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The effect of outpatient cardiac education on knowledge and health promotion/protective behaviours Wiens, Linda Marilyn 1995

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THE E F F E C T OF OUTPATIENT CARDIAC EDUCATION ON KNOWLEDGE AND HEALTH PROMOTION/PROTECTIVE  BEHAVIOURS  by LINDA MARILYN WIENS B.N., T h e U n i v e r s i t y  o f M a n i t o b a , 1974  A T H E S I S SUBMITTED I N PARTIAL F U L F I L L M E N T OF THE  REQUIREMENTS FOR THE DEGREE OF  MASTER.'' OF S C I E N C E I N NURSING in THE  FACULTY OF GRADUATE (School  We  accept to  THE  this  STUDIES  of Nursing)  thesis  the required  UNIVERSITY OF April, © Linda Marilyn  as c o n f o r m i n g standard  B R I T I S H COLUMBIA 1995 W i e n s , 1995  In  presenting  degree freely  this  at the available  copying  of  department publication  this or  thesis  in  partial  fulfilment  University  of  British  Columbia,  for reference thesis by  of this  and study.  for scholarly  his  or  thesis  her  c\vo  \  •P>gp5rtment of  | N - l M ^ j rx  The University of British Columbia Vancouver, Canada  D a t e  DE-6 (2/88)  Ap(SV  D  S  ;  )  ^  5  T  I further  purposes  gain  the  I agree agree  requirements that that  shall  It  is  for an  the Library  advanced  shall  make  it  permission for extensive  may b e granted  representatives.  for financial  permission.  of  by the head  understood  not be allowed  that  without  of m y  copying  or  my written  11  Abstract This myocardial  study  was  conducted  infarction  hospital-based knowledgeable  and  those  about  education  who  heart  program.  study  behaviours  was  A  32  and  Canada.  study.  two  of  first  subjects  their  i n the  education.  The  The  MI  from a major these  p r o g r a m s w e r e more  i n health  life  to a g r e a t e r  conceptual  extent  framework f o r  Health  and  teaching hospital the  again  (HHKQ) i n t h e four to  group p a r t i c i p a t e d  remaining  s u b j e c t s were p l a c e d  47  of  by  Profile  hospital  (HPLP)  while  s i x months l a t e r .  experimental  ages  i n western  study  Promoting L i f e s t y l e  Knowledge Quiz MI,  p a t i e n t s between the  s u b j e c t s completed  Health  from  both  pretest-posttest control  (1986)  time  and  recovering  of  in  time  Model.  r e t u r n i n g the Health  Heart  a way  first  i n a hospital-based cardiac  a n s w e r i n g and the  engaged  from H i l t o n ' s  were r e c r u i t e d Seventy-two  and  as  only  for this  adapted  h u n d r e d and  80  participated  quasi-experimental  used  Promotion/Protective One  disease  participated  g r o u p d e s i g n was this  p a t i e n t s who  outpatient cardiac education  promotion/protective than  (MI)  to determine whether  The  25  i n outpatient cardiac i n the  control  group. The  t-test  HHKQ s c o r e s in  f o r independent  to determine  i f first  outpatient cardiac education  heart  disease  discharge  than  and  g r o u p s was time  who  on  p a t i e n t s who  w e r e more k n o w l e d g e a b l e  health behaviours  those  MI  performed  d i d not.  four to T h e r e was  the p o s t t e s t  participated regarding  s i x months a f t e r a significant  hospital  increase  1X1  i n HHKQ t o t a l mean s c o r e s  and  experimental  p o s t t e s t stage.  group at  the  g r o u p s was  a l s o p e r f o r m e d on  first  MI  time  education greater  extent  the  four to  scores.  the  control  outpatient be  activity,  groups d i d not behaviours  and  on  as  independent  to determine i f  than  behaviours  those  who  to  a  d i d not.  i n t h e HPLP t o t a l  i n v e s t i g a t o r s found  provide  similar  No  scores  results  in  engage i n h e a l t h  a way  direction  cardiac education  less  for  the  i n outpatient cardiac-  groups were found  formal  programs.  teaching  on  of  life  to a greater  more on p a r t i c i p a t i o n  The  the  extent  focus  s t r u c t u r e of  of c l a s s  i n e x e r c i s e s and  More d i s c u s s i o n r e g a r d i n g  participants  t o engage  from the  regarding  s e l e c t e d t o p i c s such  activities.  indicated  t-test  for  group.  These r e s u l t s  could  participated  Other  experimental  promotion/protective than  The  t h e p o s t t e s t HPLP s c o r e s  s i x months l a t e r  between t h e  sub-scale  that  s u b - t e s t mean s c o r e s  engaged i n h e a l t h p r o m o t i o n / p r o t e c t i v e  differences and  p a t i e n t s who  nutrition  of  this  as p h y s i c a l  stress-reducing  a t t i t u d e s that motivate  i n health promotion/protective  results  content  study.  behaviours  class is  iv T A B L E OF  CONTENTS  Abstract Table  i i  of Contents  iv  List  of Tables  List  of Figures  ix  Acknowledgement  x  Chapter  1  One:  viii  Introduction  Background  to the Problem  1  Problem Statement  3  Purpose of the Study  3  Conceptual  4  Research  Framework  Hypotheses  Definition  8  o f Terms  Assumptions  .  .  9  .  10  Limitations  10  Significance.,  11  Chapter  Two:  Literature  Review  12  Self-actualization  12  Interpersonal  13  Knowledge  Support  and H e a l t h P r o m o t i o n / P r o t e c t i v e  Knowledge  and B e h a v i o u r s  Hospital-Based Outpatient  Behaviours  of the General  Cardiac Education  Cardiac Education  Public  Programs  Programs  .  .  .  .  .  15  .  .  15  .  16 24  V Summary  Chapter  32  Three:  Methodology  Research  34  Design  34  Procedure Setting  34  and  Sample S e l e c t i o n  35  Sample C r i t e r i a  35  Instruments  36  H e a l t h Promoting Heart  Lifestyle  Profile  36  H e a l t h Knowledge Quiz  Demographic  38  Information  40  Recruitment  40  Data  Collection  41  Data  Analyses  42  Procedures  Chapter  Four:  The  for Protection  P r e s e n t a t i o n and  o f Human R i g h t s  Discussion  43  of F i n d i n g s .  . . .  44  Sample  Presentation  44 of F i n d i n g s  Comparison  of P r e t e s t  47 and  Posttest  Results Within  Groups  47 Comparison  within  the e x p e r i m e n t a l group  Comparison  within  the c o n t r o l  Comparison  o f Knowledge o f H e a r t  Health Behaviours  Between Groups  group  Disease  .  .  . .  .  .  48 50  and 52  vi Comparison  of Health  Promotion/Protective  Behaviours  Between Groups  54  Discussion  56  Comparison  of Pretest  and P o s t t e s t  Results  Within  Groups  56  Comparison  o f Knowledge  o f Heart  Behaviours  Between Groups  Comparison  of Health  Disease  and H e a l t h 59  Promotion/Protective  Behaviours  Between Groups  61  Health promotion/protective  behaviours  i n the  a c t i o n phase Factors Relationship  63  i n the decision-making Between Knowledge  Promotion/Protective  phase.  .  .  .  and H e a l t h  Behaviours  67  Summary  Chapter  Five:  65  72  Summary,  Conclusions  and Recommendations  .  .  .  73  Summary  73  Conclusions  75  Recommendations  76  Nursing Future  References  Practice Research  76 78  81  V I 1  Appendix A Appendix  .  85  B  88  Appendix C  89  Appendix D  90  Appendix  E  91  Appendix F  95  Appendix G  96  Appendix H  97  Appendix  I  98  Appendix J  100  Appendix  102  K  viii List  of  Table  1:  Hospital-Based  Table  2:  Outpatient  Table  3:  Demographic  Table  4:  Comparing Heart  H e a l t h Knowledge  Posttest  f o r the Experimental  Table  5:  Table  6:  7:  Cardiac  Scores  Posttest  Education  Education  Programs  Programs  25 46  Promoting  Scores  Quiz  Lifestyle  H e a l t h Knowledge  Posttest  f o r t h e C o n t r o l Group  Scores  Comparing H e a l t h  Pretest Group  Promoting  Quiz  Lifestyle  and  .  Profile  f o r the Experimental  Comparing Heart  and  17  Information  Comparing H e a l t h and  Table  Cardiac  Tables  .  .  .  .  .  8:  Heart  Table  9:  Health  H e a l t h Knowledge Promoting  (Posttest)  Quiz  Lifestyle  Scores Profile  49  and 50  Profile  Pretest  P o s t t e s t . S c o r e s • f o r t h e C o n t r o l Group  Table  48  Pretest  Group  Pretest  .  (Posttest)  51 .  .  .  53  Scores 56  ix List Figure  1:  Hilton's  Health  Figure  2:  Adapted Health  of Figures  Promotion/Protective Promotion/Protective  Model Model  5 7  X Acknowledgement I am t h a n k f u l t o t h e s e thesis a reality:  individuals  who  a s s i s t e d me  i n making  this  * D r . C a r o l J i l l i n g s , A s s o c i a t e P r o f e s s o r , UBC S c h o o l o f N u r s i n g , and t h e s i s committee c h a i r p e r s o n , f o r h e r support and c o u n s e l r e g a r d i n g g e n e r a l and s p e c i f i c i d e a s , c o n c e p t s and principles. * Ms. A n n e Wyness, A s s o c i a t e P r o f e s s o r , UBC S c h o o l o f N u r s i n g , and s e c o n d p e r s o n on t h e t h e s i s committee, f o r h e r s u p p o r t , advice, and s k i l l a t e n c o u r a g i n g a t t e n t i o n t o d e t a i l and p r e s e n t i n g i d e a s with c l a r i t y . * Ms. L i n d a L e o n a r d , A s s o c i a t e P r o f e s s o r , UBC S c h o o l o f N u r s i n g , and t h i r d p e r s o n on t h e t h e s i s committee, f o r h e r encouragement, and s u g g e s t i o n s f o r improvement a f t e r r e a d i n g t h e p r o p o s a l and f i n a l copy. * D r . H a r o l d R a t z l a f f , A s s i s t a n t P r o f e s s o r , UBC D e p a r t m e n t o f E d u c a t i o n a l Psychology and S p e c i a l E d u c a t i o n , and Dr. W a l t e r B o l d t , P r o f e s s o r E m e r i t u s o f UBC D e p a r t m e n t o f E d u c a t i o n a l P s y c h o l o g y a n d S p e c i a l E d u c a t i o n , f o r t h e i r recommendations r e g a r d i n g s t a t i s t i c a l analysis of the data. * Dr. C h r i s t i n e Bradley, D i r e c t o r o f Research and E v a l u a t i o n i n Nursing, Vancouver H o s p i t a l and H e a l t h S c i e n c e s Centre, f o r h e r a d v i c e r e g a r d i n g computer d a t a e n t r y , and f o r w r i t i n g t h e s t a t i s t i c a l program f i l e . * The R e g i s t e r e d N u r s e s o f t h e C a r d i a c C a r e U n i t and t h e C a r d i o l o g y I n t e r v e n t i o n a l U n i t , Vancouver H o s p i t a l and H e a l t h Sciences Centre, f o r t h e i r a s s i s t a n c e i n r e c r u i t i n g p a r t i c i p a n t s f o r t h i s study.  during  * F a m i l y members a n d f r i e n d s f o r t h e i r s u p p o r t a n d p a t i e n c e t h e t i m e t h i s s t u d y was c o n d u c t e d a n d t h e t h e s i s was w r i t t e n .  1  CHAPTER ONE Introduction Background Coronary  artery disease  Canada,  accounting  Canada,  1994).  myocardial heart  Of t h e s e  deaths,  individual's  risk  there  factor  high  stress,  and t h e r i s k  1990).  M o d i f i c a t i o n of these  blood pressure,  promotion/protective  disease  risk  behaviours  coronary  with  acute  relationship  between  lack of exercise,  artery disease  f a c t o r s by engaging  (Kannel,  i n health  c o n t r i b u t e s toward reducing t h e (Kannel,  1990).  f o r whom m o d i f i c a t i o n o f r i s k  documented c o r o n a r y  i n f o r m a t i o n needs  that  blood cholesterol  i s a major c o n s i d e r a t i o n a r e those  been h o s p i t a l i z e d  (Statistics  indicating  such as h i g h  artery disease  group  i n 1992  i n Canada.  c i g a r e t t e smoking,  f o r developing  of coronary  One p o p u l a t i o n heart  1994),  i s a positive  profile  levels,  likelihood  Canada,  remains a major h e a l t h problem that  of death i n  12% w e r e c a u s e d b y a n  (Statistics  Research reveals an  i s the l e a d i n g cause  f o r 22% o f a l l C a n a d i a n d e a t h s  infarction  disease  t o the Problem  factors for  i n d i v i d u a l s who  artery disease.  address  their  factors  a n d ways t o e n g a g e i n h e a l t h p r o m o t i o n / p r o t e c t i v e  cardiac  education  To  regarding modification of r i s k  programs have been developed  i n many  behaviours,  health-care  centres. However, many p a t i e n t s who h a v e e x p e r i e n c e d infarction facet  (MI) h a v e d i f f i c u l t y  of their  recovery  while  have  concentrating  i n the hospital.  a  myocardial  on t h e e d u c a t i o n a l They a r e s t i l l  2 responding the  to the life-threatening  loss of t h e i r  denial, the  anxiety,  future  1986; Rahe,  factors, plus  such as t r e a t m e n t  Scalzi  appointments,  interfere  regular participation  information  1984; W e b s t e r  presented  p r o g r a m s . Upon d i s c h a r g e regarding  issues  instructions, 1986;  during  such as t h e i r  regarding  1986; D u r y e e ,  numerous i n t e r r u p t i o n s  noise,  and p h y s i c a l  & Christman,  1988) may  or the a b i l i t y  hospital-based  to concentrate  cardiac  lack  use  (Liddy  on  education  knowledge  prescribed physical activity, & Crowley,  diet  1987; N i c k l i n ,  Rahe e t a l . , 1 9 7 5 ) . B e c a u s e many p a t i e n t s e x p e r i e n c e  information advocated the  of  home, p a t i e n t s o f t e n  and medication  such as  1975; W e b s t e r &  1983; N i c k l i n ,  visitors,  (Gregor,  the  & Shine,  the experience  symptomatology with  emotions  a t t a c k and  and f e e l i n g s o f u n c e r t a i n t y  1988; Burke,. 1981; Budan,  These  of a heart  state of health with  depression,  (Hentinen,  Christman, 1992).  previous  experience  they  receive while  educational  hospital  1986).  becoming  shorter while  taught provide  follow-up  information period  1987; B u r k e ,  after  As a r e s u l t ,  that  (Burke,  discharge  that  needs  t o be  programs  often  i s applicable to only  t h e immediate  1981; D u r y e e ,  The f i r s t  post-  one t o two  from t h e h o s p i t a l a r e a c r u c i a l  are i n the process  from  f o r MI p a t i e n t s i s  hospital-based  1992) .  have  1 9 8 1 ; H e n t i n e n , 1986;  t h e amount o f i n f o r m a t i o n  months f o l l o w i n g d i s c h a r g e many MI p a t i e n t s  o f MI p a t i e n t s  r e t a i n i n g the  s e v e r a l authors  In addition, the h o s p i t a l stay  i s increasing.  discharge  i n the h o s p i t a l ,  ( R a l e i g h & Odtohan,  Nicklin,  difficulty  t i m e when  of adjusting to the experience  of  3 having  had  an  MI.  - They seek answers  long-term  recovery,  regarding  health promotion/protective  Greenland, &  1980;  Hutelmyer,  and  to questions  Liddy  1978;  become more r e c e p t i v e t o  & Crowley,  Steel  1987;  & Ruzicki, Problem  Patient who  have e x p e r i e n c e d  behaviours. patient's for  education  Most  an  designed  cardiac education w h i c h may  patients with  this  regarding  not  be  evidence  engagement  i n health promoting/protective  the most  r e c e i v e both  during  favourable  effect  on  the time  behaviours.  However,  designed  there  is  no  c a r d i a c knowledge and  behaviours  receive only hospital-based cardiac education who  individuals  programs have been  conclusive  patients  inform  promotion/protective  information.  the  &  Owens, McCann  programs a r e p r o v i d e d  outpatient cardiac education  t o p r o v i d e MI  who  to  l e a r n i n g about h e a l t h p r o m o t i o n / p r o t e c t i v e  Therefore,  1986;  Burke,  Statement  regarding health  hospitalization,  information (Scalzi,  Nicklin,  their  1987).  programs are MI  behaviours  regarding  h o s p i t a l - b a s e d and  i n MI  versus  the  patients  those  MI  outpatient cardiac  education. Purpose of The MI  p a t i e n t s who  cardiac and  purpose of  this  study  participate  education  was  i n both  the  Study  to determine whether h o s p i t a l - b a s e d and  p r o g r a m s a r e more k n o w l e d g e a b l e  engage i n h e a l t h p r o m o t i o n / p r o t e c t i v e  extent  than  education  those  program.  who  participate  only  about  behaviours  first  time  outpatient heart  to a  disease  greater  in a hospital-based cardiac  4 Conceptual Hilton's for  that  both  Model  (Rosenstock, In state  with  lifestyle  Promotion  that  (Pender,  1974) f o r m Model,  Pender  part  h e a l t h promotion  o f an i n d i v i d u a l ' s  self-actualization,  health  i n that  h e a l t h promoting  and w e l l - b e i n g .  satisfaction  and enjoyment  determinants  of h e a l t h promotion  cognitive-perceptual Although  Pender  health behaviours incorporate  this  (1986) s t a t e s  factors,  concept  that  and cues  this  into  them f r o m  (Pender,  human  1987) .  as an e x p r e s s i o n  engages i n s e l f of improving sense of  (1987) c a t e g o r i z e s t h e  into  modifying  factors,  to action. that  illness,  individuals  engage i n  she does n o t  her.Health Promotion  i s a weakness  environment,  to express  behaviours  Pender  behaviour  Health  T h e s e b e h a v i o u r s become  f o r t h e sake  (1987) a c k n o w l e d g e s  to protect  a desire  i s an improved  i n living.  as a p o s i t i v e  a c t on t h e  an i n d i v i d u a l  The r e s u l t  Model  Model.  way o f l i f e  behaviours  make  Health  of well-being.  of l i f e .  h e a l t h promoting  variables  i n as they  Pender's  i s viewed  level  f o r growth,  forquality  (1987) a l s o v i e w s  initiated  Both  o c c u r when i n d i v i d u a l s  and a d e s i r e  integral  d i s e a s e engage  forHilton's  i n c r e a s e s an i n d i v i d u a l ' s behaviours  (see F i g u r e 1 ) . I t  1987) a n d t h e H e a l t h B e l i e f the basis  i s the basis  and h e a l t h p r o t e c t i n g  coronary artery  a r e m o t i v a t e d by a d e s i r e  potential  study  b e h a v i o u r a l changes.  Pender's  promotion  of  the h e a l t h promoting  individuals  healthy  an  (1986) H e a l t h P r o m o t i o n / P r o t e c t i v e M o d e l  t h e c o n c e p t u a l framework o f t h i s  describes  and  Framework  Model.  Hilton  i n the H e a l t h Promotion  Model.  Figure  1.  Hilton's Health  Promotion/Protective  DECISION-MAKING  MODIFYING FACTORS Demographic characteristics Biologic characteristics Structural variables -knowledge about d i s e a s e - p r i o r contact| with disease Interpersonal influences -expectations of others - f a m i l y health| patterns Situational factors Perceived threat of disease  PHASE-  COGNITIVEPERCEPTUAL FACTORS  ACTION  model  PHASE-  LIKELIHOOD OF A C T I O N  ACTION  Importance of h e a l t h Perceived control of health Perceived selfefficacy Definition of h e a l t h as selfactualization Perceived health status Perceived benefits of health promotion and/or h e a l t h protective action  Cues t o Action -awareness of p o t e n t i a l f o r growth -advice from o t h e r s , mass media  Perceived Barriers to Action -cost -inconvenience; -extent of l i f e change required  Perceived seriousness of d i s e a s e Perceived susceptibility] to  disease  4  HEALTH PROMOTION BEHAVIOURS  HEALTH PROTECTIVE BEHAVIOURS  -a  6 In p a r t i c u l a r , fails  to  illness  the  account or  a  f o r those  that protect  Health  Health  These p e o p l e  the  concepts  M o d e l was  developed  Belief  Model which H i l t o n i n t e g r a t e s i n t o her  perceived contact  with  barriers  to  Due beyond  ( R o s e n s t o c k , .1974) .  b e n e f i t s of disease,  scope  purposes  of  portrays  how  this  perceived  of  the  of  life.  Belief  and  model a r e  to  of  why  others  the  Health  perceived  disease,  disease,  disease  explain  previous  and  perceived  investigations in this  Model has  study.  i n v o l v i n g numerous v a r i a b l e s t h a t  The  c o n d i t i o n of  that  that relate  study,  been a d a p t e d and  conceptual  significant  h e a l t h p r o t e c t i o n as  perceptions  variables  Health  v a r i a b l e s from  seriousness  threat  coronary  These h e a l t h p r o m o t i o n / p r o t e c t i o n and  The  a c t i o n , knowledge about  a number o f  p r o m o t i o n and chronic  perceived  i t s complexity  Promotion/Protective  the  q u a l i t y of  action.  to  the  in  besides  1950's t o  illness  t o do  to disease,  chronic  the  i n the  failed  susceptibility  of  model  Model.  some i n d i v i d u a l s t o o k a c t i o n t o p r e v e n t so  a  o f t e n engage  t h a t promote a h i g h e r  Promotion  Belief  cope w i t h  i n the  them f r o m f u r t h e r d i s e a s e ,  Hilton incorporates  i n t o the The  why  i n d i v i d u a l s who  i n h e a l t h behaviours  Consequently, Model  a h e a l t h p r o t e c t i o n component  long-term d i s a b i l i t y .  health behaviours engaging  lack of  become p a r t  simplified  variables play  a role  artery disease v a r i a b l e s are an  (see  to  in  health  living  continuing  t o b o t h h e a l t h p r o m o t i o n and  the  study  Figure  i n d i v i d u a l ' s way  Health  for  framework f o r t h i s  individuals adjust  of  Hilton's  of  health  are  with  2). behaviours  life.  The  protection  are: 1.  the modifying  promotion/protective  factor  o f knowledge  regarding  health  behaviours.  2.  the modifying  factor  of interpersonal  3.  the modifying  factor  of demographic  support.  characteristics. The v a r i a b l e s t h a t r e l a t e  to only health protection are:  1.  the modifying  2.  the cognitive-perceptual factor  susceptibility  2.  Figure  factor  o f knowledge  about t h e d i s e a s e .  of perceived  to disease.  Adapted Health  DECISION-MAKING  Promotion/Protective  PHASE - - - - - - - -  Model  A C T I O N PHASE -  COGNITIVEMODIFYING  FACTORS  PERCEPTUAL  FACTORS  ACTION  Interpersonal support Demographic  Self-actualization  characteristics Knowledge -about h e a l t h promotion/ protective behaviours -about t h e disease!  4  Perceived s u s c e p t i b i l i t y to disease  HEALTH PROMOTION/ PROTECTIVE BEHAVIOURS -exercise -nutrition - s t r e s s management -health responsibility  8 The  variable that 1.  The to  of t h e a c t i o n phase,  study,  1.  are the health  exercise,  cardiovascular 2. fat  4.  education  or minimizing  Sechrist  & Pender,  2.  that  improves  to decrease  total  who  t h e h a r m f u l p h y s i c a l and  or distress  (Pender,  initiative  in  (HHKQ),  four  seeking  1987) . Hypotheses  participate i n outpatient heart  disease  cardiac  and  health  Health  t o s i x months a f t e r h o s p i t a l who  1987).  the promotion of  b e h a v i o u r s , . measured by t h e Heart  f i r s t - t i m e MI p a t i e n t s  cardiac  activity  to ensure  a r e more k n o w l e d g e a b l e r e g a r d i n g  promotion/protective  than  tension  r e s p o n s i b i l i t y , or taking  t i m e MI p a t i e n t s  Knowledge Q u i z  i n relation  behaviours of:  dietary habits  and p r o f e s s i o n a l a s s i s t a n c e  (Walker,  First  descriptions  intake.  Research 1.  i n physical  e f f e c t s of negative  health  information  and t h e i r  or modifying  s t r e s s management,  psychological  factor of s e l f - a c t u a l i z a t i o n .  promotion/protective  or engaging  nutrition,  3.  promotion i s :  functioning.  and c h o l e s t e r o l  health  health  the cognitive-perceptual  variables this  relates to only  discharge  do n o t p a r t i c i p a t e i n o u t p a t i e n t  education.  First  education  t i m e MI p a t i e n t s  engage i n h e a l t h  greater  extent,  (HPLP),  four  who  participate i n outpatient  promotion/protective  measured by the H e a l t h  behaviours  Promoting L i f e s t y l e  t o s i x months a f t e r h o s p i t a l d i s c h a r g e ,  t i m e MI p a t i e n t s  who  do n o t p a r t i c i p a t e i n o u t p a t i e n t  cardiac to a Profile  t h a n do cardiac  first  education. Definition 1.  Outpatient  designed  f o rpatients with  regarding 2.  