Academic Partnerships, School of Biological Sciences, University of Essex, Colchester, United Kingdom.

Laura Northeast, MSc Lecturer, School of Sport, Equine and Animal Sciences, Writtle College, Writtle, Essex, United Kingdom.

Penny Parker, MSc Cardiac Rehabilitation Nurse Specialist, North East Essex Primary Care Trust, Colchester, Essex, United Kingdom.

Michelle Jermy, MSc MSc Graduate, School of Biological Sciences, University of Essex, Colchester, United Kingdom.

Jane Hardcastle, PhD Senior Lecturer, Christchurch Polytechnic Institute of Technology, Christchurch, Canterbury, New Zealand.

Ruth Davison, BSc Cardiac Rehabilitation Nurse Specialist, Christchurch Hospital, Canterbury District Health Board, Christchurch, Canterbury, New Zealand.

Gavin Sandercock, PhD Reader, School of Biological Sciences, University of Essex, Colchester, United Kingdom.

Jeremy Shearman, PhD Head of Department of Applied Sciences and Allied Health, Christchurch Polytechnic Institute of Technology, Christchurch, Canterbury, New Zealand.

All authors have read and approved of the manuscript. This work has not been presented or published in any other form.

The authors have no funding or conflicts of interest to disclose.

Correspondence Dominic Micklewright, PhD, School of Biological Sciences, University of Essex, Wivenhoe Park, Colchester, Essex, United Kingdom CO4 3SQ (dpmick@essex.ac.uk).

Coronary heart disease (CHD) is the leading cause of premature death worldwide,1 and cardiac rehabilitation (CR) is advocated as a method of primary and secondary prevention.2–4 Cardiac rehabilitation is usually delivered by a multidisciplinary team of healthcare professionals5 and involves medical evaluation, risk stratification, education, exercise, and counselling.3 Exercise-based outpatient rehabilitation aims to evoke lifestyle change by increasing functional capacity, changes that are consolidated during community-based CR. Although the cost of CR can vary,6 overall, it remains a cost-effective CHD intervention.6–9

Cardiac rehabilitation improves patient health and reduces premature mortality,10–12 although the recent UK Rehabilitation After Myocardial Infarction Trial study12 reported no improvement in all-cause mortality among acute myocardial infarction patients. Attempts to “standardize” CR interventions in many studies may have empirical merit but somewhat contradict the recommendation to develop individualized CR plans.4 This approach may attenuate the therapeutic potential of CR, resulting in an underestimation of potential health outcomes as reported in Rehabilitation After Myocardial Infarction Trial.13 Threats to the effectiveness of CR include poor program uptake, adherence, and engagement.6,14–17 Less than 23% of UK myocardial infarction patients participate in CR,18 and adherence among attendees is poor, with 20% dropping out within 3 months and up to 40% dropping out within 6 months.19 Although poor uptake may be attributable partly to a lack of resources, a variety of other patient factors have also been identified, including indifferent attitudes toward CR or a lack of perceived control in the CR process.20–22

Some attempts to explain varying levels of engagement in health behaviors have focused on intention formation and, in particular, social and psychological factors that influence intention formation. The Theory of Planned Behaviour,23 which has been found to account for 30% of the variation in CR intentions24 as well as a good predictor of other health behaviors,25 places emphasis on individual attitudes toward the behavior, normative beliefs about the behavior, and perceptions of their control over the behavior. Interventions designed around the Theory of Planned Behaviour have been found to increase physical activity,26 suggesting the value in tailoring support according individual beliefs and perceptions of control. The Transtheoretical Model27 describes 5 stages of behavior change that attempt to account for those most unwilling or unready to change (precontemplators), those open to the idea of change (contemplaters), those imminently about to change (preparers), those who have recently changed (actors), and those who have changed for at least 6 months (maintainers). One way to individualize CR is to vary the type of support according to what stage an individual is in. However, the level of understanding about the specific needs of nonattendees (precontemplators, contemplators, and preparers) is much less than for attendees (actors and maintainers), and instruments for assessing such needs in the context of CR are also lacking.

