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The Process of Patient Engagement in Outpatient Cardiac Rehabilitation Programs

  • Sepideh Jahandideh (a1), Elizabeth Kendall (a2), Samantha Low-Choy (a3), Kenneth Donald (a4), Rohan Jayasinghe (a5) and Ebrahim Barzegari (a6)...


The primary aim of this study was to test the causal structure of the model of therapeutic engagement (MTE) for the first time, to examine whether the model assists in understanding the process of patient engagement in cardiac rehabilitation (CR) programs. This study used a prospective design, following up patients from the Gold Coast University Hospital Cardiology ward who attended Robina Cardiac Rehabilitation Clinic. A structural equation model of the interactions among the proposed variables within the three stages of the MTE (intention to engage in CR programs, CR initiation, and sustained engagement) revealed significant relationships among these variables in a dataset of 101 patients who attended a CR program. However, no relationship was discerned between outcome expectancies and patient intention to engage in CR. Patients’ willingness to consider the treatment also mediated the relationship between perceived self-efficacy and patient intention to engage in CR. These findings help clarify the process proposed by Lequerica and Kortte (2010) in the context of patient engagement in CR programs. The findings also reveal information on how patients engage in CR programs. Importantly, this provides new information for healthcare providers, enabling them to more effectively engage patients according to their stage of engagement.


Corresponding author

*Corresponding author: Sepideh Jahandideh, Human Services and Social Work, School of Medicine and Menzies Health Institute Queensland, Gold Coast Campus, Griffith University QLD 4222, Australia. Email:


