Evaluation of Motivation in Patients with Coronary Heart Disease Who Participate in Different Rehabilitation Programs

ABSTRACT

The purpose of this study was to evaluate “motivation in patients
with coronary heart disease, who participated in different rehabilitation
programs and those who did not participate.” Fifty-one (n=51) male patients
suffering from coronary heart disease participated in the present study.
Fifteen participated in a rehabilitation program in a gym; eighteen participated
in a swimming program and eighteen consisted of the control group. The
mean age of the participants was 60.83 (SD=±3.3). Participants completed
the Sport Motivation Scale (SMS). According to the results, patients who
participated in the gym program had statistically higher levels in IM
to knowledge, to stimulation, to accomplishment and EM to interjected
regulation. On the contrary, the control group had statistically higher
levels in EM to external regulation and motivation.

INTRODUCTION

Atherosclerotic cardiovascular diseases are the major cause of death
in middle-aged and older-adults in Europe and United States (BC Ministry
of Health and Ministry Responsible for Seniors, 1996; Giannuzzi et al.,
2003; Sarafino, 1990).

Cardiac Rehabilitation programs were first developed in the 1960s when
the benefits of ambulation during prolonged hospitalization for coronary
events had been documented. Exercise was the primary component of these
programs (Giannuzzi et al., 2003). Over the past 4 decades, numerous scientific
reports have examined the relationships between physical activity, physical
fitness and cardiovascular health (Cerubini, Lowenthal, Williams &
Aging Clinical and Experimental Research, 1997; Fletcher, Balady &
Amsterdam, 2001; Oldridge, et al., 1993; Pate et al., 1995). Randomized
clinical trials of exercise training showed improvement in coronary risk
factors such as blood pressure, body composition, fitness, lipid and lipoprotein
profiles (Dunn et al., 1997; European Hear Failure Training Group, 1998;
EUROASPIRE II Study Group, 2001; Myers, 2003; Rockhill, Willet & Manson,
2001). Swimming and exercise in a gym are included in the so-called coronary
sport groups; as endurance sports with training effects suitable for rehabilitation
(Lins et al., 2003).

Although exercise is considered to be the easiest type of rehabilitation
for patients with coronary heart disease (CHD), their maintenance into
exercise programs is difficult most of the times (Harlan et al., 1995).
Reported rates of uptake of cardiac rehabilitation range from 15% to 59%
(Gattiker, Goins & Dennis, 1992; Pell, Pell & Morrison, 1996).
Approximately 20-25% of patients dropout of exercise programs within the
first three months and about 40-50% within 6 to 12 months (Song et al.,
2000; Oldridge, 1998; Oldridge, 1982).

Psychosocial variables that were found to influence the entrance and
completion of a CR program include motivation, mood states, and social
support (Myers, 2003). Motivation consistently has been shown to be a
strong indicator of initiation and maintenance of participation in a CR
program. It was found that the people that seem to have lower levels of
motivation perceive more barriers or problems associated with their exercise
programs. (Dishman & Ickes, 1981; Evenson & Fleury, 2000). The
literature on physical rehabilitation frequently refers to patient motivation
in explaining differences in outcome among patient groups with similar
pathologies (King, Taylor & Haskel, 1993; Maclean, & Pound, 2000).
Several studies have lent empirical support to the hypothesis that patient
motivation is a determinant of rehabilitation outcome (Clark & Smith,
1997; King & Barrowclough, 1989; Oldridge & Stoedefalke, 1984;
Wolf, 1969).

In general, motivation expresses the needs and the wishes that regulate
the direction, the intensity and the continuation of a specific behavior
(Deci & Ryan, 1985). Deci and Ryan (1985) explained intrinsic and
extrinsic motivators and their influence on self-determination in their
theory of self-determination. Self-determination is a quality of human
functioning that involves the experience of a choice. An important distinction
concerning motivation in exercise and sports is the one between intrinsic
and extrinsic motivated behavior for participation (Ryan et al., 1984).
Intrinsic motivation (IM) refers to an individual who participates in
an activity simply for the satisfaction of doing so (Fortier, et al.,
1995). Intrinsic motivation has been postulated to have three separate
categories: IM to know, to accomplish things and to stimulation (Vallerand
& Losier, 1999; Vallerand, et al., 1989; Vallerand &Bissonnette,
1992).

