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1 Research in Sports Medicine ISSN: (Print) (Online) Journal homepage: Motivation and Participation in a Phase III Cardiac Rehabilitation Programme: An Application of the Health Action Process Approach Birte Dohnke, Enno Nowossadeck & Werner Müller-Fahrnow To cite this article: Birte Dohnke, Enno Nowossadeck & Werner Müller-Fahrnow (2010) Motivation and Participation in a Phase III Cardiac Rehabilitation Programme: An Application of the Health Action Process Approach, Research in Sports Medicine, 18:4, To link to this article: Published online: 06 Nov Submit your article to this journal Article views: 971 View related articles Citing articles: 10 View citing articles Full Terms & Conditions of access and use can be found at Download by: [ ] Date: 21 November 2017, At: 12:19

2 Research in Sports Medicine, 18: , 2010 Copyright Taylor & Francis Group, LLC ISSN: print/ online DOI: / Motivation and Participation in a Phase III Cardiac Rehabilitation Programme: An Application of the Health Action Process Approach BIRTE DOHNKE Health Psychology, University of Education Schwäbisch Gmünd, Germany ENNO NOWOSSADECK and WERNER MÜLLER-FAHRNOW Rehabilitation Sciences, Charité - Universitätsmedizin Berlin, Berlin, Germany This longitudinal study extends the previous research on low participation rates and high dropout rates in phase III cardiac rehabilitation (CR) exercise programmes. It examines the correlates of motivation and participation 6 months after inpatient phase II CR (T1) and the predictors of dropout 6 months later (T2) using the health action process approach (HAPA). Risk perception, outcome expectancies, self-efficacy, intention (at T1), and participation (at T1 and T2) in relation to phase III CR programmes was assessed in 456 patients. Based on intention and participation at T1, patients were classified as nonintenders (56%), intenders (13%), or actors (31%). Group differences were confirmed in outcome expectancies and self-efficacy. By T2, 21% of T1 actors had dropped out. Dropouts and maintainers differed in intention and Received 26 March 2009; accepted 23 October The Cardiac Rehabilitation Outcome (CARO) II Study was funded by the German Society on Prevention and Rehabilitation of Cardiovascular Diseases (DGPR). We thank the participating inpatients rehabilitation centres: Kirchberg Klinik (Dr. Knoglinger), Klinik am Rennsteig (PD Dr. Lauten), Klinik Höhenried (Prof. Dr. Klein), Klinik Königsfeld (Prof. Dr. Karoff), Klinik Lazariterhof (Prof. Dr. Bönner), Klinik Roderbirken (Dr. Mayer-Berger), Reha-Klinik Seehof der BfA (Dr. Fuhrmann), Reha-Zentrum Oldenburg (Dr. Böhmen), and Schüchtermann-Klinik Bad Rothenfelde (Dr. Willemsen). Address correspondence to Juniorprof. Dr. Birte Dohnke, University of Education Schwäbisch Gmünd, Institute of Humanities, Department of Educational Psychology and Health Psychology, Oberbettringer Str. 200, Schwäbisch Gmünd, Germany. birte.dohnke@ph-gmuend.de 219

3 220 B. Dohnke et al. self-efficacy (at T1). Results are in line with the HAPA and suggest a perspective for tailoring motivational counselling to improve participation in phase III CR programmes. KEYWORDS cardiac rehabilitation, exercise programme participation, motivation, participation, dropout, inpatient rehabilitation centers INTRODUCTION Due to its beneficial effects, exercise is recommended in phase III cardiac rehabilitation (CR) for most cardiac patients, and exercise programmes that specifically target cardiac patients are available. Many patients, however, either do not participate or choose to drop out of such programmes. To understand this lack of commitment to exercise programmes, a number of studies have focused on identifying predictors of participation (e.g., sociodemographic or clinical variables). In contrast, the present longitudinal study uses a theoretical framework of health behaviour change to examine the social cognitive factors underlying phase III CR programme intention, adoption, and dropout. Cardiac Rehabilitation CR programmes mainly involve exercise training accompanied by risk factor modification and psychological counselling and have beneficial effects in terms of mortality prevention, physical health, risk/lifestyle factors, and psychosocial functioning (Taylor, Brown, Ebrahim, et al. 2004; Witt, Thomas, and Roger 2005). Based on the World Health Organization (WHO) definition, three phases of CR have been established: (I) the acute