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EFFECTS OF BEHAVIOR CHANGE PROGRAM ON
PHYSICAL ACTIVITYAND PHYSICAL FITNESS
IN PATIENTS STATUS POSTCORONARY ARTERY BYPASS GRAFT SURGERY
WORARAT PHOTI
A THESIS SUBMITTED IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR
THE DEGREE OF MASTER OF NURSING SCIENCE
(ADULT NURSING)
FACULTY OF GRADUATE STUDIES
MAHIDOL UNIVERSITY
2009
COPYRIGHT OF MAHIDOL UNIVERSITY
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iii
ACKNOWLEDGEMENTS
The success of this thesis can been attributed to the extensive support and
assistance from my major advisor, Asst. Prof. Napaporn Wanitkun and my co-advisor,
Assoc. Prof. Suvimol Kimpee and Dr. Taweesak Chotivatanapong. I deeply thank
them for their valuable advice and guidance in this research.
I would like to express my deep appreciation to Dr. Grit Leetongin for
external examiner of the thesis defense, his kindness and helpful guidance. I would
like to gratefully appreciate Assoc. Prof. Kanaungnit Pongthavornkamol for her
constructive comments. Grateful acknowledge extend to all the experts for their
invaluable advice and comments on this thesis ,especially Prof. Karen B. Tetz for her
time in revising and polishing my English writing.
I wish to thank all experts for kindness in examining the research
instrument and providing suggestions for improvement.
I would like to thank all nurses and other health care team member at theChest Disease Institute
for helping me to succeed in data collection. I am deeply
thankful to all patients for their cooperation to patients in my study.
I am grateful to all the lectures and staff of the Faculty of Nursing for
valuable advice and thanks also go to my older sister and friends in classmate master
program for their kind support.
Finally, I am grateful to my parents for their financial support, entirely
care, love, and believed in me. Thanks Mr. Nuttaphon for helped in any way you
could. The usefulness of this thesis I dedicate to my father, my mother and all the
teachers who have taught me since my childhood.
Worarat Photi
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Fac. of Grad. Studies, Mahidol Univ. Thesis /iv
EFFECTS OF BEHAVIOR CHANGE PROGRAM ON PHYSICAL ACTIVITY
AND PHYSICAL FITNESS IN PATIENTS STATUS POST CORONARY
ARTERY BYPASS GRAFT SURGERY
WORARAT PHOTI 4936723 NSAN/M
M.N.S. (ADULT NURSING)
THESIS ADVISORY COMMITTEE : NAPAPORN WANITKUN, Ph.D. (Adult Nursing),
SUVIMOL KIMPEE, M.ED., TAWEESAK CHOTIVATANAPONG, M.D.
ABSTRACT
This quasi-experimental study was designed to examine a Behavior Change
Program that would significantly impact physical activity and physical fitness in patients with
post coronary artery bypass graft surgery, who were admitted to the Central Chest Institute
during December 2008 May 2009.
The participants of this study were 73 patients following coronary artery bypass
graft surgery. There were patients in the control group (n=37) and the intervention group
(n=36). The two groups were matched by age and sex. Patients in the control group were fully
recruited first and then the intervention group was started on data collection two weeks later
to prevent contamination. Both groups received the cardiac rehabilitation program as usual
hospital care of the Central Chest Institute and the experimental group also participated in the
Behavior Change Program. The program was based on the specific constructs of the
Transtheoretical Model for only individuals in the preparation stage of readiness for physical
activity. Physical activity behavior (measured by expenditure of at least a moderate level of
physical activity) and physical fitness (measured by six-minute walking distance) were
assessed at pre- and post-intervention. Only daily steps were measured post- intervention. The
data were analyzed using MANOVA.
The results demonstrated that both groups had no difference in physical activity
and physical fitness pre-intervention (p>.05). Post-intervention, the intervention group had a
significantly higher level of physical activity and physical fitness than the control group
(p< 0.01).
These findings can be applied to improve physical activity and physical fitness
among patients who have had post-coronary artery bypass graft surgery and have potential
applications for other clinical settings.
KEY WORDS: BEHAVIOR CHANGE PROGRAM / CORONARY ARTERY
BYPASS GRAFT / PHYSICAL ACTIVITY /
TRANSTHEORETICAL MODEL
111 pages
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Fac. of Grad. Studies, Mahidol Univ. Thesis /v
EFFECTS OF BEHAVIOR CHANGE PROGRAM ON PHYSICALA CTIVITY AND PHYSICAL
FITNESS IN PATIENTS STATUS POST CORONARY ARTERY BYPASS GRAFT SURGERY
4936723 NSAN/M
.. ()
: , Ph.D. (Nursing), , ..(), , ..
2551 2552
73 (37 ) (36 )
2 6 () ( 6 ) MANOVA
(p > .05) (,)(6 ) (p< 0.01).
111
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vi
CONTENTS
Page
ACKNOWLEDGEMENTS iii
ABSTRACTS (ENGLISH) iv
ABSTRACTS (THAI) v
LIST OF TABLES viiiLIST OF FIGURE ix
CHAPTER I INTRODUCTION 1
Background and significance of the study
Research questions
Purpose of the research
Research hypothesis
Conceptual framework of the researchScope of the study
Definition of terms
Expected benefitsof the research
1
4
5
5
59
9
10
CHAPTER II LITERATURE REVIEW 11
CHAPTER III METHODOLOGY 37
Research design
Population and sampling
Setting
Instrument
Validity and reliability
Data collection
Protection of human right
Data analysis
37
37
38
38
42
43
47
48
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vii
CONTENTS (cont.)
Page
CHAPTER IV RESULTS 50
CHAPTER V DISCUSSION 62
CHAPTER VI CONCLUSION 69
REFERENCES 73
APPENDICES
Appendix A The experts who validated the content of the
instruments.93
Appendix B Demographic data questionnaire. 94
Appendix C Exercise Stages of Change questionnaire : ESC. 95
Appendix D Community Health Activities Model Program for
Seniors
Activities Questionnaire for Older Adults: CHAMPS
96
Appendix E Self-Efficacy for Overcoming Barriers to Exercise
questionnaire.98
Appendix F Questionnaire for evaluated patient perception of care. 99
Appendix G Self liberation card 100
Appendix H Brochures 103
Appendix I Motto 105
Appendix J Letter 106
Appendix K Behavior Change Program guideline 107
Appendix L Pedometers manual 109
Appendix M Documentary Proof of Mahidol University Institutional
Review Board110
BIOGRAPHY 111
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viii
LIST OF TABLES
Table Page
1 Physical Activity for Patients Received coronary Artery
Bypass Graft Surgery 25
2 The Behavior Change Program 46
3 Comparison of Demographic characteristics by Chi-square
and Mann-Whitney U test 51
4 Comparison of Socioeconomic Status Between Control and
Intervention Groups by Chi-square and Mann-Whitney U test. 52
5 Comparison of health behaviors : working physical activity,
diet control, smoking by Chi-square and Mann-Whitney U test 53
6 The Frequency and Percentage of Functional Class 54
7 Frequency and Percentage of Illness Conditions 55
8 Comparisons of Mean and standard deviation of Caloric
Expenditure of at Least Moderate Physical Activity Level
and Above, Daily Steps and Six-Minute Walking Distance
Between Intervention and Control Group at post-
intervention by MANOVA 56
9 Frequency and Percentage of Participants Perception of
Care quality 5810 Comparing means and standard deviations of Self-efficacy
for Overcoming Barriers by t-test 60
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ix
LIST OF FIGURES
Figure Page
1 Conceptual framework of the research 8
2 The processes of the intervention 45
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Fac. of Grad. Studies, Mahidol Univ. M.N.S. (Adult Nursing)/ 1
CHAPTER I
INTRODUCTION
Background and Significance of the Study
Acute Coronary Syndromes (ACS) is the leading cause of death and
results in high hospital costs in Thailand (Bureau of Policy and Strategy, 2005) and the
United States (Anderson et al., 2007). Coronary Artery Bypass Graft (CABG) surgeryis a treatment that may be used for patients with ACS. The number of patients who
received CABG surgery in Thailand increased from 2,213 in 2005,to 3,063 in 2007
(The Society of Thoracic Surgeons of Thailand, 2007) and the total cost for coronary
artery bypass graft surgery is more than 140,000 bath per person. In the United States,
the number of patients with ACS increased and the cost for surgery and care increased
as well (Nilsson, Algotsson, Hoglund, Luhrs, & Brandt, 2004). Moreover, even though
the patients have already been surgically treated, it is likely that they will develop this
illness again unless they change their behaviors (Eagle et al., 2004). Physical activity
can reduce the recurrence of Acute Coronary Syndromes (ASCM, 2007).
