We aimed to develop a valid and reliable measure of patients' beliefs regarding cardiac rehabilitation after AMI and to ascertain the relationship between such beliefs and attendance at the programme. Four subscales were produced through analysis of the dataset generated and, consistent with the Necessity–Concerns framework, these were divided into beliefs regarding the understanding and necessity of cardiac rehabilitation, and beliefs about concerns regarding attendance at the cardiac rehabilitation programme. The concerns about cardiac rehabilitation include those about undertaking exercise or physical activity, and practical barriers—namely, availability and cost of transport and financial implications of taking time off work. The fourth factor comprises two items about perceptions of suitability—that is, that cardiac rehabilitation is more suitable for younger, previously active people. These four subscales showed good internal reliability and had proved validity with regard to some measures of criterion (predictive) and construct (discriminant) validity.
The actual attendance rate at a cardiac rehabilitation programme was related to the subscales in the hypothesised manner. Scores of two of the subscales—necessity and suitability—differed considerably between attenders and non‐attenders. Although scores measuring concerns about the exercise component of cardiac rehabilitation and those measuring practical barriers differed as hypothesised between attenders and non‐attenders, these did not reach statistical significance.
This is the first questionnaire that has been developed to assess patients' beliefs about cardiac rehabilitation. The evaluation is encouraging, showing evidence of internal reliability and validity. However, our study has limitations and further studies are necessary to fully validate the questionnaire. Some observations between the subscales and other measures lost significance after Bonferroni correction, and these aspects of construct validity require confirmation in a larger patient sample. Test–retest reliability should be confirmed, possibly 2 weeks after discharge from hospital; this would also control for the effects of mood congruency. Further studies should include populations that are often excluded from the cardiac rehabilitation programme, such as women, and people from ethnic minority groups and patients from different socioeconomic groups, as our sample included predominantly white males. External validity also needs to be established with regard to patients who have not had AMI but who have undergone angioplasty or coronary artery bypass grafting or who have angina, as current guidelines advocate that these patients also attend the cardiac rehabilitation programme.
However, our findings suggest that this questionnaire may be a useful tool in helping to predict whether patients who have had AMI will attend the cardiac rehabilitation programme, and therefore to determine which patients may derive particular benefit from interventions aimed at increasing cardiac rehabilitation uptake. Evidence suggests that interventions targeting specific cardiac beliefs or misconceptions of patients are helpful. A randomised controlled trial conducted during hospitalisation for AMI was successful at eliciting common cardiac misconceptions and replacing these with more helpful beliefs.18
Similarly, The Angina Plan and The Heart Manual are interventions that directly target cardiac misconceptions.19,20
Reductions in psychological distress, physical limitations, reported angina and associated use of the reliever drug glyceryl trinitrate spray have been reported, as have self‐reported increases in daily walking, dietary changes, reduced healthcare contact and hospital readmission.
A recently conducted randomised controlled trial conducted during hospitalisation after AMI challenged beliefs about illness (measured using the IPQ‐R) that were previously associated with poorer outcome.21
Intervention recipients rated themselves as having a higher level of understanding of their heart condition and being better prepared to leave hospital. They had more helpful beliefs about illness, were less likely to report angina pain at 3 months and returned faster to work.
All patients participating in our study had been invited by the cardiac rehabilitation team to participate in a cardiac rehabilitation course after their discharge from hospital, and would usually have spent up to 1 h with a nurse from the team. Despite this, about a fifth of patients were unsure that cardiac rehabilitation could help them, and held concerns regarding the physical activity component that affected their attendance behaviour. We would suggest that after further satisfactory validation, this scale could be completed by patients before discharge from hospital, in order to identify those whose beliefs indicate that it is unlikely they will attend the cardiac rehabilitation programme; it may also be beneficial to assess at this time patients' beliefs regarding their cardiac disease, using validated scales (ie, from the Angina Plan, the Heart Manual or the IPQ‐R). This may enable assessment of interventions that target specific misconceptions, thus increasing attendance and optimising the overall outcome and recovery.