phase, (II) the reconditioning phase, and (III) the maintenance phase. In Germany, phase II CR typically occurs in the form of inpatient treatment in specialist rehabilitation centres (Karoff, Held, and Bjarnason-Wehrens 2007). Phase III involves a network of more than 6,600 heart groups (i.e., phase III CR programmes) that treat approximately 110,000 patients (Karoff, Held, and Bjarnason-Wehrens 2007). These heart groups provide 90-minute sessions consisting mainly of exercise training once or twice per week. The sessions are conducted by a qualified trainer and are medically supervised. Patients are reimbursed by social insurance. Most previous research has revealed low participation rates and high dropout rates in CR (Daly, Sindone, Thompson, et al. 2002; Jackson, Leclerc, Erskine, et al. 2005; Witt, Thomas, and Roger 2005). In Germany, these findings are particularly applicable to participants in phase III CR programmes: Participation in phase II CR programmes is recommended to most patients

4 Phase III CR Motivation and Participation 221 in phase II CR, but only 20% 30% of phase II patients comply within the first year after discharge (e.g., Bjarnason-Wehrens, Kretschmann, Lang, et al. 1998; Keck and Budde 1999; Löwel, Lewis, Härtel, et al. 1994; Müller- Fahrnow, Nowossadeck, Dohnke, et al. 2006; Völler, Klein, Gohlke, et al. 2000). Furthermore, many of the patients who do participate later drop out (Bjarnason-Wehrens, Kretschmann, Lang, et al. 1998; Budde and Keck 1999). A number of studies have been conducted in an effort to understand the low participation and high dropout rates in CR. Most have focused on sociodemographic variables (e.g., age, gender, education), clinical variables (e.g., diagnosis, comorbidities), centre-related variables (e.g., schedule, distance, group format), provider-oriented variables (e.g., lack of referral), and/or single psychological variables (e.g., depression, social support; Bjarnason-Wehrens, Kretschmann, Lang, et al. 1998; Daly, Sindone, Thompson, et al. 2002; Jackson, Leclerc, Erskine, et al. 2005; Keck and Budde 1999; Witt, Thomas, and Roger 2005). With regard to developing interventions, evidence from these studies (a) enables a practitioner to identify, prior to discharge, those patients who are at risk for nonparticipation and may need more motivation or a specific CR format (e.g., women) and (b) reveals barriers that interfere with optimal programme design (e.g., schedule, location). This research, however, does not indicate how patient counselling can be tailored to increase motivation and rates of long-term participation. The evidence discovered thus far is not enough to solve this problem due to the complex nature of the process of health behaviour change: therefore, additional studies are required to analyse CR participation within a theoretical framework of health behaviour change. Health Action Process Approach (HAPA) The health action process approach (Schwarzer 2001, 2008) is a model that describes the process of health behaviour change. The HAPA distinguishes between a motivational phase, which leads to behavioural intentions, and a volitional phase, which leads to actual health behaviour. The volitional phase can be further subdivided into a preactional stage and an actional stage. Three groups of individuals can be differentiated based on these phases or stages. Each group is characterised by a specific mindset. Interventions that are tailored to particular stages or mindsets are the most beneficial in terms of encouraging stage progression and persistent health behaviour change. In the motivational (nonintentional) phase or stage, individuals do not yet have an intention to act (e.g., a patient does not intend to participate in a phase III CR programme). Individuals at this stage are called nonintenders. Three social cognitive factors are important in forming an intention. The first is risk perception, which includes the vulnerability and severity of possible health threats (Garcia and Mann 2003; Renner and Schwarzer 2005; Satow and Schwarzer 1997; Schwarzer and Renner 2000; Sniehotta, Scholz,