affect  Health  to 5.  and  6.  choose t o l i v e .  to the decisions (Walker,  Actions  increased well-being  p r o t e c t i n g behaviours:  or prevent  expressed  further disease  In  individuals  e t a l . , 1987).  that  lead to a state of  and h i g h e r  impressions (Rosenstock,  Actions  quality  by s e l f - i n i t i a t e d  of  life  individuals  1974) .  that  improve  health  sense o f s a t i s f a c t i o n and  1987).  susceptibility  regarding  i n by  o f human g r o w t h a n d  activities  i n an improved  (Pender,  engaged  (Rosenstock,  A demonstration  resulting  i n living  Perceived  to disease:  the p o s s i b i l i t y  An i n d i v i d u a l ' s  of acquiring a health  personal problem  1974).  7.  Interpersonal  due  t o the involvement  h e a l t h promotion, 1987).  refers  information  1987).  well-being,  enjoyment  that provide  classes  behaviours.  health status  Self-actualization:  potential  disease,  promoting behaviours:  Health avoid  lifestyle  their  improved h e a l t h ,  4.  heart  Community-based  T h e way i n w h i c h i n d i v i d u a l s  to health,  make t h a t  (Pender,  program:  health promotion/protective  Lifestyle:  relation  3.  cardiac education  o f Terms  support:  Feelings of belonging  of other  people  and encouragement  instrumental  h e a l t h maintenance and i l l n e s s  i n facilitating  prevention  (Pender,  10 Assumptions In  this  study,  i t was a s s u m e d t h a t  to  identify  their  It  was a l s o  assumed t h a t  items  individuals  would respond  honestly to the  Due t o t i m e after  constraints,  of the Study  the long-term  2.  The q u a s i - e x p e r i m e n t a l  factor  i n the g e n e r a l i z a t i o n  (more t h a n  one  was n o t e x a m i n e d .  design of this  s t u d y was a  i n the experimental  o u t p a t i e n t c a r d i a c e d u c a t i o n program than  participants.  I t i s n o t known w h e t h e r  the program w i t h i n t h e f i r s t the hospital.  limiting  of r e s u l t s .  S i x o f t h e 25 p a r t i c i p a n t s  different  effect  a n MI) o f o u t p a t i e n t c a r d i a c e d u c a t i o n o n k n o w l e d g e a n d  health promoting/protective behaviours  from  behaviours.  on t h e q u e s t i o n n a i r e s .  1.  3.  had t h e a b i l i t y  personal health promotion/protective  Limitations  year  individuals  these  the other  6 participants  o n e t o two m o n t h s  Participants  group attended 19  attended  following discharge  were n o t r e q u e s t e d  to supply  this  information: 4.  The H e a l t h  instruments  used  Promotion L i f e s t y l e i n this  study,  e v a l u a t i o n s w i t h p o p u l a t i o n s who such  as heart disease.  Profile  has n o t undergone are living  Therefore,  5.  with  one o f t h e  psychometric a chronic  illness  t h e r e s u l t s may n o t r e f l e c t t h e  health promotion/protective behaviours complete  (HPLP),  of this  population  with  accuracy.  The p r e t e s t H e a r t  H e a l t h Knwledge Quiz  a c c u r a t e l y measure knowledge l e v e l s  of f i r s t  (HHKQ) r e s u l t s time  may n o t  MI p a t i e n t s p r i o r  a  11 to  their  hospital  h o s p i t a l i z a t i o n because to  behaviours 6.  l e a r n about h e a r t before  Completing  knowledge. written or  completing the  there  disease the  written  observed  but  may  and  pretest  HHKQ may  Some i n d i v i d u a l s may  test,  were o p p o r t u n i t i e s  be  health  quiz.  always measure  unable to  the  promotion/protective  knowledge  not  in  accurately  demonstrate knowledge based  on  actual complete  verbal  a  responses  behaviours. Significance  This  s t u d y was  development &  Catanzaro,  proposition  i n that 1988) that  cardiac  education  disease  and  that  .  at  the  situation-producing  i t involved  the  t e s t i n g of  It contributed  to  p a r t i c i p a t i o n o f MI program can i t can  promoting/protective  improve  encourage  behaviours  as  the  their  a way  an  of  i n an  life.  (Woods  the  outpatient  knowledge about  engage i n of  theory  intervention  v a l i d a t i o n of  patients  them t o  level  health  heart  12  CHAPTER TWO Literature Review In cardiac  this  chapter,  disease,  behaviours, examined.  will  the implementation  i n t e r p e r s o n a l support The v a r i a b l e  was i d e n t i f i e d 2),  and s e l f - a c t u a l i z a t i o n w i l l  i n the conceptual  of disease,  framework  review.  due t o t h e u n a v a i l a b i l i t y  be which  (see F i g u r e  This  variable  of a suitable  tool for  measurement. literature  that addressed  self-actualization,  support review  o f how p a r t i c i p a n t s '  regarding also  the cognitive-perceptual factor  and t h e m o d i f y i n g  i s discussed f i r s t .  outpatient  and  about  of health promotion/protective  n o t be d i s c u s s e d i n t h e l i t e r a t u r e  The of  r e g a r d i n g knowledge  of perceived s u s c e p t i b i l i t y  as a concept  was n o t i n v e s t i g a t e d its  the l i t e r a t u r e  factor  The l a r g e s t involvement  c a r d i a c e d u c a t i o n programs  section i n both  of interpersonal of this  chapter  h o s p i t a l - b a s e d and  influenced their  knowledge  c a r d i a c d i s e a s e and h e a l t h p r o m o t i o n / p r o t e c t i v e how t h e s e  individuals  programs p l a y e d  actually  engaged  a role  is a  i n whether  behaviours,  these  i n health promotion/protective  behaviours. Self-actualization In Simandl  a qualitative (1989),  participating regarding exercise.  study  r e p o r t e d by Frenn,  6 men a n d 4 women w i t h h e a r t d i s e a s e who  i n a cardiac rehabilitation  their  Borgeson,  view o f changes  Among t h e r e a s o n s  i n diet,  program were  Lee & were  interviewed  smoking c e s s a t i o n and  subjects described f o r pursuing  13 lifestyle to  live  changes were t h a t  a long  life.  they  enjoyed  life,  and t h a t  These d e s c r i p t i o n s were l a b e l l e d  promotion p r e c i p i t a n t s t o change by t h e authors. lifestyle  changes  expression  of this  chronic  condition  the  f o r the sake o f e n j o y i n g  of s e l f - a c t u a l i z a t i o n  results  study provide of heart  sake o f promoting  of  some e v i d e n c e  disease  subjects  d i d report  as h e a l t h  i s one e l e m e n t  by Pender  that  i nthe  (1987) .  The  i n d i v i d u a l s with the behaviours f o r  health.  described  was a p o s i t i v e s u p p o r t  wanted  Engaging i n  engage i n h e a l t h y  Support  the q u a l i t a t i v e study reported  the ten subjects  life  as d e s c r i b e d  Interpersonal In  they  how t h e p r e s e n c e  i n helping  that,  by Frenn e t a l .  nine  o f f a m i l y and f r i e n d s .  them make l i f e s t y l e  at a certain point,  (1989),  changes.  the support  Two  became  overbearing. Among t h e v a r i a b l e s t e s t e d b y D e r e n o w s k i relationship  between s o c i a l  tendency t o adhere health), choices  collected in  to wellness  and h e a l t h regarding  from a t o t a l  data  actively  value  behaviours  orientation  phases  of cardiac  r e s u l t s of both  the  presence  motivation (the  f o r the promotion of  (standards  used  f o r making  I n t h e 1988 s t u d y ,  data  were  studies  of supportive  rehabilitation.  I n t h e 1991  52 p o s t - M I m a l e p a t i e n t s who w e r e  i n an outpatient  The  , was t h e  o f 106 p o s t - M I m a l e p a t i e n t s who p a r t i c i p a t e d  were c o l l e c t e d from  involved  systems, w e l l n e s s  health behaviours).  one o f t h e t h r e e  study,  support  (1988 & 1991)  cardiac  revealed others  rehabilitation  program.  a p o s i t i v e r e l a t i o n s h i p between  and an i n c r e a s e  i n wellness  14 motivation perceived engaging  help  a l l phases  behaviours  an i n c r e a s e  the family  programs.  programs.  for  others  regimen  other  Ringel, 1989;  during others'  Garrett  1988; M i l l e r , Wikoff,  by M i l l e r  with  subjects  relationships  the r e h a b i l i t a t i o n  friendships  i n group  cardiac  the b e n e f i c i a l r o l e  participation i n establishing  t h e i n d i v i d u a l who h a d  emphasized  t h e MI p a t i e n t Christman,  Reitz  Garrett, (1985,  beliefs  regarding  the medical  perceptions  intentions  Wikoff,  McMahon & S m i t h ,  1990).  1988, 1989, 1 9 9 0 ) , perceptions  intentions  Following  discharge  of significant  t o adhere  others'  to the medical  Wikoff,  McMahon, G a r r e t t Ringel  &  & Collura, In the  i t was  found  that,  of s i g n i f i c a n t  t o adhere  indicator of the patient's  regimen.  1985; M i l l e r ,  Garrett,  his/her  as  the therapeutic  & Ashley,  McMahon,  o f t h e spouse,  the patient,  comply w i t h  1985; M i l l e r ,  Wikoff,  et a l .  the influence  r e l a t i o n s h i p with  h o s p i t a l i z a t i o n , the patient's  patient's  through  established  goals  & Ringel,  r e g i m e n were a s t r o n g  his/her  of significant  including their  i n close  i n helping  Miller,  studies  In addition,  The f i n d i n g s r e v e a l e d  studies  (Holm, F i n k ,  McMahon,  the value f o r  t h e MI.  another person  important  to  they  factor modification  Several or  increased.  As t h e  as a c t i v e p a r t i c i p a n t s i n t h e c a r d i a c  r e h a b i l i t a t i o n process,  experienced  also  rehabilitation.  increased,  as t h e y p r o g r e s s e d  F o r example,  supportive  others  i n the value  rehabilitation  risk  of cardiac  from s u p p o r t i v e  i n health  indicated outside  during  to the medical  i n t e n t i o n t o adhere  from the h o s p i t a l , t h e beliefs  regarding  regimen were a  strong  15 i n d i c a t o r of the p a t i e n t a c t u a l l y a d h e r i n g t o the m e d i c a l  regimen.  In c o n t r a s t to these f i n d i n g s , Dracup, M e l e i s , C l a r k , Cyburn,  Shields  & S t a l e y • (1984) found t h a t s p o u s a l p a r t i c i p a t i o n i n a group c o u n s e l l i n g program made no d i f f e r e n c e i n t h e p a t i e n t ' s  compliance  w i t h the t h e r a p e u t i c regimen. Ben-Sira & E l i e z e r  (1990) s t u d i e d t h e i n f l u e n c e of s o c i a l  support from the broader p e r s p e c t i v e of p h y s i c a l and p s y c h o s o c i a l readjustment  a f t e r a h e a r t a t t a c k , r a t h e r than compliance  t h e r a p e u t i c regimen. three p e r s p e c t i v e s :  t o the  The concept o f readjustment was c o n s i d e r e d from emotional  (affective),  l e v e l of functioning  ( i n s t r u m e n t a l ) , and u n d e r s t a n d i n g and acceptance o f the h e a l t h condition  (cognitive).  There was a s t r o n g r e l a t i o n s h i p between  s p o u s a l support and the p a t i e n t ' s p h y s i c a l and p s y c h o s o c i a l readjustment  a f t e r a heart attack.  Open channels o f communication  between spouses were found t o be of p a r t i c u l a r s i g n i f i c a n c e i n promoting  the t h r e e dimensions  o f readjustment  following a heart  attack. With the e x c e p t i o n of one study  (Dracup e t a t . , 1984),  s t u d i e s p r o v i d e evidence f o r the importance  of interpersonal  these support  i n m o t i v a t i n g those w i t h h e a r t d i s e a s e t o engage i n h e a l t h promotion/protective behaviours. Knowledge and H e a l t h P r o m o t i o n / P r o t e c t i v e Behaviours Knowledge and Behaviours o f the G e n e r a l P u b l i c Maccoby, Farguhar, Wood & Alexander  (1977) s t u d i e d the e f f e c t s  of a multimedia campaign and an i n t e n s i v e i n s t r u c t i o n program f o r  !6 i n d i v i d u a l s -in the general p o p u l a t i o n at h i g h r i s k Both  the multimedia  were i d e n t i f i e d premature result  as  changed t h e i r  these  methods of  that reflected  active  and  duty  Packa  h e a l t h promoting  (HPLP).  regarding  disease,  t h e r e was  elevated  blood  Hospital-Based  Cardiac  effect  risk  studies  lifestyle.  In a d d i t i o n ,  t h e more  some o f  results  they  the  engaging  engaged  i n more  subjects  scored  high  factors  and  the the  in  the  for heart  significance use  of  of  disease.  Programs  i n health promotion/protective  1).  with  Promoting  diabetes  from the h o s p i t a l  (see T a b l e  female, a l l  Health  for heart  Education  study  the  knowledge r e g a r d i n g  factors  14%  Knowledge S c o r e s  the major r i s k  levels,  in their  of h o s p i t a l - b a s e d c a r d i a c e d u c a t i o n  following discharge of  (CAD)  Although  cholesterol as  knowledge and  significant  Those p a r t i c i p a n t s  as m e a s u r e d w i t h  a l a c k of  contraceptives  The  a  a  behavioural  (86% m a l e a n d  or masters degrees).  behaviours  Profile  knowledge t e s t  for  t h a t , as  t h e r e was  learned,  similar  officers  Coronary A r t e r y Disease  Lifestyle  study  (1991) h a d  military  baccalaureate  higher  in this  found  substantial  a more h e a l t h y  program  to reduce r i s k  These authors  instruction,  disease.  behaviour.  Fleetwood  with  intensive instruction  p r e v e n t i o n programs designed  t h e more t h e p a r t i c i p a n t s  520  the  i n knowledge accompanied by  modifications  of  and  cardiovascular disease.  of both  increase  campaign  for heart  has  programs  on  behaviours  been examined i n a  number  17  Table  1  Hospital-Based  Author  Cardiac  (Year):  Rahe,  Education  Scalzi  Programs  & Shine  (1975)  Program G o a l s : To i m p r o v e t h e q u a l i t y a n d c o n s i s t e n c y o f a h o s p i t a l b a s e d c a r d i a c e d u c a t i o n p r o g r a m , a n d t o e v a l u a t e MI p a t i e n t s ' k n o w l e d g e a b o u t t h e i r i l l n e s s a n d i t s management. Program: A t e a c h i n g b o o k l e t f o r c a r d i a c p a t i e n t s was developed which p r o v i d e d i n f o r m a t i o n r e g a r d i n g the nature of h e a r t d i s e a s e , emergency p l a n n i n g , n u t r i t i o n , smoking, r e s u m p t i o n o f p h y s i c a l a c t i v i t y , p s y c h o l o g i c a l i s s u e s a n d r e t u r n t o w o r k f o l l o w i n g a n MI. The t e a c h i n g p r o g r a m i n v o l v e d i n d i v i d u a l i z e d n u r s e - p a t i e n t interaction. Design: One g r o u p , c o n v e n i e n c e s a m p l e , p r e t e s t - p o s t t e s t u s i n g a k n o w l e d g e q u e s t i o n n a i r e b e f o r e t h e t e a c h i n g b o o k l e t was g i v e n t o t h e p a r t i c i p a n t s and s h o r t l y b e f o r e d i s c h a r g e . Sample: first MI.  19  male and  5 female p a t i e n t s under  age  65  with  their  Results: T h e r e was a s i g n i f i c a n t i n c r e a s e i n t o t a l number o f correct responses. However, when e a c h s e c t i o n o f t h e exam was a n a l y z e d s e p a r a t e l y , i t was f o u n d t h a t t h e r e was a s i g n i f i c a n t i n c r e a s e i n s c o r e s f o r i s s u e s p e r t a i n i n g to o n l y the immediate p o s t d i s c h a r g e p e r i o d , s u c h as m e d i c a t i o n r e g i m e n , emergency p r o c e d u r e s , p h y s i c a l a c t i v i t y a n d r e t u r n t o work. T h e r e was no s i g n i f i c a n t i n c r e a s e i n knowledge r e t e n t i o n r e g a r d i n g long-term life-style m o d i f i c a t i o n i s s u e s s u c h as e x e r c i s e , l o w - f a t d i e t , smoking c e s s a t i o n , and s t r e s s r e d u c t i o n .  Author  (Year):  Program G o a l s : To i n a group s e t t i n g  Owens, McCann & H u t e l m y e r  (1978)  i n v e s t i g a t e the e f f e c t i v e n e s s of h e a l t h t e a c h i n g for h o s p i t a l i z e d patients with heart disease.  Program: A h o s p i t a l - b a s e d c a r d i a c t e a c h i n g program developed f o r the purpose of the study. T e a c h i n g o c c u r r e d i n f i v e 45-minute group discussion sessions. Design: obtained  One g r o u p , c o n v e n i e n c e s a m p l e , t i m e - s e r i e s w i t h d a t a u s i n g an i n t e r v i e w q u e s t i o n n a i r e p r i o r t o the e d u c a t i o n  18 Table  1  (cont.)  program, a f t e r t h e e d u c a t i o n program, and f o l l o w i n g d i s c h a r g e from the h o s p i t a l .  6 weeks a n d  Sample: patients,  and  18  25 m a l e a n d 11 f e m a l e m e d i c a l y e a r s o f age a n d o l d e r .  surgical  3 months cardiac  Results: S i g n i f i c a n t i n c r e a s e s d u r i n g h o s p i t a l i z a t i o n and t h r o u g h o u t t h e 3 month p e r i o d o c c u r r e d f o r knowledge o f r i s k f a c t o r s , k n o w l e d g e o f c o m p l i c a t i o n s o f t h e d i s e a s e and u n d e r s t a n d i n g the importance of c o n t i n u i n g medical contact. The g r e a t e s t i n c r e a s e i n k n o w l e d g e o c c u r r e d 6 weeks a f t e r d i s c h a r g e f r o m t h e h o s p i t a l , when subjects a l s o demonstrated a s i g n i f i c a n t i n c r e a s e i n the understanding of t h e i r i l l n e s s , of a p p r o p r i a t e l i f e s t y l e changes, of m e d i c a l t h e r a p y , a n d k n o w l e d g e o f when t o n o t i f y t h e p h y s i c i a n .  Author  (Year):  Budan  (1983)  Program G o a l s : Not s p e c i f i e d . The s t u d y a i m was t o e x p l o r e t h e r e l a t i o n s h i p s b e t w e e n how p a t i e n t s l e a r n w h i l e i n t h e h o s p i t a l , and a n x i e t y , s t r e s s , age, a n d e d u c a t i o n . Program: An o n g o i n g h o s p i t a l - b a s e d c a r d i o v a s c u l a r e d u c a t i o n p r o g r a m c o n d u c t e d b y s t a f f n u r s e s on a o n e - t o - o n e b a s i s . Design: One g r o u p , n o n - r a n d o m s a m p l e , p r e t e s t a n d a knowledge q u e s t i o n n a i r e d u r i n g h o s p i t a l s t a y . Sample:  12  p a t i e n t s b e l o w age  70,  diagnosed  as  posttest using  having  an  MI.  Results: T h e r e was a s i g n i f i c a n t i n c r e a s e i n k n o w l e d g e a b o u t h e a r t disease during patients' hospital stay. Anxiety decreased a f t e r exposure to the e d u c a t i o n program. No s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p was f o u n d b e t w e e n l e a r n i n g a n d p e r s o n a l s t r e s s . P a t i e n t s w i t h h i g h s c h o o l e d u c a t i o n o r l e s s were a t a d i s a d v a n t a g e . A d v a n c i n g age d i d n o t l i m i t t h e p a t i e n t s ' a b i l i t y t o l e a r n .  Author  (Year):  Mills,  Barnes,  Rodell & Terry  (1985)  Program G o a l s : To d e t e r m i n e i f k n o w l e d g e , d e m o g r a p h i c s , g e n e r a l i n t e l l i g e n c e , p r o b l e m - s o l v i n g a b i l i t y , and m o t i v a t i o n i n f l u e n c e h e a r t p a t i e n t s ' compliance t o a medical regimen. Program: A s e r i e s o f f i v e 1-hour h o s p i t a l - b a s e d p a t i e n t e d u c a t i o n c l a s s e s d e v e l o p e d by t h e p a t i e n t e d u c a t i o n team o f t h e h o s p i t a l i n w h i c h t h e s t u d y was conducted.  19 Table  1  (cont.)  Design: I n i t i a l n o n - r a n d o m s e l e c t i o n , a n d t h e n r a n d o m i z e d t o two g r o u p s t o t e s t f o r a p r a c t i c e e f f e c t w i t h a p r e t e s t . D a t a was c o l l e c t e d u s i n g a knowledge t e s t p r i o r t o e n t e r i n g t h e p r o g r a m and p r i o r to discharge, p l u s a behaviour assessment q u e s t i o n n a i r e four weeks a f t e r d i s c h a r g e . Sample: y e a r s of  277 age.  patients with  a n MI  or angina,  b e t w e e n 29  and  84  Results: The e f f e c t o f t h e p r o g r a m d e m o n s t r a t e d a s i g n i f i c a n t i n c r e a s e i n knowledge p r i o r to d i s c h a r g e from the h o s p i t a l . C o m p l i a n c e t o t h e m e d i c a l r e g i m e n was d e m o n s t r a t e d b y a s i g n i f i c a n t r e d u c t i o n i n t h e number o f c i g a r e t t e s smoked f o u r weeks a f t e r hospital discharge. No o t h e r l i f e s t y l e b e h a v i o u r s w e r e e x a m i n e d a t t h e 4-week p e r i o d . - The p r e t e s t ' g r o u p was more c o m p l i a n t t h a n t h e n o n - p r e t e s t g r o u p , i n d i c a t i n g t h a t r e p e a t e d t e s t i n g may motivate patient's to take advantage of i n f o r m a t i o n .  Author  (Year):  Hentinen  (1986)  Program G o a l s : To i n c r e a s e k n o w l e d g e a n d f e e l i n g s o f s e c u r i t y , t o a c h i e v e i n d e p e n d e n c e i n c a r e , t o comply w i t h c a r e i n s t r u c t i o n s and f o l l o w r i g h t l i f e s t y l e s , and t o a c h i e v e t h e b e s t p o s s i b l e s t a t u s o f good h e a l t h . P r o g r a m : An emphasized Design:  ongoing the  h o s p i t a l - b a s e d c a r d i a c e d u c a t i o n program  importance  Method of  of  sample  staff  nurses'  selection  not  that  involvement  i n teaching.  specified.  Data  was  c o l l e c t e d r e g a r d i n g knowledge and c o m p l i a n c e u s i n g a q u e s t i o n n a i r e , i n t e r v i e w method and p a t i e n t documents a t d i s c h a r g e , t h r e e months and one y e a r a f t e r h o s p i t a l d i s c h a r g e . Sample:  170  MI  p a t i e n t s under  65  years  of  age.  Results: T h e r e was a s i g n i f i c a n t i n c r e a s e i n k n o w l e d g e p r i o r t o discharge r e g a r d i n g the nature of coronary heart disease, p h y s i c a l a c t i v i t y and r e c o v e r y , d i e t , and s e x u a l i t y . A t t h e 3-month i n t e r v a l , t h e r e was a n i n c r e a s e i n t h e t i m e s p e n t f o r e x e r c i s e a n d a r e d u c t i o n i n t h e amount o f f a t i n t h e d i e t . However, h a l f o f t h o s e who had s t o p p e d s m o k i n g h a d a g a i n r e s u m e d t h e h a b i t a t t h e 3-month i n t e r v a l .  20 Table Author  1  (cont.) (Year):  Program G o a l s : MI, t o i d e n t i f y in lifestyle. Program: s e s s i o n s by  Fletcher  (1987)  To h e l p p a t i e n t s u n d e r s t a n d t h e p a t h o p h y s i o l o g y o f an r i s k f a c t o r s , and t o suggest p o s s i b l e m o d i f i c a t i o n s  F o u r 15-20 a nurse.  minute  individualized  cardiac  education  Design: E x p e r i m e n t a l , w i t h random a s s i g n m e n t t o t h e s t u d y g r o u p or the c o n t r o l group. D a t a c o l l e c t i o n i n v o l v e d knowledge and m o d i f i c a t i o n of t h e r i s k f a c t o r s f o r smoking, o b e s i t y , h i g h f a t d i e t and l a c k of e x e r c i s e f o r b o t h g r o u p s u s i n g a s t r u c t u r e d q u e s t i o n n a i r e , on t h e f o u r t h d a y o f h o s p i t a l i z a t i o n , a n d two a n d s i x months a f t e r d i s c h a r g e . Sample: 18 m a l e a n d 2 f e m a l e MI p a t i e n t s r a n g i n g i n age f r o m 3 0 t o 57. Ten p a t i e n t s i n the s t u d y group, and t e n p a t i e n t s i n t h e c o n t r o l group. Results: A t s i x months, t h e e x p e r i m e n t a l g r o u p d e m o n s t r a t e d a g r e a t e r r e d u c t i o n i n f a t consumption, a g r e a t e r involvement i n a c t i v e e x e r c i s e , and a g r e a t e r r e d u c t i o n i n d a i l y c i g a r e t t e c o n s u m p t i o n t h a n the c o n t r o l group. T h e r e was no d i f f e r e n c e i n w e i g h t l o s s .  