the need of psychological motivational support for improving lifestyle change in cardiac...

EXPERIMENTAL & CLINICAL CARDIOLOGY

Volume 20, Issue 9, 2014

Title: "The Need of Psychological Motivational Support for Improving Lifestyle Change in CardiacRehabilitation"

Authors: Gianluca Castelnuovo, Giada Pietrabissa, Gian Mauro Manzoni, Chiara A.m. Spatola,Emanuele A.m. Cappella, Matteo Baruffi, Gabriella Malfatto, Mario Facchini, Carla Favoccia,Ferruccio Nibbio, Anna M. Titon, Gianandrea Bertone, Mariella Montano, Luca Gondoni and Enrico Molinari

How to reference: The Need of Psychological Motivational Support for Improving Lifestyle Change inCardiac Rehabilitation/Gianluca Castelnuovo, Giada Pietrabissa, Gian Mauro Manzoni, Chiara A.m.Spatola, Emanuele A.m. Cappella, Matteo Baruffi, Gabriella Malfatto, Mario Facchini, Carla Favoccia, Ferruccio Nibbio, Anna M. Titon, Gianandrea Bertone, Mariella Montano, Luca Gondoni and Enrico Molinari/Exp Clin Cardiol Vol 20 Issue9 pages 4856-4861 / 2014

Experimental&ClinicalCardiology

The need of psychological motivational support for improving lifestyle change in cardiac rehabilitation

Perspective article

Gianluca Castelnuovo1-2*, Giada Pietrabissa1-2, Gian Mauro Manzoni1-3, Chiara A.M. Spatola1-2, Emanuele A.M. Cappella2, Matteo Baruffi2, Gabriella Malfatto4, Mario Facchini4, Carla Favoccia5, Ferruccio Nibbio5, Anna M. Titon5, Gianandrea Bertone5, Mariella Montano5, Luca Gondoni5 and Enrico Molinari1-2 1 Psychology Research Laboratory, Istituto Auxologico Italiano IRCCS, Italy 2 Department of Psychology, Catholic University of Milan, Italy 3 Faculty of Psychology, eCampus University, Novedrate, Como, Italy 4 Cardiology Division, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milano, Italy 5 Cardiac Rehabilitation Unit, Ospedale San Giuseppe, Istituto Auxologico Italiano IRCCS, Verbania, Italy

© 2014 et al.; licensee Cardiology Academic Press. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract Despite a decreasing trend in incidence

and mortality, Cardiovascular Diseases (CVDs) still

represent important causes of death and disability in

developed countries, significantly affecting individuals’

quality of life and healthcare costs . Unhealthy lifestyle

behaviors, such as poor diet, lack of physical activity and

smoking status, constitute a challenge in contrasting the

disease. Alternatively to the medical model, which rely

on the traditional approach of information and advice‐

giving, evidence to date indicate the need of

psychological actions able to address patients’ beliefs and

concerns about their health status as well as to enhance

confidence in their abilities to overcome barriers to

adherence and achieve life‐style modifications in the long

term. Even if the World Health Organization (WHO) Expert

Committee stated that Cognitive‐Behavioural Therapy (CBT)

is an important component of Cardiac Rehabilitation (CR)

programs, it does not specifically focus on eliciting patients’

motivation, leading to the development of interventions aimed

at enhancing health behavior change and among which

Motivational Interviewing (MI) has obtained varying degrees

of success. Also, the new mHealth (mobile health) approach

could represent an important strategy in order to move

motivational psychological support where necessary

(outpatient settings), maximizing the results obtained from the

CR in a long term among people suffering from CVD and

other chronic conditions.

Keywords Cardiovascular diseases, Cardiac rehabilitation,

Clinical Health Psychology, motivational strategies,

Motivational interviewing, mHealth.

The Need of Psychological Motivational Support for Improving Lifestyle Change in Cardiac Rehabi...

Exp Clin Cardiol, Volume 20, Issue 9, 2014 - Page 4856

1. Introduction

Cardiovascular diseases (CVDs) are important clinical

conditions with global prevalence and epidemic

proportions [1] significantly affecting individuals’ quality

of life and healthcare costs in many countries [2].