5 222 B. Dohnke et al. and Schwarzer 2005), particularly in nonintenders (Lippke, Ziegelmann, and Schwarzer 2005). Risk perception alone, however, seems to be insufficient to enable intention formation. The second factor is positive outcome expectancies (Garcia and Mann 2003; Lippke, Ziegelmann, and Schwarzer 2004; Luszczynska and Schwarzer 2003; Renner and Schwarzer 2005; Satow and Schwarzer 1997; Schwarzer 2008; Schwarzer and Renner 2000; Schwarzer, Schuz, Ziegelmann, et al. 2007; Sniehotta, Scholz, and Schwarzer 2005). Finally, self-efficacy (i.e., the belief in one s capabilities to mobilize the motivation, cognitive resources, and courses of action required to attain behavioural goals (Bandura 1997)) is needed (Barling and Lehmann 1999; Garcia and Mann 2003; Lippke, Ziegelmann, and Schwarzer 2004; Lippke, Ziegelmann, and Schwarzer 2005; Luszczynska and Schwarzer 2003; Renner and Schwarzer 2005; Satow and Schwarzer 1997; Schwarzer 2008; Schwarzer and Renner 2000; Schwarzer, Schuz, Ziegelmann, et al. 2007; Sniehotta, Scholz, and Schwarzer 2005). For example, the more a patient perceives himself or herself to be at risk for reinfarction, the more positive outcomes he or she expects from participation in a phase III CR programme, and the stronger he or she believes in his or her ability to participate in such a programme, the stronger his or her intention to adopt it. After an intention is formed, individuals enter the volitional phase (e.g., a patient intends to participate in a phase III CR programme). In this phase, a sequence of postintentional processes is believed to be central for health behaviour change. In the preactional stage, individuals do not yet act, as they must still implement their intention. Individuals at this stage are called intenders. For example, a patient has to make concrete plans regarding when and where to participate in a phase III CR programme. This patient must also become aware of the fact that investment of effort and perseverance is required. With this transition to the volitional phase, social cognitive factors are assumed to change in importance, thereby reflecting a mindset that differs from that of the motivational stage. At this point, the previously described motivational factors are less influential (Lippke, Ziegelmann, and Schwarzer 2005; Renner and Schwarzer 2005). Of particular importance are volitional factors such as self-efficacy; these factors enhance intentions and enable more flexible planning, particularly when barriers occur or conditions constrain the intended behaviour (Lippke, Ziegelmann, and Schwarzer 2004; Lippke, Ziegelmann, and Schwarzer 2005; Luszczynska and Schwarzer 2003; Schwarzer 2008; Schwarzer, Schuz, Ziegelmann, et al. 2007; Sniehotta, Scholz, and Schwarzer 2005). The fact that self-efficacy is important in all stages of the process of health behaviour change (although with specific meanings in each) has been taken into account by phase-specific self-efficacy constructs (Schwarzer 1998, 2008). Recent research provides empirical evidence suggesting that phase-specific self-efficacy constructs differ in their effects on various preventive health behaviors (Luszczynska and Schwarzer 2003; Scholz, Sniehotta, and Schwarzer 2005; Schwarzer,

6 Phase III CR Motivation and Participation 223 Schuz, Ziegelmann, et al. 2007; Sniehotta, Scholz, and Schwarzer 2005). In addition, as soon as individuals adopt the intended behaviour (e.g., a patient adopts the phase III CR programme), they enter the actional stage. At this stage they are called actors. To maintain the behaviour, individuals must now choose or develop beneficial conditions that will enable them to invest effort and resist the temptation to disengage from the new behaviour. Thus, their mindset has changed once again: Stronger intentions may contribute to maintenance (Lippke, Ziegelmann, and Schwarzer 2004; Lippke, Ziegelmann, and Schwarzer 2005). Self-efficacy, however, is the main stabilising factor in this stage (particularly maintenance and recovery self-efficacy; Luszczynska and Schwarzer 2003; Scholz, Sniehotta, and Schwarzer 2005; Schwarzer, Schuz, Ziegelmann, et al. 2007; Sniehotta, Scholz, and Schwarzer 2005). Studies on physical exercise confirm the assumptions of the HAPA (Lippke, Ziegelmann, and Schwarzer 2004; Lippke, Ziegelmann, and Schwarzer 2005; Scholz, Sniehotta, and Schwarzer 2005; Schwarzer, Schuz, Ziegelmann, et al. 2007; Sniehotta, Scholz, and Schwarzer 2005) and various other health behaviours (Barling and Lehmann 1999; Garcia and Mann 2003; Luszczynska and Schwarzer 2003; Renner, Kwon, Yang, et al. 2008; Renner and Schwarzer 2005; Satow and Schwarzer 1997; Schuz, Sniehotta, Mallach, et al. 2009; Schwarzer and Renner 2000; Schwarzer, Schuz, Ziegelmann, et al. 2007; for a review see also Schwarzer 2008): First, health behaviour