The UK National Service Framework for CHD4 states that a systematic approach should be used to assess individuals’ risks and needs for CR and that individualized plans should be developed to meet those needs. Individualization of CR is important because it has been found to reduce the likelihood and length of hospitalization,28 perhaps because the process of discussing individual support with participants improves their self-efficacy.29 However, there is currently no standardized method of performing such individual assessments, especially once discharged from hospital. Appendix A of the National Service Framework30 provides audit tools recommended by the British Cardiac Society and the Royal College of Physicians and also suggests that the Hospital Anxiety and Depression Scale31 of Dartmouth Co-Op Charts might be used to assess the psychological needs of CR patients. These methods undoubtedly have their uses in CR; however, because they are general scales, they lack the specific CR focus needed to identify and cater for individual patient needs. There is a need for a CR-specific method of making early assessments of CR patients needs so that salient information is available to develop appropriate individual support in ways that improve CR uptake, adherence, and engagement.

The aim of this study was to develop and test a short CR inventory (CRI) that practitioners can use to understand individual CR needs of patients and to tailor their support during CR accordingly. The development of the scale, involving interviews with CR patients and the writing of a pool of questionnaire items, was conceptually driven by the Theory of Planned Behaviour,23 in the sense that interviewees and respondents were asked about matters relating to their attitudes and intentions toward CR. From this conceptual basis, the aim of this study was to develop a new questionnaire that would measure CR-specific constructs that are most pertinent to intentions toward and engagement with CR. It is hoped that the information that the resulting questionnaire can provide will help CR practitioners with an evidence-based method upon which to identify individual patient needs and provide focused tailored support.

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Method

Design

The CRI was developed in 4 stages. A comprehensive literature review (stage 1) and semistructured interviews with 15 CR patients (stage 2) were both used to build a conceptual framework of differing patient preferences and CR needs. The conceptual framework was used to develop the first draft of the CRI that was administered to 380 CR patients (stage 3). Factor analysis was used to reduce the number of CRI items and identify key engagement factors in CR (stage 4).

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Stage 1: Literature Review

A search of journal literature published between January 1970 and December 2007 was carried out using the key terms cardiac rehabilitation and adherence (the latter keyword to reduce the wide scope of research retrieved, for greater specificity) in the computer databases CINAHL, Sports Discus, Web of Knowledge, PsychINFO, PubMed, Medline, and The Cochrane Library. CINAHL retrieved 1389 hits for cardiac rehabilitation and 84 hits for cardiac rehabilitation and adherence, respectively; Sports Discus, 720 and 18 hits; Web of Knowledge, 6676 and 173 hits; PsychINFO, 23 and 172 hits; PubMed 12747 and 225 hits; Medline, 2509 and 94 hits; and Cochrane 5676 retrieved hits for both keywords. Reference lists of specifically relevant articles were scanned for any further useful studies.

From the initial database search, 54 articles were identified as directly relating to adherence and engagement with CR, each of which was read in detail to identify key themes. The key themes affecting engagement in CR that were identified from the literature review in stage 1 were demographic mediators, situational/social influences, psychological factors, illness-related influences, and the CR environment. An overview of the literature used to generate CRI items is presented in Supplement 1 (http://repository.essex.ac.uk/id/eprint/12464).

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Stage 2: Semistructured Interviews

Semistructured tape-recorded interviews, lasting approximately 30 minutes, were conducted with 15 patients (11 men and 4 women; age, 69.5 ± 12.8 years) recruited from a UK community–based CR program. Each interview comprised a series of open questions designed to elicit views, opinions, beliefs, and attitudes about CR based upon the themes identified in the literature review and components of the Theory of Planned Behaviour.23 Interviews were transcribed, from which 514 salient statements were extracted and categorized in relation to each of the themes. On this basis, it was possible to further develop subcategories under each theme, which were then used to construct the preliminary CRI. The conceptual framework, presented as themes and subcategories, is given in Supplement 1 (http://repository.essex.ac.uk/id/eprint/12464), and the initial pool of CRI items is organized according to the framework components. Interviewee sources are also mapped against each CRI item in Supplement 1 (http://repository.essex.ac.uk/id/eprint/12464).