Author  (Year):  Liddy & Crowley  (1987)  Program Goals: Not s p e c i f i e d . The s t u d y g o a l s w e r e t o d e t e r m i n e i f MI p a t i e n t s a n d t h e i r s p o u s e s r e c e i v e d e n o u g h i n f o r m a t i o n a b o u t t h e c a r d i a c event and t h e r e c o v e r y p r o c e s s w h i l e i n the h o s p i t a l . Program: Ongoing h o s p i t a l - b a s e d c a r d i a c r e h a b i l i t a t i o n program t h r e e h o s p i t a l s , b u t no d e t a i l s p r o v i d e d r e g a r d i n g t h e s p e c i f i c nature of these programs. Design: intensive  One g r o u p , c o n v e n i e n c e s a m p l e , d a t a c o l l e c t e d i n t e r v i e w s two t o t h r e e m o n t h s p o s t MI.  b y means  Sample: following  E i g h t men their first  81  and MI,  t h r e e women b e t w e e n a g e s 34 and t h e i r spouses.  and  in  of  Results: Two t o t h r e e m o n t h s p o s t MI, t h e r e was o n l y a s u p e r f i c i a l u n d e r s t a n d i n g of the d i s e a s e p r o c e s s , the r e c o v e r y p r o c e s s and the i d e n t i f i c a t i o n of a n g i n a l p a i n s f o r b o t h p a t i e n t s and s p o u s e s . The i n f o r m a t i o n study p a r t i c i p a n t s r e c e i v e d regarding p h y s i c a l a c t i v i t y was t o o g e n e r a l t o a p p l y t o e v e r y d a y l i v i n g . T h e y h a d o n l y a  21 Table  1  (cont.)  s u p e r f i c i a l understanding of t h e i r prescribed diets, including a lack of understanding f o r r e d u c i n g t h e i r c h o l e s t e r o l l e v e l . The s u b j e c t s found t h a t t h e i n f o r m a t i o n r e c e i v e d d u r i n g t h e i r h o s p i t a l i z a t i o n l a c k e d m e a n i n g u n t i l a f t e r d i s c h a r g e , when many q u e s t i o n s s u r f a c e d .  Author  (Year):  R a l e i g h & Odtohan  (1987)  Program G o a l s : To e n s u r e t h e q u a n t i t y and q u a l i t y o f i n f o r m a t i o n t h a t t h e MI p a t i e n t r e c e i v e s w h i l e i n t h e h o s p i t a l . Program: A c a r d i a c h e a l t h e d u c a t i o n program t h a t i n v o l v e d i n d i v i d u a l i z e d i n s t r u c t i o n a n d w h i c h was d e v e l o p e d b y t h e s t a f f o f t h e h o s p i t a l i n w h i c h t h e s t u d y was c o n d u c t e d . Design: E x p e r i m e n t a l , w i t h random a s s i g n m e n t t o e i t h e r an experimental o r c o n t r o l group. Data c o l l e c t i o n occurred regarding knowledge and p h y s i c a l a c t i v i t y p r i o r t o t h e program f o r t h e e x p e r i m e n t a l g r o u p , a n d p r i o r t o h o s p i t a l d i s c h a r g e a n d two m o n t h s a f t e r d i s c h a r g e f o r both t h e experimental and c o n t r o l groups. Sample:  N i n e MI p a t i e n t s i n e a c h  group  Results: The e x p e r i m e n t a l group d e m o n s t r a t e d a s i g n i f i c a n t l y h i g h e r knowledge l e v e l than t h e c o n t r o l group, b o t h a t t h e time o f h o s p i t a l d i s c h a r g e a n d two m o n t h s a f t e r d i s c h a r g e . A t t h e 2-month i n t e r v a l , t h e e x p e r i m e n t a l g r o u p h a d resumed 70% o f t h e i r p r e h o s p i t a l i z a t i o n a c t i v i t i e s , w h i l e t h e c o n t r o l group had resumed o n l y 48% o f t h e i r a c t i v i t i e s .  Author  (Year): Murray  (1989)  Program G o a l s : Not s p e c i f i e d . T h e s t u d y a i m was t o i n v e s t i g a t e t h e t y p e o f i n f o r m a t i o n MI p a t i e n t s r e c e i v e d , a n d w h e t h e r i t met t h e i r p e r c e i v e d i n f o r m a t i o n needs. Program: An ongoing h o s p i t a l - b a s e d c a r d i a c e d u c a t i o n program t h a t i n v o l v e d p r i n t e d m a t e r i a l and t e a c h i n g i n a group o r on an i n d i v i d u a l b a s i s by a s t a f f nurse. Design: Data  One g r o u p ,  collection  patients Sample:  used  method o f sample  selection  not specified.  f a c e - t o - f a c e i n t e r v i e w s between author and  on t h e day o f o r t h e day b e f o r e 17 m a l e a n d 8 f e m a l e  anticipated  discharge.  p a t i e n t s b e t w e e n 27 a n d 71 y e a r s o f  22 Table age  1  (cont.)  with  confirmed  first  MI.  Results: These p a t i e n t s s t a t e d t h a t they f e l t w e l l - p r e p a r e d f o r d i s c h a r g e f r o m t h e h o s p i t a l , b u t w e r e o n l y a b l e t o s t a t e a few s p e c i f i c i t e m s o f a d v i c e o r i n f o r m a t i o n when q u e s t i o n e d j u s t p r i o r t o discharge. I n a d d i t i o n , t h e y f e l t t h a t t h e i n f o r m a t i o n was n o t r e l e v a n t t o t h e i r p e r s o n a l needs. T h i r t y - s i x percent of the patients s a i d t h e y were n o t g i v e n i n f o r m a t i o n r e g a r d i n g emergency a c t i o n i n t h e e v e n t o f c h e s t p a i n a t home. A l t h o u g h most p a t i e n t s were t o l d how l o n g i t w o u l d t a k e t o r e s u m e t h e i r n o r m a l l e v e l s o f a c t i v i t y , many h a d u n r e a l i s t i c e x p e c t a t i o n s o f t h i s t a k i n g 6 m o n t h s o r m o r e .  Author  (Year):  Thompson  (1991)  Program G o a l s : To p r o v i d e s u p p o r t and e d u c a t i o n f o r c a r d i a c p a t i e n t s a n d t h e i r s p o u s e s . T h e s t u d y a i m was t o d e t e r m i n e t h e e f f e c t o f t h i s p r o g r a m on t h e knowledge o f p a t i e n t s a n d t h e i r s p o u s e s . Program: I n d i v i d u a l i z e d c a r d i a c e d u c a t i o n and c o u n s e l l i n g conducted by a C a r d i a c C a r e n u r s e i n f o u r 3 0-minute s e s s i o n s d u r i n g t h e patients' hospital stay. Design: Experimental, w i t h p a t i e n t s and spouses a s s i g n e d t o e i t h e r a treatment group which r e c e i v e d t h e e d u c a t i o n and c o u n s e l l i n g program, p l u s r o u t i n e care, and a c o n t r o l group which r e c e i v e d o n l y r o u t i n e care. Data c o l l e c t i o n o c c u r r e d b e f o r e t h e i n t e r v e n t i o n , and 5 days, 1 month, 3 m o n t h s , a n d 6 m o n t h s l a t e r . Sample: 60 men u n d e r MI, a n d t h e i r w i v e s .  t h e a g e o f 66 who h a d e x p e r i e n c e d t h e i r 30 c o u p l e s w e r e p l a c e d i n e a c h g r o u p .  first  Results: Both p a t i e n t s and spouses i n t h e experimental group had s i g n i f i c a n t l y h i g h e r knowledge s c o r e s than those i n t h e c o n t r o l group on e a c h o c c a s i o n .  Author  (Year):  Pommier  (1992)  Program G o a l s : To e n c o u r a g e making l i f e l o n g changes i n l i f e s t y l e . The a u t h o r a l s o t r i e d t o d e t e r m i n e i f t h e r e was a n i n c r e a s e o f k n o w l e d g e r e g a r d i n g CAD f r o m a t t e n d i n g CAD c l a s s e s a n d what f a c t o r s a f f e c t e d l e a r n i n g and knowledge r e t e n t i o n . Program: which  A 6 0 - m i n u t e CAD r e h a b i l i t a t i o n  i n c l u d e d an e x p l a n a t i o n  class  of the disease  designed  process,  by t h e author  risk  factors,  23 1  Table  (cont.)  .  symptoms, n u t r i t i o n , p h y s i c a l a c t i v i t y , a f t e r d i s c h a r g e from the h o s p i t a l . Design: later.  One  group,  pretest before  Sample:  100  m a l e p a t i e n t s b e t w e e n 37  medications  class,  and  and  77  and  self-help  a p o s t t e s t one  years  of  month  age.  Results: Y o u n g e r p a t i e n t s a n d t h o s e w i t h more y e a r s o f f o r m a l e d u c a t i o n had h i g h e r p r e t e s t s c o r e s ( h i g h e r b a s e l i n e knowledge). T h e r e was a s i g n i f i c a n t i n c r e a s e i n s c o r e s b e t w e e n p r e t e s t a n d p o s t t e s t r e s u l t s i n d i c a t i n g an i n c r e a s e i n k n o w l e d g e one m o n t h a f t e r the c l a s s . M a r r i e d p a t i e n t s had s i g n i f i c a n t l y h i g h e r s c o r e s t h a t unmarried p a t i e n t s .  The patients  results do  of  g a i n and  the m a j o r i t y of retain  following participation However,  i n three  Crowley,  1987;  retain  of  studies indicate  knowledge a f t e r  hospital  studies  1989)  there  information regarding  (Rahe e t a l . , 1975; i s evidence  specific  health  that  discharge  i n hospital-based cardiac education  these  Murray,  these  programs.  Liddy,  &  t h a t p a t i e n t s do  not  promotion/protective  behaviours. Four cardiac  of  the  education  studies review programs  behaviours  al.,  1986;  Two  Hentinen,  of these  rather  than  way  life.  of  cigarettes  authors  Mills  after  hospital-based  i n health  hospital  F l e t c h e r , 1987;  examined the  investigating  e f f e c t i v e n e s s of  f o r engaging  promotion/protective 1985;  the  discharge  (Mills  R a l e i g h & Odtohan,  c h a n g e s i n o n l y one  health promotion/protective  et  1987).  behaviour, behaviours  as  e t a l . (1985) r e p o r t e d a r e d u c t i o n i n number  smoked 4 weeks a f t e r  hospital  discharge,  and  Raleigh  of &  a  24 Odtohan  (1987) r e p o r t e d  activities  for,the experimental  (1986) a n d F l e t c h e r cardiac  education  such as d i e t ,  an i n c r e a s e  Fletcher  group:  from a b r o a d e r smoking,  Both reported  ofp r e h o s p i t a l i z a t i o n  On t h e o t h e r  (1987) e x a m i n e d t h e e f f e c t  exercise,  investigations. and  an increased resumption  perspective  Hentinen  of hospital-based by i n c l u d i n g  behaviours  and weight l o s s i n t h e i r  a reduction  i n d i e t a r y f a t consumption  i n e x e r c i s i n g 3 t o 6 months a f t e r  (1987) a l s o r e p o r t e d  hand,  a reduction  hospital  discharge.  i n c i g a r e t t e smoking a t 6  months. In  summary,  effective also  hospital-based  i n helping patients  Cardiac  Education  A number o f o u t p a t i e n t reported  and e v a l u a t e d  outpatient  and in  l e a r n about t h e i r  i n encouraging health promotion/protective  Outpatient  in  cardiac education  Table  cardiac  2.  outpatient  cardiac education  programs  They have been examined  behavioural  heart  disease  behavioural  programs have  changes.  education.  been  A summary o f t h e s e l e c t e d  chosen f o r review for their  effect  on  l i f e s t y l e c h a n g e s f o l l o w i n g MI p a t i e n t s '  cardiac  and  Programs  i n the l i t e r a t u r e .  education  programs a r e  are  presented  knowledge involvement  25  Table  2  Outpatient  Author  Cardiac  (year):  Program G o a l s : methods o f r i s k  Education  Scalzi,  Programs  Burke & Greenland  (1980)  To i n c r e a s e knowledge o f c o r o n a r y h e a r t factor reduction.  disease and  Program: An o r g a n i z e d e d u c a t i o n a l program d u r i n g h o s p i t a l i z a t i o n , and f o l l o w - u p w i t h c l i n i c v i s i t s a t 1, 3, 6, 12, 18 a n d 24 m o n t h intervals. Design: Quasi-experimental, time-series. Patients i n the f i r s t 6 months a s s i g n e d t o c o n t r o l g r o u p , a n d p a t i e n t s i n t h e n e x t 6 m o n t h s assigned to experimental group. Sample: P a t i e n t s w i t h f i r s t MI E x p e r i m e n t a l g r o u p - - 1 9 p a t i e n t s (17 men a n d 2 women) C o n t r o l g r o u p - - 1 3 p a t i e n t s (11 men a n d 2 women) Results: No s i g n i f i c a n t c h a n g e s i n o v e r a l l k n o w l e d g e s c o r e s b e t w e e n t h e two g r o u p s o v e r t i m e . F o l l o w - u p i n s t r u c t i o n r e s u l t e d i n a s i g n i f i c a n t d i f f e r e n c e i n compliance i n medications and weight l o s s for the experimental group. T h e r e w e r e no d i f f e r e n c e s b e t w e e n t h e groups r e g a r d i n g smoking compliance, d i e t a r y r e s t r i c t i o n compliance, and r e t u r n t o w o r k . Comments: Each subject r e c e i v e d i n d i v i d u a l i z e d i n s t r u c t i o n i n the h o s p i t a l and d u r i n g c l i n i c v i s i t s .  Author (1983)  (Year):  Sivarajan,  Newton, A l m e s ,  Kempf, M a n s f i e l d  & Bruce  Program G o a l s : To s t u d y t h e e f f e c t o f e x e r c i s e combined w i t h a t e a c h i n g - c o u n s e l l i n g program on smoking, d i e t a n d w e i g h t changes. Program: E x e r c i s e program--30-minute weekly c l a s s e s f o r 12 w e e k s .  low-level  exercise  T e a c h i n g - c o u n s e l l i n g program--8 one-hour group c l a s s e s . Content included heart disease and heart attack, n u t r i t i o n , p h y s i c a l a c t i v i t y , s t r e s s and r e l a x a t i o n , and emotional r e a c t i o n s t o a h e a r t attack. Design:  Experimental  design--patients  randomized  to control  26 Table  2  group,  (cont.) exercise  group,  Data c o l l e c t e d during  and  exercise  and  teaching-counselling  h o s p i t a l i z a t i o n , at  3 months,  and  at  group.  6 months.  Sample: Men a n d women, 70 y e a r s o l d a n d u n d e r , w i t h f i r s t Entered experiment immediately post h o s p i t a l discharge. Initial randomization: E x e r c i s e group--88 E x e r c i s e and t e a c h i n g - c o u n s e l l i n g group--86 Control—84  MI.  Results: The t e a c h i n g - c o u n s e l l i n g p r o g r a m d e m o n s t r a t e d l i m i t e d e f f e c t i v e n e s s , w i t h the o n l y s i g n i f i c a n t changes i n reduced c o n s u m p t i o n o f s o d i u m - c o n t a i n i n g f o o d s and i n c o f f e e i n t a k e a t 3 months, b u t n o t a t 6 months, f o r t h e t e a c h i n g - c o u n s e l l i n g g r o u p . T h e r e w e r e no s i g n i f i c a n t c h a n g e s b e t w e e n t h e g r o u p s r e g a r d i n g smoking r e d u c t i o n and w e i g h t l o s s . Comments:  Author (1984)  A l l teaching  (Year):  Dracup,  sessions  Meleis,  were g r o u p  Clark,  sessions.  Clyburn,  Shields  &  Staley  Program G o a l s : To e v a l u a t e t h e e f f e c t s o f g r o u p c o u n s e l l i n g on c o m p l i a n c e t o n o t s m o k i n g , d e c r e a s e d BP, d e c r e a s e d b o d y w e i g h t , a n d w e e k l y e x e r c i s e f o r MI a n d c o r o n a r y b y p a s s s u r g e r y p a t i e n t s a n d spouses. Program: 10-week s e r i e s o f w e e k l y 90 m i n u t e s s e s s i o n s t h a t focused on a n x i e t y a n d s t r e s s r e d u c t i o n , r e l a x a t i o n t e c h n i q u e s , and r i s k factor reduction. All  groups  Design: collected  involved  at  i n exercise  training  3X/week.  Quasi-experimental, three-group, time-series. b a s e l i n e , 10 week, a n d 6 m o n t h i n t e r v a l s .  Sample:  28  s u r g e r y who program.  were e n r o l l e d i n an  patients  with  an  MI  and  30  patients  outpatient  E x p e r i m e n t a l g r o u p #1--17 p a t i e n t s c o u n s e l l i n g program. E x p e r i m e n t a l g r o u p #2--22 p a t i e n t s  cardiac  Results:  After  following  spouses  and  spouses,  6 months, b o t h e x p e r i m e n t a l  bypass  rehabilitation  and  p a t i e n t s i n c o u n s e l l i n g program. C o n t r o l group--19 p a t i e n t s and s p o u s e s c o u n s e l l i n g program).  Data  in but  only  (spouses d i d not  groups  attend  experienced  27 Table  2  (cont.)  significant  weight  differences  i n weekly e x e r c i s e  l o s s and  decreased level  systolic and  BP.  T h e r e were  smoking b e h a v i o u r  no  among a l l  groups. Comments: sessions.  Author  The  experimental  Method of  (Year):  Niskala  Program G o a l s : disease, Program:  educate p a t i e n t s  factor reduction,  f r o m h o s p i t a l by  arranged  as  of  and  regarding  lifestyle  coronary  patients  a community h e a l t h  55  artery  modification. one  week a f t e r  nurse,  with  subsequent  needed.  Design: One g r o u p , n o n - r a n d o m p o s t t e s t design. Program e v a l u a t i o n r e g a r d i n g h e a l t h knowledge, h e a l t h health functions (physical, emotional, s o c i a l ) . Sample:  group  reported.  (1987)  Home i n s t r u c t i o n f o r c a r d i a c  discharge visits  To  risk  intervention consisted  group assignment not  male and  6  female p a t i e n t s ,  post  behaviour,  MI.  Results: T h o s e who w e r e k n o w l e d g e a b l e a b o u t t h e i r h e a r t c o n d i t i o n a l s o engaged i n h e a l t h b e h a v i o u r and had b e t t e r p h y s i c a l f u n c t i o n i n g . Comments: Individualized instruction. No t i m e i n t e r v a l b e t w e e n i n t e r v e n t i o n a n d e v a l u a t i o n reported. No r e p o r t on r e l i a b i l i t y a n d v a l i d i t y t e s t i n g o f t h e questionnaire. No s t a t i s t i c a l r e p o r t o t h e r t h a n p e r c e n t a g e r e s u l t s on questionnaire reported.  Author  (Year):  Billington  Program G o a l s : more h e a l t h y Program:  To  change a t t i t u d e s and  8 weekly  Design:  health  behaviour  towards  a  lifestyle. sessions,  i n s t r u c t i o n were e x e r c i s e , techniques. Participants  (1988)  entered Patients  patients  contacted  attended  the  program  i n length.  Topics  1 month a f t e r h o s p i t a l  were i n i t i a l l y  were p l a c e d  program.  2 hours  d i e t , s t r e s s management a n d  selected  i n the  at  of  relaxation  discharge.  random. The  experimental  group  first that  7  28 Table  2  (cont.)  •  The r e m a i n i n g 7 p a t i e n t s r e c e i v e d l i t e r a t u r e d i s c h a r g e from the h o s p i t a l .  one  month  after  D a t a c o l l e c t i o n d u r i n g h o s p i t a l i z a t i o n f o r b o t h g r o u p s , a n d 3 1/2 m o n t h s a f t e r p r o g r a m c o m p l e t i o n f o r t h e e x p e r i m e n t a l g r o u p a n d 3 1/2 month a f t e r r e c e i v i n g l i t e r a t u r e f o r t h e c o n t r o l g r o u p . Sample: P a t i e n t s who h a d b e e n h o s p i t a l i z e d E x p e r i m e n t a l group--7 p a t i e n t s C o n t r o l group--7 p a t i e n t s Results: exercise  MI.  E x p e r i m e n t a l group demonstrated g r e a t e r changes i n l e v e l s , d i e t , a n d s t r e s s management t h a n t h e c o n t r o l g r o u p .  Comments: No v a l i d i t y reported. Very  f o r an  E d u c a t i o n a l s e s s i o n s o c c u r r e d i n group s e s s i o n s . a n d r e l i a b i l i t y i n f o r m a t i o n on t h e q u e s t i o n n a i r e  s m a l l sample  size.  A u t h o r ( Y e a r ) — M i l l e r , W i k o f f , McMahon, G a r r e t t & R i n g e l ( 1 9 8 8 ) ; M i l l e r , W i k o f f , McMahon, G a r r e t t , R i n g e l , C o l l u r a , S i n i s c a l c h i , Sommer & W e l s h (1989) ; M i l l e r , W i k o f f , G a r r e t t , McMahon & S m i t h (1990) Program G o a l s : To a s s i s t p a t i e n t s w i t h f o r m u l a t i n g a h e a l t h p l a n t h a t addressed problems of a t t i t u d e s toward m e d i c a l regimen p r e s c r i p t i o n s , a d h e r e n c e t o m e d i c a l regimen, c o p i n g methods and societal adjustments. Program: One home v i s i t b y a n u r s e 30 d a y s p o s t h o s p i t a l d i s c h a r g e t h a t f o c u s e d on a s s e s s m e n t , p r o b l e m i d e n t i f i c a t i o n , a n d d e v e l o p m e n t of a h e a l t h p l a n . Design: assigned  to  Quasi-experimental groups.  time-series, subjects  Experimental group r e c e i v e d n u r s i n g i n t e r v e n t i o n d i s c h a r g e from h o s p i t a l . Control  group d i d not  receive this  alternately  3 0 days  after  intervention.  E v a l u a t i o n f o r both groups o c c u r r e d p r i o r to h o s p i t a l d i s c h a r g e , 30 d a y s , 60 d a y s , 1 y e a r a n d 2 y e a r s a f t e r h o s p i t a l d i s c h a r g e . Sample: Initial 2 year  Patients with sample: sample:  first  Experimental  d i a g n o s i s of  group--58  C o n t r o l group--57 E x p e r i m e n t a l group--29 C o n t r o l group--22  MI  at  29 Table  2  (cont.)  Results: T h e r e were no s i g n i f i c a n t d i f f e r e n c e s between g r o u p s i n a d h e r e n c e t o t h e m e d i c a l r e g i m e n a t 60 d a y s a n d 1 y e a r . However, a t t h e 2 y e a r p e r i o d , t h e r e was a s i g n i f i c a n t d i f f e r e n c e f o r c o m p l i a n c e to d i e t f o rt h e experimental group, b u t no d i f f e r e n c e s between t h e groups i n compliance t o a c t i v i t y , s t r e s s r e d u c t i o n , and medications. C o n t r o l g r o u p was more c o m p l i a n t w i t h s m o k i n g c e s s a t i o n . F a v o u r a b l e a t t i t u d e s i n f l u e n c e d compliance t o d i e t , smoking c e s s a t i o n and s t r e s s r e d u c t i o n . Comments: Individualized instruction. O n l y o n e home v i s i t w i t h a f o c u s o n i n s t r u c t i o n .  Author  (Year):  Fridlund,  Hogstedt,  Lidell  & Larsson  (1991)  Program g o a l s : To e v a l u a t e t h e i n f l u e n c e o f a c a r i n g i n t e n t i o n i n p r e v e n t i n g secondary i l l n e s s and i n promoting an improved l i f e s i t u a t i o n , l i f e s t y l e m o d i f i c a t i o n s , and l e s s h e a l t h complaints. Program: 6-month r e h a b i l i t a t i o n p r o g r a m t h a t i n c l u d e d 2 - h o u r w e e k l y s e s s i o n s f o c u s i n g on l i f e s t y l e , l i f e s t r e s s a n d s o c i a l s u p p o r t . P a r t i c i p a n t s a l s o were i n v o l v e d i n a n e x e r c i s e a n d r e l a x a t i o n program. Design: F o l l o w i n g h o s p i t a l d i s c h a r g e , p a r t i c i p a n t s were randomly d i v i d e d i n t o an experimental g r o u p t h a t was i n v o l v e d i n a n e x e r c i s e a n d e d u c a t i o n a l r e h a b i l i t a t i o n p r o g r a m a n d a c o n t r o l g r o u p t h a t was not i n v o l v e d i n t h e r e h a b i l i t a t i o n program. F o l l o w - u p a t h o s p i t a l d i s c h a r g e , 6 a n d 12 m o n t h s a f t e r MI. Sample: MI P a t i e n t s d i s c h a r g e d f r o m t h e h o s p i t a l . E x p e r i m e n t a l g r o u p - - 5 2 (45 men a n d 7 women) C o n t r o l g r o u p - - 5 8 (51 men a n d 7 women) Results: E x p e r i m e n t a l g r o u p showed i n c r e a s e d p h y s i c a l c a p a c i t y a t 6 m o n t h s , l e s s r e i n f a r c t i o n s a t 12 m o n t h s , h i g h e r p e r c e i v e d life s a t i s f a c t i o n a t 12 m o n t h s , b e t t e r l e i s u r e s i t u a t i o n a t 6 m o n t h s , a n d b e t t e r p a r t n e r s i t u a t i o n a t 12 m o n t h s . T h e r e were no s i g n i f i c a n t d i f f e r e n c e s between t h e groups r e g a r d i n g d i e t a l t e r a t i o n s and smoking h a b i t s a t 6 m o n t h s a n d 12 m o n t h s . Comments:  Instruction occurred  i n group  sessions.  30 In  a l l of these  investigators  concentrated  promotion/protective complying with the  participants  physical  and  changes  activity,  In changes.  weight  differences  loss,  session.  effectiveness consumption involved  rather  than  behaviours  a s a way o f  programs,  i n specific  health  e t a l . , (1980); (1988)  Dracup e t  reported  such as t a k i n g  reduction  to,or  f o c u s i n g on  education  Scalzi  diet,  programs,  This  medications,  i n blood  such as decreased  pressure, changes i n  anxiety,  independence,  fatigue,  perceived  p a r t i c i p a n t s d i d n o t make  regarding  education  loss,  significant  1989, 1991) d i d n o t f i n d a n y activity,  stress  reduction  program c o n s i s t e d o f o n l y one  S i v a r a j a n e t a l . (1983) r e p o r t e d  and weight  disease,  plan,  and i n c r e a s e d  e t a l . (1988,  i n c i g a r e t t e smoking,  limited  reduction  even though t h e e d u c a t i o n  in fat  program  sessions.  Two o u t p a t i e n t heart  on a d h e r i n g  and s o c i a b i l i t y .  