change is a dynamic process in which individuals pass through motivational and preactional stages in order to enter and remain in the actional stage. Second, each stage is characterised by a certain mindset. Different patterns of social cognitive factors should emerge in the different stages and be important for transitioning into the next stage, remaining in the same stage, or transitioning to a previous stage. The Present Study This longitudinal study extends the previous literature on low participation rates and high dropout rates in CR using the HAPA as a theoretical framework. First, correlates of phase III CR programme motivation and participation 6 months after phase II CR (T1) were examined by testing cross-sectional stage differences in social cognitive factors between CR programme nonintenders, intenders, and actors. Due to the assumption of stage-specific mindsets, discontinuity patterns were expected across the three stages (i.e., patient groups). Based on the HAPA assumptions and empirical evidence on intention formation, risk perception and positive outcome expectancies were expected to be higher in intenders than in nonintenders. Conversely,

7 224 B. Dohnke et al. negative outcome expectancies were hypothesised to be lower in intenders than in nonintenders. With respect to predictors of behaviour, self-efficacy was postulated to be highest in actors, though it was believed that it would increase across all three patient groups due to its importance in all phases of health behaviour change. Second, dropout 6 months later was considered a stage transition backward from the actional stage at T1 to nonparticipation at T2. To examine predictors of dropout at T2, differences in social cognitive factors between CR programme dropouts and maintainers were examined at the 6-month follow-up (T1). Theoretically and empirically founded, motivational factors were hypothesised to be less important than volitional factors. Thus, risk perception and outcome expectancies were not expected to differ significantly. Self-efficacy and intention, however, were expected to be lower in dropouts than in maintainers. METHODS A sample of 456 patients was derived from participants based on the 6- month follow-up of the longitudinal cardiac rehabilitation outcome (CARO) II study (Müller-Fahrnow, Nowossadeck, Dohnke, et al. 2006), which consecutively enrolled participants in nine inpatient rehabilitation centres in Germany. Patients were admitted for phase II CR after acute myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, heart valve replacement surgery, or coronary heart disease. Questionnaires were administered by mail at the 6-month (T1) and 12-month (T2) follow-ups. Measures Main study measures at T1 included the social cognitive factors risk perception, outcome expectancies, phase-specific self-efficacy, and intention. Measures at both T1 and T2 included behaviours such as participation. Risk perception was measured by a simple count of perceived risk factors obtained by asking patients which of eight cardiovascular risk factors applied to them (e.g., inactivity, hypertension, overweight) on a scale of 1 no, 2yes, 3do not know. Outcome expectancies, self-efficacy, and intention were measured as statement items specific for regular phase III CR programme participation (1 = not at all true, 4 = exactly true), adapting commonly used HAPA measures for physical activity (Schwarzer, Schuz, Ziegelmann, et al. 2007). To assess outcome expectancies, the stem If I regularly participate in a phase III CR programme,... was followed by three pros (e.g., then I do something good for my health ; Cronbach s α =.79) and three cons

8 Phase III CR Motivation and Participation 225 (e.g., then it costs me every time a lot of time ; Cronbach s α =.76). Selfefficacy included two subscales corresponding to maintenance and recovery (i.e., readoption) of CR programme participation. The stem I am confident that I am able... was followed by 10 maintenance barriers (e.g., to maintain regular phase III CR programme participation even if I have a lot on my plate ) and three recovery barriers (e.g., to readopt regular phase III CR programme participation even if I give it up for a few weeks ; for both subscales Cronbach s αs =.96). Measures of outcome expectancy and self-efficacy were calculated with a mean score. To measure CR programme intention, patients were asked to indicate how much the statement I intend to participate regularly in a phase