The recommended minimum for physical activity was moderate physical
activities consuming about 3-6 METs 30 minutes of continued physical activity or the
sum of at least 30 min of intermittent exercise, five days per week. Moderate physical
activity levels were complementary in the production of health benefits (Haskell,
2007). Many studies demonstrated the benefits of physical activity and exercise. Both
physical activity and exercise decreased and prevented artherosclerotic heart disease.
A meta analysis of 51 intervention studies found that rehabilitation programs (exercise
only) reduced mortality rate by 27% (Jolliffe, Rees, Taylor, Thompson, Oldridge, &
Ebrahim, 2001). The six-minute walk test and quadriceps muscle strength test
improved significantly in patients who received a supervised exercise program
(Jonsdottira, Andersen, Sigurosson, & Sigurosson, 2006). An average increase in
HDL-C levels was 4.6%. Triglyceride and LDL-C were reduced by 3.7% and 5.0%
respectively (Thompson et al., 2003). Nowadays, even if physical activity and exercise
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Worarat Photi Introduction /2
are supported, research has found that the majority of persons in the United States do
not engage in consistent physical activity for the recommended minimum 30 minutes
of moderate-intensity activity in most days of the week. In 2001, 54.6% of persons
did not have enough activity to meet the recommendations (Centers for Disease
Control and Prevention, 2003). In Thailand, a total of 45% of patients with ACS did
not have regular physical activity (Wanitkun, 2003).
There is not a simple way to motivate patients to regularly do physical
activities that are appropriate with their competency. Only providing knowledge and
skill about exercise is not sufficient to bring about continuous exercise for health.
(U.S. Preventive Services Task Force, 2006). Primary and secondary prevention
should be emphasized, including a focus on ways individual persons can improve
their abilities such as skill, motivation from their lifestyle, self- efficacy overcoming
barriers and self-monitoring. Readiness for behavior change or stages of change is
associated with a benefit and cost (pros and cons) analysis of behavior change
(Prochaska et al.,1994). The lifestyles and barriers of each person are different; hence,
they use different processes of change (Lowther, Mutrie, & Scott, 2007). Providing
one program for behavior change is not always effective for people at various stages of
readiness.
Literature review demonstrated that education technique (Kawchareanta,
2003), group support (Kaduang, 2004), self-efficacy enhancement (Jompong, 2003;
Leangchawengwong, 1998; Lipun, 1999), and motivation promotion (Intaratool,
2005) were used for behavior change. These techniques included the same content
and details for every person. After the patients received the program, they could
change their behaviors. However, the literature review demonstrated that thetranstheoretical model(TTM) based activity promotion interventions are effective in
promoting activity adoption, initial results on longer term adherence are disappointing
(Adams, & White, 2003; Dallow & Anderson, 2003; Spencer, Malone, Roy, & Yost,
2006). The TTM was useful in explaining the longitudinal effects of exercise. After
one year, 60% of those in the intervention group were adopters compared to 16% of
those in the education program(Findorff, Stock, Gross, & Wyman, 2007).
Prior to the current research, cardiac rehabilitation program at the Central
Chest institute for physical activity enhancement of patients with ACS emphasized the
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education technique for a group or person and then all of them received the same
content. This program was not developed in terms of appropriate individual lifestyle,
barriers, and readiness for changing behavior. The literature review demonstrated that
an effective program should be developed by a combination of psychotherapy and
behavior change, and it should motivate a change from risky behavior to healthy
behavior. The program development should emphasize the appropriate individual
persons style (Wanitkun, 2005) and readiness for change (Prochaska, Redding, &
Evers, 2002).
The conceptual framework of this study is based on the Transtheoretical
model which integrates behaviors and classifies individuals in respect to readiness for
behavior change. There are 5 stages of change which consist of precontemplation,
contemplation, preparation, action, and maintenance (Prochaska, Redding, & Evers,
2002; Wilson & Schlam, 2004). Based on the transtheoretical model, individuals in
each stage were assisted with various unique combinations of strategies or processes
to aid the patients in changing their behavior. Individuals in the contemplation stage
used dramatic relief, environmental reevaluation, (Prochaska, Redding, & Evers,
2002) consciousness raising, decisional balance, and self-efficacy overcoming barriers
(Kim, Hwangb, & Yoo, 2004), while individuals in the preparation stage used self-
liberation (Prochaska, Redding, & Evers, 2002), reinforcement management, self-
efficacy for overcoming barriers (Kim et al., 2004), environmental reevaluation, and
counter-conditioning (Tseng, Jaw, Lin, & Ho, 2003) for behavior change.
The literature review found that the transtheoretical model is effective for
behavior change in areas such as physical activity (Dallow & Anderson, 2003;
Griffin-Blanke, Dejoy, 2006; Plotnikoff, Brunet, Courneya, Birkett, Marcus, &Whiteley, 2007; Titze, Martin, Seiler, Stronegger, & Marti, 2001; Woods, Mutrie, &
Scott, 2002) and exercise (Kim et al., 2004; Spencer, Malone, Roy, & Yost, 2006;
Tseng, Jaw, Lin, & Ho, 2003). An outcome of exercise and physical activity behavior
was measured with caloric expenditure and cardiorespiratory fitness (Kim et al., 2004;
Spencer, B, Malone, Roy, & Yost, 2006; Tseng et al., 2003; Spencer et al.,2006;
Tseng et al., 2003). Moreover, the transtheoretical model is effective for eating
behavior change ( Wilson & Schlam, 2004) and for use in behavior change that
involves more than one behavior (Kim, et al., 2004; Johnson, et al., 2006; McKee,
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Worarat Photi Introduction /4
Bannon, Kerins, & FitzGerald, 2006; Prochaska, et al., 2007). Measured outcomes
include stress management (Tseng et al., 2003), fasting blood glucose level (Kim et
al., 2004), and eating behavior (Johnson, Driskell,Johnson, Dyment, Prochaska,
Prochaska, et al., 2006; Wilson & Schlam, 2004).
Individuals in each stage used various processes; thus, stage matched
interventions can enhance the physical activity more than non stage matched
interventions (Dallow & Anderson, 2003). The participants in this study were patients
who received CABG surgery. They could not be treated by medication, and were
concerned about the importance of risk factor reduction, and cardiac rehabilitation
enhancement. They gained education about exercise or physical activity; thus, they
have learned about the cost of non physical activity. They received a cardiac
rehabilitation program from a physiotherapy team. Not all of them succeeded in
physical activity. Some patients did not change behavior or met the criteria. Likewise
some patients succeeded in changing their behavior but they did not regularly
participate in physical activity. Education alone cannot motivate patients to reach the
recommended physical activity level. This study developed the Behavior Change
Program for the patients in this group. The Behavior Change Program included self-
liberation (Prochaska, Redding, & Evers, 2002), reinforcement management, self-
efficacy overcoming barriers (Kim et al., 2004), environmental reevaluation, and
counter conditioning (Tseng et al., 2003).
Research Question
1.
Does a Behavior Change Program have an effect on physical activities
(caloric expenditure of at least moderate physical activity level, and daily steps) of
CABG patients in the preparation stage?
2. Does a Behavior Change Program have an effect on physical fitness
(six-minute walking distance) of CABG patients in the preparation stage?
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Purposes of the Study
1. To compare physical activities(caloric expenditure of at least moderate
physical activity level, and daily steps) of CABG patients in the preparation stage for
those who received a Behavior Change Program and those who received usual care.
2. To compare physical fitness (six-minute walking distance) of CABG
patients in the preparation stage for those who received a Behavior Change Program
and those who received usual care.
Research Hypotheses
1. The intervention group will have a significantly greater caloric
expenditure of at least moderate physical activity level when compare to, the control
group.
2. The intervention group will have a significantly higher number of daily
steps than the control group.
3. The intervention group will have a significantly longer six-minute
walking distance than the control group.
Conceptual Framework of the research
The conceptual framework of this study is based on the transtheoretical
model (TTM) which emerged from comparative analysis of leading theories of
psychotherapy and behavior change (Prochaska, & DiClemente, 1983). The TTM
consists of various stages of change, process of change, self-efficacy, and decisional
balance (Prochaska et al., 2002; Wanitkun, 2005). The TTM integrates behaviors to
classify individuals with respect to readiness for behavior change. So, individuals in
each stage use different strategies or processes, self - efficacy overcoming barriers,
and weight of the cost-benefit to aid them in changing their behavior. The TTM
construes change as a process-involving progress through a series of five stages:
Precontemplation, Contemplation, Preparation, Action, and Maintenance.