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Stage 3: Cardiac Rehabilitation Inventory Development and Administration

The initial CRI version comprised 11 items to gather demographic information, an item to identify Transtheoretical Model27 stage of change, and 42 Likert statements that were representative of the literature review and interviews. After agreeing on the topic of the 42 items, 2 of the authors independently wrote each CRI item, taking care to avoid ambiguities, educational bias, demand effects, prestige bias, and acquiescence effects in the wording. The independently written items were compared and then a finalized version of each item was agreed upon, sometime after further revision. Items on the CRI were sequenced in a way to minimize order-presentation bias as best as possible. Items were individually printed and then the ordering, conducted jointly by 2 of the authors, was achieved through iteration.

A 5-point Likert response set was used for each item: strongly agree, agree, undecided, disagree, and strongly disagree. Each response was given a score ranging from 0 to 4, with positive items receiving a score of 4 for strongly agree responses and 0 for strongly disagree responses. Negative CRI items were reverse scored so that strongly disagree responses received 4 and strongly agree responses received a score of 0. A Likert scale was chosen because it is a closed scale that can be easily scored and because, since attitudes towards aspects of CR came out strongly during the development of the conceptual framework, Likert scales are widely regarded as the most effective method of attitudinal measurement.

The CRI was administered face to face on an individual basis to 418 community-based CR patients from 11 CR sites in the United Kingdom (n = 320) and 1 CR site in New Zealand (n = 98). Respondents were eligible to participate if they had been treated or diagnosed with any coronary heart or circulatory disease or had been referred to CR because of hypertension, hypercholesterolemia, or morbid obesity. The CRI was administered using large black-and-white font and special provision was made to help patients who, for whatever reason, were unable to read the CRI or write down their responses. Only English-speaking respondents were recruited and they were free to withdraw at any time. For 319 of the respondents, the CRI was administered during the first 6 weeks of their community-based CR program. The remaining 99 respondents had been attending CR for at least 6 months.

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Stage 4: Cardiac Rehabilitation Inventory Missing Item Analysis, Data Reduction, Reliability and Validity of the Cardiac Rehabilitation Inventory

All data analysis was conducted using SPSS v 19 (IBM Inc, New York). Of the 418 respondents, 38 had returned their questionnaires with missing responses. In total, there were 119 missing responses, amounting to 0.68% in a total item matrix of 17 556 (418 respondents × 42 items). Missing items were filled using iterative Markov chain Monte Carlo multiple imputation methods incorporating linear regression to scale variables. In the imputation model, minimum and maximum filled values were constrained from 0 to 4, respectively, and rounding was set to produce whole numbers only, thus ensuring the filled values corresponded with the CRI response scoring system. Ten iterations were required before all missing data were filled.

The identification of subscales was conducted by using factor analysis of the 42 CRI items in accordance previously described methods.32,33 Sampling adequacy was assessed using the Kaiser-Meyer-Olkin statistic, and Bartlett test was used to check sphericity. A scree analysis was conducted to determine the appropriate number of factors to extract, which is advocated as a reliable method.32 After considering the unrotated solution, 5 different methods of rotation were attempted (varimax, direct oblimin, quartimax, equamax, and promax) to determine which one produced the most distinct factors with items that did not load on other components. It was decided to retain an equal number of items in each of the CRI subscales, and this was determined by the number of items in the smallest factor identified that had a loading of greater than 0.3.