III CR programme in the coming months applied to them. Participation was assessed by the frequency measure, How often do you participate in a phase III CR programme per week or month? With regular participation as criterion for the present study, answers were dichotomised based on the heart group schedule of one or two sessions a week (0 = less than one time a week, 1= one or more times a week). Data Analysis Chi-square tests were used to compare proportions; t tests and univariate analyses of (co)variance were used to compare means. Degrees of freedom and t values were adjusted for unequal variances. First, correlates of phase III CR programme motivation and participation at T1 were examined by analysing discontinuity patterns in the social cognitive factors (all at T1) across CR programme nonintenders, intenders, and actors. The appropriate method, therefore, involves analyses of variance and polynomial contrast analyses (cf., Armitage and Arden 2002). To adjust the alpha level for multiple testing and control for any confounders, a multiple analysis of covariance was performed (cf., Armitage, Povey, and Arden 2003). If both quadratic and linear trends were significant in supporting discontinuity (Armitage and Arden 2002), differences between adjunct stages were interpreted on the basis of pairwise comparison results. Second, predictors of CR programme dropout at T2 were examined by conducting a multiple analysis of covariance and a multivariate logistic regression analysis. RESULTS CR Motivation and Participation at 6 Months Follow-Up (T1) Patient classification was based on both intention and participation measures: Patients who reported having participated in a phase III CR programme at least once a week were assigned to the actional stage (i.e.,

9 226 B. Dohnke et al. actors). Nonparticipants were classified by their intention: Those with an intention (i.e., exactly true or likely true in response to I intend to participate regularly in a phase III CR programme in the coming months ) were assigned to the preactional stage (i.e., intenders), whereas those without an intention (i.e., not at all true or not likely true) were assigned to the nonintentional stage (i.e., nonintenders). Classification resulted in 56% nonintenders, 13% intenders, and 31% actors. Patients in the three stages differed significantly in terms of gender, age, and indication for phase II CR (ps <.05). The proportion of male patients, the proportion of patients following a bypass grafting, and patient age increased across stages (see Table 1). Further analyses therefore controlled for these variables by entering them as a covariate (age) or further factor (sex, rehab indication). The MANCOVA indicated significant differences across stages, F(10, 888) = 16.98, p <.001, η 2 =.16. The only significant control variable was age, F(5, 443) = 11.25, p < 0.001, η 2 =.11. Univariate Fs and contrast analyses produced the results described below (see Table 2). Risk perception did not differ significantly across stages. Age was significant, F(1, 447) = 50.69, p <.001, η 2 =.10, indicating that younger patients reported more risk factors, B =.06, SE =.01, p <.001. Stage differences in pros and cons were significant. Whereas the linear trend was significant for both pros and cons, the quadratic trend was significant only for cons. A comparison of adjunct stages revealed that cons differed significantly only between intenders and actors. This indicates that intenders expected more cons from a regular phase III CR programme participation than did actors. In addition, age significantly predicted cons, F(1, 447) = 5.62, p <.05, η 2 =.01, indicating that younger patients expected more cons, B =.01, SE =.004, p <.05. TABLE 1 Age, Gender, and Indication for Phase II CR Across the Three Subsamples of Phase III CR Participation at 6-Month Follow-up (T1) Nonintenders Intenders Actors Total N (%) 257 (56) 60 (13) 139 (31) 456 (100) Gender: male n (%) 240 (93) 53 (88) 118 (85) 411 (90) Age in years M (SD) (10.53) (8.46) (9.41) (10.03) Indication for phase II CR n (%) CABG 106 (41) 23 (38) 78 (56) 207 (45) MI 99 (39) 22 (37) 47 (34) 168 (37) PTCA 18 (7) 6 (10) 8 (6) 32 (7) HVR 10 (4) 4 (7) 1 (1) 15 (3) CHD 24 (9) 5 (8) 5 (4) 34 (8) Notes. CABG: coronary artery bypass grafting, MI: myocardial infarction, PTCA: percutaneous transluminal coronary angioplasty, HVR: heart valve replacement, CHD: coronary heart disease without an acute cardiac event. p <.05; p <.01.