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Worarat Photi Introduction /6
The decisional balance refers to the weight of the benefit and cost
consideration (pros and cons) of changing behavior. Individuals in each stage have
different benefit and cost considerations
(Kim, 2007). The 10 processes of change are
the covert and overt activities that people use to progress through the stages.
(Prochaska et al., 2002). Self-efficacy overcoming barriers are combined with the
TTM. The meaning of self-efficacy overcoming barriers is the confidence in
overcoming the barriers to performing physical activity (Bandura, 1997 ).
The program in this study was developed for CABG patients in the
preparation stage. This group is concerned about the importance of risk factor
reduction and cardiac rehabilitation enhancement. This group received education about
exercise or physical activity; thus, they have learned about the cost of non physical
activity. They received a cardiac rehabilitation program by a physiotherapy team.
After surgery, the patient may have wounds. Manipulation of the chest cavity, and use
of retractors during surgery may all contribute to postoperative pain. They may also
experience anxiety and fear about self care post operation. They have barriers to
physical activity in their lifestyle. These factors lead to some patients being unable to
change behavior or meet the criteria. Other patients may succeed in changing their
behavior, but do not participate in regular physical activity. Thus, the Behavior
Change Program should be focused on appropriate individuals. Persons in the
preparation stage were ready to begin physical activity. The goal is to reinforce and
increase physical activity behavior.
The Behavior Change Program focused on identified barriers to physical
activity and using processes of change for motivating the behavior change. This
program was composed of self liberation (Prochaska et al., 2002; Tseng et al., 2003),counter-conditioning, stimulus control, environmental reevaluation(Tseng et al., 2003),
reinforcement management, and self-efficacy (Kim et al., 2004)for increasing physical
activity and physical fitness.
Self-efficacy for overcoming barriers to exercise is the confidence a person
feels about performing physical activities (Bandura, 1997). Persons with higher self-
efficacy maintained physical activity level, perceived less effort in doing physical
activity, and reported more positive effects from physical activities (Prochaska et al.,
2002; Wanitkun, 2005). The Behavior Change Program increased patients self
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efficacy by discussing their physical activity barriers and identifying strategies to
overcome the barriers, thus leading to increased physical activity. Counter-
conditioning skills are important to learn when trying to fit short bouts of moderately
intense physical activity into the day. These skills are important to guide patients who
are thinking about changing physical activity behavior (preparation stages) to proceed
to the action stage. Self-liberation represents making a firm commitment to changing
health behavior. Helping patients to set realistic personal activity goals is important to
guide physical activity behavior change. Environmental reevaluation included
consideration and assessment by persons about how the problem affects the social
environments and physics. Stimulus Control was control of causes that trigger the
behavioral problem, including removal of cues for unhealthy habits and addition of
prompts for healthier alternatives. Reinforcement Management provided rewards for
controlling or maintaining the physical activity.
These processes increased self-efficacy (Dallow & Anderson, 2003),
benefits consideration (pros) of physical activities (Fahrenwaldm & Walkerm, 2003)
and decreased cost consideration (cons) of exercise or physical activity (Griffin-Blake
& DeJoy, 2006).
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Worarat Photi Introduction /8
Normal pathway The Behavior Change Program pathway
Figure 1 Conceptual framework of the research
Coronary artery bypass graft
surgery patients
in preparation stage
Behavior Change Program
- Substitution of alternative behaviors
for the problem behavior:counter-
conditioning (Tseng, Jaw, Lin, & Ho,
2003).
- Consideration and assessment by
person of how the problem affects the
social environments and
physics:environmental reevaluation
(Tseng, Jaw, Lin, & Ho, 2003).
- Persons choice, commitment and
recommitment to change the
behavioral problems: selfliberation(Prochaska, Redding, &
Evers, 2002; Tseng, Jaw, Lin, & Ho,
2003).
- Control of situations and other
causes that triggers the problem
behavior: stimulus control (Tseng,
Jaw, Lin, & Ho, 2003).
- Provided rewards for controlling or
maintaining the healthy behavior:
reinforcement management (Kim,
Hwangb, & Yoo, 2004)- Increased confidence a person feels
about performing physical activity:
self-efficacy (Kim, Hwangb, & Yoo,
2004)1.Physical activities
- Caloric expenditure
of at least moderate
physical activity level
not improve.
- Mean daily steps
not improve.
2. Physical fitness
- Six-minute walking
distance not improve.
Not engage in
physical activity
because of
- Confidence a person
feels about performingphysical activities not
improved or
decreased.
- Benefit analysis of
physical activities not
improved or
decreased.
- Cost analysis of
physical activities
increased.
- Cannot combine
physical activities into
lifestyle.
Do engage regular
physical activity
because of -
Confidence a person
feels aboutperforming physical
activities was
increased.
- Benefit analysis of
physical activities
was increased .
- Cost analysis of
physical activities was
decreased.
- Can combine
physical activities into
lifestyle.
1.Physical activities
- Caloric expenditure
of at least moderate
physical activity level
was increase.
- Mean daily steps
was increase.
2. Physical fitness
- Six-minute walking
distance was increase.
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Scope of the Study
This study aimed to examine the effect of a Behavior Change Program on
physical activities (caloric expenditure of at least moderate physical activity level,
daily steps) and physical fitness (six-minute walking distance) of CABG patients
compared with usual care. The participants in this study were patients who received
CABG and were admitted to Center Chest Institute. The data were collected during the
months from May 2008 to May 2009.
Definitions of Terms
Physical activity was defined as any bodily movement produced by
skeletal muscles that results in energy expenditure (Caspersen, Powell, & Christenson,
1985). The physical activity in this study was moderate physical activities that were
measured by
- Caloric expenditure of at least moderate physical activity
level per week can be measured by the Community Health Activities Model Program
for Seniors Activities Questionnaire for Older Adults (CHAMPS)
- Daily steps can be measured by a Pedometer.
Physical fitnesswas defined as a set of attributes that are either related
health or skill. The degree to which people have these attributes can be measured
with specific tests (Caspersen et al., 1985). There are four components that include
cardiorespiratory fitness, muscular strength and muscular endurance, flexibility, and
body composition (ACSM, 2007; Wisan & Rapeepol, 2548). In this study, physical
fitness refers to six-minute walking distance that can be measured by the six-minute
walk test.
Behavior Change Program was defined as a program based on the
transtheoretical model and literature review of physical activity change for CABG
patients in the preparation stage (Prochaska et al., 2002 ; Wilson & Schlam, 2004).
This program includes self-efficacy overcoming barriers, environmental reevaluation,
stimulus control, reinforcement management, counter-conditioning, and self liberation.
Duration of the Behavior Change Program was seven weeks.
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Worarat Photi Introduction /10
Expected benefit of the research
1. The established program will be an effective nursing care to promote
physical activity behavior and to promote strengthening of physical fitness among
CABG patients who are in the preparation stage.
2. The strategies of the program will be a guideline for nurses in cardiac
units to implement for CABG patients who are in the preparation stage.
3. The findings will be preliminary knowledge for further study regarding
developing interventions appropriate for CABG patients in other stages of change and
patients with other diseases.
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CHAPTER II
LITERATURE REVIEW
The purpose of this study was to examine the effects of the Behavior
Change Program on physical activities (caloric expenditure of at least moderate
physical activity level and above, daily steps) and physical fitness (six-minute walking
distance) among coronary artery bypass graft (CABG) patients compared with
receiving usual care. This chapter presents a review of theoretical content and related
concepts of interest regarding three topics as follows:
1. Acute Coronary Syndromes.
1.1 Definition and pathophysiology
1.2 Risk factors
1.3 Coronary artery bypass graft surgery
1.4 Recovery processes
2. Physical activity and physical fitness in patients with coronary artery
bypass graft.
2.1. Definitionof physical activity and physical fitness
2.2.
Method for measure physical activity and physical fitness
2.3.
Benefit of physical activity
2.4.Physical activity and physical fitness of patients with
coronary artery bypass graft.
3.
Changing health behavior based on the Transtheoretical Model.
3.1.Basic concept of transtheoretical model
3.2.Application of the Transtheoretical model to Behavior
Change Program for patients with coronary artery bypass graft
3.3.Effects of a Behavior Change Program on physical activity
and physical fitness
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Worarat Photi Literature Review / 12
1. Acute Coronary Syndromes.
1.1 Definition and Pathophysiology
Acute Coronary Syndrome with ischemic heart disease is a condition
resulting from atherosclerotic plaque accumulating on the internal walls of coronary
arteries. Narrowing arteries lead to decreased blood flow to cardiac muscle. The initial
event in coronary atherosclerosis is endothelial injury. The factor most described is
hypercholesterolemia. Low-density lipoprotein (LDL) cholesterol diffuses into the
coronary arteries; once oxidized, it induces a severe inflammatory reaction leading to
endothelial dysfunction. This disturbs the balance between the vasodilator and
antiproliferative agent nitric oxide, and the vasoconstrictor agent endothelin. Release
of chemotactic and growth factors also occurs, and inflammatory cells are attracted to
the site of atherosclerosis. Oxidized LDL is taken up by macrophages, leading to the
development of a lipid core surrounded by smooth muscle cells and fibrous tissue,
forming the atherosclerotic plaque. The narrowing arteries lead to decreased blood
flow to cardiac muscle in the affected area, causing insufficient blood supply and
insufficient oxygenation. Thus, they are characterized by an imbalance between
myocardial oxygen supply and demand (Anderson, 2007; Libby & Theroux, 2005;
Wenger, Helmy, Patel & Lerakis, 2005).