The reliability of each CRI subscale was evaluated using Cronbach’s α (internal consistency) as well as split-half reliability with a Spearman-Brown correction. Validity of the resulting CRI component structure was tested using confirmatory factor analysis in AMOS version 22 (IBM, New York). In the first instance, goodness of fit was evaluated using χ2, but given its sensitivity to sample size, such a measure is considered an overstringent criterion.34 Therefore, additional goodness-of-fit indices were also used, including CMIN/degrees of freedom (CMIN/df), root-mean-square error of approximation with 90% confidence intervals, and P values (PClose). Validity of the 3 subscales was also evaluated by standard linear multiple regression analysis to assess how well each identified CRI subscale predicted CR intentions (calculated as the sum of items 10, 18R, 19R, 22R, 27R, 29R, 34, 36R, 49R, with R denoting reverse scored items; Supplement 1, http://repository.essex.ac.uk/id/eprint/12464). Further validation of the CRI was established using 1-way analysis of variance and Tukey post hoc tests to compare CRI subscale outcomes between respondents who were categorized according to 5 stages of engagement with CR. The 5 engagement categories, which corresponded with the Transtheoretical Model stages of change,27 were precontemplaters (no intention of attending within the next 6 months), contemplaters (would consider attending but am not ready), preparers (would like to attend within the next month), actors (recently attended), and maintainers (have been attending regularly for some time and intend to continue).

Differences in CRI outcomes and intentions between demographic groups were analyzed using independent-samples t tests for gender and cohort (United Kingdom vs New Zealand) and 1-way analysis of variances for age group, ethnicity, education status, employment status, and access to transport. An α level of .05 was used to indicate significance. Where there were significant analysis of variance outcomes, post hoc Tukey tests were conducted.

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Results

Cardiac Rehabilitation Inventory Data Reduction Using Factor Analysis

The 42 CRI items were subjected to factor analysis to identify salient factors of CR engagement (Table 1). Sampling adequacy was indicated by a Kaiser-Meyer-Olkin value of 0.857 and significant Bartlett test of sphericity (χ2861 = 5121, P < .0001). Twelve factors were revealed with an eigenvalue exceeding 1, but after inspecting the scree plot, only 3 were retained for further analysis. The 3 factors accounted for 31.2% of the overall variance in CRI scores (component 1, 19.5%, eigenvalue = 8.2; component 2, 7.1%, eigenvalue = 3.0; component 3, 4.6%, eigenvalue = 1.9). Equamax orthogonal rotation with Kaiser normalization produced the simplest structure and the fewest number of CRI items loading heavily on more than 1 factor. Six items with the highest rotated coefficients were retained for each component, thus reducing the total number of CRI items to 18. The wording of the retained items were inspected and then component 1 was labeled “outcome anxiety”; component 2, “process anxiety”; and component 3, “autonomy.” Good levels of internal consistency, calculated using Cronbach’s α and split-half Spearman-Brown coefficients (rSB), were found for each CRI component (outcome anxiety, α = .726, rSB = 0.731; process anxiety, α = .724, rSB = 0.706; autonomy, α = .653, rSB = 0.603). Cronbach’s α for all 18 retained items was .825. The revised 18-item CRI structure with component labels, rotated component coefficient values, and Cronbach’s α values are provided in Table 2. The final version of the CRI with guideline for its administration is given in Supplement 2 (http://repository.essex.ac.uk/id/eprint/12463).

TABLE 1

TABLE 1

TABLE 2

TABLE 2

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Confirmatory Factor Analysis

The 3-factor structure for the CRI was tested using confirmatory factor analysis using the maximum likelihood estimation method. Outcome anxiety, process anxiety, and autonomy were entered into the model as latent variables; each was connected to their corresponding 6-component CRI items that were entered as observed variables. This model converged but, as typically expected with large samples,34 produced a poor global χ2 test outcome (χ2132 = 426, P < .001). Other accepted goodness-of-fit estimates34 for the model were adequate (CMin/df = 3.2, root-mean-square error of approximation = 0.073 with 90% confidence interval, 0.065–0.081, PClose < .001).