10 TABLE 2 Social Cognitive Variables Across the Three Subsamples at 6-Month Follow-up: Means (Standard Deviations) and MANCOVA Results for Stage Differences and Discontinuity Patterns, Controlling for Age, Gender, and Indication for Phase II CR Nonintender (NI) Intender (I) Actor (A) Total N Trend analyses (p) Pairwise comparisons (mean difference) Main effect: stage (F) Linear Quadratic NI I I-A Risk perception 3.11 (1.73) 3.43 (1.54) 3.06 (1.69) 3.14 (1.70) Pros 2.81 (0.72) 3.25 (0.58) 3.60 (0.46) 3.11 (0.73) Cons 1.98 (0.82) 2.00 (0.82) 1.41 (0.57) 1.81 (0.79) Maintenance SE 2.24 (0.84) 2.64 (0.79) 2.83 (0.93) 2.47 (0.90) Recovery SE 2.39 (1.00) 3.00 (0.82) 3.31 (0.86) 2.75 (1.02) Notes. Pros: positive outcome expectancies; Cons: negative outcome expectancies; SE: self-efficacy. + p <.10; p <.05; p <

11 228 B. Dohnke et al. Finally, maintenance and recovery self-efficacy differed significantly between stages, but only the linear trend was significant. That is, patients in higher stages demonstrated higher self-efficacy to maintain and readopt regular phase III CR programme participation. CR Dropout at 12-months follow-up (T2) Dropout from phase III CR programme participation at T2 was considered a backward transition from the actional stage at T1 to nonparticipation at T2. Consequently, hypothesis testing was restricted to the T1 actors who returned their T2 questionnaire. To identify the factors that may have contributed to attrition, differences in the main study variables between the T1 actors who did return their T2 questionnaire (n = 125, 90%) and those who did not (n = 14, 10%) were tested. The results showed a significant difference only with regard to gender, indicating that T1 actors who returned their T2 questionnaire were less likely to be female (n = 16, 13% vs. n = 5, 36%), χ 2 (1, 139) = 5.15, p <.05. All further analyses therefore controlled for gender. Twenty-six patients dropped out of the phase III CR programme by T2 (21%; patients maintaining: n = 99, 79%). The groups (dropouts and maintainers) did not differ significantly in terms of gender (male: n = 109, 87%), age (M = 59.85, SD = 9.39), or indication for phase II CR (n = 125: 57% CABG, 34% MI, 4% CHD, 4% PTCA, and 1% HVR). To test the hypothesis that mainly volitional factors are important for phase III CR programme dropout at T2, a MANOVA was conducted to compare mean level differences in social cognitive factors between CR programme dropouts and maintainers at the 6-month follow-up (T1). Of the two factors, dropout and gender, only dropout was significant, F(6, 117) = 2.32, p <.05, η 2 =.11. Univariate Fs showed significant differences not in motivational factors, but in volitional factors (see Table 3). Participants who dropped out at T2 already reported weaker intention and lower self-efficacy to maintain regular phase III CR programme participation at T1. The difference in recovery self-efficacy was marginally significant, suggesting that participants with lower self-efficacy to readopt regular phase III CR programme participation at T1 also tended to drop out more frequently by T2. In addition, a logistic regression analysis tested the predictive values of the volitional factors at T1 for CR programme dropout by T2. The stepwise method revealed a significant effect of intention, OR = 0.30 (95%CI ), and maintenance self-efficacy, OR = 0.60 (95%CI ), in the second (backward) step, Nagelkerkes R 2 =.14. Gender was entered in the first step of the analysis and had no significant effect.