1.2 Risk factors
The exact cause of atherosclerotic plaque is yet unknown. However, it has
been found that factors associated with coronary artery disease can be divided into two
types.
1.2.1Unmodified risk factors:
1.
Age: The progress of fatty streak and fibrous plaque
increases with age. The prevalence of fatty streaks in the coronary arteries increases
with age. Between the ages of 2 to 15 years of age, approximately 50 percent of people
already have fatty streaks, while from 21 to 39 years of age, 85 percent of people have
fatty streaks. (Berenson et.al., 1998). Platelet aggregation activities increase with age.
The lipid composition of the platelet membrane changes in people of higher age
causees artherosclerosis (Korkushko, Sarkisov, Lishnevskaya & Gorbach, 2000).
2.
Sex: Men develop this illness when they are 40 years oldand women develop it at 55 years of age. (Agingthai Institute, 2006). The prevalence
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of Acute Coronary Syndrome in premenopausal females is lower than for males;
however, the prevalence of Acute Coronary Syndrome in postmenopausal females is
higher than for males (Alberta & Ruskina, 2001). The average rate of progression of
subclinical atherosclerosis in postmenopausal women was lower in those taking
unopposed micronized 17b-estradiol (1 mg/d) group than in those taking the placebo
(-0.0017 mm/y vs 0.0036 mm/y ).The difference in average progression rates between
the placebo and estradiol groups was 0.0053 mm/y (Hodis et al., 2001).
3. Family history: Family history of myocardial infarction is
associated with thicker intima-media thickness (IMT). Persons with a family history of
myocardial infarction had significantly thicker intima-media thickness (IMT) than
persons with no family history (Stensland-Bugge, Bnaa & Joakimsen, 2001; Jerrard-
Dunne, et al., 2003) Positive family histories were independent predictors for redo
CABG(Odd ratio = 2.4) (Mennander et al., 2005).
1.2.2 Modified risky factors:
1. Hyperlipidemia: Fatty streak and fibrous plaque lesions in
the aorta and coronary vessels were associated with serum triglyceride
concentrations, and LDL cholesterol concentrations. (r = 0.50, 0.43 respectively)
(Berenson et al., 1998). The symptoms of inflammatoryprocesses emerge at the same
time asatherosclerotic plaques accumulating on the internal walls of coronary arteries
(Libby, Ridker & Maseri, 2002) whose processes were explained in the
pathophysiology of Acute Coronary Syndromes. A high serum triglyceride level (2
mmol/L) was an independent predictor for redo CABG and odd ratio was 1.6
(Mennander, Angervuori, Huhtala, Karhunen, Tarkka & Kuukasjarvi, 2005).
2.
Smoking: A history of smoking is associated withcoronaryartery and carotid artery disease (Ehtisham, Chimowitz, Furlan & Lafranchise, 2005).
The number of smokers increased in terms of the percentage of intimal surface
involved with fibrous plaques in the aorta (1.22% in smoker vs 0.12% in nonsmoker)
and fatty streaks in coronary vessels (8.27% in smoker vs 2.98% in nonsmoker)
(Berenson et al., 1998).
3.
Hypertension: Hypertension was associated withcoronary
artery and carotid disease (Ehtisham et al., 2005). The renin-angiotensin system
contributes to the pathogenesis of atherosclerosis. Angiotensin II may elicit
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inflammatory signals in vascular smooth muscle cells. The transcription factor NF-B
participates in most signaling pathways involved in inflammation (Altman, 2003).
4.
Diabetes: Diabetes is a state of increased plasma
coagulability (Mooradian, 2003). Diabetic patients have impaired endothelium-
dependent vasodilatation, hyper-coagulability, increased PAI-1 level in the arterial
wall with impaired fibrinolysis, decrease of endothelial nitric oxide synthase, and
increase of endothelin-1 (Altman, 2003). The study showed after a follow up of 7
years was done, that mortality in diabetic patients was higher than in non-diabetics
and for diabetic patients with no history of myocardial infarction (Haffner et al., as
cited in Altman, 2003).5.
Psychosocial: Systematic review demonstrated a moderate
association between depression, social support and psychosocial work characteristics
and CHD etiology and prognosis (Kuper, Marmot, & Hemingway, 2002). Anxiety and
depression were associated withthedevelopment of coronary artery disease (Januzzi,
Stern, Pasternak & DeSanctis, 2000). The mechanism was thought to be a reduction in
vagal tone and increase in susceptibility to ventricular fibrillation (Albert & Ruskina,
2001).
6.
Physical activity: When leisure-time physical activity
increased, the risk of Acute Coronary Syndromes (ACS) decreased. Leisure-time
physical activity was divided into four levels based on the frequency of physical
activity in the survey. There were I get practically no exercise at all, I exercise
occasionally, I exercise once or twice a week, and I exercise vigorously at least
twice a week. Persons who were physically active at least twice a week had a 41%
low risk of developing ACS more than those who performed no physical activity
(hazard ratio=0.59) (Sundquist, Qvist, Johansson & Sundquist, 2005). An energy
expenditure of about 1600 kcal or 6720 kJ per week has been found effective in
halting the progression of coronary artery disease, and an energy expenditure of about
2200 kcal or 9240 kJ per week had been shown associated with plaque reduction in
patients with heart disease (Franklin, Swain & Shephard, 2003; Warburton, Nicol &
Bredin, 2006). Persons who reported less than 30 minutes a week of physical activity
at baseline had a risk ratio concerning subsequent mortality compared with 30 or more
minutes of physical activity a week (2.82 vs 2.15) (Martinson, O'Connor& Pronk,
2001).
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1.3 Coronary artery bypass graft
Coronary artery bypass graft (CABG) surgery was indicated for patients
with Acute Coronary Syndromes to relieve symptoms, improve quality of life, and
prolong life. Coronary artery bypass was the construction of new pathways between
the aorta and coronary arteries beyond the obstructing lesion. Conduits used for
coronary artery bypass graft surgery were saphenous vein, internal mammary artery,
and radial artery. There were indications for CABG following ACC/AHA guidelines
(Anderson, 2007).
- Compelling anatomy, such as left main coronary artery disease (50%).
-
Multivessel disease with or without depressed ejection fraction.
- Two-vessel disease, proximal left anterior descending lesion with
depressed ejection fraction < 50%.
- Coronary artery disease does not respond to medical treatment.
Coronary artery bypass graft is a major surgery. During cardiopulmonary
bypass blood is circulated by a pump to other organs of the body independent of
physiologic control and non pulsatile flow. This allows surgeons to operate on a still,
bloodless field. During manipulation of the heart, changes in hemodynamic stability
may cause many complications.
1. Cardiovascular complication The majority of cardiovascular
complications were atrial fibrillation (AF). Atrial fibrillation occurs in 28.2% at 0 to
11 days after operation in patients who had CABG surgery (Zaman, 2000), and causes
longer lengths of stay.(Martin & Turkelson, 2006)
2. Renal complication The study by Stallwood, Grayson, Mills, & Scawn
(2004) revealed that 53 patients (2.4%) developed acute renal failure (ARF) followingCABG. Thirty-four patients (1.5%) developed ARF without requiring dialysis, while
19 patients (0.9%) who developed ARF required dialysis support. Acute renal failure
associated with effectiveness of cardiac output or hypotension. Therefore, renal
perfusion insufficiency. Cardiopulmonary bypass graft (CPB) represents a specific risk
factor (Martin & Turkelson, 2006). CPB results in reduced glomerular filtration rate,
reduced renal blood flow, and redistribution of blood flow from the cortex to the outer
medulla(Young & Dai, 2000).
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3. Respiratory complication. Pulmonary complications were among the
most frequently reported complications and occur in 33% of patients after coronary
artery bypass graft (CABG) surgery (Hulzebos, 2003). Pulmonary complications result
from cardiopulmonary bypass graft, length of surgery, resultant increase in the amount
of needed anesthetic agents, and pain (Martin & Turkelson, 2006).