Extrinsic Motivation (EM), on the other hand, is related to external
factors, such as rewards and punishment (Vallerand & Perrault, 1999;
Ryan & Deci, 2000). The three types of extrinsic motivation, from
the least self-determined to the most self-determined, are external regulation,
interjected regulation and identification (Ryan et al., 1990).

The third type of motivation, amotivation, is characterized by
the thought that actions have no control over outcomes (Deci & Ryan,
1985). In other words, amotivated individuals believe that forces out
of their control determine behaviors.

The specific purpose of this study was to examine the differences in
motivation between patients, who participated in different cardiac rehabilitation
programs and patients who did not participated.

METHOD

Sample

A sample of 51 male patients suffering from coronary heart disease was
selected and divided into 3 groups. Fifteen (n=15) participated in a rehabilitation
program in a gym, eighteen (n=18) participated in a swimming program and
eighteen (n=18) patients consisted of the control group. The participants
couldn’t choose the type of activity and all of them followed a
phase III cardiac rehabilitation program. The mean age of patients was
(mean±S.D. 60.83 ± 3.3).

Procedures

The sampling procedure required that the prospective subjects met the
following criteria: (1) having undergone cardiac-related procedures such
as coronary artery bypass graft surgery (CABG) or percutaneous transluminal
coronary angioplasty (PTCA); (2) able to participate in the cardiac rehabilitation
programs for more than 15 weeks (for the exercise groups) with an attendance
rate of more than 70%. Exclusion criteria were clinically unstable heart
failure, unstable arrhythmias and other exercise limiting concurrent condition
as skeletal or muscular disorders. All exercise patients followed the
routine 3 times per week for 45-90 minutes per session at an intensity
of 60-85% of the maximum heart rate (MHR).

The duration of the rehabilitation programs was 20 weeks. During the
20-week period, the type and intensity of exercise and heart rate and
blood pressure before, during and after exercise were recorded for all
subjects in the exercise groups. Exercise patients did not participate
in any other physical training.

Each training-session in the gym rehabilitation program consisted of
walking, cycling or running on an ergometer. It consisted of 10 minutes
warm–up, 10 minutes stretching and flexibility exercises, of 25
minutes endurance training with heart rate (HR) maintained on 60% – 85%
of the maximum heart rate (MHR) and 10 minutes cool–down.

The swimming exercise program included 10 minutes warm-up, 10 minutes
stretching and flexibility exercises in the pool, 12 minutes walking in
the pool with kickboards and barbell and 12 minutes running or walking
in the pool with alternative intensity in a distance of about 200-250m,
with heart rate (HR) maintained on 60% – 85% of the maximum heart rate
(MHR) and 10 minutes cool-down.

Permission to conduct the investigation was received from the local athletic
association and the individual coaches. Each participant took 10-15 minutes
to complete the questionnaire and responses to the instrument were kept
anonymous. The participants were advised to ask for help if confused about
either the instructions or the clarity of any particular item. No problems
were encountered in completing either of the inventories or understanding
the nature of the questions.

Questionnaire

Patients completed the Sport Motivation Scale (SMS) developed by Pelletier,
Fortier, Vallerand and Tuson (1995). The SMS consists of seven sub-scales
that measure the three types of motivation: intrinsic, extrinsic, and
amotivation. There are four items per sub-scale, thus there are a total
of 28 items being assessed. Each item represents a possible reason why
patients with coronary heart disease participated in an exercise rehabilitation
program. Subjects must rate the extent to which each item corresponds
to one of their participation motives on a seven-point Likert scale, ranging
from “not at all” (1) to “exactly” (7). The English
questionnaire is valid, consistent, and reliable. Pelletier et al. (1995)
found that the English translation of the questionnaire had a satisfactory
level of internal consistency. Additionally, correlations between the
subscales and confirmatory factor analysis have confirmed the determination
continuum and the construct validity of the scale (Pelletier, et al. 1995).

Statistical Analysis

The data was analyzed in two steps. First, internal consistency of subscales
was assessed using Cronbach alphas (Cronbach, 1951). Secondly, a one –way
MANOVA was used to determine if significant differences existed among
patients exercise groups and control group across the seven SMS subscales.
When the results of the one –way MANOVA were statistically significant,
Post hoc Scheffe analysis were conducted to determine which specific patient-group
means were significantly different from one another. The level of significance
was 0.5.