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Alexander, JL and Wagner, CL (2006). How cardiac rehabilitation relates to quality of life. Rehabilitation Nursing, 31, 155157.
Anderson, L, Oldridge, N, Thompson, DR, Zwisler, A-D, Rees, K, Martin, N and Taylor, RS (2016). Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. Journal of the American College of Cardiology, 67, 112.
Araya-Ramírez, F, Briggs, KK, Bishop, SR, Miller, CE, Moncada-Jiménez, J and Grandjean, PW (2010). Who is likely to benefit from phase II cardiac rehabilitation? Journal of Cardiopulmonary Rehabilitation and Prevention, 30, 93100.
Arbuckle, JL (2012). IBM SPSS Amos 21 user's guide. Chicago, IL: IBM.
Arbuckle, JL and Wothke, W (1999). Amos 4.0 user's guide. Chicago, IL: SPSS.
Australian Bureau of Statistics. (2017). Cause of death, Australia, 2017 (Cat. no. 3303.0). Canberra, Australia: Author. Retrieved from's%20leading%20causes%20of%20death,%202017~2
Bains, B, Powell, T and Lorenc, L (2007). An exploratory study of mental representations for rehabilitation based upon the Theory of Planned Behaviour. Neuropsychological Rehabilitation, 17, 174191.
Bakker, EC, Nijkamp, MD, Sloot, C, Berndt, NC and Bolman, CA (2015). Intention to abstain from smoking among cardiac rehabilitation patients: The role of attitude, self-efficacy, and craving. Journal of Cardiovascular Nursing, 30, 172179.
Banner, D, Lear, S, Kandola, D, Bates, J, Horvat, D, Ignaszewski, A and Singer, J (2017). The experiences of patients undergoing a virtual cardiac rehabilitation program. Canadian Journal of Cardiology, 33, S221.
Barg, CJ, Latimer, AE, Pomery, EA, Rivers, SE, Rench, TA, Prapavessis, H and Salovey, P (2012). Examining predictors of physical activity among inactive middle-aged women: An application of the health action process approach. Psychology & Health, 27, 829845.
Baumgartner, H and Homburg, C (1996). Applications of structural equation modeling in marketing and consumer research: A review. International journal of Research in Marketing, 13, 139161.
Bennett, P, Mayfield, T, Norman, P, Lowe, R and Morgan, M (1999). Affective and social-cognitive predictors of behavioural change following first myocardial infarction. British Journal of Health Psychology, 4, 247256.
Blanchard, CM, Reid, RD, Morrin, LI, McDonnell, L, McGannon, K, Rhodes, REEdwards, N (2009). Does protection motivation theory explain exercise intentions and behavior during home-based cardiac rehabilitation? Journal of Cardiopulmonary Rehabilitation and Prevention, 29, 188192.
Blasche, G and Marktl, W (2011). Recovery intention: Its association with fatigue in the working population. International Archives of Occupational and Environmental Health, 84, 859865.
Boosman, H, van Heugten, CM, Winkens, I, Smeets, SM and Visser-Meily, JM (2016). Further validation of the Motivation for Traumatic Brain Injury Rehabilitation Questionnaire (MOT-Q) in patients with acquired brain injury. Neuropsychological Rehabilitation, 26, 87102.
Bright, FA, Kayes, NM, Worrall, L and McPherson, KM (2015). A conceptual review of engagement in healthcare and rehabilitation. Disability and Rehabilitation, 37, 643654.
Broadbent, E, Ellis, CJ, Thomas, J, Gamble, G and Petrie, KJ (2009). Further development of an illness perception intervention for myocardial infarction patients: A randomized controlled trial. Journal of Psychosomatic Research, 67, 1723.
Browne, MW and Cudeck, R (1993). Alternative ways of assessing model fit. Sage Focus Editions, 154, 136136.
Carroll, DL, Rankin, SH and Cooper, BA (2007). The effects of a collaborative peer advisor/advanced practice nurse intervention: cardiac rehabilitation participation and rehospitalization in older adults after a cardiac event. Journal of Cardiovascular Nursing, 22, 313319.
Chervinsky, AB, Ommaya, AK, deJonge, M, Spector, J, Schwab, K and Salazar, AM (1998). Motivation for traumatic brain injury rehabilitation questionnaire (MOT-Q): Reliability, factor analysis, and relationship to MMPI-2 variables. Archives of Clinical Neuropsychology, 13, 433-446.
Clark, AM, Redfern, J and Briffa, T (2014). Cardiac rehabilitation: Fit to face the future? BMJ Publishing Group Ltd and British Cardiovascular Society.
Colombo, M, Bucher, L and Sprenger, J (2017). Determinants of judgments of explanatory power: Credibility, Generality, and Statistical Relevance. Frontiers in Psychology, 8, 1430.
Cup, EH, Scholte op Reimer, W, Thijssen, MC and van Kuyk-Minis, M (2003). Reliability and validity of the Canadian Occupational Performance Measure in stroke patients. Clinical Rehabilitation, 17, 402409.
de Melo Ghisi, GL, Grace, SL, Thomas, S and Oh, P (2015). Behavior determinants among cardiac rehabilitation patients receiving educational interventions: an application of the health action process approach. Patient Education and Counseling, 98, 612621.
del Pozo-Cruz, B, Carrick-Ranson, G, Reading, S, Nolan, P and Dalleck, LC (2018). The relationship between exercise dose and health-related quality of life with a phase III cardiac rehabilitation program. Quality of Life Research, 16.
