Cardiovascular disease is currently the leading cause of death in Canada and other developed countries. Physical activity based cardiac rehabilitation programs have been shown to reduce the likelihood of subsequent cardiac events and even reverse the disease process. However, factors influencing physical activity in cardiac patients are still not clearly understood. The overall objective of this dissertation was therefore to better understand motivation and physical activity in a cardiac rehabilitation context. Specifically, theory-based motivational variables were studied as correlates of physical activity. To accomplish this objective, a two-purpose research approach was taken. First, two articles (Article-1 and Article-2) aimed to test and integrate concepts from two strong motivational theories: Self-Efficacy Theory (SET) and Self-Determination Theory (SDT) into one comprehensive model using the novel and rigorous approach of Noar and Zimmerman (2005). The second purpose of this dissertation was to extend the findings from the first purpose by investigating physical activity and motivational patterns over a 24-month period in cardiac patients (Article 3). With regards to the first purpose, Article-1 revealed that the integration of SDT and SET was feasible as the integrated model had good model fit, explained more variance in self-determined motivation, confidence, and physical activity and supported similar number of hypothesised links in a cross-sectional cardiac sample as well two other samples: primary care adults and university students. Due to the cross-sectional nature of Article-1, Article-2 tested the integrated SDT-SET model from cardiac patients with longitudinal data of patients following a cardiac rehabilitation program. Although no motivational variables predicted residual change in physical activity at 4-months, this longitudinal model was found to have good model fit. Across both articles, the integration of SDT and SET was found to be possible. However, more research is needed to further test the integration of these theories. As for the second purpose of this dissertation, Article-3 investigated physical activity and motivational patterns of cardiac rehabilitation participants over the course of 24 months. Distinct patterns were found for physical activity, self-determined motivation, barrier self-efficacy and outcome expectations. In addition, individuals in the higher patterns of the motivational/expectancy variables had greater probability of being in the maintenance physical activity pattern compared to individuals in the other motivational/expectancy patterns. Therefore, this article extended findings from the first purpose by linking SDT and SET variables to long-term physical activity behaviour. SDT and SET should continue to be investigated together in order to increase our understanding of the mechanisms leading to greater motivation and subsequent increases in physical activity levels. Having a theoretically supported pathway to build motivation is ideal to inform future interventions and cardiac rehabilitation programs.

Purpose: The current U.S. population exceeds three hundred million with approximately 20% living in non-urban rural areas. A higher percentage of rural residents have diagnosed heart disease and report poorer health compared to non-rural residents; however, it is not known whether risk factor modification for heart disease and health status differ based on degree of rurality. The purposes of this study were: 1) to compare differences in health status and cardiac risk factors between cardiac patients living in large and small/isolated rural areas, and 2) to compare the health status of rural cardiac patients with a national sample. Method: A secondary analysis using data from three separate studies was completed using a comparative descriptive design. The Cardiac Rehabilitation participant sample (n-191) included individuals 3 to 12 months post-cardiac event. The Arizona Heart Institute and Foundation Heart Test measured risk factors and the eight subscales of the Short-Form, Medical Outcomes study measured health status. Findings: No significant differences in health status were found; all participants rated their health moderately high. However, individuals in large rural areas reported significantly better general health than those in the normative sample. No differences in smoking, blood pressure, diabetes, or overweight/obese BMI were found between the two rural groups. Differences in exercise, and anger were present between the two groups. Significant differences were identified in waist circumference between the genders placing women at higher risk for heart disease. Conclusions: Identifying health status and cardiovascular risk factors of rural individuals informs interventions to be tested for rural residents.