f o rreduction  8 group  an emphasis  F r i d l u n d e t a l . , (1991) r e p o r t e d  between t h e groups  medications.  teaching  changes  adjustments  two o f t h e s e Miller  health  i n these  cardiac  programs, t h e  i n specific  i n h e a l t h behaviours  psychosocial  satisfaction,  education  (1987) a n d B i l l i n g t o n  interpersonal friction,  life  and  seven  behaviours.  s t r e s s management.  specific  treatment  made s i g n i f i c a n t  (1984); N i s k a l a  significant  with  of engaging  of these  promotion/protective al.,  on changes  a prescribed  For five  cardiac  behaviours,  broader perspective  life.  and  outpatient  cardiac  education  studies  report  and t h e r e l a t i o n s h i p o f knowledge  level  knowledge to health  about  31 promotion/protective who  were  behaviours.  Niskala  knowledgeable regarding  their  engaged i n h e a l t h p r o m o t i o n / p r o t e c t i v e (1980)  f o u n d no  control  and  follow-up  significant  experimental  cardiac  condition  behaviours.  the  during  hospitalization  experimental  for medications  compared  to  the  the  of  programs,  The  other  their  five  effect Five  pretest  on  of  while  al., by  et  the  only  one  a l . (1988,  specific  et  during  and  weight  period.  For  individualized  studies  education  the  d i d not  a  loss both  basis. examine  1989,  the  et  intervals  1990;  In  the  group  a nurse  experimental  for a  during  the  there  first  study  received  thirty  group  two-year p e r i o d  programs,  the  F r i d l u n d et  1988).  by  days  effect  received  after  was  a  to  two  months  first  one  to  one  lack  of  discharge.  program extended  f o r a p e r i o d beyond the  a  education  a l . (1980) e x a m i n e d t h e  the  these  involved  cardiac  experimental  a home v i s i t  i n which  instruction  outpatient  Billington,  1990),  of  of  programs  hospitalized, enabling  a l . , 1988,  Scalzi  In both  cardiac  following hospital One  program  discharge.  concentrated  effect  session during  educational  hospital  the  1989,  of  at  cardiac  a l . , 1983;  hospital discharge.  instruction  an  cardiac education  Miller  after an  on  and  the  knowledge.  to determine  teaching  follow-up  p a r t i c i p a n t s were s t i l l  Sivarajan et et  occurred  outpatient  a l . , 1980;  1991;  Miller  cardiac  these  investigators (Scalzi  instruction  outpatient  et a l .  group d i d demonstrate  d i f f e r e n c e i n compliance c o n t r o l group d u r i n g  those  also  Scalzi  significant  these  that  d i f f e r e n c e s i n knowledge between  groups  p e r i o d . However,  (1987) r e p o r t e d  two  32 months  following hospital  investigated  by  F r i d l u n d et  s i x months a f t e r Two the  discharge.  hospital  a l . (1991)  one  Sivarajan  to  two  months  concentrated  the  1 - h o u r c l a s s e s e a c h week, b e s i d e s program  analysis  r e v e a l e d no  control weight  groups loss.  education  discharge,  also  significant  The  the  of but  specific not  at  food  the  hospital  group  items  information indicated  group a t t e n d e d  hospital  in  g r a p h form and  on  a very  small  these  The  eight  Statistical  experimental smoking in  changes  and  and  the  regarding  following hospital  Billington  collection  i n a matrix size  of  Billington  participants  in  (1988)  the  t w o - h o u r c l a s s e s s i x weeks  in exercise levels,  sample  of  t h r e e months  program r e p o r t e d by  discharge.  regarding data  changes  behaviours  at  the  low-level  that participated  i n v o l v e d eight weekly c l a s s e s .  following  in a  discharge.  significant  In  s i x month p e r i o d .  cardiac education  experimental  for  during  groups attended  changes between the  specific  experimental  discharge.  participating  weeks a f t e r  regarding  cardiac education  experimental  c l a s s e s d i d r e p o r t making  consumption  The  f o r 12  program  i n v o l v e d weekly s e s s i o n s  following hospital  e t a l . (1983) s t u d y ,  exercise  rehabilitation  discharge.  programs d i d p r o v i d e  first  The  (1988) p r o v i d e d  tools.  nutrition  of percentages, only  Although  seven  and  the  the  stress  no results management  r e s u l t s were  subjects i n each  based  group.  Summary It  i s evident  that  f u r t h e r study  health promotion/protective  behaviours  of  the  effect  on  for individuals  knowledge who  and  participate programs  that  information during  i n outpatient  have been examined p r o v i d e  regarding- the e f f e c t  the f i r s t  one  Weak s t u d y d e s i g n s , tools,  information  gap.  limited  cardiac  regarding  education discharge.  data  collection  a n a l y s i s , o r l a c k of emphasis behaviours  a s a way  The  and i n c o n s i s t e n t  following hospital  lack of information  lack of s t a t i s t i c a l  i s required.  of outpatient  t o two m o n t h s  health promotion/protective this  cardiac education  of l i f e  regarding contribute  34  CHAPTER THREE Methodology The  details  r e g a r d i n g the process  presented  i n this  chapter.  design,  procedure,  instruments, protection  sample  recruitment,  o f human  This  i n c l u d e s an  selection, data  study  g r o u p d e s i g n as  an  the  was  first  consisted but  criteria,  data  analysis,  illustrated  1;  who  X  and  the  Posttest 02 02  group c o n s i s t e d of  2)  t h o s e p a t i e n t s who  or a program i n t h e i r  2 months o f  d i d not  collection  pretest-posttest control  X--Intervention; 02--0bservation  conducted,  those  the  below:  Pretest 01 01  experimental  of  are  Design  o u t p a t i e n t c a r d i a c e d u c a t i o n program at the h o s p i t a l  study  study  e x p l a n a t i o n of  data  a quasi-experimental  Experimental group C o n t r o l group  The  this  rights.  used  (01--0bservation  sample  collection,  Research This  of conducting  their  hospital  p a t i e n t s who  a t t e n d an  local  discharge.  were a d m i t t e d  where  community, The  to the  control same  outpatient cardiac education  attended this  within group  hospital,  program.  Procedure Observation for  1  (01)--During  their  first  MI,  knowledge  level  regarding heart  the  extent  to which  subjects' admission  t h e y were a s s e s s e d w i t h  they  d i s e a s e and  to the  respect to t h e i r  hospital present  healthy behaviours,  engaged i n h e a l t h p r o m o t i o n / p r o t e c t i v e  and  35 behaviours  before  their  Intervention outpatient following  the h o s p i t a l ,  extent  from the  2  t o s i x months  regarding heart  at  they  to the  Interventional  Cardiac Unit  disease  and  and  to  their  healthy behaviours,  and  promotion/protective  study  Sample S e l e c t i o n was  Care U n i t  (CIU)  respect  from  time.  Setting for this  an  2 months  following discharge  again with  engaged i n h e a l t h  that period i n  sample  first  in  hospital.  (02)--Four  to which  behaviours  admitted  to v o l u n t a r y p a r t i c i p a t i o n  s u b j e c t s were a s s e s s e d  level  The  hospital.  c a r d i a c education program w i t h i n the  Observation  the  to the  (X)--This refers  discharge  knowledge  admission  of  s e l e c t e d f r o m p a t i e n t s who (CCU)  a major  or  the  were  Cardiology  teaching hospital  i n western  Canada. Sample Inclusion with the  their ages of  first 30  investigator's the  time  criteria MI,  and  promotion/protective  also  had  considered  and  T h i s age of  to  the  spoke E n g l i s h , and r a n g e was  chosen,  caring for first  behavioural  a coronary  time  CCU  who  based MI  such  as  following their  study.  on  between  the as  challenge  MI. first  MI  Those p a t i e n t s w i t h  rheumatoid a r t h r i t i s  a major mental  were  CIU  open t o making h e a l t h  changes  i n the  or  patients,  angioplasty following their  for inclusion  with  and  p a t i e n t s a r e most  major p h y s i c a l c h a l l e n g e neuropathy,  read  experience  when t h e s e  P a t i e n t s who  were p a t i e n t s a d m i t t e d  who  75.  Criteria  such  as  or  were a  diabetic  schizophrenia  3 or Alzheimer's  d i s e a s e were e x c l u d e d  from the  study.  Instruments Health  Promoting L i f e s t y l e  Profile  Health promotion/protective Health  Promoting L i f e s t y l e  Sechrist  & Pender  instrument  (1987)  behaviours  Profile  were measured w i t h  (HPLP) d e v e l o p e d  (see A p p e n d i x A ) .  The  i n the  actualization,  domains o f  of  this  behaviours  i n t e r p e r s o n a l support,  exercise, nutrition,  Walker,  subscales  measure the h e a l t h p r o m o t i o n / p r o t e c t i v e  perceptions  by  the  and  self-  s t r e s s management a n d  health  responsibility. For Walker, senior  a pilot  response  internal  The  four nursing promotion  also  internal  the  a 107  community  participated  With the item  952  of  173  i t for and  .919,  r was  graduate  inclusion  of  stability.  indicating  .854,  high  indicating  f o r content  their  and  item  validity  were knowledgeable r e g a r d i n g  the  adults  settings.  An  107  by  health  recommended  i t e m HPLP was  (43 6 f e m a l e a n d a t t e m p t was  i n health-promoting  i n c l u d e d s u b j e c t s who  i t to  consistency,  evaluated  instrument,  items  HPLP.  testing  sample o f  this  to evaluate  test-retest  f a c u l t y members who  was  form of  c o n s i s t e n c y was  q u e s t i o n n a i r e was  Reliability convenience  students  for internal  literature.  result  initial  (1987) a d m i n i s t e r e d  variance,  c o n s i s t e n c y and  stability.  who  the  undergraduate nursing  Cronbach's alpha  various  of  S e c h r i s t & Pender  clarity,  the  test  516  and  male)  on  a  from  made t o i n c l u d e a d u l t s  behaviours.  were i n a c t i v e  performed  those  The i n v e s t i g a t o r s who  participated  37 i n exercise mean age  programs.  of 39.2  item-total  S u b j e c t s ranged i n age  years.  c o r r e l a t i o n s were d e l e t e d .  of which had  item-total  analysis,  at which p o i n t  and  eliminated.  were  Items w i t h low  The  C o n s t r u c t v a l i d i t y t e s t i n g of the  i n t o another f a c t o r a n a l y s i s .  l o a d on any  actualization, health  r e s p o n s i b i l i t y , exercise,  The  s t r e s s management.  named h e a l t h promoting  alpha c o e f f i c i e n t s of  .702  s u b s c a l e s measures o n l y the S t a b i l i t y t e s t i n g was of 63  adults  s c o r e of  at an  .926  each of the to  expected  These s i x f i r s t - o r d e r second-order  factor  i t e m HPLP i n d i c a t e d  .904,  i n d i c a t i n g that  s i n g l e concept of t h a t  performed by a d m i n i s t e r i n g  e n t i r e s c a l e and  .922.  each of  .808  to  a  Each of  6 f i r s t - o r d e r factors  had  the  subscale.  the HPLP to a sample  i n t e r v a l of 2 weeks, which r e s u l t e d  f o r the  the  nutrition,  h i g h i n t e r n a l c o n s i s t e n c y w i t h an alpha c o e f f i c i e n t of 6 subscales representing  these items  lifestyle.  F u r t h e r r e l i a b i l i t y t e s t i n g of t h i s 48  the  factor  f a c t o r s were l a b e l l e d s e l f -  f a c t o r s were found to l o a d s i g n i f i c a n t l y on one which was  entering  A l l these items l o a d e d on  .35  support, and  single  factor  f i n a l 48-item H e a l t h  f a c t o r s at a l e v e l of  interpersonal  following  were s u b j e c t e d to  accomplished by  or h i g h e r .  with a  r e m a i n i n g 7 0 items, most  .25,  items d i d not  Promoting L i f e s t y l e P r o f i l e was  to 88,  alpha c o e f f i c i e n t s  c o r r e l a t i o n s of 22  from 18  .905  i n a Pearson r  f o r the  subscales  (Walker et a l . , 1987). P e r m i s s i o n to use g r a n t e d by Dr.  the H e a l t h Promoting L i f e s t y l e P r o f i l e  Susan Walker  (see Appendix  B).  was  38 This wellness,  i n s t r u m e n t was rather  than  developed  from  the p e r s p e c t i v e of  the p r e v e n t i o n of i l l n e s s .  a healthy l i f e s t y l e  f o r a broad p o p u l a t i o n base.  limitation  study  be  for this  misleading for individuals  event  o f a n MI.  20-30 m i n u t e s that  at least  Item  a n MI  i n that  signs"--is  after  onset  i n the  hospital  that  individuals  who  accurately  Heart  the  second  S i n c e S.  altered  i n any  stage  of  this  22-item  investigator  i n an not  that  vigorously  for  impression recovery  from  for physical r e c o v e r i n g from signs  (see Appendix  (four  and that B),  t o s i x months  designed that  (see  specifically  several  items  apply to i n d i v i d u a l s  for do  who  are  a heart attack.  Heart  Quiz H e a l t h Knowledge Quiz  (HHKQ) was  t o measure the knowledge v a r i a b l e .  the h e a l t h p r o m o t i o n / p r o t e c t i v e behaviours and  illness  explanatory letter  measures knowledge r e g a r d i n g h e a r t d i s e a s e and  activity  may  Walker requested way  study  a h e a r t a t t a c k , and  describe behaviours  from  the  aware o f p h y s i c a l  MI.  t h e q u e s t i o n n a i r e was  H e a l t h Knowledge A  of another  have had  monthly  misleading for individuals  d i s c h a r g e ) were i n f o r m e d  A p p e n d i x D)  recovering  body a t l e a s t  o f t h e HPLP n o t b e  participants  item #13--"Exercise  t h e y n e e d t o c o n s t a n t l y be  symptoms o f t h e the content  a r e r e c o v e r i n g from  expectation during early  # 4 3 - - " O b s e r v e my  changes/danger  i n t h e HPLP  3 t i m e s p e r week"--may g i v e t h e i s an  t o measure  This i s a  a number o f i t e m s  who  In p a r t i c u l a r ,  vigorous exercise  a n MI.  not  i n that  I t seeks  promoting  stress  management  developed  This quiz  knowledge r e g a r d i n g  of n u t r i t i o n ,  (see Appendix  by  E).  physical  39 The included matter,  process  f o r e s t a b l i s h i n g content  and adaptation  of the quizzes  used  p r o g r a m a t t h e major, t e a c h i n g  conducted.  Content v a l i d i t y  of this  knowledge t e s t s d e v e l o p e d by o t h e r Hicks  & Heyward,  c o n t r i b u t i o n o f Budan  one, in  Smith,  two, f o u r  and seven,  t h e development  contribution 13,  of quiz  study  applied i n the cardiac (Rahe e t a l . , 1975; Budan,  The i n v e s t i g a t o r acknowledges  (1983) i n t h e d e v e l o p m e n t  of quiz  items  f o r t h e c o n t r i b u t i o n o f Rahe e t a l . items  was  q u i z was a l s o e s t a b l i s h e d b y t h e  authors  1991).  cardiac  two a n d t h r e e ,  (1975)  and f o r t h e  o f S m i t h e t a l . (1991) i n t h e d e v e l o p m e n t  of quiz  items  14, 19, 20, 21, a n d 2 2 . The  process  Knowledge Q u i z patient  f o r e s t a b l i s h i n g face v a l i d i t y  involved obtaining  education,  t h e judgments  i n c l u d i n g two c l i n i c a l  chairperson  of a.hospital patient  coordinator  of a cardiac rehabilitation  another  facility.  nutritionist, included The  nurse  education  o f the Heart  o f experts  committee,  judgments  a p h y s i o t h e r a p i s t , and an occupational  i n determining  the face v a l i d i t y  HHKQ was p i l o t - t e s t e d artery disease  hospital  i n western  pilot-tested  of this  on p a t i e n t s w i t h  who w e r e a d m i t t e d  Canada where t h i s  i n cardiac  and t h e  program a t of a t h e r a p i s t were  instrument. newly  t o the major  study  Health  specialists, the  and teaching  I n a d d i t i o n , the expert  coronary  also  i n the outpatient  h o s p i t a l where t h i s  examination and m o d i f i c a t i o n o f concepts  the  o f thw HHKQ  a p p l i c a t i o n o f -the i n v e s t i g a t o r ' s k n o w l e d g e o f t h e s u b j e c t  education  1983;  validity  diagnosed teaching  was c o n d u c t e d .  on p a r t i c i p a n t s o f t h e o u t p a t i e n t  cardiac  I t was education  40 program d u r i n g February, hospital.  1993, a t t h i s  same  F u r t h e r c h a n g e s w e r e made t o t h o s e q u e s t i o n s t h a t  consistently patients,  March and A p r i l ,  answered  ambiguous  incorrectly.  Based  on v e r b a l  answer, c h o i c e s f o r a s e l e c t e d  feedback  were from  number o f q u e s t i o n s  were changed t o i n c r e a s e c l a r i t y . Demographic  Information  Demographic during  the pretest  posttest, cardiac from  i n f o r m a t i o n was o b t a i n e d f r o m phase o f the study  participants  were a s k e d  i f study p a r t i c i p a n t s  programs,  either  the  communities  local  their  transfer  program  (see Appendix G ) .  determine  i n the c i t y  F).  Forthe  following  their  had attended other c a r d i a c  education  s t u d y was c o n d u c t e d ,  study p a r t i c i p a n t s  d i s c h a r g e from  discharge  T h i s i n f o r m a t i o n was r e q u i r e d t o  where t h i s  t o which  t o and  (see Appendix  participants  whether they had a t t e n d e d any  education or r e h a b i l i t a t i o n  the hospital  study  the c i t y  or i n  returned  hospital  after  of this  study  location. Recruitment Individuals were i d e n t i f i e d  who met t h e c r i t e r i a  by t h e i n v e s t i g a t o r .  f o r admission  After  their  physical  stablized  and t h e y were i n t h e r e c o v e r y s t a g e o f t h e i r  hospital,  staff  patient with  these p a t i e n t s .  it.  study  These nurses  o f the study and asked  I f the patients  responded  condition  stay i n the  i n t h e CCU a n d C I U o f t h e h o s p i t a l  recruitment f o r this  the nature in  nurses  to the study  i n which  o c c u r r e d made t h e i n i t i a l informed-the  patients  i f t h e y were w i l l i n g i n the affirmative,  contact  regarding  to participate the study  41 investigator regarding As  approached  t h e p a t i e n t a n d p r o v i d e d more  t h e study. a component o f t h e i r  program,  study  participants  hospital-based cardiac  were i n f o r m e d  ongoing o u t p a t i e n t c a r d i a c education this  study  was l o c a t e d .  outpatient  cardiac education  education  in  regarding  Appendix  the investigator together  regarding  I).  ensure p a r t i c i p a n t s '  questionnaires For HPLP w i t h  with  a cover  the completion  letter  HHKQ, a n d that  during  their  were r e q u e s t e d  hospital  to the present  promoting/protecting that were  behaviours.  of the  stay. were r e q u e s t e d  state of their Since  some i t e m s  i n the explanatory according  to  t o complete t h e  C) t o r e p l y t o t h e s e  items  hospital  They were a l s o i n s t r u c t e d  admission.  i n an envelope  t o complete t h e health o n t h e HPLP  cannot be a p p l i e d t o t h e h o s p i t a l informed  included  o f the q u e s t i o n n a i r e s (see  p r i v a c y following completion  Participants  reference  participants  a willingness to participate  g a v e them t h e HPLP,  the pretest, participants  to behaviours  other  the existence of local  These q u e s t i o n n a i r e s were d i s t r i b u t e d  questionnaires.  of this  Collection  patients indicated  demographic p r o f i l e , instructions  P a t i e n t s from  where  programs.  eligible  t h e study,  t h e e x i s t e n c e o f an  program a t t h e h o s p i t a l  program.  Data After  about  education  S e e A p p e n d i x H f o r a summary  communities were a l s o i n f o r m e d cardiac  details  to their  letter  refer  setting, (see Appendix  way o f l i f e t o complete  prior to t h e HHKQ  42 according  to  their  questionnaires recruitment occurred  were c o l l e c t e d  and  data  the  A p p e n d i x J) hospital.  to the  and  copy of  an  This  the  and  HPLP, The in the  and  use  second phase of  September,  between the  the  using  a p p l i e d to both  the  subtests  the  t-test  knowledge q u i z  s m a l l number o f  possibility  of  from  as  the  questionnaires  behaviours.  study  experimental  the the  t-test total  subscales  subtests  a normal  the  (see  the  heart A  stamped  mailed one  month,  a reminder.  occurred  a  Data  between  Analysis  for determining  items  discharge  respond a f t e r  health promotion/protective  and  letter  mailed  knowledge r e g a r d i n g  mailed  the  study  1994.  was  of  cover  included with  was  the  p a r t i c i p a n t s were  to complete  their  questionnaires  were d e t e r m i n e d by test  study,  requested  Participant  1994.  I f p a r t i c i p a n t s d i d not  Differences  stage  May,  appropriate  s t a t e of  completed  phase of  following their  Data  knowledge and  first  health promotion/protective  for this  1994  and  this  The  investigator.  for this  r e t u r n e n v e l o p e was  questionnaires.  collection  present  their  self-addressed  January,  s i x months  They were a g a i n  according  second  to  with  level.  the  1993  second phase of  four  by  collection  same q u e s t i o n n a i r e s  disease  knowledge  between September,  For these  present  may  and  behaviours  at  the  f o r independent  scores  i n each of  f o r the these  i n each sub-test.  groups.  HHKQ a n d  of  the  data.  reduces The  the  instruments.  inaccurate results This  in  posttest  d i f f e r e n c e s between the  provide  distribution  c o n t r o l groups  groups due  to  the  investigator  43 recognizes  that  a .non-parametric  b e t w e e n two g r o u p s to  such  t h e knowledge q u i z  consistency, level  f o rdetermining  a s t h e Mann W h i t n e y U t e s t  sub-test  the t-test  test  scores.  However,  c o u l d be a p p l i e d  f o r the purpose o f  was a p p l i e d t o a l l t h e d a t a ,  was a p p l i e d t o t h e s u b - t e s t  scores  differences  to reduce  a  but a higher  the probability of  error. Procedures Before  implementing  f o r P r o t e c t i o n o f Human the study,  Rights  t h e p r o p o s a l was r e v i e w e d  approved by t h e U n i v e r s i t y Behavioural  Sciences  f o r R e s e a r c h I n v o l v i n g Human S u b j e c t s .  Screening  and  Committee  I t was a l s o r e v i e w e d  and  a p p r o v e d b y t h e h o s p i t a l - w i d e R e s e a r c h Committee a n d t h e N u r s i n g R e s e a r c h Committee An  attached  included with  the  results  their and  cover  letter  i n which the study  that b r i e f l y  each o f the hand-delivered  questionnaires(see participants  of the hospital  Appendices  were a s s u r e d  I and J ) .  of anonymity  of the questionnaires.  participation  i n the study  i n t h e two p h a s e s  explained  conducted.  the study  was  and m a i l e d In these  cover  letters,  and c o n f i d e n t i a l i t y  They were a l s o i n f o r m e d  was v o l u n t a r y a n d t h a t  r e t u r n o f t h e q u e s t i o n n a i r e s was r e g a r d e d  participate  was  of the study.  as t h e i r  regarding that  completion consent  to  44  CHAPTER FOUR Presentation and Discussion of Findings The  demographic  the  experimental  The  findings  by  information  and c o n t r o l  i n relation  a discussion  groups  a g e s o f 32  age  limit  stage,  limit  (75 y e a r s )  an  behaviours. completed  outpatient  comprised  a total  Seven p a t i e n t s  Five  disease  were t r a n s f e r r e d  Of  group.  outlying  areas  cardiac  drive  o f t h e h o s p i t a l where t h i s  outpatient  community.  to attend  local  cardiac  Another  education  t o make c h a n g e s i n t h e upper age  72 p a r t i c i p a n t s  education  12% (3)  i s that  program  f o r the large  5 0 % (36)  i n communities  where  of these there  programs.  