In an attempt to strengthen the fit of the model, a 2-factor model was created by repeating the factor analysis. This simplest 2-factor structure with no cross-loading of items between components was found using Oblimin rotation with Kaiser normalization (factor 1, items 45, 46, 54, 40, 37, 41, 51, and 31 with α = .825 and rSB = 0.811; factor 2, items 16, 15, 14, 23, 17, 34, 53, and 43 with α = .669 and rSB = 0.628). The 2-factor structure was also tested using confirmatory factor analysis, but this did not improve the goodness of fit of the model (χ2103 = 321, P < .001; CMin/df = 3.1, root-mean-square error of approximation = 0.071 with 90% confidence interval, 0.062–0.080, PClose < .001). Consequently, the original 3-factor CRI structure was accepted; the confirmatory factor analysis model with standardized regression weights (factor loadings) is presented in the Figure.

FIGURE. C

FIGURE. C

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Multiple Regression Analysis of the Cardiac Rehabilitation Inventory

The total amount of variance (adjusted r2) in CR intentions that could be explained by the revised CRI was 57.5% (r2 = 0.575; F3, 414 = 189, P < .0001). Outcome anxiety accounted for 71.6% of variance in CR intentions (adjusted r2 = 0.716, β = 1.0, t = 20.3, P < .0001), process anxiety accounted for 3.1% of the variance (adjusted r2 = 0.031, β = .04, t = 0.9, P = .369), and autonomy accounted for 11.0% of the variance (adjusted r2 = 0.110, β = .17, t = 3.4, P = .001).

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Demographic Categories, Cardiac Rehabilitation Inventory Outcomes, and Cardiac Rehabilitation Intentions

Respondent Cohort Comparisons

Between the UK and NZ cohorts, there were no differences in the proportion of age categories (χ24 = 4.2, P = .373) or the proportion of men and women (χ21 = 0.6, P = .455). However, there were differences between the UK and NZ cohorts in the representation of ethnic groups (χ25 = 11.6, P = .04), educational achievement (χ24 = 22.3, P < .001), employment status (χ24 = 124.1, P < .001), access to transport (χ24 = 16.2, P = .003), and Transtheoretical Model stage of change (χ24 = 42.4, P < .001). Frequency and percentage data for each demographic category are presented in Table 3.

TABLE 3

TABLE 3

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Demographic Category Comparisons

Differences for outcome anxiety were found between the United Kingdom and New Zealand (t416 = 3.5, P < .001) and between age groups (F4, 392 = 3.6, P = .007), access to transport categories (F4, 393 = 4.1, P = .003), and stage of change categories (F4, 417 = 20.6, P < .001). For process anxiety, differences were found between age groups (F4, 392 = 5.2, P < .001), ethnic groups (F5, 394 = 3.5, P = .004), and access to transport categories (F4, 393 = 5.8, P < .001). Autonomy differences were found between the UK and NZ cohort (t416 = −2.2, P = .03), age groups (F4, 392 = 5.1, P < .001), and stage of change categories (F4, 417 = 2.9, P = .021). Differences in CR intentions were found between age groups (F4, 392 = 4.5, P = .002), access to transport categories (F4, 393 = 2.5, P = .041) and, as expected, strongly according to stage of change (F4, 417 = 57.3, P < .001). There were no other CRI outcome or CR intention differences among demographic groups. All CRI and intention outcomes, with Tukey post hoc comparisons, are presented in Table 3.