Among the major risk factors, unhealthy diet, lack of

physical activity and tobacco use typically represent a

challenge in contrasting the disease and there is increasing

awareness that psychosocial attributes may act as

mediators, or even directly as causal factors, for CVD [3].

Cardiac Rehabilitation (CR) programs are essentially

aimed at helping people regain strength, preventing

condition from worsening, reducing risk factors as well as

increasing individuals’ adherence to pharmacotherapy

and enhancing their quality of life through customized

plans of exercise and education [4‐6]. However, important

difficulties have been underlined with regard to treatment

adherence and long‐term efficacy of the programs. Thus

more research is needed in order to develop strategies

capable to enhance patients’ motivation and compliance

to both actively take part in CR programs [7] and to

maintain the achieved results over time.

2. The Cardiac Rehabilitation Process

According to the WHO [8], CR could be defined as ʺthe

sum of activities required to influence favorably the

underlying cause of disease, as well to ensure the patients

the best possible physical, mental and social conditions so

that they may, by their own efforts, preserve, or resume

when lost, as normal a place as possible in the life of the

communityʺ (p. 5, 1993). Behind CR there are at least

three illness models: the traditional biomedical approach

of medicine, the epidemiological risk factor model and

the biopsychosocial framework, which characterize the

clinical health psychology practice [9]. CR is focused on

three key areas: ʺmedical aims (prevention of cardiac

mortality, reduction of cardiac mortality, decrease of

symptoms); psychological aims (restoring the patientsʹ

self‐confidence, reducing anxiety and depression,

improving stress management, regaining a satisfying

sexuality); socioeconomic aims (return to work, if

appropriate, independence in everyday life activities,

reduction of direct medical costs through, e.g., early

discharge from the hospital, less medication, fewer

hospitalizationsʺ (p. 6), [8].

The WHO divides CR in 3 steps [9‐12]: step 1 is the acute

phase (usually the treatment corresponds to the hospital

setting); step 2 is convalescence (the period following the

acute cardiac event); , step 3 is represented by the long‐

term CR at home, for which telemedicine allows

continuous remote monitoring.

3. The need of psychosocial interventions in long‐term Cardiac Rehabilitation to overcome barriers

In the systematic review and meta‐synthesis of

qualitative studies purposed by Neubeck et al. [5],

attention has been given to both obstacles and barriers

usually faced by people and influencing their decision to

attend CR.

ʺFirstly, there are service and system level barriers:

physician recommendation, interaction with the

healthcare team, and misconceptions surrounding CR.

Secondly there are practical barriers: transport and

parking, cost, and language. Thirdly there are personal

barriers: perception of CHD (coronary heart disease) and

CR, and belief in ability to control CHD. Finally there are

specific issues which affect culturally and linguistically

diverse patients and particulary women (p. 7‐8, [5]).

Personal barriers, such as wrong beliefs about CR,

dysfunctional perception of both CVDs and CR and belief

in the ability of controlling CVDs factors and

consequences may then be effectively targeted by clinical

health psychology interventions. ʺThose who were most

likely to attend (CR) were also most likely to believe

CHD was caused by biomedical risk factors and that they

had some control over it. Those who were least likely to

attend believed that CHD was caused by psychosocial

factors and that they had little or no control over itʺ (p. 8,

2012). Because too often causing resistance in patients, the

authors also suggested clinicians not to take a directive,

didactic approach to promote attendance at CR , but

ʺinstead, techniques such as motivational interviewing,

combined with flexible community alternatives to facility

CR, can promote the uptake in people who have declined

CRʺ (p. 8, [5].) Another suggested solution is to promote

peer‐group support among patients [13].

The fundamental importance of psychological support in CR

has been also underlined by Grande and Badura [14] and, in

the same way the American Heart Association [15] stated

that cardiac rehabilitation programs should consist of a

multifaceted and multidisciplinary approach to overall

cardiovascular risk reduction, and that programs consisting

in exercise training alone should not be considered cardiac

rehabilitation at all.