4. Neuropsychological complication Patients who require coronary artery
bypass surgery are at an increased risk for neurological complications (Ganushchak,
Fransen, Visser, JongJos, & Maessen, 2004) Stroke can be caused by hypotension or an
embolic event during or after surgery. Manipulation of the aorta has been implicated in
embolic events (Engstrom, 2003). Most patients have confusion or unconsciousness
(Martin & Turkelson, 2006).
5. Gastrointestinal complication. The range of gastrointestinal
complication occurrence was 0.12 to 2%. Complications included peptic ulcer,
perforated ulcer, pancreatitis, acute cholecystitis, bowel ischemia, diverticulitis, and
liver dysfunction. The nurse should monitor the patients bowel sounds, abdominal
distention, nausea, and vomiting. The intubated patient will have a nasogastric tube.
Placement and patency should be assessed as well as amount, color, and characteristics
of the drainage(Martin & Turkelson, 2006).
6. Pain The pain experienced by patients who receive coronary artery bypass
surgery results from tissue injury (nociceptive pain). The patient may have a median
sternotomy incision, leg incision, and radial incision. Manipulation of the chest cavity, use
of retractors during surgery, and electrocautery may all contribute to post-operative pain.
Other sources of pain include the removal of the chest tubes. This usually occurs 24 to 48
hours after operation (Martin & Turkelson, 2006).
7. Wound infection The incidence of infection of sternal and leg
incisions after cardiac surgery was less than 3% (Martin & Turkelson, 2006).
1.4 Recovery in coronary artery bypass graft patients.
Recovery from an illness or surgery to normal life is a dynamic process
encompassing both biophysical and psychosocial components. Patients who received
coronary artery bypass graft had lower recovery before the operation and this
increased after the operation. Recovery at discharge was the lowest, then gradually
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increased at 6 months after CABG (Lopeza, Yingb, Poonc & Wai, 2007). Autonomic
cardiovascular function including respiratory sinus arrhythmia, valsalva maneuver,
respiratory function and heart rate variability reached the lowest level 3-6 days after
surgery, returning to pre-surgery values at about 30-60 days postoperatively (Soares,
Moreno, Cravo & Nobrega, 2005). Mean energy expenditure after the operation was
28.87, 28.69, and 31.69 kcal/kg/day at 3, 6, and 12 months respectively. This study
showed that since 3 months after coronary artery bypass graft surgery, patients can
tolerate moderate physical activity (Barnason, et al., 2000). Psychological recovery
and depression levels increased or were stable at 1 week, then gradually decreased in
the 3rdand 6th month (Lopeza et al., 2007). Depression levels were the highest in pre
operation then gradually significantly decreased during the hospital stay, discharge,
and 6 weeks were the lowest respectively (Doering, Moser, Lemankiewicz, Luper &
Khan, 2005). The quality of life related to physical health, role-physical, social, bodily
pain, mental, vitality, and general health was the lowest in pre operation, then
gradually increased in the 3rdand 6thmonth respectively (Barnason et al., 2000).
Recovery of patients who received coronary artery bypass graft surgery
differed. Risk factors associated with recovery were as follows:
1.
Age: Older patients had low functional capacity compared
to younger patients (Pierson et al., 2003).
2. Sex: Men had higher physical functioning (Treat-Jacobson
& Lindquist, 2004), and functional capacity when compared to women (Pierson et al.,
2003). Women had more physical symptoms and side effects, including unstable
angina, congestive heart failure, and depressive symptoms in the six to eight weeks
after CABG surgery when compared to men (Vaccarino et al., 2003).3. Depression: Postoperative depression has effects on
recovery from coronary artery bypass graft surgery. At discharge, patients with higher
depression reported poorer emotional health with physical recovery and achieved
shorter walking distances compared to patients with lower depression. Moreover, in
post CABG patients, higher depression was found to be associated with increased
infection, and impaired wound healing (Doering, Moser, Lemankiewicz, Luper &
Khan, 2005).
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4. Pain: Moreover, patients reported that they stayed in the
hospital with the longest period and experienced the most pain (Sarpy, Galbraith &
Jones, 2000).
5. Exercise: The study showed that patients who participated
in regular exercise had higher functional status (Treat-Jacobson & Lindquist, 2004)
and functional capacity than patients who did not participate in regular exercise
(Pierson et al., 2003).
2. Physical activity and Physical fitness of coronary artery bypass
graft surgery patients
2.1 Definitions of physical activity and physical fitness
Physical activity was defined as any bodily movement produced by
skeletal muscles that results in energy expenditure. The energy expenditure can be
measured in kilocalories. Physical activity in daily life can be categorized into
occupational, sports, conditioning, household, or other activities (Caspersen, Powell &
Christenson, 1985). ACSM/AHA developed a new protocol to promote health
through an accessible exercise program. The recommended minimum was moderate
physical activities consuming about 3-6 METs 30 minutes of continued physical
activity or the sum of at least 30 min of intermittent exercise, five days per week or
vigorous-intensity 20 minutes per day, three days per week. Moderate and vigorous
intensity activities were complementary in the production of health benefits and a
variety of activities can be combined to meet 450-750 METs per week (Haskell,
2007).
Exercise was defined as a subset of physical activity that was planned,
structured, and repetitive and had as a final or an intermediate objective, the
improvement or maintenance of physical fitness (Caspersen et al.,1985).
Physical fitness was defined as a set of attributes that were either
related health or skill. The degree to which people have these attributes can be
measured with specific tests (Caspersen et al.,1985). There were four components
which were cardiorespiratory fitness, muscular strength and muscular endurance,
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flexibility, and body composition (ACSM, 2007; Kantarattanakool & Koonchon Na
Ayutthaya, 2005).
1.
Cardiorespiratory fitness
Cardiorespiratory fitness was aerobic fitness or aerobic
endurance related to the ability of performing large muscle, dynamic, moderate to high
intensity exercise for prolonged periods. Maximal oxygen uptake (VO2max) was
accepted as the criterion measure of cardiorespiratory fitness. Maximal oxygen uptake
is the product of maximal cardiac output and arterial-venous oxygen difference. Direct
measurement of VO2max was not feasible or desirable, so a variety of submaximal and
maximal exercise tests can be used to estimate VO2max (ACSM, 2007). Aerobic
fitness or aerobic endurance was measured by oxygen use per 1 kilogram per min
(ml/kg/min)or metabolic equivalent task [MET]. The mean of maximum ventilatory
oxygen comsumption (VO2 max) in males and females was 12 and 10 METs
respectively (Kantarattanakool & Koonchon Na Ayutthaya, 2005).
2. Muscular strength and muscular endurance
Muscular strength and muscular endurance are the ability of
the muscle to exert force and the muscles ability to continue to perform for successive
exertions or many repetitions. Muscular strength and muscular endurance are health-
related fitness that prevent coronary artery disease, prevent osteoporosis, control type
2 diabetes, lower risk of injury, and promote weight management (Kantarattanakool &
Koonchon Na Ayutthaya, 2005).
3. Flexibility
Flexibility is the ability to move a joint through its complete
range of motion. It is important for athletic performance and the ability to carry out theactivities of daily life. Flexibility depends on a number of specific variables, including
distensibility of the joint capsule, adequate warm-up, and muscle viscosity.
Complicance of various other tissues affects the range of motion (Kantarattanakool &
Koonchon Na Ayutthaya, 2005).
4. Body composition
It is well established that excessive fat body is associated with
hypertension, type 2 diabetes, coronary heart disease, stroke, and hyperlipidemia.The
basic body composition can be expressed as the relative percentage of body mass that
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is fat and fat-free tissue using a two-compartment model. Body composition can be
estimated by both laboratory and field technique that vary in terms of complexity,
cost, and accuracy. The examples for estimated body composition are the
anthropometric method, body mass index, circumference, skinfold measurements, and
densitometry etc.
The indispensable components are cardiorespiratory fitness or aerobic
fitness. These components measure submaximal exercise capacity by various methods.
The literature review showed that the six minute walk test has been used to evaluate
cardiorespiratory fitness within programs for exercise or physical activity
enhancement in coronary artery disease (Jonsdottira, et al., 2006; Solway, Brooks,
Lacesse & Thomas, 2001; Wright, Khan, Gossage & Saltissi, 2001; Kawchareanta,
2003; Intaratool, 2005). Even though the test was considered submaximal, it may
result in near maximal performance for those with low fitness levels or disease.
Several multivariate equations are available to predict peak oxygen consumption from
the 6 minute walk test (Kantarattanakool, 2005; ACSM, 2007).