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Discussion

Outcome anxiety, process anxiety, and autonomy were identified as important constructs of CR engagement and were found to be a good predictor of CR intentions. We labeled the first CRI subscale outcome anxiety because the items focus on beliefs about experiencing negative outcomes either as a direct or an indirect consequence of CR. We would define outcome anxiety in this context as apprehensive feelings, thoughts, or dispositions about the consequences of participating in CR. Interestingly, this construct is similar to the feelings of fear and anxiety that some patients attribute to limiting their physical activity.35 Process anxiety differs in that it represents feelings, thoughts, and dispositions of apprehension that are specifically associated with the CR intervention itself. This CRI subscale perhaps reflects some of the barriers to participating in CR that have been identified by others, such as low self-efficacy,36 worries about exercising in front of others,20,37,38 and kinesiopohbia (fear of movement).39 The final CRI subscale, autonomy, focuses on the agency patients feel to be able to improve their prognosis by developing a better understanding of their condition, participating in CR, and implementing other lifestyle changes. Autonomy is perhaps an indication of participants’ proclivity to take an active role and responsibility for their rehabilitation, which, as indicated in a previous study,24 is associated with a sense of control. A recent systematic review revealed that patients who view their condition as symptomatic, as controllable, and with severe consequences and who feel that they understand their condition are more likely to attend CR.40

Outcome anxiety accounted for just under three-quarters of the variance in CR intentions. We also found that CR attendees (actors and maintainers) had significantly greater outcome anxiety compared with nonattenders (precontemplators, contemplators, and preparers). Clearly, those not attending CR have no reason to be anxious about an outcome of something they are not doing, but what our results do highlight is than during the initial period of CR uptake, attendees may experience an increase in anxiety about the effects of CR on their condition and health. Individual support might then focus on reducing outcome anxiety because dropout rate is greater among those with elevated levels of anxiety.41

Process anxiety was a poor predictor of CR intentions, but respondents younger than 60 years were found to be less anxious about CR processes than were older respondents. Given that age is a known barrier to CR uptake and adherence,19–22 more effective age group support might focus on reducing process anxiety. Examples of how this might be achieved include varying the induction process, refining age-appropriate activities, or using peer buddies or CR mentors. These or other similar methods might also help increase feelings of autonomy, which, somewhat unsurprisingly, were found to be lowest among those older than 70 years.

Autonomy, measured using the CRI, accounted for only 11% of CR intentions but was lowest among the precontemplators. Most CR guidelines focus on support for those already attending CR, but much could be done to better understand how to support and encourage nonattenders, especially given the recent added importance placed on improving uptake and adherence.42 Although it is not possible to say how strong an influence low autonomy has on the decision not to participate in CR, it might be that efforts to support self-efficacy, locus of control, and autonomy could help such individuals move out of a precontemplative stage.

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Practical Cardiac Rehabilitation Inventory Recommendations to Support Individual Patient Needs

By convention, CR is structured according to patient clinical status or risk stratification,5 and it is less common to provide further tailoring around psychosocial factors despite substantial evidence of their importance to uptake and adherence.10,11,13,16–20 Tailoring CR according to individual preference, choice, and psychosocial factors has been advocated in a variety of studies, reviews, and guidelines.3,4,7,18–20,24,35,43,44 The remainder of this discussion will focus on how the CRI can be used to determine individual patient needs and some of the practical steps that can be taken to accommodate those needs.

Administering the CRI to CR attendees should be carried out at the earliest opportunity, once it is known they will be referred for CR and regardless of whether the person intends to uptake CR or not. As previously discussed, it is especially important to engage with precontemplators, and the CRI will provide information that can help in supporting the particular needs of this group of patients. First, it is important to gather early information upon which individual needs can be accommodated in any subsequent CR plan. Second, the process of administering and discussing CRI outcomes provides an opportunity for collaborative interaction with the practitioner, which, in itself, should help to develop genuine feelings of agency, confidence, and individuality among attendees. Further detailed guidelines on how to interpret CRI responses are provided in Supplement 2 (http://repository.essex.ac.uk/id/eprint/12463).