In the up‐to‐date practice of CR, psychosocial services are

growing in importance and role [16, 17] and European

guidelines [18], intensively encourage psycho‐educational

activities increasing the likelihood of permanent lifestyle

changes.

4. Motivational strategies for improving long‐term Cardiac

Rehabilitation

In order to achieve a positive, comprehensive and sustainable

outcomes in the long term, CR programs must include

exercise training, risk factor management, clinical assessment

and patient education as well as psychosocial support and

lifestyle intervention, defined as ʺsystematic education in

techniques to change health behavior ... essential for

implementing changes in lifestyle and ... important element

in preventing heart disease and cardiac rehabilitationʺ (p. 29)

[19]. In clinical health psychology, different methods has

been developed with the aim of enhancing health behavior

change. The Prochaska and DiClementeʹs Transtheoretical

Stages of Change model (TTM) [20, 21], the Hochbaum and

Rosenstockʹs health belief model [22], the Bandura’s self‐

efficacy theory [23‐25], the Gabrielsenʹs concept of action

competence [19], as well as cross‐cutting approaches such as

Motivational Interviewing or counseling, health

communication, biofeedback and evaluation, group activities



and practical testing are just a few.

Particularly, a growing and promising method in CR is

represented by Motivational Interviewing (MI) [26‐32], a

client‐centered yet directive method for enhancing intrinsic

motivation to change by exploring and resolving client

ambivalence [33, 34].

Accomplished in the 1990s by William R. Miller and

Stephen Rollnick, this therapeutic approach is currently

widely used in CR practice for improving health and

preventing relapses. Based on the TTM, Motivational

Interviewing enhances individuals’ resources and self‐

efficacy and helps ‐ patients to express their own

barriers to change, to explore how their current health

behavior may conflict with their own goals and values

and to prepare strategies that optimally promotes their

action competence.

By the use of a guiding style which lies between and

incorporates elements of directing and following styles,

as well as reflective listening and open‐ended questions

strategies, the provider invites the persons to verbalize

their own arguments for changing.

Eliciting “change talk” (opposed to the concept of

“resistance to change”) and commitment for change

people are persuaded to modify their behavior(s) in the

way they speak, also increasing confidence in achieving

their personal goals. In fact, research findings indicates

that change is more likely to be long‐lasting in patients

who attribute their changes to their own efforts [35].

Change talk involves statements or non‐verbal

communications indicating that the client may be

considering the possibility of change and studies

demonstrate a clear correlation between clients’

statements about change and outcomes reported levels

of success in modifying their behavior: the more

someone talks about change, the more likely they are to

change. This ensures that patients can process the

knowledge they encounter and make decisions on a

qualified basis [20].

However, some criticisms about the real added value of

MI in short‐term and long‐term CR have been expressed

by Chair et al. [36, 37]. Particularly, improvements in

clinical outcomes, psychological variables and health‐

related quality of life have been shown to be limited in a

sample of patients receiving 10 sessions of motivational

interviewing, considering long‐term effects [36]. Even

worse results have been found in a short‐term protocol

considering patients receiving usual care plus 4 sessions of

motivational support, each lasting 30‐45 min, that pointed

out increased patients’ anxiety levels after 3 months follow

up [37].

Further research is needed but interventions including

motivational interviewing spirit and principles are

generally considered being effective in eliciting lifestyle

change [27, 38‐41].

5. Relevant factors that threat motivation in health

settings

Blascovich masterfully described several factors (a

nonexhaustive list) that can threat motivation, with

negative consequences for health: ʺOne factor involves

danger and safety. Though potential physical danger is an

obvious health‐related factor, potential psychological

danger, such as loss of self‐esteem, negative affective

experience, and social sanctions, perhaps plays an even

larger role in increasing individuals’ demand evaluations in

modern society. On the other hand, perceptions of physical

and psychological safety decrease demand evaluations.