2.2 Physical activity and physical fitness measurements.
2.2.1 Physical activity measurements.
There are varieties of methods available to measure physical
activity such as self-report, behavioral observation, and electronic monitors (Laporte,
Monotoyee, & Caspersen, 1985). Self-report methods are self-administered or
interviewer-administered recall questionnaires, activity logs, diaries, or proxy reports.
Physical activity can be measured in terms of type, intensity, duration, and frequency.
The data from self-report questionnaires are calculated to reflect the rate of energyexpenditure during physical activity. Physical activity levels are generally expressed in
METS. Self-report measures of physical activity have been widely used in survey
studies (Brownson, Eyler, King, Brown, Shyu, & Sallis, 2000) and intervention studies
(Allison, & Keller, 2000).
A literature review demonstrated exercise self-report is needed to assess
frequency, intensity, and duration of physical activity to define the dose-response
association between physical activity and health outcomes (Sallis, & Saelen, 2000). In
this study, physical activity was measured using the Community Healthy Activities
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Model Program for Seniors Activities Questionnaire for Older Adults (CHAMPS).
The CHAMPS questionnaire was developed in 2001 for use with older adults . This
questionnaire was translated into Thai language by using a back-translation processes
and evaluated in terms of content validity by Wanitkun(2003). Construct validity of
the relationship between caloric expenditure computed from a list of activities of
CHAMPS was measured, and intention to exercise was assessed by the Exercise
Stages of Change. There were significant differences in caloric expenditure during all
physical activities (F4396=13.41,p< 0.001) and those engaging in moderate to vigorous
physical activities (F4360= 17.81, p < 0.001) among the 5 stages.
The CHAMPS questionnaire was composed of 39 items. There were 37
items for assessing intensity, frequency, and duration of activities. Three questions
were asked regarding each activity: was the activity done? Yes/No if yes, two
questions of frequency and duration were asked. There was one item for other
activities and 1 item for recheck. The exact number or frequency of a particular
activity was reported. All physical activities were reported into frequency per week
and estimated caloric expenditure per week of physical activity (Stewart, et al., 2001).
However, there was also a method for evaluating physical activity which used a
pedometer.
Pedometers objectively measure ambulatory activities throughout the day
in the form of step counts. They are tools for monitoring and motivation in physical
activity interventions. Pedometers are easy to use and relatively inexpensive compared
with other motion sensors. The pedometer has been applied to motivate physical
activities in adults (Stovitz, VanWormer, Center, & Bremer, 2005), older (Wellman,
Kamp, Kirk-Sanchez, & Johnson, 2007), and type 2 diabetes patients (Tudor-Locke,Myers, Bell, Harrisd, & Rodgere, 2002). Moreover, the pedometer has been applied to
measurement of physical activities in a community sample of working women (Speck,
& Looney, 2001), and men and women aged 2574 years (Sequeira, Rickenbach,
Wietlisbach, Tullen, & Schutz, 1995).
2.2.2 Physical fitness measurements.
Physical fitness was measured from the six minutes walk test
[6MWT]. The objective of the six minutes walk test was to cover the greatest distance
in the period lasting six minutes. VO2max could be estimated from the equation. The
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six minutes walk test has been used to evaluate cardiorespiratory fitness within some
clinical patients such as those with congestive heart failure and pulmonary disease. It
has also been widely used for preoperative and postoperative evaluation and for
measuring the response to therapeutic interventions for pulmonary and cardiac disease.
The distance of one meter walk was measured by using oxygen 0.1 ml per body
weigh 1 kilogram. The method for administering the six minute walk test was as
follows: (American Thoracic Society, 2002).
1. Prepare the equipment and location for six minute walk
test. The equipment included a countdown timer, a chair that can be easily moved
along the walking course, mechanical lap counter, worksheet on a clipboard, a source
of oxygen, sphygmomanometer, telephone, automated electronic defribrillator. Thelocation was indoor, along a long, flat, straight course. The walking course must be 30
meters in length. A 100 fit hallway is, therefore, required. The length of the corridor
should be marked every 3 meters.
2. The patient should sit to rest on a chair, located near the
starting position for at least 10 minutes before the test starts. During this time, check
for contraindications, measure pulse and blood pressure, and make sure that clothing
and shoes are appropriate. Pulse oximetry is optional. If it is performed, measure and
record baseline heart rate and oxygen saturation.
3. Instruct the patient about objects and methods of this test.
4. Set the lap counter to zero and the timer to six minutes.
Move to the starting point where the patient is waiting to start. You should also stand
near the starting line during the test. Do not walk with the patients.
5. Do not talk to anyone during the walk. Each minute, tell
the patients the following You are doing well. You have minutes to go
6. For the post test, measure vital signs and oxygen
saturation.
7. Record the additional distance covered (the number of
meters in the final partial lap) using the markers on the wall as distance guides.
Calculate the total walking distance, rounding to the nearest meter, and record it on the
worksheet.
2.3 Benefit of physical activity
Physical activity has been classified using the MET intensity as follows:
light(< 3 METs), moderate(3-6 METs), and vigorous (> 6 METs) (Ainsworth, 2000).
Regular exercise has both direct and indirect beneficial effects on the severity for coronary
atherosclerosis and recovery after an operation.
2.3.1 Antiatherogenic effect. Physical activity was associated
with less severe CAD, larger coronary luminal diameters, and reduced progression of
atherosclerosis. These beneficial effects seem to be due to the attenuation of coexisting
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risk factors by exercise. These include the following reduction of adiposity,
particularly in those with excessive upper body and abdominal fat, elevated plasma
triglycerides, with an increase in HDL cholesterol levels and Improvement in insulin
sensitivity and glucose use and reduction in risk of type 2 of diabetes.
2.3.2 Antithrombotic effect. Exercise training favorably
affects this process, in particular the fibrinolytic system. Exercise for six months in
healthy older patients resulted in a significant improvement in hemostatic indices, with
a reduction in plasma fibrinogen levels, an increase in mean tissue plasminogen
activator, an increase in active tissue plasminogen activator, and a reduction of
plasminogen activator inhibitor. Short and long term exercise affects platelet
activation. Platelet activation is important for the pathophysiological mechanisms of
unstable coronary syndrome and acute MI. Short-term exercise can lead to increased
platelet activity, and long-term exercise may abolish or reduce this response.
2.3.3 Endothelial function. The vascular endothelium plays
an important role in the regulation of arterial tone and local platelet aggregation, in
part through the release of endothelium-derived relaxing factors, that prevent coronary
artery disease. Emerging evidence suggests that aerobic exercise improves endothelial
function.
2.3.4 Autonomic Function. The balance between sympathetic
and parasympathetic activity modulates cardiovascular activity. In coronary artery
disease was found over sympathetic nervous system that associated heart disease
(Fletcher, et al., 200; Kantarattanakool & Koonchon Na Ayutthaya, 2005). Exercise
training is associated with a relative enhancement of vagal tone, improved heart rate
recovery after exercise, and reduced morbidity in patients with cardiovascular disease(Rosenwinkel, Bloomfield, Arwady, & Goldsmith, 2001). Long-term endurance
training significantly influences how the autonomic nervous system controls heart
function. Endurance training increases parasympathetic activity and decreases
sympathetic activity in the human heart at rest (Carter, Banister, & Blaber, 2003).
2.3.5 Anti-Ischemic Effects. There were a number of
mechanisms by which endurance exercise training may improve the relative balance
between myocardial oxygen supply and demand and thereby result in an anti-ischemic
effect. Increased metabolic capacity and improved mechanical performance of the
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who engaged in regular exercise had a higher functional status (Treat-Jacobson &
Lindquist, 2004) and a higher functional capacity higher when compared to persons
who did not exercise (Pierson et al., 2003).
2.4 Physical activities and physical fitness of patients who received
coronary artery bypass surgery after discharge.
Patients who received coronary artery bypass surgery after discharge can
start physical activity as follows: (Kantarattanakool & Koonchon Na Ayutthaya,
2005):
Table 1 Physical Activity for Patients Received coronary Artery Bypass Graft
Surgery
Week Activities
First week - Do light work around the house (such as sweeping, or feeding pet)
- Walk leisurely for exercise or pleasure 5 minutes, two time per day
Second
week
- Walk leisurely for exercise or pleasure 10 minutes, two time per day
- Do light work around the house(such as dish washing, preparing
food or cooking)
- Do light gardening (such as watering plants)
- Lift less 3 kilogram
Third week - Walk leisurely for exercise or pleasure 15-20 minutes, two time
per day
- Do light work around the house
- Do light work around the house, laundry by washing machine ,
preparing food or cooking
- Do light gardening
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Table 1 Physical Activity for Patients Received coronary Artery Bypass Graft
Surgery (Continue).