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<p>Despite the known benefits of regular exercise for cardiac patients (Jolliffe et al., 2001) and the delivery of cardiac rehabilitation programs to facilitate exercise participation in this population, exercise adherence remains a challenge for these individuals as evidenced by the reported decline in exercise participation over time (e.g., Moore et al., 2006). Investigating cardiac patients' motivation or willingness to engage in exercise may provide a better understanding of why some patients are better maintainers of exercise and others are not. Using self-determination theory (Deci & Ryan, 1985; 2002), the present study investigated changes in need satisfaction and selfdetermined motivation, as well as the role of perceived autonomy support relative to patient motivation, in the early months of participation in cardiac rehabilitation. It was hypothesized that need satisfaction and autonomous forms of behavioural regulation would increase over time, and that perceived autonomy support (ratings of exercise leaders' tendencies to acknowledge patients' perspectives, provide choices and contingent feedback, etc.) would positively predict changes in behavioural regulation, mediated by changes in psychological need satisfaction. Another aim of the study was to examine how autonomous forms of behavioural regulation related to cardiac patients' exercise intentions and self-managed exercise behaviour, and it was hypothesized that this relationship would be positive for both exercise intentions and behaviour. Fifty-three male participants (Mage= 62.83 ± 10.78) who were enrolled in a hospital-based cardiac rehabilitation program completed assessments of perceived autonomy support, need satisfaction and behavioural regulation at weeks 4, 8, and 12 of program participation. At week 14, participants' self-managed exercise behaviour and their exercise intentions to engage in independent exercise for the next 4 weeks were assessed. In general, participants' scores for all variables of interest were relatively high. Consistent with hypotheses, autonomy and relatedness need satisfaction, along with integrated and intrinsic regulation increased from week 4 to week 12 during cardiac rehabilitation. However, perceived autonomy support was not related to changes in need satisfaction or behavioural regulation, and thus, support for mediation was not obtained. Nonetheless, the high ratings of perceived autonomy support reflect the exercise leaders' natural tendency to use an autonomy supportive teaching style with patients. In addition, a positive relationship was found between autonomous forms of behavioural regulation (i.e., integrated and intrinsic) and exercise intentions, lending support to the SDT framework. The positive findings for need satisfaction, autonomous regulation, exercise intentions, and behaviour reflect a highly self-determined group of cardiac patients who are choosing to engage in self-managed exercise while still participating in the supervised cardiac rehabilitation program. These findings are promising in terms of regular exercise adoption in this population.</p> / Thesis / Master of Science (MSc)

The physiological and psychosocial benefits of sustained exercise adherence among individuals with coronary artery disease (CAD) have been well-documented (e.g., Blumenthal et al., 1997; Rozanski et al., 1999; Wenger et al., 1995). Despite these known benefits, approximately 80% of patients who enter the maintenance phase of cardiac rehabilitation drop out after one year (Balady et al., 1994; Hedback, Perk, Wodlin, 1993 ). Among this 80%, less than 25% continue to exercise at levels that will maintain or improve cardiorespiratory fitness (Daltroy, 1985; Radtke, 1989). Self-efficacy has been identified as a significant predictor of adherence to exercise beyond the initial 6 months of participation. In addition to self-efficacy, outcome satisfaction has been suggested as a potentially significant predictor of adherence to exercise beyond the initiation phase (i.e., beyond the first 6 months). Unfortunately, most research examining these predictors of adherence has been conducted among asymptomatic populations. Thus, little is known about the predictive utility of self-efficacy and outcome satisfaction in relation to sustained exercise adherence among the CAD population. The purpose of the present study was to examine self-efficacy (Bandura, 1986) and outcome satisfaction (Rothman, 2000) in the prediction of adherence to maintenance cardiac rehabilitation in 101 men (M age= 68.15 ± 8.03) with coronary artery disease (CAD). A series of three hierarchical multiple regression analyses were conducted to predict onsite, offsite and total adherence to the maintenance cardiac rehabilitation exercise prescription. Interestingly, Exercise Beliefs (i.e., days of aerobic exercise per week believed necessary to maintain cardiovascular health), one of the study covariates, emerged as an important predictor of both offsite and total exercise adherence and explained a significant amount of variance in these variables (R2 = .25 [offsite], .23 [total],ps < .01). As predicted, self-regulatory efficacy was a significant predictor and explained a significant amount of variance in onsite exercise adherence (R2 = .17 [scheduling],p < .001). Task self-efficacy was not a significant predictor and did not account for a significant amount of variance in onsite exercise adherence. Also as predicted, task self-efficacy was a significant predictor and explained a significant amount of variance in offsite exercise adherence (R2= .10,p < .05). Self-regulatory efficacy was not a significant predictor and did not account for a significant amount of variance in offsite exercise adherence. In addition, consistent with hypothesis, both task self-efficacy and self-regulatory efficacy were significant predictors of total exercise adherence and explained a significant amount of the variance in this variable (R2 = .12 [task], .07 [scheduling],ps < .05). Contrary to hypothesis, outcome satisfaction did not explain a significant amount of variance in exercise adherence (onsite, offsite, and total) beyond that explained by self-efficacy (task and self-regulatory) alone. Taken together, this research has enhanced our knowledge of the psychosocial predictors of adherence to the maintenance cardiac rehabilitation exercise prescription among men with CAD. These findings also have important implications for health care professionals working in the area of cardiac rehabilitation. Specifically, it is up to health care professionals to ensure that patient beliefs regarding the maintenance cardiac rehabilitation exercise prescription are accurate, and that patients are efficacious in their ability to engage in the elemental physical aspects of exercise and to effectively schedule exercise into their daily lives. / Thesis / Master of Science (MS)