i n the experimental  their  interest i n  One o f t h e r e a s o n s  from h o s p i t a l s  and were a b l e  above t h e upper  30 participated i n  and t h e remaining  education  between  These 3 0 p a r t i c i p a n t s  program.  group,  o r no c a r d i a c  the subjects  over  Of t h e 102 s u b j e c t s ,  education  i n the control  infrequent  desire  o f t h e seven p a t i e n t s  the study.  cardiac  and t h e i r  number o f p a r t i c i p a n t s i n t h e c o n t r o l g r o u p  are  followed  number o f 102 s u b j e c t s  who d i d n o t p a r t i c i p a t e i n a n o u t p a t i e n t  subjects  are presented,  were r e c r u i t e d because o f t h e i r  the experimental  were p l a c e d  chapter.  Sample  a n d 80 w e r e r e c r u i t e d .  l e a r n i n g more a b o u t h e a r t health  i n this  of the r e s u l t s .  the pretest  the  c h a r a c t e r i s t i c s f o r both  are described  t o both hypotheses  The At  and other  12% (3)  group,  a cardiac  were  education  resided within  s t u d y was c o n d u c t e d ,  p r o g r a m was p r o v i d e d ,  from  program i n  an hour's and where an  but they  attended  45 programs of  in-the area  of  their  the programs a t t e n d e d  investigator  as  being  by  residence.  these  similar  participants The  on  groups  experimental the  fact  focused  Table  similar,  on m a k i n g  individuals lifestyle  i n the younger  changes  after  group d i d not  experimental  group had  experimental  Also,  the  experimental  participants in  the  of  less  (20%  control than  group than i n the  group).  [5]  grade  i n the  A  age  u p p e r age  r a n g e may and  this  may  compared  t o 21%  [10]  the  MI.  experimental  to note  In  focus  be  None o f  the the  h i g h e r number o f group had  that  less  and  the  age  the  of  40.  (8%  [2]  in  group).  to  an  8.5%  [4]  education  r e t u r n i n g the p o s t t e s t  s u b j e c t s i n the  experimental  post-high school education  group compared  The  widowered  group compared  by  making  why  control  four subjects with study  of  not  on  participants i n the  is  addition,  a reason  more w i d o w e d a n d  experimental  8 completed  experimental  of  also  female  i n the  other  range o f t e n are  an  fewer  control  the  i n c l u d e s u b j e c t s below the  group had  education  80 y e a r - o l d s u b j e c t s i n s p i t e  slightly  group).  questionnaires.  [13]  group  two  changes a f t e r  a n MI,  experimental  the  t h e mean age  in this  lifestyle  the  study p a r t i c i p a n t s  i t is interesting  i n c l u d e d the  that individuals  by  by  group.  Although  is.very  group  attended  i n f o r m a t i o n r e c e i v e d from  3.  the d e s c r i p t i o n s  outpatient cardiac  t h a t was  experimental  demographic  summarized control  i n the  H  on  6 s u b j e c t s , t h e y were j u d g e d  to the  program d e s c r i b e d i n Appendix  Based  t o 32%  [15]  i n the  (52%  control  46 3  Table  Demographic  Information Withdrawals* Total  Exp.  Control  Exp.  Control  Sample  Group  Group  Group  Group  n=102  n=25  n=47  57  57  58  Mean A g e Age  n=5  n=25  58  56  Ranges 30-39  years  6  0  4  0  2  40-49  years  19  8  5  0  5  50-59  years  37  7  19  3  8  60-69  years  25  6  10  2  7  70-79  years  13  2  8  0  3  2  2  0  0  0  Male  83  23  37  4  19  Female  19  2  10  1  6  80  years  Gender  Marital  Status  Single  9  3  3  0  3  69 7  14  34  5  16  1  4  0  2  Separated  3  1  1  0  1  Widow(er)  12  5  4  0  3  Married Divorced  Education Grades  0-7  Grades  8-11  Grade  4  0  0  1  3  27  4  15  0  8  12 o r  equiv.  30  8  17  1  4  C.C/T.S.**  22  10  4  3  5  University  19  3  11  0  5  Working  61  16  27  4  14  Not  41  9  20  1  11  85  21  40  4  20  17  4  7  1  5  Employment  status  working  Language  group  English  as  first  language Other  as  first  language *Subjects  who d i d n o t  complete the p o s t t e s t  ^Community C o l l e g e / T e c h n i c a l S c h o o l  47 Presentation Of  t h e 72 s u b j e c t s  the  study  65%  response rate  for this  group,  group.  25 s u b j e c t s  a n 83% r e s p o n s e r a t e  analysis  i n t h e c o n t r o l group,  47 s u b j e c t s  by r e t u r n i n g the p o s t t e s t questionnaires,  experimental for  of Findings  only  group.  t h e 72 s u b j e c t s  i na  i n the  the posttest  i n the experimental  was p e r f o r m e d u s i n g  resulting  O f t h e 30 s u b j e c t s  returned  completed  questionnaire, Statistical  who c o m p l e t e d t h e  study. Comparison o f P r e t e s t and P o s t t e s t R e s u l t s The  Within  p r e t e s t a n d p o s t t e s t HHKQ s c o r e s  groups were a n a l y z e d experimental  behaviours  cardiac education.  a n d HPLP s c o r e s  a more c o m p l e t e  and c o n t r o l groups  promotion/protective outpatient  to obtain  regarding regardless  for  f o r both groups.  t h e HHKQ t o t a l mean  for paired  a level  o f 0.01 was u s e d  HPLP s u b - s c a l e chosen  the  scores.  t-test  probablility  incorrectly sub-test  significant  scores  of a type-I  error,  that  there  and sub-scale  mean  scores,  differences.  o f 0.05 was u s e d  scores. mean  A  a level  scores  i . e . , the probability  when  i nreality  and t h e  o f 0.01 was  o f t h e same d a t a  were s i g n i f i c a n t  significant  scores,  a n d HPLP s u b - s c a l e  measurements on s e c t i o n s  concluding  significant  o level  a n d HPLP t o t a l  The h i g h e r  observations  o n t h e HHKQ s c o r e s a n d  f o r t h e HHKQ s u b - t e s t  f o r t h e HHKQ s u b - t e s t  repeated  A significant  scores  knowledge and h e a l t h  of participation i n  b e t w e e n p r e t e s t a n d p o s t t e s t was p e r f o r m e d HPLP s c o r e s  f o r both  description of the  their  The t - t e s t  Groups  because  increases of  differences i n t h e r e were no  48 Comparison w i t h i n the experimental The  experimental  HHKQ t o t a l  group.  g r o u p made s i g n i f i c a n t  s c o r e s between t h e p r e t e s t  improvements  and p o s t t e s t  i n the  periods,  with  significant  i n c r e a s e s i n t h e s u b - t e s t s c o r e s f o r h e a r t d i s e a s e and  nutrition.  T h e r e w e r e i n c r e a s e s i n t h e mean s c o r e s  activity  a n d s t r e s s management f r o m  periods,  b u t t h e s e were n o t s i g n i f i c a n t  also  r e p o r t e d making l i f e s t y l e  significant  Table  difference  the pretest  changes,  for physical  to the posttest  (see Table  4).  This  group  as i n d i c a t e d by t h e  b e t w e e n t h e HPLP t o t a l mean s c o r e s b e t w e e n t h e  4  Comparing Heart the Experimental  H e a l t h Knowledge Q u i z  Pretest  and P o s t t e s t  Scores f o r  G r o u p n = 25 Pretest  Posttest  , Mean  S.D.  Mean  i S.D.  12 36  3 09  16 44  3 38  6 06*  24  2 06t  H e a r t D i s e a s e (7)  4 92  1 60  6 04  1 27  3 86*  24  2 79tt  N u t r i t i o n (7)  3 60  1 80  5 40  1 47  4 87*  24  2 79ft  1 68  0 95  2 24  0 97  2 50  24  2 79ft  2 20  1 00  2 76  .0 72  2 50  24  2 79tt  Quiz Scores  (TPS)  T o t a l S c o r e s (22)  t Value _Obtained  t d.f.'Critical  Sub-tests:  Physical Activity  (4)  Stress Management (4) TPS:  T o t a l P o s s i b l e Score  tfTwo-tailed c r i t i c i a l  fTwo-tailed c r i t i c a l  t a t a 0.01  t a t a 0.05  *Indicates s i g n i f i c a n t difference  49 p r e t e s t ,and-posttest p e r i o d s . the  s u b - s c a l e mean s c o r e s  nutrition.  T h e r e was  s t r e s s management,  Table  i n c r e a s e s were r e p o r t e d i n  of h e a l t h r e s p o n s i b i l i t y ,  e x e r c i s e , and  a n i n c r e a s e i n t h e s u b - s c a l e mean s c o r e f o r  but t h i s  was  not s i g n i f i c a n t  (see Table 5 ) .  5  Comparing H e a l t h Scores HPLP  Significant  f o r the Experimental  Scores  Profile  Postest  Mean  S .D.  116.28  18 52  133.76  22.91  38.32  5 65  39.08  (40) 18 .72  5 27  8.92  Scores  P r e t e s t and P o s t e s t  G r o u p n = 25  Pretest  (TPS) Total  Promoting L i f e s t y l e  Mean  S.D.  t Value Obtained  d.f.  t Critical  3.63*  24  2.06t  7 .18  0.57  24  2.79ft  25.24  6.24  5.27*  24  2 .79fr  3 66  13 .20  3 .82  4.95*  24  2.79tt  15.16  4 09  19.04  .4.08  4.13*  24  2.79ft  18.92  4 18  19.28  3.81  0.35  24  2.79ft  16 .24  3 72  17.92  3.74  2 .10  24  2.79tt  (192) Sub-scales: Self-actualiz a t i o n (52) Health  respon-  sibility  E x e r c i s e (20) Nutrition  (24)  Interpersonal support Stress  (28)  manage-  ment (28) TPS:  T o t a l P o s s i b l e Score  ttTwo-tailed c r i t i c a l  tTwo - t a i l e d c r i t i c a l  t a t a 0. 01  t a t o 0. 05  *Indicates s i g n i f i c a n t difference  50 Comparison w i t h i n As  with  the  the  experimental  significant  improvements  pretest  posttest  and  occurred  only  increase  i n the  physical  activity,  control a  pretest  Table  but  However, scores  control  lifestyle  periods.  (see  changes,  HPLP t o t a l  scores  T h e r e was  an  stress Table as  6).  The  indicated  between  by  the  S i g n i f i c a n t changes were r e p o r t e d  in  6  Control  H e a l t h Knowledge Q u i z  Group n  =  Quiz Scores  (TPS)  T o t a l Scores  (22)  Pretest  and  Posttest  Scores  47  Pretest  Posttest  Mean  S.D.  Mean  S.D.  t Value Obtained  d.f.  t Critical  13  36  2 70  14  83  2 86  3 93*  46  2 Olt  5 38  1 19  6 00  1 27  3 19*  46  2 68ft  ' 3 89  1 45  4 40  1 56  2 51  46  2 68tt  1 76  0 84-  2 15  0 86  2 65  46  2 68ft  2 30  0 86  2 30  0 88  0 00  46  2 68ft  Sub-tests: Heart D i s e a s e Nutrition  (7)  (7)  Physical Activity  (4)  Stress Management TPS:  the  increase  disease.  significant  made  between  significant  f o r n u t r i t i o n and  t h e s e were not making  a  group a l s o  mean s c o r e s  for heart  mean s c o r e s  reported  posttest  the  HHKQ t o t a l  d i f f e r e n c e between the  Comparing Heart the  sub-test  group a l s o  and  sub-test  group.  group,  i n the  periods.  i n the  significant  control  (4)  T o t a l P o s s i b l e Score  ttTwo-tailed  critical  trwo-tailed c r i t i c a l  t a t o 0.01  *Indicates  t at a  significant  0.05 difference  for  51 the  same s u b - s c a l e s  health  as r e p o r t e d  responsibility,  increases  by t h e experimental  exercise,  i n the sub-scale  mean  and n u t r i t i o n . scores  namely,  There a l s o were  for self-actualization  s t r e s s management, b u t t h e s e w e r e n o t s i g n i f i c a n t  Table  group,  and  (see Table 7 ) .  7  Comparing Scores  Health  Promoting L i f e s t y l e  f o r the Control  HPLP Scores  Total  Mean  scores  122  Pretest  and P o s t t e s t  t Value Obtained  t d.f. C r i t i c a l  G r o u p n = 47  Pretest  (TPS)  Profile  S.D.  70  22 75  39 21  19  Posttest . Mean S.D. 134  13  20 80  5 34*  46  2 Olt  6 82  40 04  7 21  1 19  46  2 68ft  98  6 00  24 79  5 49  5 85*  46  2 68tt  9 45  3 36  11 30  3 11  3 80*  46  2 68tt  15 77  4 56  19  02  3 60  5 83*  46  2 68ft  21 23  4 26  20 70  4 42  -1 32  46  2 68ft  17 06  4 33  18 28  3 76  2 58  46  2 68tt  (192) Sub-scales: Self-actualization Health  (52)  respon-  s i b i l i t y (40) E x e r c i s e (20) Nutrition  (24)  Interpersonal support  (28)  S t r e s s management (28) TPS:  T o t a l P o s s i b l e Score  tfTwo-tailed c r i t i c a l  tTwo-tailed  t a t a 0.01  critical  t a t o 0.05  *Indicates s i g n i f i c a n t difference  52 Comparison Between  o f Knowledge o f H e a r t  Disease  and H e a l t h  Groups  The  findings  section.  related  This hypothesis  participate regarding  to hypothesis was t h a t  #1 a r e p r e s e n t e d  first  time  i n outpatient cardiac education  heart  first-time  cardiac  at  knowledgeable  disease and h e a l t h promotion/protective  behaviours,  hospital  MI p a t i e n t s who do n o t p a r t i c i p a t e  discharge  i n outpatient  education.  The with  i n this  MI p a t i e n t s who  a r e more  m e a s u r e d b y t h e HHKQ, f o u r t o s i x m o n t h s a f t e r than  Behaviours  equivalence  of both  the experimental  and c o n t r o l  groups  r e s p e c t t o k n o w l e d g e r e g a r d i n g h e a r t d i s e a s e a n d i t s management  t h e p r e t e s t s t a g e was d e t e r m i n e d  using the t-test  groups on t h e p r e t e s t t o t a l  quiz  control  i n knowledge l e v e l  groups were s i m i l a r  (obtained  t value  scores.  Both  = 1.42, t w o - t a i l e d c r i t i c a l  for  independent  t h e experimental and at the pretest t value  stage  a t o 0.05 =  1.99) To in  determine  i f those  first  time  MI p a t i e n t s who  o u t p a t i e n t c a r d i a c e d u c a t i o n w e r e more k n o w l e d g e a b l e  months a f t e r outpatient  hospital  discharge  cardiac education,  than  the t-test  used.  A pooled  v a r i a n c e was u s e d  larger  standard  deviation.  significant four  > one-tailed  critical  hospital  t h a t t h e r e was a  for the experimental  discharge  t o f 1.67 f o r a  g r o u p s was  t h e s m a l l e r sample had t h e  indicated  scores  four to s i x  who d i d n o t p a r t i c i p a t e i n  f o r independent  because  The r e s u l t s  i n c r e a s e i n HHKQ t o t a l  t o s i x months a f t e r  those  participated  0.05).  (obtained t value  group = 2.15  S i n c e -the HHKQ t e s t e d f o r k n o w l e d g e o f t h e n a t u r e disease, test  nutrition,  physical  f o r independent  determine test  section  groups w i t h  differences  results.  a  (obtained t value  0.01) .  groups  There  i n each  d i f f e r e n c e was f o u n d  higher = 2.70  than  o f these  sub-  i n the n u t r i t i o n  the control  > one-tailed  were no s i g n i f i c a n t  i n the other  display  a p o o l e d v a r i a n c e was u s e d t o  t h a t on t h e p o s t t e s t , s u b j e c t s i n t h e e x p e r i m e n t a l  group s c o r e d s i g n i f i c a n t l y section  a n d s t r e s s management, t h e t -  b e t w e e n t h e two g r o u p s  A significant  indicating  activity,  of heart  o f HHKQ a n d s u b - t e s t  critical  differences  three sub-tests scores.  group i n t h i s one t of 2.38 f o r  b e t w e e n t h e two  See T a b l e  mean s c o r e s , o b t a i n e d  t  8 fora  v a l u e s and  Table 8 Heart  Health  Knowledge Quiz  Scores  Experimental (n = 25)  (Posttest)  Control (n = 47)  Quiz Mean Scores (TPS)  Mean  S.D.  Mean  S.D.  t Value Obtained  T o t a l s c o r e s (22)  16.44  3.38  14.83  2.86  2.15*  70  1.67f  d.f.  t Critical  Sub-test scores: Heart d i s e a s e (7)  6.04  1.27  6.00  1.27  0.13  70  2.38tt  N u t r i t i o n (7)  5.40  1.47  4.40  1.56  2.70*  70  2.38ft  2 .24  0.97  2.15  0.86  0.41  70  2.38fr  2.76  0.72  2.30  0.88  2.20  70  2.38ft  Physical  Acti-  v i t y (4) S t r e s s Management (4) TPS:  T o t a l P o s s i b l e Score  ttOne-tailed c r i t i c a l  fOne-tailed c r i t i c a l  t a t a 0.01  t a t a 0.05  *Indicates s i g n i f i c a n t  difference  54 critical  t  values.  Comparison The  of H e a l t h  Promotion/Protective  findings related  section.  This hypothesis  participate  MI  four  to  do  those in  the  group,  behaviours  not  the  Initially,  control failed  72  32%  to complete  These i n i t i a l  for  at  of  was  two  sub-scales  of  are  The regarding  HPLP.  listed  The  of  the  scores  the  items  f o r both  i n the 48  of  items  on  do  the  first  time  education. that  posttest on  of  only  the  subjects  experimental  items  on  the  HPLP  e a c h HPLP i t e m into  groups.  the The  obtained missing  same  the p o s t t e s t  were d i s t r i b u t e d that  among t h e  subjects  failed  control  groups  six  to  K.  experimental  t-test  s i n c e 30%  f o r both  health promotion/protective using  than  performed  were e n t e r e d  statements  i n Appendix  equivalence  determined  HPLP t o t a l  f o r the m i s s i n g  measured by  t h e p r e t e s t and  the  mean s c o r e s  These omitted  the  of  the p r e t e s t stage  used  questionnaires.  was  or  extent,  subjects  the p r e t e s t q u e s t i o n n a i r e s  procedure  complete  the  who  HPLP q u e s t i o n n a i r e s  missing,  this  in health  discharge,  the  Groups  in  patients  engage  a n a l y s i s was  items of  MI  i n outpatient cardiac on  data  one  questionnaire.  items  time  subjects at both  however,  g r o u p and  groups  hospital  Between  are presented  to a greater  conducted  questionnaires without  both  first  participate  a n a l y s i s was  were c o m p l e t e d by stages.  that  s i x months a f t e r  p a t i e n t s who Data  was  #2  i n outpatient cardiac education  promotion/protective HPLP,  to hypothesis  Behaviours  and  behaviours  f o r independent  groups.  The  results  at  the p r e t e s t  groups  on  indicated  stage  the p r e t e s t that  both  55 the  experimental  and  control  promotion/protective value  = 1.21, To  outpatient  t value  i f first  cardiac education  behaviours,  m e a s u r e d by  months a f t e r not  behaviours  critical  determine  hospital  participate  t-test  no  at  significant  groups -0.07  at  time  the p r e t e s t stage a  MI  at  HPLP,  0.05  =  in health  of  the  first  participated  score  MI  d i f f e r e n c e s i n HPLP t o t a l  the p o s t t e s t stage  w e r e no  significant  the  two  groups a t  the  direction  of  t value  t of  1.67  d i f f e r e n c e s i n the  the p o s t t e s t stage, a significant = 2.30  at  a  the  two  t-test See  Table  9 for  score There  between the  two  were  = Similarly,  HPLP s u b - s c a l e  scores  t h e r e was  d i f f e r e n c e f o r the  < one-tailed critical  did  for  groups.  0.05).  although  four to s i x  subscale  scores  (obtained t value  in  p a t i e n t s who  used.  and  between the  t  promotion/protection  time  v a r i a n c e was  HPLP t o t a l  the p o s t t e s t stage  (obtained  to a g r e a t e r extent than  health  1.99).  p a t i e n t s who  engaged  a pooled  < one-tailed critical  (obtained  of  regarding  i n outpatient cardiac education,  results  differences  the  at  discharge,  independent groups with the  groups were s i m i l a r  2.38  between  a trend  exercise  t of  there  at  in  scores a  0.01).  56 Table 9 Health  Promoting  Lifestyle  Profile  Experimental (n = 25) HPLP Scores (TPS)  Scores  (Posttest)  Control (n = 47) t Value  t  Mean  S .D.  Mean  133 .76  22 .91  134.13  20.80  -0.07  70  1.67f  39.08  7 .18  40.04  7.21  -0.54  70  2.38tt  25.24  6 .24  24.79  5.50  0.31  70  2.38tt  E x e r c i s e (20)  13 .20  3 .82  11.30  3.11  2.30  70  2.38tt  N u t r i t i o n (24)  19.04  4 .8  19.02  3 .60  0.02  70  2.38ft  19.28  3 .81  20.70  4.42  -1.36  70  2.38ft  17.92  3 .74  18.28  3 .77  -0.39  70  2.38tt  Total  scores  S.D.  Obtained  d.f.  Critical  (192) Sub-Scales: Self-actualiz a t i o n (52) Health responsib i l i t y (40)  Interpersonal support (28) S t r e s s management (28) TPS:  T o t a l P o s s i b l e Score  ttOne-tailed c r i t i c a l  tOne-tailed c r i t i c a l  t a t a 0.05  t a t a 0.01  Discussion Comparison  of P r e t e s t and P o s t t e s t Results Within  Although mean s c o r e s period,  both  mean s c o r e s  the experimental  o n t h e HHKQ t h a n  o n t h e HHKQ f r o m  group had s i g n i f i c a n t l y  the control  groups demonstrated  Groups higher  total  group a t t h e p o s t t e s t  significant  improvement  i n total  the pretest to the posttest periods.  57 The  c o n t r o l g r o u p , who d i d n o t r e c e i v e  made s i g n i f i c a n t  improvements  outpatient  i n the heart  HHKQ b e t w e e n t h e t i m e o f h o s p i t a l i z a t i o n later. heart  The e x p e r i m e n t a l disease  mean s c o r e s posttest  g r o u p made s i g n i f i c a n t  f o r the n u t r i t i o n  periods.  This  i s consistent with  f o rthe nutrition  i n the  increase i n  the findings i n relation group had s i g n i f i c a n t l y  s e c t i o n o f t h e HHKQ t h a n d i d t h e  findings indicate that  management h a s o c c u r r e d  participation  i n outpatient  benefited  from  education  programs.  their  investigators. programs,  forfirst  i n hospital-based  i s consistent with  (1992)  found  physical  activity  Other  programs have  found  hospital  discharge  (Pommier,  o f these  increases  1991; R a l e i g h  i n v e s t i g a t i o n s and those  education  about  c o n s i s t e n t l y learned by cardiac  hospital  & Odtohan,  1986; Owens e t a l . , 1 9 7 8 ) .  education  cardiac  i n knowledge  a n d up t o 6 m o n t h s a f t e r  1992; Thompson,  Hentinen,  cardiac  investigators of hospital-based significant  cardiac  information  a s t h e t o p i c t h a t was m o s t  MI p a t i e n t s .  regardless of  the findings of other  that hospital-based  improved p a t i e n t s ' knowledge, w i t h  i l l n e s s and  T h e y may h a v e  I n a r e v i e w o f 14 h o s p i t a l - b a s e d  Duryee  their  t i m e MI p a t i e n t s  cardiac education.  participation This  l e a r n i n g about  programs  results  improvements  group.  These  1987;  t o s i x months  s e c t i o n between t h e p r e t e s t and  higher  scores  education,  section of the  s e c t i o n as w e l l , b u t a l s o had a s i g n i f i c a n t  #1 i n w h i c h t h e e x p e r i m e n t a l  its  disease  and four  to h y p o t h e s i s  control  cardiac  level  before  discharge  1987; F l e t c h e r ,  In contrast of this  education  study,  to the Liddy  &  58 Crowley  (1987)  understanding Scalzi for  et  the  of  results  of  However,  hospitalization study  their  participants  process  find  d i d not  gained  and  information the  significant  i n both  the  posttest periods.  s c a l e mean s c o r e s that  their  subjects  behaviours first  MI  heart  from  i t i s not  to  of  known  the  HHKQ  groups  Factors  friends  experimental  making  significant  responsibility  engaged i n extent MI,  This  health  four  a  pretest  posttest periods.  their  may  groups had  between the  health  a greater  such  i n knowledge,  also reported and  study  media  f a m i l y and  mean s c o r e s  than before  education  their  disease.  increase  patients  cardiac  s i x months l a t e r ,  p r e t e s t and  i n both  cardiac  during  awareness to  nutrition,  between the  promotion/protective months a f t e r  Both groups  exercise,  the  study,  c o n t r o l and  i n HPLP t o t a l  i n knowledge  i n d i c a t e t h a t MI  posttest  to  illness.  later.  knowledge d u r i n g  gained  Participants  increase  outpatient  3 months  in this  four  group.  i n the  and  their  increase  However, b e t w e e n c o m p l e t i o n  control  indicates  receive  a p r e t e s t and  f o r the  significant  significant  knowledge r e g a r d i n g  to  superficial  3 months a f t e r  l e a r n i n g , heightened  and  a  i n hospital-based  conducted  phase.  contributed  especially  involvement  not  only  i n v e s t i g a t i o n may  hospitalization  presentations,  increases  a  p a r t i c i p a n t s gained  self-motivated  have  who  since  was  hospitalization during  disease  this  b e n e f i t from t h e i r  whether  p a t i e n t s had  between h o s p i t a l i z a t i o n  programs.  and  their  c o n t r o l group,  The  as  t h a t MI  a l . (1980) d i d n o t  education,  do  found  to  regardless  six of  sub-  59 receiving with  outpatient cardiac education.  