Week Activities
Fourth week - Walk fast or briskly for exercise 20-25 minutes, two time per day
- Do light work around the house
- Do light gardening
Fifth to
sixth week
- shopping, sweep leaves
- Ride a bicycle (general)
- Lift 3-5 kilogram 3-5 kilogram
- Walk fast or briskly for exercise 25-30 minutes, one to two time
per day
Sixth to
twelve week
- gardening, planting, digging sandbox
- Home activities (such as washing windows, cleaning gutters or
scrubbing floors inside home)
- Activities about lawn and garden (such as digging, spading, raking)
- Walk fast or briskly for exercise least 30 minutes, one to two time
per day
Cardiorespiratory fitness was a part of physical fitness evaluated for
patients who received coronary artery bypass surgery. Cardiorespiratory fitness was
measured from the six minute walk test (Jonsdottira, et al., 2006; Solway, Brooks,
Lacesse & Thomas, 2001; Wright, Khan, Gossage & Saltissi, 2001; Kawchareanta,
2003; Intaratool, 2005). Results of the six minute walk test were measured 1-2 days
before discharge.
3. Effects of Behavior Change Program based on Transtheoretical
Model on physical activity and physical fitness
3.1 Transtheoretical Model and applied to behavioral change.
The transtheoretical model developed in 1970 to 1980 emerged from a
comparative analysis of leading theories of psychotherapy and behavioral change.
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Based on the transtheoretical model, individuals in each stage use various unique
combinations of strategies or processes to aid them in changing their behavior. The
strengths of the transtheoretical model were sensitivity to level of readiness,
incremental change over time, and specific interventions for each stage. Moreover,
behavior change was a dynamic processes that occurred either progressively or in a
relapsing pattern. These theories consist of various stages of change, processes of
change, decisional balance, and self-efficacy for overcoming barriers (Prochaska,
Redding & Evers, 2002; Wanitkun, 2005).
3.1.1 Stages of Change: SC
The stage construct was important because it represents a
temporal dimension. The Transtheoretical Model construes change as a process-
involving progress through a series of six stages (Prochaska, Redding & Evers, 2002)
- Precontemplation is the stage in which the person does not
intend to change according to the recommended behavior, usually measured as the
next six months. A person may be in this stage because they were uninformed or under
informed about the consequences of their behavior, they may have tried to change a
number of times and became demoralized about their abilities to change. Both groups
tend to avoid information, talking, or thinking about their high-risk behaviors.
- Contemplation is the stage in which persons intend to
change within the next six months. They start to recognize that it is necessary to
change, and are aware of the pros of changing but also acutely aware of the cons. This
group is not ready for traditional action-oriented programs. They need more support
regarding motivation and self-confidence in order to move to action, and they have not
made a commitment to take action yet.- Preparation is the stage in which persons intend to take
action within a month. They have participated in some exercise, but have not met the
criteria yet. This group has a plan of action such as talking to their physician, joining a
health education class, consulting a counselor, buying a self-help book, or relying on a
self-change approach.
- Action is the stage where the person has obviously modified
his/her behavior within the past six months. He/she has regularly exercised but less
than 6 month; therefore, relapse might happen in this group.
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- Maintenance is the stage in which the person has been
exercising regularly for more than six months. They are less tempted to relapse and
increasingly more confident that they can continue their changes.
- Termination is the stage in which persons have no
temptation to engage in a sedentary lifestyle and have full self-efficacy for engaging in
regular exercise for more than 5 years.They are sure they will not return to their old
unhealthy behavior as a way of coping.
Persons in different stages of change have different behaviors. A
comparison of lifestyle between the precontemplation stage and the action stage
showed that persons in the action stage had significantly higher exercise, vegetable
and fruit consumption compared to the person in the precontemplation stage. While
persons in the action stage had significantly lower smoking and alcohol consumption
when compared to persons in the precontemplation stage (Lam, et al., 2006).
3.1.2 Decisional balance
The decisional balance concept is comprised of a cost-benefit
analysis of a behavior change at that time, derived from Janis and Manns (1977)
model decision making. The original version includes four categories of pros
(instrumental gains for self and for others and approval from self and from others ), and
four categories of cons (instrumental costs to self and to others and disapproval from
self and from others)(Prochaska, Redding & Evers, 2002; Wanitkun, 2005). From the
literature review, it was found that eventually only the Pros and Cons subscales were
used, and many studies confirm two factors of decisional balance (Prochaska, Redding
& Evers, 2002; Wanitkun, 2005).
The study indicated that pros scores were lower during the
precontemplation and contemplation stages compared to the action and maintenance
stages, while cons scores were higher during the precontemplation and contemplation
stages compared to the action and maintenance stages (Kim, 2007).
3.1.3 Self-efficacy
Self-efficacy was derived from Banduras Social Cognitvie
theory (1997). Self-efficacy is the situation-specific confidence that people have that
they can cope with high-risk situations without relapsing to their unhealthy or high-
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risk behaviors. The method for increasing self-efficacy was information, including
enactive mastery experience, vicarious experience, verbal persuasion, and physiological
and affective states. Self-efficacy for overcoming barriers to exercise is the
confidence a person feels about performing physical activities. (Bandura,1997).
Persons with higher self-efficacy maintained physical activity levels, perceived less
effort in doing physical activity, and reported more positive effects from physical
activities ( Prochaska, Redding & Evers, 2002; Wanitkun, 2005).
There were six barriers of physical activity that
included negative effects, which were excuse making, exercising alone, inconvenient
to exercise, resistance from others, and bad weather. The study indicated that self-
efficacy increased during the precontemplation and to the action and maintenance
stages (Wanitkun, 2003; Kim, 2007).
3.1.4 Processes of change
Processes of change were the process that persons use to
progress through the different stages of change, and provide important guides for
intervention programs (Prochaska, Redding & Evers, 2002). The processes were also
categorized into two factors: experiental and behavioral processes.
The experiental processes were as follows:
- Consciousness raising increased awareness about causes,
consequence, and cures for details of behavioral problems. The person attempted to
seek new information and gain understanding and feedback about the problem.
- Self-reevaluation was combined both emotional and cognitive
assessments of values by persons with respect to the unhealthy behavior.- Environmental Reevaluation was consideration and assessment
by persons of how the problem affects the social environments and physics.
- Social Liberation was awareness, and acceptance by
persons of alternative, and problem-free life styles in the society.
- Dramatic relief was initially produced and increased
emotional experiences occurred, often involving intense emotional experiences related
to the problem behavior.
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The behavioral processes were as follows:
- Counter-condition was alternative behaviors for the
unhealthy behavior.
- Helping Relationship was combined with trusting, accepting,
caring, and utilizing the support during attempts to change the unhealthy behavior.
- Reinforcement Management was provided rewards for
controlling or maintaining the healthy behavior.
- Self-liberation was the persons choice, commitment and
recommitment to change the behavioral problems.
-
Stimulus Control was control of causes that trigger the
behavioral problem, including removal of cues for unhealthy habits and addition of
prompts for healthier alternatives.
Using the processes of change differentiated at different stages
of exercise behavior. There were significantly differences in conscious raising, self
revaluation, counter-conditioning, helping relationship, stimulus control,and
reinforcement management across the stage of change(Kim, 2007). The study of
Tseng (2003) showed scores for self-reevaluation, self-liberation, and counter-
conditioning increased from the pre-contemplation stage to the preparation stage and
from the preparation stage to the maintenance stage. However, consciousness raising,
social liberation, reforcement management, and helping relationships should be used
for earlier stages (precontemplation stage to preparation stage). In contrast, dramatic
relief, environment reevaluation and stimulus control should be used for later stages
(preparation stage to stagemaintenance) (Tseng, Jaw, Lin & Ho, 2003).
The Transtheoretical model has been applied successfully in behavior
change for people, including smokers (Narkarat, 1997), children, teens, senior
citizens, work sites, medical patients (Spencer, Malone, Roy & Yost, 2006), obese
women (Dallow & Anderson, 2003) menopausal women (Chitima, 2003) adults,
sedentary adults, women (Adams & White, 2003) diabetes patients (Jackson,
Asimakopoulou & Scammell, 2007; Kim, Hwang & Yoo, 2004)) and cardiac
rehabilitation patients (McKee, Bannon, Kerins & FitzGerald, 2006).
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The study by Spencer, Malone, Roy & Yost (2006) demonstrated
application of the Transtheoretical model in exercise behavioral programs for children,
teens, senior citizens, medical patients, sedentary adults, and obese women, and a
range of intervention programs lasting from about 2 weeks to 2 years. Stage matched
interventions appear to be effective in promoting exercise (Spencer, Malone, Roy &
Yost, 2006). Adams & White (2003) studied 16 intervention programs for
adults.These programs had a time range of about 1 time to 2 years. This study revealed
that stage matched interventions based on the Transtheoretical model are more
effective than non-stage matched interventions (Adams & White, 2003).