Ding, L, Velicer, WF and Harlow, LL (1995). Effects of estimation methods, number of indicators per factor, and improper solutions on structural equation modeling fit indices. Structural Equation Modeling: A Multidisciplinary Journal, 2, 119143.
Dohnke, B, Nowossadeck, E and Müller-Fahrnow, W (2010). Motivation and participation in a phase III cardiac rehabilitation programme: an application of the health action process approach. Research in Sports Medicine, 18, 219235.
Doig, E, Prescott, S, Fleming, J, Cornwell, P and Kuipers, P (2015). Development and construct validation of the Client-Centredness of Goal Setting (C-COGS) scale. Scandinavian Journal of Occupational Therapy, 22, 302310.
Dunlay, SM, Pack, QR, Thomas, RJ, Killian, JM and Roger, VL (2014). Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction. The American Journal of Medicine, 127, 538546.
Fishbein, M and Ajzen, I (1975). Belief, attitude, intention and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley.
Gardiner, FW, Nwose, EU, Regan, E, Park, BK, Bwititi, PT, Crockett, J and Wang, L (2018). Outpatient cardiac rehabilitation: Patient perceived benefits and reasons for non-attendance. Collegian.
Gaskin, J (2016). Excel StatTools. Stats tools package.
George, D and Mallery, P (2003). Reliability analysis. In SPSS for Windows, step by step: A simple guide and reference (14th ed., pp. 222232). Boston, MA: Allyn & Bacon.
Godlaski, TM, Butler, L, Heron, M, Debord, S and Cauvin, L (2009). A qualitative exploration of engagement among rural women entering substance user treatment. Substance Use & Misuse, 44, 6283.
Graffigna, G, Barello, S and Triberti, S (2016). Patient engagement: A consumer-centered model to innovate healthcare. Berlin, Germany: Walter de Gruyter GmbH & Co KG
Greenland, S, Senn, SJ, Rothman, KJ, Carlin, JB, Poole, C, Goodman, SN and Altman, DG (2016). Statistical tests, p values, confidence intervals, and power: A guide to misinterpretations. European journal of epidemiology, 31, 337350.
Hair, JF, Black, WC, Babin, BJ, Anderson, RE and Tatham, RL (2006). Multivariate data analysis (6th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.
Hair, J Jr, Black, W, Babin, B and Anderson, R (2010). Multivariate data analysis: A global perspective. Upper Saddle River, NJ: Prentice Hall.
Hansen, TB, Berg, SK, Sibilitz, KL, Zwisler, AD, Norekvål, TM, Lee, A and Buus, N (2018). Patient perceptions of experience with cardiac rehabilitation after isolated heart valve surgery. European Journal of Cardiovascular Nursing, 17, 4553.
Hattar, A, Pal, S and Hagger, MS (2016). predicting physical activity – Related outcomes in overweight and obese adults: A health action process approach. Applied Psychology: Health and Well-Being, 8, 127151.
Holliday, RC, Ballinger, C and Playford, ED (2007). Goal setting in neurological rehabilitation: patients' perspectives. Disability and rehabilitation, 29, 389394.
Hutchinson, P, Meyer, A and Marshall, B (2015). Factors influencing outpatient cardiac rehabilitation attendance. Rehabilitation Nursing, 40, 360367.
Jahandideh, S, Kendall, E, Low-Choy, S, Donald, K and Jayasinghe, R (2018). The process of patient engagement in cardiac rehabilitation: A model-centric systematic review. Behaviour Change, 35, 185202.
Jolly, K, Taylor, R, Lip, G, Greenfield, S, Raftery, J, Mant, JStevens, A (2007). The Birmingham Rehabilitation Uptake Maximisation Study (BRUM). Home-based compared with hospital-based cardiac rehabilitation in a multi-ethnic population: Cost-effectiveness and patient adherence. Health Technology Assessment, 11, 1118.
José Liébana-Cabanillas, F, Sánchez-Fernández, J and Muñoz-Leiva, F (2014). Role of gender on acceptance of mobile payment. Industrial Management & Data Systems, 114, 220240.
Kasila, K, Hallman, M, Kautiainen, H, Vanhala, M and Kettunen, T (2018). The gap between behavioral risk status and willingness to change behavior among healthcare professionals. Perspectives in Public Health, 1757913917751564.
Kersten, P, McPherson, KM, Kayes, NM, Theadom, A and McCambridge, A (2015). Bridging the goal intention–action gap in rehabilitation: A study of if-then implementation intentions in neurorehabilitation. Disability and rehabilitation, 37, 10731081.
Kjær, T, Gyrd-Hansen, D and Willaing, I (2006). Investigating patients’ preferences for cardiac rehabilitation in Denmark. International Journal of Technology Assessment in Health Care, 22, 211218.
Kline, R (2005). Methodology in the social sciences: Principles and practice of structural equation modeling (2nd ed.). New York: Guilford Press.
Kortte, KB, Falk, LD, Castillo, RC, Johnson-Greene, D and Wegener, ST (2007). The Hopkins Rehabilitation Engagement Rating Scale: Development and psychometric properties. Archives of Physical Medicine And Rehabilitation, 88, 877884.
Law, M, Baptiste, S, Carswell, A, McColl, MA, Polatajko, H and Pollock, N (2014). Canadian Occupational Performance Measure (5th ed.). Ottawa: CAOT Publications.