those  cardiac education  Fletcher  patients  promotion/protective  during  after  changes  behaviours  Since  recovery subjects  i n specific  such  smoking and resumption  their  hospital  (1987) a n d R a l e i g h & O d t o h a n  do make p o s i t i v e  cigarette  as  i n both  changes,  Between  exercise, activities  other  and c o n t r o l  groups  to a greater  extent  MI r e g a r d l e s s o f r e c e i v i n g v a r i a b l e s mentioned e a r l i e r ,  such  i n f o r m a t i o n and t h e i n f l u e n c e o f  for the control  t o e x p l a i n these  behavioural  group.  Disease  and H e a l t h  Behaviours  Groups  mean s c o r e s time  education  t h e r e was a s i g n i f i c a n t  for the experimental  increase i n the  group,  MI p a t i e n t s who p a r t i c i p a t e  hypothesis  months a f t e r  hospital  participate  behaviours, discharge,  #1 was  disease  m e a s u r e d b y t h e HHKQ,  total  supported.  four  to six  MI p a t i e n t s who do  i n outpatient cardiac education.  These r e s u l t s a r e  testing  first  and h e a l t h  time  c o n t r a s t t o t h e knowledge  than  HHKQ  i n outpatient cardiac  a r e more k n o w l e d g e a b l e r e g a r d i n g h e a r t  promotion/protective  in  first  o f Knowledge o f H e a r t  Because  First  that  health  behaviours  need t o be c o n s i d e r e d  especially  Comparison  not  their  cardiac education,  and f r i e n d s  found  of prehospitalization  the experimental  s e l f - m o t i v a t e d l e a r n i n g , media  family  (1987)  Hentinen  f o l l o w i n g a n MI.  t o s i x months a f t e r  outpatient  discharge.  as n u t r i t i o n ,  engaged i n h e a l t h p r o m o t i o n / p r o t e c t i v e four  areconsistent  r e p o r t e d b y i n v e s t i g a t o r s who e x a m i n e d t h e e f f e c t o f  hospital-based (1986),  These r e s u l t s  done b y  Scalzi  et a l .  (1980),  60 who  did not find  experimental  significant  posttest  and c o n t r o l groups  d i f f e r e n c e s between t h e  three  months a f t e r h o s p i t a l  discharge. Although  the findings  i n this  t h e s e r e s u l t s must b e v i e w e d w i t h increases only  such as n u t r i t i o n a l  priority  for patients  hospital.  hospitalized education class.  classes,  This  frequently high  therefore  following  i n the early period of this  a r e approached  intent  o f t h e HHKQ s u p p o r t s  this  During  their  increasing condition activity  attending  i s also their  fact  i n that  on g a i n i n g  the outpatient  high from  when cardiac  that  MI  patients habits  as a  Many p a t i e n t s a r e the f i r s t cardiac  o n e t o two education  for then u t r i t i o n participants i n the knowledge  cardiac  may f o c u s  regarding  education  classes.  i n s t e a d on  s a f e management o f t h e i r  a t home, s u c h a s m e d i c a t i o n l i m i t a t i o n s and a b i l i t i e s ,  discharge  nutritional  i n scores  knowledge r e g a r d i n g  a  keen i n t e r e s t i n t h e n u t r i t i o n  hospitalization, patients  their  long-term  outpatient  i n an o u t p a t i e n t  e x p e r i m e n t a l g r o u p may h a v e f o c u s e d n u t r i t i o n while  following  from t h e h o s p i t a l .  difference  group occurred i n  about  t o l e a r n about n u t r i t i o n d u r i n g  The s i g n i f i c a n t  significant  a n MI i s o f t e n  regarding  t o improve  a f t e r discharge  hypothesis # 1 ,  investigator i s that  express  months a f t e r h o s p i t a l d i s c h a r g e  section  learning  investigator's experience  ready  setting.  because  habits  they often  verbalize  priority  caution  However,  The e x p e r i e n c e patients  support  for the experimental  the n u t r i t i o n section.  changes  the  i n t h e HHKQ s c o r e s  study  administration  rather  and p h y s i c a l  than on l o n g - t e r m  changes  61 such as n u t r i t i o n a l et  habits  (Duryee,  sections the  o f t h e HHKQ.  groups  of  heart  This  at the posttest  opportunities  differences  lack  disease,  as p a r t  they  stage.  management  Stress  completed  self-motivated  t h e knowledge q u i z  i n the experimental  information of two  differences  family  i n three  In  of Health  this  participate  study,  HPLP,  four  patients  Therefore,  education  at the pretest i n thehospital-  group p a r t i c i p a t e d i n cardiac  group's higher  f a c t o r s mentioned  education.  mean  scores,  above,  such as  t o media p r e s e n t a t i o n , and to the lack  of the four  between t h e  HHKQ s u b - t e s t  scores  stage.  Promotion/Protective i t was f o u n d cardiac  behaviours  that  Behaviours  first  education  to a greater  Groups who  do n o t e n g a g e i n h e a l t h extent,  who do n o t p a r t i c i p a t e i n o u t p a t i e n t #2 was n o t s u p p o r t e d .  Between  t i m e MI p a t i e n t s  t o s i x months a f t e r h o s p i t a l d i s c h a r g e ,  hypothesis  the nature  a n d f r i e n d s may h a v e c o n t r i b u t e d  i n outpatient  promotion/protective  other  exposure  groups a t t h e p o s t t e s t  Comparison  between  f o r t h e s t r e s s management s e c t i o n o f t h e  In addition,  from  of outpatient  for the experimental  learning,  cardiac  i s not r o u t i n e l y addressed  although not s i g n i f i c a n t , knowledge q u i z .  difference  e s p e c i a l l y regarding  of the hospital-based  s t r e s s management c l a s s a s p a r t may a c c o u n t  three  s t a g e may b e b e c a u s e p a t i e n t s h a d  based program, b u t p a t i e n t s  This  i n the other  of significant  t o learn the content,  program before  MI  1987; Rahe  a l . , 1975) . T h e r e w e r e no s i g n i f i c a n t  a  1992; S t e e l & R u z i c k i ,  measured by t h e  t h a n do f i r s t  cardiac  time  education.  T h e r e was n o d i f f e r e n c e  62 between the  e x p e r i m e n t a l , and  promotion/protective their al.  first  MI.  (1983),  who  They d i d not weight al.  loss  (1988,  subjects  1989,  compliance  the  1990)  a way  are  in this  similar  significant stress  although  comparable  to the  to t h i s  groups.  series  similar  between the  Miller  results groups  and et  days  of c l a s s e s in  that that  for physical at  improvement  experimental  study.  diet  a t 30  taking medications  a significant  f o r the  experiencing  of Sivarajan et  intervention  They had  r e d u c t i o n and  to a healthy diet  to those  experimental  differences  after  i n health  i n smoking h a b i t s ,  only a single  t h e r e was  life  procedure  and  study.  i n engaging  of  differences  control used  groups  d i s c h a r g e i n comparison  diet,  1 year,  as  a d e s i g n and  significant  between  t h e r e w e r e no  and  used  attended  activity,  behaviours  These r e s u l t s  find  post-hospital  control  60  days  in  group a f t e r  2  years. The  lack  t h e HPLP t o t a l experimental  of a s i g n i f i c a n t mean s c o r e s a t  group d i d not  a c t i o n phase of exercise,  the  a greater extent description the  specific  scales the  the  behaviours  framework f o r t h i s  control  involvement  of  group. the  to which of the  the  sample groups  a c t i o n phase, p l u s  that  identified  the in  health responsibility) For  a more  engaged  i n the  factors  the  to  precise of  this  the  These r e s u l t s ,  two  groups f o r  study ( i . e .  sample groups  analyzed.  two  indicates  h e a l t h promotion/protective behaviours,  o f t h e HPLP w e r e a l s o  extent  stage  engage i n the b e h a v i o u r s  s t r e s s management a n d  than  of the  the p o s t t e s t  conceptual  nutrition,  d i f f e r e n c e between the  six  in  sub-  which d e s c r i b e  four  i n the  study  specific  decision-  63 making phase of and  conceptual  self-actualization), Health The  phases in  the  are  discussed  promotion/protective  conceptual  that  d e s c r i b e the process  decision-making  p h a s e and  of  the  HPLP i n c l u d e d t h e  of  the  a c t i o n phase.  discussed  in this  exercise  group  sub-scale  significant. was  a  two  groups  (13.20 v s .  f o r an  experimental  c o m p o n e n t was  an did  these  i n the  The  the  study  sample  c a n n o t be  experimental  decide  to  six  engage  These  are  sub-scales behaviours  four sub-scales  a difference  are  control  11.20),  but  this  their  group first  design  group  in  The the  d i f f e r e n c e was indicate  not  that  there  t o e x e r c i s e more t h a n MI.  The  only other  the study  that reported a difference i n exercise group  r e p o r t e d by  s i z e was  only  generalized. (Dracup e t  report significantly  i n mean  exercise section.  the  involved i n outpatient cardiac  whose i n t e r v e n t i o n d i d n o t the  major  (see F i g u r e 2 ) .  than  months a f t e r  behaviour  results  individuals  t h e r e was  experimental  literature  study  of  only  scored higher  i n the  and  a c t i o n phase  i n c l u d e s two  a c t i o n phase.  results  described  this  the  four health promotion/protective  The  f o r the  g r o u p 4-6  education,  study  behaviours the  of  T h i s d i f f e r e n c e i n mean s c o r e s may  tendency  control  o f how  four subscales,  between the  experimental  behaviours  section.  Among t h e s e scores  ( i . e . i n t e r p e r s o n a l support  below.  framework f o r t h i s  health promotion/protective  the  the  framework  higher  i n c l u d e an  Billington  (1988).  7 i n each group, The  other  a l . , 1984;  levels  of  exercise  two  However,  and  therefore  studies that  F r i d l u n d et a l . ,  exercise for  in  the  used 1991)  64 experimental in physical Therefore those  of  group.  However,  activity  the  was  results  t h i s study  information physical  about  activity  T h e r e was nutrition  of  benefits  was  not  no  significant adherence 1990;  a l . , 1991)  Other  exercise, the  the  of  cannot  attended  a  but  be  class  that  to  provided  involvement  two  groups  in  for  the  HHKQ f o r  the  stage despite  of  of  groups w i t h  a  the  outpatient  experimental design,  a l . , 1980;  intervention.  compared  actual  n u t r i t i o n sub-test  after  the  between the  posttest  between the  participation  intervention.  investigators  diet  et  t h i s study, and  Other  Fridlund  et  perceived  life  for  the  t h e r e was  control  (1991),  no  groups  investigators  al.  group.  the  s i t u a t i o n and  cardiac  also  d i d not  respect  6 months  ( M i l l e r et  Sivarajan  et  a l . , 1983;  find  to  al.,  1988,  Fridlund  had  significant difference  for  the  stress  experimental a better  experimental  very  small  As  with  the  t h e r e was  and  the  exercise, no  group, results  but  between  management  different results.  In  et  a  study  as  cannot  n u t r i t i o n and  reduction  mentioned be  in  the  stress  above,  the  sample  generalized.  stress  significant difference  by  higher  l e i s u r e s i t u a t i o n than a  the  sub-scale  the  group r e p o r t e d  B i l l i n g t o n (1988) r e p o r t e d  s i z e was  results,  component  studies  of  studies,  .  scores.  levels  at  u s e d an  cardiac  Scalzi  experimental  control  of  a part  i n the  differences a  two  a  these  significant difference  group.  to  as  subjects  the  e d u c a t i o n p r o g r a m s who  In  these  i n which  difference  experimental  1989,  included  sub-scale scores  significant  i n both of  management  between the  two  sub-scale groups  65 for  the h e a l t h r e s p o n s i b i l i t y  information cardiac it  was  i n the  literature  e d u c a t i o n on found  that  responsibility,  5 and It  both  with  Factors  t o compare  sample  However,  those  the  study with  the  of other  the m o d i f y i n g  factor  perceptual  factor  HPLP.  results  of  results those  sizes,  in this  study  health improvements  in  stage  (see  these  of other  s t u d i e s due  of to  for exercise  for nutrition  and  were  investigators. phase  phase df the  interpersonal  of s e l f - a c t u a l i z a t i o n of  f o r the behaviours  especially  results  i n the decision-making  In the decision-making  The  of o u t p a t i e n t  improved  g r o u p s made s i g n i f i c a n t  no  sub-scale scores at the p o s t t e s t  i n d e s i g n and  s t r e s s management.  is  effect  is  7).  the a c t i o n phase i n t h i s  consistent  There  However,  groups demonstrated  since both  is difficult  differences  r e g a r d i n g the  health responsibility.  the h e a l t h r e s p o n s i b i l i t y Tables  sub-scale scores.  two  conceptual support  that  framework,  and  there  the c o n g n i t i v e -  were i n c l u d e d i n  sub-scales are d i s c u s s e d i n  the  this  section. The unaffected There  was  modifying by no  the  factor  intervention  significant  interpersonal- support this was  study not  offered  topic  interpersonal  difference  support  between the  was  of d i s c u s s i o n  at the h o s p i t a l  support  remained  of o u t p a t i e n t cardiac  sub-scale scores at  interpersonal  a major  of  where t h i s  not  two  education. groups  the p o s t t e s t investigated  i n the  cardiac  s t u d y was  f o r the  stage.  In  in detail.  education  conducted,  and  It  program which  was  66 attended may  by  19  have been  able  of the  their  level  of  The  their  interpersonal He  support  who  e x p e r i e n c e d by attendance  support  f o r the p a t i e n t  how  involvement  (Fridlund  of  the  1991),  1990),  and  Holm e t a l . (1985),  Ben-Sira  & Eliezer  interpersonal  e x p e r i e n c e d by  Dracup e t a l . (1984), blood pressure,  p a t i e n t s who spouses  and  The factor the  support  two  participated t h o s e who  s c o r e s on  who  of  no  body weight i n the  of  of  and  the et a l .  spouse  Most from  other the p e r s p e c t i v e  influences  the s u b j e c t ' s Derenowski  e t a l . (1985,  a result  of  subjects.  significant and  at  interpersonal  support  1988,  1989, in  the  The  one  difference  exception in  weekly e x e r c i s e between  intervention  t h e HPLP s u b s c a l e  this  the  from  together with  the  their  d i d not.  of s e l f - a c t u a l i z a t i o n stages  found  as  Data  support  (1990) a l l r e p o r t e d i m p r o v e m e n t  health promotion/protective behaviours  smoking,  level  Miller  not  collected.  the q u a l i t y  support  were  outpatient cardiac  et a l . , 1991).  interpersonal  Spouses  partner.  i n health promotion/protective behaviours.  (1988,  is  and  subjects i s Fridlund  have s t u d i e d i n t e r p e r s o n a l  the presence  the  of both p a t i e n t  e d u c a t i o n programs improves  of  attended  their  examined i n t e r p e r s o n a l  cardiac  investigators  towards  the program a f f e c t s  showed t h a t  group.  themselves,  p a r t n e r were n o t  o n l y i n v e s t i g a t o r who  t h e p e r s p e c t i v e o f how  experimental  support  support  t h e number o f s p o u s e s  e d u c a t i o n program w i t h  (1991) .  s u b j e c t s i n the  i n need of a d d i t i o n a l  to improve  regarding  25  study  remained  f o r the c o g n i t i v e - p e r c e p t u a l unchanged  (see T a b l e s  5,  7,  f o r both and  9),  groups  at  indicating  67 that  self-actualizing  not  affected  One  reason  by  the  addressed  majority  of  the  finding i n the  may  types  of  perceptual  factor  as  of o u t p a t i e n t c a r d i a c be  experimental  group.  s i n c e i t has  "enjoyment  of  not  t o an life"  been w i d e l y element of as  concept,  and  what  i t i s not  Only  to making h e a l t h  this  individuals  t o engage i n h e a l t h p r o m o t i o n / p r o t e c t i v e Health  the  self-actualization  known a b o u t  Between Knowledge and  by  cognitive-  Consequently,  i t s role  not  investigated.  a precipitant  p r o m o t i o n / p r o t e c t i v e b e h a v i o u r a l changes.  Relationship  was  Also,  this  were  education.  that s e l f - a c t u a l i z a t i o n  interventions could affect  e t a l . (1989) r e f e r r e d  identified  t h e HPLP s u b s c a l e ,  c a r d i a c e d u c a t i o n program attended  s u b j e c t s i n the  known what  Frenn  as measured by  intervention  for this  directly  traits,  little  is  i s i n motivating behaviours.  Promotion/Protective  Behaviours An an  overall  f o r the  performance life  level  the  Niskala, this  study.  individual  conducted  Neither of  In both visits  (1980) u s e d  of  this  study,  reveals that  regarding health promotion/protective group d i d not  result  in a  higher  of h e a l t h p r o m o t i o n / p r o t e c t i v e behaviours  knowledge and  1987).  findings  experimental  when c o m p a r e d w i t h  examined both  al.  of  i n c r e a s e d knowledge l e v e l  behaviours  of  review  of  the  control  follow-up  two  other  et a l ,  these  similar  i n design  s t u d i e s are  s t u d i e s , the  experimental  subjects.  design,  years.  intervention  They  as  found  no  1980; to  c o n s i s t e d of  However,  i n this  way  studies  (Scalzi  these  f o r two  Only  a  h e a l t h behaviours  i n t h e homes o f t h e  an  group.  as  study,  Scalzi but  significant  et  68 difference after  b e t w e e n t h e two g r o u p s  hospital  discharge.  between t h e groups weight  reduction,  months a f t e r  i n knowledge s c o r e s  They r e p o r t e d  i n thebehaviours  of medication  remain regarding disease  and making h e a l t h  behavioural  changes  for individuals  group, w i t h  higher  HHKQ t o t a l  nutrition  sub-test  nutrition  d i dnot result  difference  o f t h e HHKQ.  activity  sub-test  compared w i t h  groups had s i g n i f i c a n t  promotion/protective  that  regarding  toward a  f o r the experimental  group  even though  there  on t h ep h y s i c a l  When p r e t e s t r e s u l t s  w i t h i n t h e groups,  (although  were  i t was f o u n d  that  d i f f e r e n c e s i n k n o w l e d g e arid h e a l t h  behaviour  f o u r t o s i x months l a t e r . have c o n t r i b u t e d t o these In t h e conceptual  i na  d i f f e r e n c e i n behaviour  t h e r e was a t e n d e n c y  o f t h e HHKQ.  posttest results  resulted  i n c r e a s e i n knowledge  d i f f e r e n c e between t h e groups scores  first  f o r the experimental  d i f f e r e n c e s were n o t s i g n i f i c a n t ) ,  was n o s i g n i f i c a n t  their  difference occurring i n the  i na significant  Instead,  many  influence learning  who h a v e e x p e r i e n c e d  This  i n exercise behaviour  t h e mean s c o r e  and  study,  promotion/protective  mean s c o r e  the only significant  regarding nutrition.  and  study, s i x  The i n t e r v e n t i o n o f o u t p a t i e n t c a r d i a c e d u c a t i o n  significantly  both  i n this  of this  the variables that  about h e a r t  MI.  compliance  discharge.  Because o f t h e i n c o n c l u s i v e r e s u l t s questions  months  significant differences  two v a r i a b l e s n o t e x a m i n e d  hospital  three  scores  from t h e time  Clearly,  there  of their  first  a r e other v a r i a b l e s  results.  framework f o r t h i s  study,  knowledge  about  MI  69 h e a r t d i s e a s e and h e a l t h p r o m o t i o n / p r o t e c t i v e  b e h a v i o u r s i s but  one  of the v a r i a b l e s i n the d e c i s i o n - m a k i n g phase t h a t c o n t r i b u t e to a c t i o n phase of engaging i n h e a l t h p r o m o t i o n / p r o t e c t i v e a way  of l i f e .  There may  be o t h e r v a r i a b l e s b e s i d e s  influence health promotion/protective v a r i a b l e t h a t was  not  behavioural  examined i n t h i s study due  s u i t a b l e t o o l i s the c o g n i t i v e - p e r c e p t u a l s u s c e p t i b i l i t y to d i s e a s e . f u r t h e r c a r d i a c problems may  behaviours  time MI p a t i e n t s .  One  to the l a c k of a perceived  s u s c e p t i b i l i t y for  be a f a c t o r t h a t r e q u i r e s  consideration  when examining knowledge and h e a l t h p r o m o t i o n / p r o t e c t i v e for f i r s t  as  knowledge that .  changes.  f a c t o r of  However, p e r c e i v e d  the  Frenn et a l . (1989) and  behaviours  Holm et a l .  (1985) both r e p o r t e d t h a t s u b j e c t s made l i f e s t y l e changes to prevent f u r t h e r i l l n e s s or death, and experience  those who  b e l i e v e d they were l i k e l y  r e c u r r e n t c a r d i a c events were more l i k e l y to adhere to  t h e r a p e u t i c regimens.  T h i s may  e x p l a i n why  the c o n t r o l group,  d i d not p a r t i c i p a t e i n an o u t p a t i e n t c a r d i a c e d u c a t i o n r e p o r t e d making s i g n i f i c a n t h e a l t h p r o m o t i o n / p r o t e c t i v e changes i n e x e r c i s e , n u t r i t i o n ,  the conceptual  f a c t o r s not  who  program, behavioural  and h e a l t h r e s p o n s i b i l i t y .  a d d i t i o n , other c o g n i t i v e - p e r c e p t u a l  Hilton's  to  In  incorporated  into  framework f o r t h i s study, but which are i n c l u d e d i n  (1986) h e a l t h p r o m o t i o n / p r o t e c t i v e  model, such as  importance  of h e a l t h and p e r c e i v e d b e n e f i t s of h e a l t h promotion and/or h e a l t h p r o t e c t i v e a c t i o n , may of t h i s  need t o be c o n s i d e r e d  t o e x p l a i n the r e s u l t s  study.  S e v e r a l other  f a c t o r s t h a t may  have i n f l u e n c e d study f i n d i n g s  70 m u s t a l s o be  considered.  the  of  majority  information  to  outpatient months  later  one  of  A  For  of  al.  more s p e c i f i c outpatient  findings  not  items  a  diet  low  cardiac  the  enough t o how  is in relation  was  six  make domains  statement. f o r the  days or  1  They  experimental year. study  n u t r i t i o n subscale  of  than the  regarding more  learned as  by  specific However, who  the  n u t r i t i o n s e c t i o n of Subjects  this  but  knowledge,  items  of  the  measure t h i s  features the  may  the  a  subjects  reflected in  The found  have i n f l u e n c e d  accurately  the  to  c o n t r o l group.  instrument to  four  cholesterol diet.  f o r the the  receiving  in several  behaviour  rather  have a p p l i e d  example o f  may  is  s t r e s s management.  diet  a f t e r 60  education,  to  stage of  this  to  f a t , low  i n scores  specific  and  i n the  information  findings  between  behaviours  statements of  Appendix A),  g r o u p may  Another  by  address  for p a r t i c i p a n t s to  exercise  features  group compared  items were not  accurately  study  posttest  a period  but  the  general  difference  experimental  the  i n compliance  instrument  (see  program attended  time p e r i o d  (1990) s u p p o r t  years,  following  HHKQ f o r t h i s  study  et  only  behaviours  significant  short  example,  diet  The  and  nutrition,  a f t e r two  nutritious  received  too  difference  HPLP i n c l u d e d  have i n f l u e n c e d  promotion/protective  Miller  number o f  findings.  this  be  s u c h as  significant  group only  education  health  time,  findings a  may  education  group d i d not  testing interval.  cardiac  the  the p a r t i c i p a n t s .  f a c t o r t h a t may  the  significant at  experimental  needs of  Another related  the  Perhaps  have  the in  the  HPLP  behaviour. affected  HPLP e x e r c i s e  sub-  71 scale in  a n d t h e HHKQ p h y s i c a l a c t i v i t y  t h e mean s c o r e s  experimental the four  T h e r e was a n i n c r e a s e  o f t h e HPLP e x e r c i s e s u b - s c a l e  group,  experimental  sub-test.  which  group  c o u l d be an i n d i c a t i o n  t o e x e r c i s e more t h a n  t o s i x month p e r i o d .  