The Transtheoretical model has been applied in behavior change for
medical patients. Kim, Hwangb & Yoo (2004) evaluated a stage-matched intervention
(SMI) for promoting exercise in Korean patients with type 2 diabetes, and the range of
intervention programs was 12 weeks. This study found the stage of change in the
intervention groups increased, whereas that of the control group did not change.
Physical activity levels in the intervention group increase (+14.78 METs x h/week),
whereas the control group did not change significantly (+0.39 METs x h/week). In the
intervention group FBS and HbA1C decreased (-17.18 mg/dl, , and -0.88%respective),
whereas in the control group FBS and HbA1C increased (+10.61 mg/dl, and +0.41%
respective) (Kim, Hwangb & Yoo, 2004). Jackson, Asimakopoulou & Scammell
(2007) studied the effects of a program to promote physical activity based on the
Transtheoretical model in 34 patients with type 2 diabetes. The intervention group
received a physical activity leaflet and one by one interview with a dietitian a week
after their routine appointment, and measuredtheir physical activity level at baseline
and after 6 weeks. This study showed that physical activity levels in the interventiongroup were greater than in the control group (Jackson, Asimakopoulou & Scammell,
2007).
Additionally, the transtheoretical model has been applied in behavior
change for coronary artery disease patients. McKee, Bannon, Kerins & FitzGerald
(2006) studied the effects of the Behavior Change Program. The program was used for
patients with coronary artery disease. The program undertook phase III of cardiac
rehabilitation for the patients, and lasted for 14 weeks. This program demonstrated that
there were significant improvements in the stage of change by the end of the program
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and over the next six months when compared to patients before entering the program
(McKee, Bannon, Kerins & FitzGerald, 2006).
Chitima (2003) studied an exercise program for menopausal women in
Chiang-Mai province. The range of the intervention was eight weeks. They compared
caloric expenditure, knowledge, exercising behavior, HDL level, and LDL, VO2 max
between pre and post exercise program. They found that after participants received
the exercise program, they had significantly higher mean scores than prior to
participating in the exercise program. Sittipreechachan (2005) studied the effect of the
Trantheoretical model application on low back pain prevention among workers in
sanitary production factories. The intervention lasted for 12 weeks. In comparing
knowledge about preventing low back pain pre and post intervention in the
intervention group and control groups, they found that after participants received the
intervention they had significantly higher mean scores than before receiving the
intervention. Moreover, they found that following the intervention, the participants in
intervention group had significantly higher knowledge about preventing low back pain
than those in the control group. Narkarat, (1997) studied the effects of a smoking
Behavior Change Program on smoking in middle school students. The length of
intervention was 10 weeks. When comparing attitude, perceived risks and effect of
smoking, and smoking behavior between pre and post smoking Behavior Change
Program, researchers found that those in the intervention group had significantly
higher attitude, perceived risks and effects of smoking, and outsmoking behavior than
before receiving the smoking Behavior Change Program. The students in the
intervention group also had higher significantly higher attitude, perceived risks and
effects of smoking, and rate of outsmoking behavior than those in the control group.However, there are few studies that look at how to promote exercise in persons with
chronic disease by using this framework in Thailand.
3.2 Application of transtheoretical model to Behavior Change
Program for CABG patients
Thestage matched intervention for behavioral change that is based on the
Transtheoretical model is more effective than a non-staged intervention (Adams &
White, 2003). The Transtheoretical model has been applied in behavior change for
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people who have a readiness for change. Theprocesses of change used for behavior
change in the preparation stage were self liberation with choices and commitment to
change. It was believed that one can change and tell other persons (Prochaska,
Redding & Evers, 2002; Tseng, Jaw, Lin & Ho, 2003).Kim, Hwangb & Yoo (2004)
studied the use of processes of change for behavioral change in older persons. This
study showed that participants used self-reevaluation, counter-conditioning,
environmental reevaluation processes during pre-contemplation to preparation, and
preparation to action. While environmental reevaluation and stimulus control
processes were used during preparation to action (Tseng, Jaw, Lin & Ho, 2003),
decisional balance and self efficacy were used to develop the exercising program for
Korean participants with type 2 diabetes. This study revealed that the intervention
group compared to the control group showed significant improvements in stages of
change for exercising behavior, physical activity levels, and reductions in FBS and
HbA1c (Kim, Hwangb & Yoo, 2004).
Marcus, et al.(2007) studied delivery channels, telephone, print and
control, to determine whether one was more effective in promoting physical activities.
At six months, both telephone and print arms significantly increased in minutes of
moderate intense physical activities compared with the control arm, with no
differences between the telephone and print arms. At 12 months, the number of
moderate intensity minutes of physical activity for the print participants was
significantly higher than for both telephone and control participants (Marcus, et al,
2007).
The literature review concerning methods of intervention included
telephone, computer, and print-based materials, including brochures, posters, reports,manuals. Most interventions incorporated more than one method of delivery (Spencer,
Malone, Roy & Yost, 2006). Exercising Behavior Change Programs ranged in length
from 1 session to 2 years (Conn, Minor, Burks, Rantz & Pomeroy, 2003). The
majority of developed programs for behavioral change based on the transtheoretical
model had a range of 2 weeks to 2 years (Spencer, Malone, Roy & Yost, 2006).
Criteria for diagnosis of unstable angina were based on the duration and
intensity of angina as graded according to The Canadian Cardiovascular Society
Grading Scale(Anderson, 2007)
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Class 1 Ordinary physical activity does not cause. Angina occurs with
strenuous, rapid, or prolonged exertion at work or recreation.
Class 2 Slight limitation of ordinary activity. Angina occurs on walking
or climbing stairs rapidly walking uphill; walking or stair climbing after meal; in cold,
in wind, or under emotional stress; or only during the few hours after awakening.
Angina occurs on walking more than 2 blocks on the level and climbing more than 1
flight of ordinary stairs at a normal pace and under normal conditions.
Class 3 Marked limitations of ordinary physical activity. Angina occurs
on walking 1 to 2 blocks on the level and climbing 1 flight of stairs under normal
condition and at a normal pace.
Class 4 Inability to carry on any physical activity without discomfort.
Angina symptoms may be present at rest.
Cardiac patients may be further stratified regarding safety during exercise
using published guidelines (AACVRP, 2003). Risk stratification criteria from the
AACVPR were presented following:
1. Characteristics of patients at high risk for exercise participation.
1.1 Presence of complex ventricular dysrhythmias during
exercise testing or recovery.
1.2 Presence of angina or other significant symptoms.
1.3
High level of silent ischemia (ST depression 2 mm)
during exercise testing or recovery.
1.4 Presence of abnormal hemodynamics with exercise testing
or recovery.
1.5
Ejection fraction < 40%.
1.6 History of cardiac arrest or sudden death.
1.7 Complex dysrhythmias at rest.
1.8
Complicated myocardial infarction or revascularization
procedure.
1.9
Presence of congestive heart failure.
1.10Presence of signs or symptoms of post event/ post
procedure ischemia.
1.11Presence of clinical depression.
2. Characteristics of patients at moderate risk for exercise participation
2.1
Presence of angina or other significant symptoms2.2
Mild to moderate level of silent ischemia during exercise
testing or recovery (ST segment depression < 2 mm from baseline)
2.3 Functional capacity < 5 METs
2.4 Rest ejection fraction 40% to 49%
3. Characteristics of patients at lower risk for exercise participation
3.1 Absence of complex ventricular dysrhythmias during
exercise testing and recovery
3.2 Absence of angina or other significant symptoms
3.3 Presence of normal hemodynamics during exercise testing
and recovery
3.4
Functional capacity 7 METs3.5 Resting ejection fraction 50%
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3.6 Uncomplicated myocardial infarction or revascularization
procedure
3.7
Absence of complicated ventricular dysrhythmias at rest
3.8
Absence of congestive heart failure
3.9
Absence of signs or symptoms of posteven/postprocedure
ischemia
3.10Absence of clinical depression.
3.3 Effects of Behavior Change Program on physical activity and
physical fitness.
Programs for persons in the preparation stage included substitution of
alternative behaviors for the problem behavior (counter-conditioning), consideration
and assessment by the person of how the problem affects the social environments and
physics (environmental reevaluation) (Tseng, Jaw, Lin, & Ho, 2003), the persons
choice, commitment and recommitment to change the behavioral problems (self
liberation) (Prochaska, Redding, & Evers, 2002; Tseng, Jaw, Lin, & Ho, 2003),
control of situations and other causes that trigger the problem behavior(stimulus
control), prov