Another factor is required effort. The greater the effort

required to perform well in a situation, the greater the

demand. Again, this effort can be primarily physical or

psychological. To the extent that the individual possesses

task‐relevant skills, abilities, and knowledge, the greater the

resource evaluation, and the less likely the experience of

threat. This factor also probably moderates danger–safety

and required effort evaluations in predictable ways. The

presence of others can moderate both demand and resource

evaluations. Supportive, nonevaluative others are likely to

increase resources and perhaps to decrease danger, whereas

nonsupportive or evaluative others are likely to increase

demands and perhaps to decrease resources; it is assumed, of

course, that the individual possesses the resources such as

skills, abilities, and knowledge to perform. ... Individual

difference factors can also moderate demand and resource

evaluations in such a way as to cause challenge or threat

responses. ... Finally, dispositions are very likely to play an

important moderating role in demand and resource

evaluationsʺ (p. 490, [42]).

Interventions not properly taking into account the

importance of working on motivation may indirectly

contribute to a ʺgeneral weakening of interconnected

physiological, psychological, and social systems, increasing

many health risks for individuals repeatedly exposed to

threatening motivated performance situationsʺ (p. 489, [42]).

Also, ʺHow individuals evaluate their demands and

resources affects their motivational states, which in turn lead

to differing patterns of physiological responsivity:

Motivation in which evaluated individual resources

outweigh situational task demands (i.e., challenge) does not

appear pathophysiological, and motivation in which

evaluated individual resources are outweighed by

situational task demands (i.e., threat) does appear

pathophysiologicalʺ (p. 491, [42]).

As indicated by Wright et al. [43], the individualʹs level of

initial motivation (reflecting the maximum energy spent

by a person for goals attainment) represents one of the

key predictor in successfully preventing and managing

CV risk factors in CR [44‐50].

6. mHealth for long‐term Cardiac Rehabilitation: the role

of new technologies.

Web‐based and Internet‐based technologies may allow the

creation of collaborative outpatient rehabilitation programs,

providing patients with a remote and continuous

psychological‐medical support, education and monitoring in

order to enhance motivation, compliance and engagement in

treatment. Positive results have been described and

documented for weight‐loss reduction and obesity

rehabilitation [51‐61], as well as for CR Health applications

for lifestyle improvement include surveillance, internet‐

based educational and psychological support and interactive

motivational tools [4]. From a cost‐effective perspective,

further researches are needed in order to evaluate the real

costs and the economical added value of telemedicine and e‐

health. Certainly, they allow to reduce travel time, hospital

admissions and usersʹ service costs [62‐66]. However,

technical problems and patients’ lack of knowledge of the


Exp Clin Cardiol, Volume 20, Issue 9, 2014 - 858

tools as well as patients, caregivers and clinicians

skepticism or reticence could limit the spread of e‐health

solutions [67].

The new mHealth (m‐health, mhealth, mobile health)

approach, supported by mobile communication devices,

such as mobile phones, tablet computers and PDAs, for

health services and information [68‐72], constitutes an

important resource in order to move motivational

psychological support where necessary (outpatient settings)

then to promote lifestyle modifications over time [50, 73‐

80].

In conclusion, more studies should investigate both

possible advantages and applications of mHealth

technologies in long‐term CR.

7. Conclusion

Further studies assessing psychosocial risks factors and

providing motivational support during CR need to be

developed in order to improve patients’ healthier lifestyle

and well‐being. Comparison between different clinical

psychology‐based programs (such as psychological

interventions, psycho‐educational programs,

psychotherapies, educational training, stress management,

biofeedback, counseling sessions and relaxation techniques)

and in‐depth analysis of how different psychological

approaches and protocols work (for instance, Acceptance

and Commitment Therapy [81]; expressive writing [45]),

also require to be inquired and specifically adapted for

treating patients eventual comorbidities, such as obesity [48,

50]. In fact, the majority of patients referring to cardiac

rehabilitation (CR) program are overweight or obese [82]

and obesity itself is associated with an increased risk of heart

attack representing, particularly among women, an

independent predictor of CVD [83] and also acting through

its influence on hypertension, hypercholesterolemia, insulin

resistance, type 2 diabetes, glucose intolerance, left

ventricular hypertrophy, and functional capacity (FC) [46,

47, 84‐89]. To conclude, psychological and psychosocial

interventions need to be improved and adapted to the

specific health condition presented by the patients, both in

traditional settings and in new mHealth scenarios [57, 60, 90‐

93].

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