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Supporting High Outcome Anxiety, High Process Anxiety, or Low Autonomy

After completing the CRI, each respondent will have profile of scores for the 3 components. Generally speaking, lower outcome anxiety scores, lower process anxiety scores, and higher autonomy scores are good. Respondents could score poorly in an individual component or any combination of components. The extent of their needs will be broadly proportionate to both the number of components that they score poorly in as well as the magnitude of each score. Once the CRI profile for a respondent has been established, attempts should be made to negotiate a CR program with them that corresponds with their individual needs. This kind of accommodation and intervention should have a preservative influence on CR intentions and, as suggested in other studies, engagement and adherence behavior.11–13,16–20,37,38,40

Those with high outcome anxiety may be reluctant to persist with CR because of feelings of vulnerability and an irrational fear that CR will exacerbate their prognosis. As noted earlier, those attending CR have high outcome anxiety than nonattendees do; therefore, once an individual agrees to attend CR, help should be provided to prepare them for the increase in anxiety that they will most likely experience. Once they have started, support should focus on reducing outcome anxiety. It may be advantageous for such individuals to begin CR by attending education sessions before any involvement in exercise in an attempt to redress irrational beliefs and assuage their anxiety. Those with high process anxiety may feel unfamiliar, uncomfortable, or intimidated by the group or exercise environment associated with CR, and as we have reported, older individuals appear to be particularly prone to these feelings. Such individuals may benefit from having a progressive introduction to CR that perhaps first involves watching an exercise session, meeting other CR participants in a nonexercising context, and having a mentor who is an existing participant. It may also be beneficial to take into consideration their individual preferences with respect to types of exercise and gender groups. Those who have low autonomy scores are likely to have a high external locus of control, resulting in greater dependency on others and passive engagement in CR. In some instances, it will be possible to address low autonomy by simply helping with the practical matters, such as CR travel, timing, location, and subsidization. For other individuals, a lack of autonomy might be improved by involving them in decision-making processes about their CR, offering them a choice, and then getting them to reflect on the outcomes of their choices. These suggestions of how to address high anxiety and low autonomy are by no means exhaustive but rather examples of how practitioners might use CRI information to provide appropriate levels of individual support. The overarching principle is to tailor support according to individual need, and the CRI can provide some of the information needed in this process.

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Limitations

There are several limitations to the CRI development work presented in this article. First is the need for more extensive validity testing against actual attendance and engagement with CR. Although we have shown that CRI measurements differ between respondents at different stages of change, what is now needed is to perform a large-scale validation study to assess whether the 3 CRI constructs have any predictive, discriminant, or concurrent validity against actual CR engagement. A further study is also needed to assess whether interventions involving CRI informed tailored support improves the uptake and ongoing engagement with CR. Another limitation, evident in Table 3, is that certain demographic groups were underrepresented in our study. In particular, we would like to see better representation of women, nonwhite ethnic groups, and pre-retirement age groups in further CRI studies. In addition, the inclusion of other demographic information in future studies would also improve the validity of the CRI, such as marital status, primary CHD diagnosis, and history of CHD.

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Conclusions

We have developed the CRI, which can be used to identify individual needs of individual CR patients with respect to 3 dimensions of outcome anxiety, process anxiety, and autonomy. The CRI and its subscales were found to be reliable. Differences in CRI outcomes were found between those at different Transtheoretical Model stages of change, helping to validate the scale. Although we recognize that further validity testing is needed, the CRI is a useful instrument that can furnish CR practitioners with the information they need to tailor the CR environment and program according to individual needs. The CRI has heuristic potential in terms of future implementation and could impact on meaningful client outcomes and future CHD preventative strategies.

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What’s New and Important

  • Outcome anxiety, process anxiety, and autonomy are useful constructs in attempting to understand the individual needs of community-based CR patients.
  • The CRI is an evidence-based short questionnaire that can help CR practitioners to identify the individual needs of their patients.
  • The CRI has heuristic potential in terms of future implementation and could impact on meaningful client outcomes and future coronary heart disease preventative strategies.
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Keywords:

cardiovascular diseases; exercise; questionnaires; rehabilitation

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