However,  t h e items  in  t o carry out an e f f e c t i v e  exercise subscale  been c o n f u s e d at  least  times  3 times  p e r week,"  " E x e r c i s e v i g o r o u s l y f o r 20-30 m i n u t e s  3 times  #18 o f t h e HHKQ,  schedule  f o r someone who i s r e c o v e r i n g  "A recommended m a i n t e n a n c e  Because o f t h e i n f o r m a t i o n p r o v i d e d  "40  "20 m i n u t e s 3 t i m e s  minutes  3 times  Another  pretest  example  heart may  disease  o f instrument  or after  they  recovering  o f t h e HHKQ.  on t h i s  subject.  features  Subjects  exercise attack  is...."  s u b j e c t s may h a v e  t h e c o r r e c t answer o f  surrounding the  f r e q u e n t l y completed the  from t h e i r  The content  i n f l u e n c i n g study  had received information  about  MI i n t h e h o s p i t a l .  differences i n the heart  o f t h e s t r e s s management  HHKQ may n o t a c c u r a t e l y r e f l e c t  class  i n t h e HPLP,  t o the circumstances  explain the lack of s i g n i f i c a n t  section the  while  from a h e a r t  a week" r a t h e r t h a n  of the pretests.  HHKQ d u r i n g  "40 m i n u t e s 3  a week."  f i n d i n g s may b e r e l a t e d completion  of either  a week" a s a n s w e r c h o i c e s f o r  question  chosen  t o know  I n a d d i t i o n , s u b j e c t s may h a v e  and t h e choice  a week" o r "20 m i n u t e s  information  e x e r c i s e program as measured by  o f t h e HPLP.  b y t h e HPLP i t e m  f o r a tendency i n  i n the physical  s e c t i o n o f t h e HHKQ may n o t b e e s s e n t i a l  the  for the  t h e c o n t r o l group a t t h e  activity order  scores  the information  In addition, i t i s d i f f i c u l t  This disease  section of  received during a t o measure a  72 s u b j e c t i v e domain such such  a s s t r e s s management u s i n g  an o b j e c t i v e t o o l  as a m u l t i p l e - c h o i c e q u i z . Summary Both the c o n t r o l  disease  a n d made s i g n i f i c a n t  promotion/protective periods. time  MI p a t i e n t s r e s u l t e d disease  experimental  promotion/protective The  results  investigators  d i d not result f o r engaging  behaviours  of t h i s  study  promotion/protective  behaviours  education.  in a  behaviours f o r  i n health  are similar  t o those  of other  g r o u p d i d n o t engage i n h e a l t h  a s a way o f l i f e  to a greater  of p a r t i c i p a t i o n  Because o f t h e i n c o n c l u s i v e r e s u l t s  interval  susceptibility and instrument  to disease, program content, items  should  extent  i n outpatient  o t h e r v a r i a b l e s t h a t may h a v e i n f l u e n c e d s t u d y  perceived  i n knowledge  signficant  life.  group as a r e s u l t  for first  The i n t e r v e n t i o n o f  a s a way o f  i n that the experimental  the control  improvement  group a t t h e p o s t t e s t stage.  between t h e groups  heart  between t h e p r e t e s t and p o s t t e s t  and h e a l t h p r o m o t i o n / p r o t e c t i v e  difference  study,  l e a r n e d about  i n health  i n a significant  cardiac education  cardiac  improvements  behaviours  outpatient  than  groups  The i n t e r v e n t i o n o f o u t p a t i e n t c a r d i a c e d u c a t i o n  about h e a r t the  and experimental  of this  results testing  be i n v e s t i g a t e d f u r t h e r .  such  as  73  CHAPTER FIVE Summary, Conclusions and Recommendations This  chapter  includes  results,  conclusions  relation  to nursing  a  summary o f  b a s e d on  these  p r a c t i c e and  the  study  results,  and  process  and  recommendations  in  research.  Summary This patients  study  who  was  education  disease  and  greater  extent  cardiac  education  control  group design  These  CCU  the  was  CIU  of  from  their  four  to  s i x months  first  one  for this  the  and  t o two  participate  study.  ages of  teaching  HPLP a n d  of  later.  Of  the  and  these  and  two  were r e c r u i t e d Canada.  hospital  while  completed  same q u e s t i o n n a i r e s  subjects  who  completed  cardiac education  h o s p i t a l discharge  group,  the  i n outpatient  80  subjects  months a f t e r while  hundred  HHKQ i n t h e  r e t u r n i n g these  remaining  cardiac education,  47  a  hospital-based  h o s p i t a l i n western  the  Seventy-two  to  pretest-posttest One  32  MI  heart  behaviours  in a  quasi-experimental  participated i n outpatient  experimental  control  A  a major  MI.  answering  25  p a r t i c i p a t e d only  used  completed  by  study,  the  program.  study  mail  who  p a t i e n t s between the  subjects  recovering  those  time  outpatient  p r o g r a m s w e r e more k n o w l e d g e a b l e a b o u t  than  and  first  and  engaged i n h e a l t h p r o m o t i o n / p r o t e c t i v e  t i m e MI  from the  to determine whether  p a r t i c i p a t e d i n both hospital-based  cardiac  first  conducted  and  during  in the the  were p l a c e d  subjects,  who  were p l a c e d  in  the  did  in not  the  group.  For  a comparison  o f p r e t e s t and  posttest results  within  both  74 the  experimental  was  d o n e o n t h e HHKQ s c o r e s  both in  and c o n t r o l  scores  Data analyses performed  The  the control results  using  the t-test  and c o n t r o l  indicated  scores  their  hospitalization.  that  group engaged than  HPLP s c o r e s  the  g r o u p s was  t o determine  scores f o r  i fthe experimental  group  The s u b - t e s t  knew more  d i s e a s e a n d i t s management.  four  i n c r e a s e i n HHKQ  t o s i x months  analyses  after  revealed that  group  t h e r e was  i n only the  s e c t i o n o f t h e HHKQ.  experimental  sub-scales  that  scores, and  and s u b - t e s t  t h e r e was a s i g n i f i c a n t  using  the t-test  p e r f o r m e d on t h e p o s t t e s t t o t a l  extent  scores  increase f o r the experimental  Data analyses  the  revealed  i n outpatient cardiac education  f o r the experimental  significant  nutrition  groups  f o r independent  group r e g a r d i n g heart  total  a  Results  observations  between t h e p r e t e s t and p o s t t e s t p e r i o d s .  g r o u p who h a d p a r t i c i p a t e d than  for paired  i n c r e a s e i n t h e HHKQ t o t a l  o n t h e p o s t t e s t HHKQ t o t a l  experimental  a t-test  a n d HPLP s c o r e s .  groups had a s i g n i f i c a n t  HPLP t o t a l  the  groups,  and c o n t r o l  f o r independent  HPLP s c o r e s  groups  the control  group.  exercise sub-scale  was n o t s i g n i f i c a n t .  behaviours  and c o n t r o l  scores of  i f the experimental to a greater  No d i f f e r e n c e s w e r e f o u n d  between t h e e x p e r i m e n t a l i n t h e HPLP,  and sub-scale  t o determine  i n health promotion/protective  g r o u p s was a l s o  groups.  i n total Of t h e s i x  t h e r e was a n i n c r e a s e i n t h e mean s c o r e s o f f o r the experimental  group,  but this  increase  75  Conclusions The  following conclusions  1.  First  disease,  and  as  of  a way  whether  they life  or not  2. cardiac  time do  MI  p a t i e n t s do  four  to  s i x months a f t e r  they p a r t i c i p a t e d  First education  do  not  time may  MI be  participate  3.  First  specific  For  heart  disease,  first  two 4.  cardiac  MI  patients are  example,  education as  p a t i e n t s who 5.  time may  a way  they  do  not  A gain  MI  first  engage  and  promotion/protective  group g a i n e d  to  l e a r n i n g about  periods  in  their  l e a r n more a b o u t n u t r i t i o n  and  s t r e s s management d u r i n g  than the  discharge. participate  i n health  for first  extent  time  relationship with For  i n outpatient  promotion/protective than  i n outpatient cardiac  behaviours.  patients  health  i n knowledge r e g a r d i n g h e a r t  n e c e s s a r i l y , have a d i r e c t  MI  and  education.  certain  to a g r e a t e r  behaviours  time  disease  to  p a t i e n t s who  life  engage  promotion/protective  experimental  during  tend  hospital  not  of  i n outpatient  responsive  disease  physical activity,  First  behaviours  behaviours  months a f t e r  than  behaviours  education.  more k n o w l e d g e a b l e a b o u t h e a r t behaviours  their  hospitalization,  participate  i n outpatient cardiac  time  promotion/protective  their  i n outpatient cardiac  p a t i e n t s who  topics regarding heart  recovery.  g a i n knowledge r e g a r d i n g  engage i n h e a l t h p r o m o t i o n / p r o t e c t i v e  health promotion/protective who  are:  time  MI  education. disease  MI  and  health  p a t i e n t s does  engaging  example,  first  not  in health  subjects  knowledge r e g a r d i n g n u t r i t i o n ,  in  the  but  did  not  76 follow to  a healthy  to  s i x months l a t e r .  groups a  diet  a greater  Although  there  f o r knowledge r e g a r d i n g  tendency  greater  for subjects  extent  6.  than  T h e r e may  perceived patients  i n the  those be  susceptibility  extent  no  the  c o n t r o l group  d i f f e r e n c e between  physical activity,  there  experimental  to  i n the other  was  than  group  may  the  have  exercise  four  to  been a  c o n t r o l group.  factors besides  to disease,  knowledge,  that motivate  t o make h e a l t h p r o m o t i o n / p r o t e c t i v e  first  such time  as MI  behavioural  changes.  involved  outpatient  Recommendations Nursing  Practice  N u r s e s must cardiac to  education  consider  cardiac  continue programs.  innovative  education  participants. participation  t o promote and  and  less  involvement  perspectives  that w i l l  Perhaps  This  meet  there on  results  f o r the  the  needs  the  t o be  s u g g e s t e d by  the  relationship  between knowledge g a i n e d  promotion/protective education  programs  instruction class  behaviours. c o u l d be  regarding  In  regarding  the  subjects  adjusted  exercises  s t r e s s management management o f  i n the  The  and  content to  experimental  of  include and  group  find in  less  continue  active  is a  direct  health cardiac  formal  more i n v o l v e m e n t  appropriate  tended  as  on  outpatient  classes, providing  s t r e s s may  outpatient  emphasis  d i d not  engaging  necessity  the  information,  that  the  d e l i v e r y of  a greater  physical activity,  p a r t i c i p a n t s i n doing  recovery.  study  in  includes  unique needs of  d e l i v e r y of  in this  be  for their  of  stage  of  information  to have m e r i t  t o know more a b o u t  since stress  77 management emphasis  than  on  doing  Participants learning as  Therefore,  i n the  by  regarding  information  about  The  that  i s seen  as  group of explained  in this  25  the  are  in  result  in nutrition,  such  stage, could  included  and  continue  in  same  therefore  receive  to  initiate  less  cardiac  and/or education  distribution  subjects  was One  Four,  almost reason  was  centres.  o f numbers twice for  that  50%  as  for  of  the no  offered.  t o p r o m o t e and  improve  this  large  this  g r o u p came f r o m d i s t a n t c o m m u n i t i e s w h e r e was  as  programs.  outpatient  subjects.  in a Other  B o t h g r o u p s knew t h e  disease  MI  outpatient  MI.  posttest  in  i n knowledge  d i s t a n t from major urban  i n the 47  from an  s i x months p o s t  f o r nurses of  classes.  nutrition.  information  increase  an  interest  phase  group d i d not  education  i n Chapter  cardiac education  N u r s e s must  show a n  a t t i t u d e s , n e e d t o be  of h e a r t  cardiac  c o n t r o l group of  discrepancy,  outpatient  at  implementation  for this  experimental  subjects  nature  to  programs.  disease  i n communities  evidence  study. the  i n the  the  changes  a r e many o p p o r t u n i t i e s  participate  this  experimental  motivational  i n outpatient  There  The  the  these  i n knowledge r e g a r d i n g  measured f o u r  heart  during  e a r l y recovery  However,  cardiac education  amount r e g a r d i n g  a l s o n e e d s t o be  seemed t o  in providing  f o r the as  the  t h a t promote b e h a v i o u r a l  outpatient  programs  increase  programs.  change,  discussions  there  group  during  i s value  nutrition  behavioural  emphasis  experimental  their  there  but  stress-reducing activities  education  regarding  methods  c o n t r o l group,  about n u t r i t i o n  evidenced  cardiac  the  hospital-based  as  78 cardiac  education  disease  and engage i n h e a l t h p r o m o t i o n / p r o t e c t i v e  regardless  programs,  s i n c e p a t i e n t s do l e a r n a b o u t  of p a r t i c i p a t i o n  However, n u r s e s n e e d information  i n outpatient  behaviours  cardiac  education.  t o b e a w a r e t h a t p a t i e n t s may a l s o  from other  sources  such as t h e media,  Some o f t h e s e  sources  nurses need t o incorporate  may p r o v i d e  and  i n their  teaching  t o programs t h a t p r o v i d e  reliable  information.  addition,  n u r s e s have t h e knowledge and e x p e r t i s e c o n t r i b u t i o n s to these  by In  t o a l s o make  programs.  Research Further  cardiac  research  education  behaviours regarding  that  investigates the effect  on knowledge and h e a l t h  i s required.  The f i n d i n g s i n t h i s  i n outpatient  knowledge by engaging  as  a way o f l i f e .  be  discussed  cardiac  information,  education  and t h e m o t i v a t i o n  promotion/protective  instance,  first what  education,  of information  MI p a t i e n t s b e s t r u c t u r e d t o m o s t  motivate  study  raise  questions  as a r e s u l t o f  and t h e a p p l i c a t i o n o f  i n health promotion/protective  What k i n d  i n cardiac  of outpatient  promotion/protective  t h e r e l a t i o n s h i p between knowledge g a i n e d  participation this  counselling  this possibility  patients  Future  health  misinformation  directing  valuable  receive  f a m i l y and f r i e n d s ,  community h e a l t h p r o m o t i o n programs a n d i n d i v i d u a l programs.  their  behaviours?  programs?  and which How  behaviours  topics  should  e f f e c t i v e l y meet b o t h  should  a program f o r t h e need f o r  t o engage i n h e a l t h What f a c t o r s b e s i d e s  t i m e MI p a t i e n t s t o make b e h a v i o u r a l i s the influence of the modifying  knowledge  changes?  factors of  For  79 interpersonal education, and  support  and  perceived  the  in  hospital  The  to disease,  changes?  i n developing  with  and  This  i n the  a variety  of  l e a r n i n g needs and  lifestyle  profiles  best  regarding  behavioural  changes,  information.  Further  different  are  the  also raise method  or  do  study  d i d not  nutrition.  schedule,  test  for specific  Interviewing  study  may  study  behaviours.  provide  research  f o r measuring h e a l t h y  specifically changes of  variables  describe  individuals  There  or  the  i s a l s o needed  have h e a r t  i s a need to develop  s u c h as p e r c e i v e d  of  whether  information more using  profile  used  in  for them  to  exercise  responsibility regarding  the  extent  promotion/protective to develop  using  a  statements  health promotion/protective  who  of  especially  their  information  behaviours  both  styles.  requesting  health  p a r t i c i p a n t s engage i n h e a l t h  Further  to  programs,  conducted  lifestyle  behaviours,  and  to  i n health  intake, plus  more a c c u r a t e  helpful  question  c o u l d be  and  patients  methods p r o v i d e  participants,  stress-reducing activities,  behaviours  profile  other  s i n c e the  keep a r e c o r d o f d a i l y n u t r i t i o n a l  to which  the  for obtaining  research  behaviours,  MI  t a r g e t groups  learning  methods t h a t measure i n v o l v e m e n t  promotion/protective this  i n motivating  t h a t would  age  self-actualization  cardiac education  community,  study  s u c h as  i n f o r m a t i o n w o u l d be  more e f f e c t i v e  findings in this  accurate  characteristics  c o g n i t i v e - p e r c e p t u a l f a c t o r s of  nurses  people  demographic  susceptibility  make b e h a v i o u r a l  the  and  lifestyle that  behavioural  disease.  instruments  susceptibility  t h a t measure  to disease  other  t h a t may  have  80 an  i n f l u e n c e on  engaging  i n health promotion/protective  In a d d i t i o n , f u r t h e r research that  comprehensively  measures knowledge o f h e a r t  promotion/protective Further for in  p a t i e n t s t o make b e h a v i o u r a l continuing education  study  included In  of  the  continued  data,  collection regarding  but  what of  the  time  and  health  early  seven  post-hospitalization health  statistical  analyses  the use  other variables,  f o r p a t i e n t s who  f o r the  not  be  for a  which  items.  of d i f f e r e n t  a l s o needs and  this  normal  HHKQ s u b - t e s t s  hypotheses proposed  There  knowledge and  participation  of< o u t p a t i e n t c a r d i a c e d u c a t i o n  The  with  frame r e q u i r e d  and-whether  long-term  particularly  effect  instruments.  acquisition behaviours  the  investigation.  examined again,  disease  m e t h o d s s i n c e t h e r e may  o n l y between f o u r and summary,  instrument  changes.  i n r e p e a t i n g the  u s i n g non-parametric  distribution  the  i n promoting  behavioural  i s merit  changes,  classes after  effective  promotion/protective There  an  behaviours.  r e s e a r c h i s needed r e g a r d i n g  p e r i o d w o u l d be  be  i s r e q u i r e d to develop  behaviours.  how  engaging  t o be  these  and  study  improved  further  could  data  investigation  variables influence  i n health  have e x p e r i e n c e d  in this  requires  an  promotion/protective MI.  81 References Ben-Sira,  Z.,  after Billington,  & Eliezer,  heart E.  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N i s k a l a , H. (1987). The r o l e of community h e a l t h nurses i n c a r d i a c r e h a b i l i t a t i o n . Home H e a l t h c a r e Nurse. 5_(3), 10-15. Owens, J.F., McCann, C. S., & Hutelmyer, C. M. (1978). C a r d i a c r e h a b i l i t a t i o n : A p a t i e n t e d u c a t i o n program. N u r s i n g Research, 27, 148-150. Pender, N. J . (1987). H e a l t h promotion i n n u r s i n g p r a c t i c e Norwalk, C o n n e c t i c u t : A p p l e t o n & Lange.  (2nd e d . ) .  Pommier, B. E. (1992). F a c t o r s a f f e c t i n g l e a r n i n g i n a coronary a r t e r y disease r e h a b i l i t a t i o n c l a s s . R e h a b i l i t a t i o n Nursing, 17(2), 64-67. Rahe, R. H., S c a l z i , C , & Shine, K. (1975).. A t e a c h i n g e v a l u a t i o n q u e s t i o n n a i r e f o r p o s t m y o c a r d i a l i n f a r c t i o n p a t i e n t s . Heart and Lung. 4, 759-766. R a l e i g h , E. H. & Odtohan, B. C. (1987). The e f f e c t of a c a r d i a c t e a c h i n g program on p a t i e n t r e h a b i l i t a t i o n . Heart and Lung. 16, 311-316. Rosenstock, I. M. (1974). H i s t o r i c a l o r i g i n s of the health belief model. H e a l t h E d u c a t i o n Monographs. 2, 328-334. S c a l z i , C. C , Burke, L. E. , & Greenland, S. (1980). E v a l u a t i o n of an i n p a t i e n t e d u c a t i o n a l program f o r c o r o n a r y p a t i e n t s and f a m i l i e s . Heart and Lung, 9, 846-853. S i v a r a j a n , E. S., Newton, K. M., Almes, M. J . , Kempf, T. M., M a n s f i e l d , L. W., & Bruce, R. A. (1983). L i m i t e d e f f e c t s of o u t p a t i e n t t e a c h i n g and c o u n s e l l i n g a f t e r m y o c a r d i a l i n f a r c t i o n : A c o n t r o l l e d study. Heart and Lung. 12, 65-73. Smith, M. M., H i c k s , V. L., & Heyward, V. H. (1991). Coronary h e a r t d i s e a s e knowledge t e s t : D e v e l o p i n g a v a l i d and r e l i a b l e t o o l . Nurse P r a c t i t i o n e r . 16(4), 28-38. S t a t i s t i c s Canada: Causes of Death, 1992. (1994). Ottawa, Canada: M i n i s t e r of I n d u s t r y , S c i e n c e and Technology.  84 Steel,  J . M.,  & Ruzicki,  D.  (1987) . A n e v a l u a t i o n  of the  effectiveness of cardiac teaching during hospitalization. and Luna. 1 6 , ( 3 ) , 306-311.  Heart  Thompson, D. R. (1991) . E f f e c t o f i n - h o s p i t a l c o u n s e l i n g o n k n o w l e d g e i n m y o c a r d i a l i n f a r c t i o n p a t i e n t s and spouses. P a t i e n t E d u c a t i o n a n d C o u n s e l i n g . 18., 171-177. W a l k e r , S. N., S e c h r i s t , K. R., & P e n d e r , N. J . ( 1 9 8 7 ) . T h e h e a l t h promoting l i f e s t y l e p r o f i l e : Development and p s y c h o m e t r i c c h a r a c t e r i s t i c s . N u r s i n g R e s e a r c h . 3_6(2), 7 6 - 8 1 . W e b s t e r , K. K., & C h r i s t m a n , N. J . ( 1 9 8 8 ) . P e r c e i v e d u n c e r t a i n t y a n d coping post myocardial i n f a r c t i o n . Western J o u r n a l o f Nursing R e s e a r c h , 10, 3 8 4 - 4 0 0 . Woods, N. F. & C a t a n z a r o , M. ( 1 9 8 8 ) . N u r s i n g r e s e a r c h : T h e o r y a n d p r a c t i c e . T o r o n t o : T h e C. V. Mosby Company.  85  Appendix A HEALTH-PROMOTING LIFESTYLE Scoring Instructions:  PROFILE  Items are s c o r e s as Never (R) Sometimes (S) O f t e n (0) R o u t i n e l y (R)  = 1 =2 = 3 = 4  A s c o r e f o r o v e r a l l h e a l t h - p r o m o t i n g l i f e s t y l e i s o b t a i n e d by c a l c u l a t i n g a mean o f the i n d i v i d u a l ' s responses t o a l l 48 items; s i x s u b s c a l e s c o r e s a r e o b t a i n e d s i m i l a r l y by summing the r e s p o n s e s to s u b s c a l e items and d i v i d i n g b y the number o f items on the s u b s c a l e . The use o f means r a t h e r than sums o f s c a l e items i s recommended t o r e t a i n the 1 t o 4 m e t r i c o f item responses and to a l l o w meaningful comparisons o f s c o r e s a c r o s s s u b s c a l e s . The items i n c l u d e d on each s c a l e are as follows: Health-Promoting L i f e s t y l e  1 to 48  Self-actualization  3, 8, 9, 12, 16, 17, 21, 23, 29, 34, 37, 44, 48  Health R e s p o n s i b i l i t y  2, 7, 15, 20, 28, 32, 33, 42, 43,  Exercise  4, 13, 22, 30,  Nutrition  1, 5, 14, 19, 26,  I n t e r p e r s o n a l Support  10, 18, 24, 25, 31, 39,  S t r e s s Management  6, 11, 27, 36, 40, 41,  46  38 35 47 45  References Pender, N. J . CT:  (1987).  H e a l t h promotion i n n u r s i n g p r a c t i c e ( 2 n d e d . ) .  Norwalk,  A p p l e t o n & Lange.  Walker, S. N., S e c h r i s t , K. R., & Pender, N. J . (1987). The H e a l t h - P r o m o t i n g Lifestyle Profile: Development and p s y c h o m e t r i c c h a r a c t e r i s t i c s . Nursing R e s e a r c h . 36(2), 76-81. Walker, S. N., V o l k a n , K., S e c h r i s t , K. R., & Pender, N. J . (1988). H e a l t h promoting l i f e s t y l e s o f o l d e r a d u l t s : Comparisons w i t h young and middle-aged a d u l t s , c o r r e l a t e s and p a t t e r n s . Advances i n N u r s i n g S c i e n c e . 1 1 ( 1 ) , 76-90. Walker, S. N. , K e r r , M. J . , Pender, N. J . , & S e c h r i s t , K. R. (1990). A Spanish language v e r s i o n o f the Health-Promoting L i f e s t y l e P r o f i l e . N u r s i n g Research. 39(5), 268-273.  