Lee, KM and Kim, YS. (2003). The significance of motivation for rehabilitation in stroke patients. Journal of Korean Academy of Rehabilitation Medicine, 27, 309313.
Lequerica, AH and Kortte, K (2010). Therapeutic engagement: A proposed model of engagement in medical rehabilitation. American Journal of Physical Medicine and Rehabilitation, 89, 415422.
Marzolini, S, Mertens, DJ, Oh, PI and Plyley, MJ (2010). Self-reported compliance to home-based resistance training in cardiac patients. European Journal of Cardiovascular Prevention & Rehabilitation, 17, 3549.
McMurray, JP, McNeil, HMA, Lafortune, CB, Black, SB, Prorok, JM and Stolee, PP (2016). Measuring patients’ experience of rehabilitation services across the care continuum. Part II: Key dimensions. Archives of Physical Medicine and Rehabilitation, 97, 121130.
Medley, AR and Powell, T (2010). Motivational interviewing to promote self-awareness and engagement in rehabilitation following acquired brain injury: A conceptual review. Neuropsychological Rehabilitation, 20, 481508.
Norušis, MJ (2012). IBM SPSS statistics 19: Advanced statistical procedures companion. Upper Saddle River, NJ: Prentice Hall.
O'Brien, A, White, S, Fahmy, R and Singh, SP (2009). The development and validation of the SOLES, a new scale measuring engagement with mental health services in people with psychosis. Journal of Mental Health, 18, 510522.
Ozer, MN (1999). Patient participation in the management of stroke rehabilitation. Topics in Stroke Rehabilitation, 6, 4359.
Roth, GA, Johnson, C, Abajobir, A, Abd-Allah, F, Abera, SF, Abyu, GAlam, K (2017). Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015. Journal of the American College of Cardiology, 70, 125.
Rouleau, CR, King-Shier, KM, Tomfohr-Madsen, LM, Bacon, SL, Aggarwal, S, Arena, R and Campbell, TS (2018). The evaluation of a brief motivational intervention to promote intention to participate in cardiac rehabilitation: A randomized controlled trial. Patient Education and Counseling, 101, 19141923.
Safarnia, H, Akbari, Z and Abbasi, A (2011). Review of competitive intelligence & competitive advantage in the industrial estates companies in the Kerman City: Appraisal and testing of model by Amos graphics. International Business and Management, 2, 4761.
Shanks, LC, Moore, SM and Zeller, RA (2007). Predictors of cardiac rehabilitation initiation. Rehabilitation Nursing, 32, 152157.
Sniehotta, FF, Gorski, C and Araújo-Soares, V (2010). Adoption of community-based cardiac rehabilitation programs and physical activity following phase III cardiac rehabilitation in Scotland: A prospective and predictive study. Psychology and Health, 25, 839854.
Sniehotta, FF, Scholz, U and Schwarzer, R (2005). Bridging the intention–behaviour gap: Planning, self-efficacy, and action control in the adoption and maintenance of physical exercise. Psychology & Health, 20, 143160.
Soper, DS (2018). A-priori Sample Size Calculator for Structural Equation Models. Retrieved from Stats Tools Package:
Sullivan, KA, White, KM, Young, RM and Scott, C (2009). Predicting behaviour to reduce stroke risk in at-risk populations: The role of beliefs. International Journal of Therapy and Rehabilitation, 16, 488496.
Turner-Stokes, L, Vanderstay, R, Stevermuer, T, Simmonds, F, Khan, F and Eagar, K (2015). Comparison of rehabilitation outcomes for long term neurological conditions: A cohort analysis of the Australian Rehabilitation Outcomes Centre Dataset for Adults of Working Age. PloS One, 10, e0132275.
Walker, KC, Valentiner, LS and Langberg, H (2018). Motivational factors for initiating, implementing, and maintaining physical activity behavior following a rehabilitation program for patients with type 2 diabetes: a longitudinal, qualitative, interview study. Patient Preference and Adherence, 12, 145152.
Wasserstein, RL and Lazar, NA (2016). The ASA's statement on p-values: Context, process, and purpose. The American Statistician, 70, 129133.
Wray, JM, Funderburk, JS and Maisto, SA (2017). Willingness to engage in health behavior change interventions among primary care patients positive for tobacco use and at-risk drinking. Primary Care Companion to the Journal of Clinical Psychiatry, 19, 17m02209.
Weston, R, Gore, PA, Chan, F and Catalano, D (2008). An introduction to using structural equation models in rehabilitation psychology. Rehabilitation Psychology, 53, 340356.
Williams, DM (2010). Outcome expectancy and self-efficacy: Theoretical implications of an unresolved contradiction. Personality and Social Psychology Review, 14, 417425.
Woodgate, J, Brawley, LR and Weston, ZJ (2005). Maintenance cardiac rehabilitation exercise adherence: Effects of task and self-regulatory self-efficacy. Journal of Applied Social Psychology, 35, 183222.


The Process of Patient Engagement in Outpatient Cardiac Rehabilitation Programs

  • Sepideh Jahandideh (a1), Elizabeth Kendall (a2), Samantha Low-Choy (a3), Kenneth Donald (a4), Rohan Jayasinghe (a5) and Ebrahim Barzegari (a6)...


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