RESULTS

The internal consistency of the Sport Motivation subscales was determined
by calculating Cronbach’s Coefficient Alpha. The seven subscales
of SMS demonstrated acceptable internal reliability (IM to know =. 70,
IM to stimulation =. 80, IM to accomplishment =. 75, EM to external regulation
=. 69, EM to interjected regulation =. 66, EM to identified regulation
=. 75 and amotivation =. 70). These findings are supported by previous
study (Papageorgiou, 2001).

A one – way MANOVA indicated significant differences between the three
patients groups across the seven SMS subscale, Wilk’s Lambda=. 113,
(F7,14=9.892, P<0.05, eta squared=0.664).

Univariate ANOVA results indicated a significant difference only for
the six dependent variables. Statistically significant differences were
found for IM to know (F2,41=13.485, P<0.05, eta squared=0.397),
IM to stimulation (F2,41=43.581, P<0.05, eta squared=0.680),
IM to accomplishment (F2,41=6.581, P<0.05, eta squared=0,243),
EM to external regulation (F2,41=6.548, P<0.05, eta squared=0.242),
EM to interjected regulation (F2,41=22.913, P<0.05, eta
squared=0.528) and amotivation (F2,41=5.707, P<0.05, eta
squared=0.218). Scheffe post hock analysis indicated that patients who
participated in the gym rehabilitation program had statistically higher
levels in IM to know, to stimulation. to accomplishment and EM to interjected
regulation. Additionally, the control group had statistically higher levels
in EM to external regulation and Amotivation. Table 1 provides the means
and standard deviations for these dependent variables.

Table 1 Means and Standard Deviations of Motivation Variables by Group

Variables Gym Group Swimming Group Control Group
M±SD M±SD M±SD
IM to know 4.56±0.798 3.73±0.504 3.44±0.455
IM to stimulation 4.64±0.432 4.18±0.175 3.39±0.433
IM to accomplishment 4.41±0.701 3.75±0.365 3.98±0.358
EM to external regulation 4.10±0.991 3.76±0.240 4.5±0.342
EM to introjected regulation 3.79±0.729 3.46±0.311 2.69±0.286
Amotivation 1.47±0.588 1.63±0.208 2.0±0.450

DISCUSSION AND CONCLUSION

This study explored the influence of two specific types, frequency and
duration of exercise cardiac rehabilitation programs in-patient motivations.

Findings from this study indicated that patients who participated in
the gym rehabilitation program had statistically higher levels in IM to
know, to stimulation, to accomplishment and EM to interjected regulation,
than patients who participated in the swimming rehabilitation program
and patients who did not participate in any program (control group). One
of the possible reasons for the differences between the two exercise patient
groups may be due to the fact that swimming is not very much allowed for
cardiac patients, despite the valuable advantages as an overall physical
conditioning and leisure avocation (Kawahatsu et al., 1986). According
Ebbeck, Gibbons and Loken-Dahle (1995) the differences in reasons for
participating depend on the type of physical activity in which the individual
is involved.

Specifically, patients who participated in a gym program to fulfill intimacy
or acceptance needs were motivated intrinsically to participate in order
to gain knowledge, to experience stimulation and accomplishment (Stults,
2001). According to previous studies, personal satisfaction, knowledge
and pleasure (IM) constitute the main reasons of adult’s participation
in exercise programs (Ebeck et al., 1995; Eix, 2001; Brodkin & Weiss,
1990). These findings are consistent with the findings of previous studies
that suggest effects of the type of rehabilitation in-patients motivation
(Papageorgiou, 2001).

However, the gym exercise group differs significantly from the swimming
and control group in EM to introjected regulation. Introjection is related
to the internal pressures that the patient may put on himself. The guilt
that they feel when they fail to complete a health task or a training
session, will motivate them so as to make it up (Vlachopoulos, Karageorghis
& Terry, 2000). According to Brodkin & Weiss (1990) health reasons
were rated highest by older adults for participating in exercise programs.
Additionally control group had statistically higher levels in EM to external
regulation and Amotivation.

Given the study findings, further research is suggested. A research design
for assessing long-term adherence is recommended. Previous studies indicated
that the dropout rate for an exercise program remains high until 12 months,
with an average attrition rate of 50% (Comoss, 1988; Oldridge, 1979; Song
et al., 2001). It is imperative to assess adherence changes over a long-term
period, focusing on the motivation related variables influencing participation
in rehabilitation programs.

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