9/90: Encl.:  snw Health-Promoting L i f e s t y l e P r o f i l e L i s t o f p u b l i c a t i o n s r e p o r t i n g use o f L i f e s t y l e  Profile  86  Appendix A (cont.) LIFESTYLE PROFILE  NEVER  SOMETI  OFTEN  D I R E C T I O N S : T h i s q u e s t i o n n a i r e c o n t a i n s statements regarding y o u r present way of life or p e r s o n a l habits. P l e a s e r e s p o n d to e a c h item a s a c c u r a t e l y as p o s s i b l e , a n d try not to skip a n y item. Indicate the regularity with w h i c h y o u e n g a g e in e a c h b e h a v i o r by c i r c l i n g : N for never. S for s o m e t i m e s , O for often, or R for routinely.  1.  Eat breakfast.  N  S  0  R  2.  R e p o r t a n y u n u s u a l s i g n s o r s y m p t o m s to a p h y s i c i a n .  N  S  O  SL  3.  Like m y s e l f .  N  S  O  R  4.  P e r f o r m s t r e t c h i n g e x e r c i s e s at least 3 times per week.  N  s  0  R  5.  C h o o s e f o o d s w i t h o u t preservatives o r other additives.  N  S  O  R  6.  T a k e s o m e t i m e for relaxation e a c h d a y .  N  s  0  R  7.  H a v e m y c h o l e s t e r o l level c h e c k e d a n d k n o w the result.  N  s  O  R  8.  A m e n t h u s i a s t i c a n d o p t i m i s t i c a b o u t life.  N  s  O  R  9.  F e e l I a m g r o w i n g a n d c h a n g i n g p e r s o n a l l y in positive d i r e c t i o n s .  N  s  O  R  10.  D i s c u s s p e r s o n a l p r o b l e m s a n d c o n c e r n s with p e r s o n s c l o s e to m e .  N  s  11.  A m a w a r e of t h e s o u r c e s of s t r e s s in m y life.  N  s  12.  Feel h a p p y a n d c o n t e n t .  N  s  13.  E x e r c i s e v i g o r o u s l y for  N  s  o  R  14.  Eat 3 r e g u l a r m e a l s a d a y .  N  s  0  JB  15.  R e a d articles o r b o o k s a b o u t p r o m o t i n g health.  N  s  o  R  16.  A m aware of m y p e r s o n a l s t r e n g t h s a n d w e a k n e s s e s .  N  s  o  R  17.  W o r k t o w a r d l o n g - t e r m g o a l s in m y life.  N  s  o  R  18.  Praise o t h e r p e o p l e e a s i l y f o r their a c c o m p l i s h m e n t s .  N  s  o  R  19.  R e a d labels to identify the nutrients in p a c k a g e d f o o d .  N  s  g  R  20.  Q u e s t i o n m y p h y s i c i a n o r s e e k a s e c o n d o p i n i o n w h e n I d o not agree with recommendations.  N  s  0  R  21.  L o o k forward to t h e future.  N  s  22.  Participate in s u p e r v i s e d e x e r c i s e p r o g r a m s o r activities.  N_  s  0  R  23.  A m aware of what is i m p o r t a n t to m e in life.  N  s  0  R  20-30 m i n u t e s  at least  3 times  per week.  £Z O  OC  R O  3 R  R  over ->  87 CO  E n j o y t o u c h i n g a n d b e i n g t o u c h e d by p e o p l e c l o s e to m e .  N  S  25.  Maintain m e a n i n g f u l a n d fulfilling interpersonal relationships.  N  S  26.  Include r o u g h a g e / f i b e r ( w h o l e g r a i n s , raw fruits, raw vegetables) in m y diet.  27.  P r a c t i c e relaxation o r meditation for 15-20 minutes daily.  28.  D i s c u s s m y health c a r e c o n c e r n s with qualified p r o f e s s i o n a l s .  29.  Respect my own accomplishments.  30.  C h e c k m y p u l s e rate w h e n e x e r c i s i n g .  31.  S p e n d time with c l o s e f r i e n d s .  32.  H a v e my b l o o d p r e s s u r e c h e c k e d a n d k n o w what it is.  33.  Attend e d u c a t i o n a l p r o g r a m s o n i m p r o v i n g the e n v i r o n m e n t in w h i c h we live.  34.  F i n d e a c h d a y interesting a n d c h a l l e n g i n g .  35.  P l a n or select m e a l s to i n c l u d e the " b a s i c four" f o o d g r o u p s e a c h d a y .  36.  C o n s c i o u s l y relax m u s c l e s b e f o r e s l e e p .  37.  F i n d m y living e n v i r o n m e n t p l e a s a n t a n d s a t i s f y i n g .  38.  E n g a g e in r e c r e a t i o n a l p h y s i c a l activities ( s u c h as w a l k i n g , s w i m m i n g , s o c c e r , bicycling).  39.  F i n d it e a s y to e x p r e s s c o n c e r n , love a n d w a r m t h to others.  N  40.  C o n c e n t r a t e o n pleasant t h o u g h t s at b e d t i m e .  N  41.  F i n d c o n s t r u c t i v e w a y s to e x p r e s s m y f e e l i n g s .  N  42.  S e e k i n f o r m a t i o n f r o m health p r o f e s s i o n a l s a b o u t h o w to take g o o d c a r e of  OFTEN  24.  >•  o o o o_ o o o  ROUTINEL  (cont.)  SOMETIME  A  NEVER  Appendix  R R  JR s R N s R N s R N s R H s N s O Jl N s o J3 R M. s O N s SL R N s -2, R N _s o R N s <D R N  Ji  myself.  N  43.  O b s e r v e m y b o d y at least m o n t h l y for p h y s i c a l c h a n g e s / d a n g e r s i g n s .  N  44.  A m realistic a b o u t the g o a l s that I set.  N  45.  U s e s p e c i f i c m e t h o d s to c o n t r o l m y stress.  N  46.  A t t e n d e d u c a t i o n a l p r o g r a m s o n p e r s o n a l health c a r e .  47.  T o u c h and am t o u c h e d by people I care about.  N  48.  Believe that m y life h a s p u r p o s e .  N  IL  s s s s  s JL JL s s s  O  R  -Q  R R  CL  R  O  R  O O  R  0  R  O  R  O  R  0_  R  © S Walker, K. Sechrist, N . Pender, 1985. Reproduction without author's express written consent is not permitted. Permission to use this scale may be obtained from: Health Promotion Research Program, S c h o o l of Nursing. Northern Illinois University, DeKalb, Illinois 60115.  89 Appendix  C  Pretest Instructions  f o r Completing the Health Lifestyle Profile  Promoting  The q u e s t i o n n a i r e o n t h e f o l l o w i n g two p a g e s c o n t a i n s statements a b o u t y o u r way o f l i f e a n d p e r s o n a l h a b i t s . P l e a s e r e a d t h e i n s t r u c t i o n s a t t h e t o p o f t h e next page b e f o r e r e s p o n d i n g t o any o f the statements. In these i n s t r u c t i o n s , you a r e asked t o respond t o the statements a c c o r d i n g t o y o u r p r e s e n t way o f l i f e . S i n c e y o u a r e now i n t h e h o s p i t a l , y o u r way o f l i f e i s d i f f e r e n t f r o m y o u r u s u a l e x p e r i e n c e s . Some o f t h e s t a t e m e n t s o n t h i s q u e s t i o n n a i r e r e f e r t o a c t i v i t i e s t h a t do n o t a p p l y t o t h e h o s p i t a l s e t t i n g . Please respond t o these s t a t e m e n t s a c c o r d i n g t o y o u r way o f l i f e a n d p e r s o n a l h a b i t s b e f o r e y o u came t o t h e h o s p i t a l . P l e a s e r e a d e a c h s t a t e m e n t c a r e f u l l y a n d c i r c l e o n l y one o f t h e f o u r responses t o the r i g h t o f each statement. Do n o t s k i p a n y o f t h e statements. I t i s n o t n e c e s s a r y t o s p e n d t o o much t i m e o n a n y o n e item.  90 Appendix  D  Posttest Instructions  f o r Completing the H e a l t h Lifestyle Profile  Promoting  The q u e s t i o n n a i r e on t h e f o l l o w i n g two p a g e s c o n t a i n s s t a t e m e n t s a b o u t y o u r p r e s e n t way o f l i f e a n d p e r s o n a l h a b i t s . P l e a s e r e a d t h e i n s t r u c t i o n s a t t h e t o p o f t h e n e x t page b e f o r e r e s p o n d i n g t o any o f the statements. P l e a s e r e a d e a c h s t a t e m e n t c a r e f u l l y a n d c i r c l e o n l y one o f t h e f o u r responses to the r i g h t of each statement. Do n o t s k i p a n y o f t h e statements. I t i s n o t n e c e s s a r y t o s p e n d t o o much t i m e on a n y one item. T h i s q u e s t i o n n a i r e was n o t d e s i g n e d f o r i n d i v i d u a l s who h a v e h a d a heart attack. You may f i n d t h a t s e v e r a l i t e m s do n o t a c c u r a t e l y d e s c r i b e t h e way o f l i f e a n d p e r s o n a l h a b i t s t h a t a r e m o s t a p p r o p r i a t e f o r t h o s e i n d i v i d u a l s who a r e r e c o v e r i n g f r o m a h e a r t attack. However, p l e a s e c i r c l e t h e r e s p o n s e f o r e a c h i t e m a c c u r a t e l y d e s c r i b e s y o u r way o f l i f e o r p e r s o n a l  t h a t most habits.  91 Appendix Heart Circle Heart 1.  one correct answer  f o r each  Knowledge  Quiz  question  Disease To b e t o l d t h a t y o u h a v e h a d a h e a r t a t t a c k means a. y o u r h e a r t s t o p p e d f o r a few s e c o n d s . b. y o u have an i r r e g u l a r h e a r t rhythm. c. d.  2.  Health  E  t h e r e i s p e r m a n e n t damage t o a p a r t y o u h a v e a weak h e a r t .  A heart  attack  a.  there  b.  the blood off.  c. d.  there there  occurs  that  of the heart  when  i s t o o much f a t i n t h e b l o o d . supply  to a part  i s n o t enough b l o o d i s a weakened h e a r t  of the heart i n the heart valve.  muscle  The p a i n o f a h e a r t a t t a c k i s due t o a. an i r r e g u l a r h e a r t rhythm. b. t o o l i t t l e b l o o d i n t h e h e a r t chambers c. a l a c k o f oxygen t o t h e h e a r t muscle d. dead h e a r t muscle.'  4.  A n g i n a o r p a i n from t h e h e a r t c a n be f e l t as a. a sore t h r o a t and a cough. b. numbness i n t h e l e f t a r m a n d p a i n i n t h e j a w . c. d i z z i n e s s and a severe headache. d. a lower backache and a stomach ache.  5.  N i t r o g l y c e r i n e , i n tablet or spray reducing chest p a i n because i t  form,  a.  makes t h e b l o o d chambers.  b.  widens  c.  makes t h e h e a r t b e a t s l i g h t l y reaches the heart muscle.  d.  acts  as a b l o o d  The most a p p r o p r i a t e spray i s  i s a good drug f o r  flow, m o r e q u i c k l y t h r o u g h  the a r t e r i e s  i s cut  chambers.  3.  6.  muscle.  the heart  of the heart. faster  s o t h a t more  blood  thinner. time t o use N i t r o g l y c e r i n e t a b l e t s or  a.  when a n g i n a  b.  only after pain.  or heart  c.  a t the f i r s t  d.  on a r e g u l a r b a s i s  p a i n h a s become  an a c t i v i t y  severe.  t h a t has caused angina  sign of angina  or heart  throughout  pain.  t h e day.  or heart  92 7.  For  angina  or h e a r t  pain,  a.  u s e one N i t r o g l y c e r i n e t a b l e t h a v e p a i n a f t e r 5 m i n u t e s , go department.  b.  u s e one N i t r o g l y c e r i n e t a b l e t o r s p r a y , w a i t 5 m i n u t e s , and i f you s t i l l have p a i n a f t e r d o i n g t h i s f o u r t i m e s , go v i s i t y o u r f a m i l y d o c t o r .  c.  u s e one N i t r o g l y c e r i n e t a b l e t o r s p r a y , w a i t 20 m i n u t e s , a n d i f y o u s t i l l h a v e p a i n a f t e r d o i n g t h i s two t i m e s , go to t h e h o s p i t a l emergency d e p a r t m e n t . u s e one N i t r o g l y c e r i n e t a b l e t o r s p r a y , w a i t 5 m i n u t e s , and i f you s t i l l have p a i n a f t e r d o i n g t h i s t h r e e t i m e s , go t o t h e h o s p i t a l e m e r g e n c y d e p a r t m e n t .  d.  o r spray, and i f you still t o the h o s p i t a l emergency  Nutrition 8.  Which of the f o l l o w i n g b l o o d heart disease? a. A n i n c r e a s e i n HDL. b. A n i n c r e a s e i n LDL. c. Cholesterol. d. Triglycerides.  9.  The a. b. c. d.  10.  C h o l e s t e r o l c a n be f o u n d i n w h i c h o f t h e a. Peanut b u t t e r and avocados. b. Shrimp and m o z a r e l l a c h e e s e . c. C a n o l a o i l and margarine. d. A p p l e s and oranges.  11.  Which  food  a. b. c. d.  Macaroni. Whole wheat 1% m i l k . Nuts. .  12.  One a. b. c. d.  total blood cholesterol l e s s than 2.0. l e s s than 5.2. b e t w e e n 6.0 a n d 7.0. 8.5 o r h i g h e r .  i s high  in  fats  level  helps  t o aim  to lower  the  risk  for i s  following  fat?  bread.  s e r v i n g o f meat, f i s h o r p o u l t r y i s e q u a l 1 cup. 3 tablespoons. a deck of p l a y i n g c a r d s . 6 ounces.  to  foods?  of  93 13.  14.  Most  c o u l d b e n e f i t from a d i e t  higher  b.  lower i n breads, and p o u l t r y .  c.  higher  d.  lower i n breads, and p o u l t r y .  The a. b. c. d.  Physical 15.  o f us  a.  i n breads,  rice rice  i n vegetables  and and  and  rice  pasta  is  and and  higher  and  type of f a t that i s s o l i d monosaturated. polyunsaturated. saturated. unsaturated.  that  pasta  lower  i n meat,  fish  in fat.  pasta  and  lower  i n meat,  a t room t e m p e r a t u r e  is  fish  called  Activity  F o r t h e f i r s t 2 months a f t e r e x e r c i s e program i s a.  r e s t i n g a t home f o r one hospital.  b. c. d.  jogging walking walking  a heart  attack,  month a f t e r  a  recommended  discharge  from  the  f o r a h a l f h o u r e v e r y o t h e r day. d a i l y a t an i n c r e a s e d p a c e a n d l e n g t h . 5 b l o c k s e a c h day.  16.  Which of the f o l l o w i n g i s a d i r e c t b e n e f i t of someone who h a s h a d a h e a r t a t t a c k ? a. A stronger heart muscle. b. Larger coronary a r t e r i e s . c. Enlarged lungs. d. An i n c r e a s e d r e s t i n g h e a r t r a t e .  17.  The a.  18.  in fat.  higher  exercise for  t e r m " t a r g e t h e a r t r a t e " i n r e l a t i o n t o e x e r c i s i n g means d e c i d i n g on a n y h e a r t r a t e t h a t i s f a s t e r t h a n y o u r r e s t i n g h e a r t r a t e , and t h e n making y o u r h e a r t b e a t a t that rate while exercising.  b.  making your h e a r t exercising.  beat  as  fast  as  c.  i n c r e a s i n g your heart r a t e to heart rate while exercising.  d.  i n c r e a s i n g y o u r h e a r t r a t e t o a b o u t 75% o f t h e h i g h e s t l e v e l r e a c h e d d u r i n g y o u r most r e c e n t e x e r c i s e s t r e s s test.  35  possible beats  A recommended m a i n t e n a n c e e x e r c i s e s c h e d u l e r e c o v e r i n g from a heart a t t a c k i s a. 60 m i n u t e s t w i c e a week. b. 40 m i n u t e s 3 t i m e s a week. c. 15 m i n u t e s 7 t i m e s a week. d. 20 m i n u t e s 3 t i m e s a week.  while  above y o u r  resting  f o r someone who  is  94 Stress 19.  20.  Management The t e r m " s t r e s s " c a n be d e s c r i b e d as a. a normal r e a c t i o n t o change. b.  the usual  c.  the response to cope.  d.  t h e r e s p o n s e o f t h e body t o p l e a s a n t  The e x p e r i e n c e  response t o any t o an e v e n t  of stress  disturbance. that  s t r a i n s a person's  ability  situations.  involves  a. b. c.  adapting to a d i f f i c u l t s i t u a t i o n . being exposed t o a c h a l l e n g i n g s i t u a t i o n . i d e n t i f y i n g those s i t u a t i o n s that are d i f f i c u l t handle.  d.  an i n a b i l i t y  to handle a d i f f i c u l t  to  situation.  21.  W h i c h o f t h e f o l l o w i n g i s a common p h y s i c a l prolonged stress? a. A change i n a p p e t i t e . b. A slower heart rate. c. Decreased metabolism. d. Increased concentration.  22.  What a. b. c. d.  i s a v e r y e f f e c t i v e way t o r e l a x ? B r e a t h i n g s l o w l y and r h y t h m i c a l l y . C o n t r o l l i n g your emotions. Concentrating on m u s c l e t e n s i o n . I n v o l v e m e n t i n community activities.  response to  Appendix F Demographic Please  provide  I.D.  Information  t h e f o l l o w i n g i n f o r m a t i o n about y o u r s e l f :  1.  Date  2.  Age  3.  Gender  4.  M a r i t a l Status a. Single b. Married  dd/mm/yy  a.  male  b.  ( c i r c l e one) c. Divorced d. Separated e.  Widow(er)  Language(s) u s u a l l y spoken a. English b. Chinese c. German d. Indo-Pakistan specifv: e. Italian f. Portuguese/Spanish 6.  female  at g. h. i .  home ( c i r c l e French Japanese Greek  jk.  Scandinavian snecifv: Other, p l e a s e  Highest l e v e l o f education completed a. Grade 0 - 7 b. Grade 8 - 1 1 c. G r a d e 12 o r e q u i v a l e n t d. e.  7.  Community C o l l e g e / T e c h n i c a l University  Employment a. b. c.  8.  Status  (circle  Employed Unemployed Retired  specify  ( c i r c l e one)  School  a l l that  d. e. f.  a l l that  apply)  Unemployment Insurance Disability Social Assistance  Occupation  9. F o r t h e s e c o n d p a r t o f t h i s s t u d y , y o u w i l l be m a i l e d questionnaire. P l e a s e e n t e r y o u r name a n d a d d r e s s h e r e :  Name Street City  o r Town  Apt. # Province  Postal  Code  this  96 Appendix G I.D. # Health-Related 1. the  Information  Have you j o i n e d any c a r d i a c e d u c a t i o n programs s i n c e you l e f t hospital? a.  Yes  b.  No  I f y e s , p l e a s e s t a t e where t h i s program was l o c a t e d , how the program was o r g a n i z e d (eg. c l a s s e s , home v i s i t s by a nurse) and the t o p i c s of d i s c u s s i o n .  2. you  Have you p a r t i c i p a t e d i n an o r g a n i z e d e x e r c i s e program l e f t the h o s p i t a l ? a.  Yes  b.  since  No  I f y e s , p l e a s e s t a t e where t h i s program was l o c a t e d , when you began the program, and how o f t e n you a t t e n d the e x e r c i s e program.  97 Appendix  H  OUTPATIENT CARDIAC EDUCATION PROGRAM Program  Schedule  Hours:  Wednesdays,  Overview o f  1000 - 1200 h o u r s  Sessions  Resource  Session I the heart  Registered Nurse  *  How  * * * * * *  What i s c o r o n a r y a r t e r y d i s e a s e ? What i s a h e a r t a t t a c k ? S i g n s a n d symptoms o f a h e a r t a t t a c k Emergency p l a n n i n g Identifying risk factors Medications  works  Session I I * * * *  Dietitian  What i s c h o l e s t e r o l ? G o o d c h o l e s t e r o l ? Bad c h o l e s t e r o l ? How t o r e d u c e d i e t a r y f a t , c h o l e s t e r o l , a n d saturated fatty acids Understanding food labels T i p s on e a t i n g o u t  Session I I I * * * * *  Occupational Therapist  E f f e c t s o f s t r e s s on t h e body Sources of Stress Techniques f o r managing s t r e s s Planning a balanced lifestyle Energy c o n s e r v a t i o n  Session IV * * * * * *  Person  The b e n e f i t s o f e x e r c i s e P r e p a r i n g f o r an e x e r c i s e program Understanding the exercise p r e s c r i p t i o n Sexual activity I d e n t i f i c a t i o n o f community r e s o u r c e s Emotional r e a c t i o n a f t e r a heart attack  Spouses a r e encouraged  to attend  Physiotherapist Registered Nurse  98 Appendix  I  Cover L e t t e r f o r P r e t e s t Lifestyle  Adjustments A f t e r a Heart  Attack  I am a M a s t e r o f S c i e n c e i n N u r s i n g s t u d e n t a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a . One o f t h e r e q u i r e m e n t s of t h i s course of s t u d i e s i s to conduct a r e s e a r c h p r o j e c t . T h i s i s a r e q u e s t f o r you to participate i n this research project. F o r t h i s p r o j e c t , I am a s k i n g i n d i v i d u a l s who h a v e h a d a h e a r t a t t a c k to answer q u e s t i o n s about t h e i r knowledge o f h e a r t d i s e a s e , and t h e i r health habits. As someone who h a s b e e n t h r o u g h t h e e x p e r i e n c e o f a h e a r t a t t a c k , you can p r o v i d e v a l u a b l e i n f o r m a t i o n t h a t w i l l h e l p n u r s e s t o i n c r e a s e t h e i r u n d e r s t a n d i n g o f what i t i s l i k e t o make l i f e s t y l e changes a f t e r a h e a r t a t t a c k . This w i l l help nurses to p r o v i d e improved e d u c a t i o n programs t h a t w i l l encourage i n d i v i d u a l s who h a v e h a d a h e a r t a t t a c k t o make e f f e c t i v e l i f e s t y l e c h a n g e s . The e n c l o s e d q u e s t i o n n a i r e s a s k a b o u t y o u r k n o w l e d g e o f h e a r t d i s e a s e , and y o u r h e a l t h h a b i t s . Please r e a d the i n s t r u c t i o n s at the b e g i n n i n g o f e a c h s e c t i o n c a r e f u l l y , and t h e n p r o c e e d t o c o m p l e t e t h e q u e s t i o n n a i r e s without the h e l p of other people. I t w i l l take you a p p r o x i m a t e l y 30 m i n u t e s t o c o m p l e t e t h e s e q u e s t i o n n a i r e s . Your this  c a r e w i l l n o t be a f f e c t e d i f y o u d e c i d e n o t s t u d y or i f you withdraw.from the study.  to p a r t i c i p a t e  in  P l e a s e complete t h e s e q u e s t i o n n a i r e s at y o u r l e i s u r e w h i l e you are here i n the h o s p i t a l . I f y o u a r e i n t e r r u p t e d , o r become t i r e d , i t i s b e t t e r t o t a k e a r e s t and r e t u r n t o t h e s e q u e s t i o n n a i r e s a t a l a t e r time. When y o u h a v e c o m p l e t e d t h e q u e s t i o n n a i r e s , p l e a s e p l a c e them i n t h e e n v e l o p e p r o v i d e d a n d g i v e them t o m y s e l f o r y o u r n u r s e b e f o r e you l e a v e the h o s p i t a l . I n 4 - 6 months purpose of t h i s knowledge about personal health  y o u w i l l b e m a i l e d t h e s e same q u e s t i o n n a i r e s . The i s to determine i f t h e r e have been changes i n your h e a r t d i s e a s e , i n y o u r way o f l i f e a n d i n y o u r habits.  On one o f t h e q u e s t i o n n a i r e s i s a n i d e n t i f i c a t i o n number t h a t i s k e p t s e p a r a t e f r o m t h e l i s t o f names, a n d i s known o n l y t o m y s e l f a s t h e researcher. You a r e a s s u r e d o f c o m p l e t e a n o n y m i t y a n d c o n f i d e n t i a l i t y regarding your responses. Y o u r name w i l l n o t be a s s o c i a t e d w i t h the i n f o r m a t i o n you have p r o v i d e d . C o m p l e t i n g and r e t u r n i n g t h e s e q u e s t i o n n a i r e s i s c o n s i d e r e d c o n s e n t t o p a r t i c i p a t e i n t h e two p h a s e s o f t h i s s t u d y .  as  your  102 Appendix List 6 4  omissions #3 : Like omissions. #9: Feel  of  O m i t t e d HPLP  3  2  1  Items  myself.  I am g r o w i n g directions.  #25:  K  and  Maintain meaningful relationships.  changing p e r s o n a l l y  and  fulfilling  in positive  interpersonal  omissions #21: Look forward t o the f u t u r e . #36: Consciously r e l a x muscles before sleep. omissions #2 : R e p o r t any u n u s u a l s i g n s o r symptoms t o a p h y s i c i a n . #4: P e r f o r m s t r e t c h i n g e x e r c i s e s a t l e a s t 3 t i m e s p e r week. #16: Am a w a r e o f my p e r s o n a l s t r e n g t h s a n d w e a k n e s s e s . #22 : P a r t i c i p a t e i n s u p e r v i s e d e x e r c i s e programs or #31: omission #5 : #6 : #8 : #10 : #11: #13 : #17:  activities. Spend time w i t h  close  friends.  Choose foods w i t h o u t p r e s e r v a t i v e s or o t h e r T a k e some t i m e f o r r e l a x a t i o n e a c h d a y . Am e n t h u s i a s t i c a n d o p t i m i s t i c a b o u t l i f e . Discuss to me.  personal  problems  and  concerns with persons  Am a w a r e o f t h e s o u r c e s o f s t r e s s i n my life. E x e r c i s e v i g o r o u s l y f o r 20-30 m i n u t e s a t l e a s t 3 p e r week. Work t o w a r d l o n g - t e r m g o a l s i n my life.  #20:  Q u e s t i o n my p h y s i c i a n o r s e e k a s e c o n d not agree w i t h recommendations.  #26:  I n c l u d e r o u g h a g e / f i b e r (whole g r a i n s , v e g e t a b l e s ) i n my d i e t . R e s p e c t my own accomplishments.  #29 #32 #34 #35  additives.  opinion raw  close  times  when I  fruits,  raw  Have my b l o o d p r e s s u r e c h e c k e d a n d know what i t i s . F i n d e a c h day i n t e r e s t i n g and challenging. Plan or s e l e c t meals to i n c l u d e the " b a s i c f o u r " food g r o u p s e a c h day.  #41: #42 :  F i n d c o n s t r u c t i v e ways t o e x p r e s s my f e e l i n g s . S e e k i n f o r m a t i o n f r o m h e a l t h p r o f e s s i o n a l s a b o u t how t a k e good c a r e of m y s e l f .  #43 :  O b s e r v e my b o d y a t l e a s t m o n t h l y changes/danger s i g n s .  #45 #46 #47  do  Use  specific  Attend  methods  educational  T o u c h and  am  to  c o n t r o l my  p r o g r a m s on  t o u c h e d by  for  people  physical  stress.  personal I care  health  about.  care.  to  

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