12 Phase III CR Motivation and Participation 229 TABLE 3 Social Cognitive Variables at T1 for Phase III CR Dropout at 12-Month Follow-Up (T2): Means (Standard Deviations) and MANOVA Results for Group Differences, Controlling for Gender Maintainer Dropouts Total N F η 2 Risk perception 3.16 (1.71) 2.85 (1.67) 3.10 (1.70) Pros 3.63 (0.43) 3.51 (0.58) 3.60 (0.46) Cons 1.39 (0.52) 1.42 (0.62) 1.39 (0.54) Maintenance SE 2.91 (0.93) 2.43 (0.98) 2.81 (0.96) Recovery SE 3.37 (0.86) 3.04 (0.90) 3.30 (0.88) Intention 3.97 (0.30) 3.73 (0.67) 3.92 (0.41) Notes. Pros: positive outcome expectancies; Cons: negative outcome expectancies; SE: self-efficacy. + p <.10; p <.05; p <.01. DISCUSSION This longitudinal study extends the previous literature on low participation rates and high dropout rates in CR by examining motivation and participation in a phase III CR programme. The analysis was conducted within the theoretical framework of health behaviour change. In particular, the HAPA was applied to identify correlates of phase III CR motivation and participation 6 months after phase II CR, and predictors of CR dropout 6 months later. The rate of phase III CR participation 6 months after phase II CR was low (31%), which is in accordance with previous research (Bjarnason- Wehrens, Kretschmann, Lang, et al. 1998; Keck and Budde 1999; Löwel, Lewis, Härtel, et al. 1994; Müller-Fahrnow, Nowossadeck, Dohnke, et al. 2006; Völler, Klein, Gohlke, et al. 2000). An additional 13% of patients still intended to participate regularly. This is rather surprising, as information and motivation regarding a phase III CR programme are provided during phase II CR: patients are expected to adopt phase III CR programme participation within the following 6 months. Intention formation was hypothesised to be influenced by increasing risk perception (Garcia and Mann 2003; Lippke and Sniehotta 2003; Lippke, Ziegelmann, and Schwarzer 2005; Renner and Schwarzer 2005; Satow and Schwarzer 1997; Schwarzer and Renner 2000; Sniehotta, Luszczynska, Scholz, et al. 2005; Sniehotta, Scholz, and Schwarzer 2005), increasing positive outcome expectancies and decreasing negative outcome expectancies (Garcia and Mann 2003; Lippke, Ziegelmann, and Schwarzer 2004; Luszczynska and Schwarzer 2003; Renner and Schwarzer 2005; Satow and Schwarzer 1997; Schwarzer and Renner 2000; Schwarzer, Schuz, Ziegelmann, et al. 2007; Sniehotta, Scholz, and Schwarzer 2005), and increasing self-efficacy (Barling and Lehmann 1999; Garcia and Mann 2003; Lippke and Sniehotta

13 230 B. Dohnke et al. 2003; Lippke, Ziegelmann, and Schwarzer 2004; Lippke, Ziegelmann, and Schwarzer 2005; Renner and Schwarzer 2005; Satow and Schwarzer 1997; Schwarzer, Schuz, Ziegelmann, et al. 2007; Sniehotta, Luszczynska, Scholz, et al. 2005). Our cross-sectional results are in line with these model predictions: Patients who intended to participate expected more positive consequences and reported higher self-efficacy in relation to regular phase III CR programme participation when compared with patients who did not intend to participate. Risk perception and negative outcome expectancies, however, did not differ significantly between intenders and nonintenders. This finding will be discussed later. Increasing self-efficacy (Luszczynska and Schwarzer 2003; Satow and Schwarzer 1997; Schwarzer and Renner 2000; Schwarzer, Schuz, Ziegelmann, et al. 2007; Sniehotta, Scholz, and Schwarzer 2005) was hypothesised to be important for CR adoption. Again, our cross-sectional findings are in line with this hypothesis: Participants reported higher self-efficacy in relation to regular phase III CR programme participation than patients who only intended to participate. In addition, participants expected more positive and fewer negative outcomes from regular phase III CR programme participation when compared with patients who only intended to participate. This finding is supported by evidence from the literature (Barling and Lehmann 1999; Renner and Schwarzer 2005). The three patient groups (nonintenders, intenders, and actors) differed significantly in social cognitive factors over and above gender, age, and indication for phase II CR. This finding confirmed the independent influence of social cognitions. Stage-specific patterns of the social cognitive factors (mindsets) were supported by the discontinuity pattern in negative outcome expectancies: Comparison of adjunct stages indicated that expecting negative behavioural consequences seems to characterise the mindset of nonactors (i.e., cardiac patients who do not participate in a phase III CR programme). Thus, this social cognitive factor did not differentiate the mindset of nonintenders from that of intenders. Instead, a decrease in negative outcome expectancy characterises the mindset of actors. This suggests that expecting negative consequences from phase III CR programme participation prevents intenders from translating their intentions into action. This finding thereby moves beyond HAPA assumptions and previous evidence that negative outcome expectancies are less important than positive outcome expectancies for intention formation (Schwarzer 2008) by revealing their importance in the following behavioural stage. Finally, it is noteworthy that the overall difference in risk perception was not significant. This finding, however, should not be interpreted as an indication that risk perception plays no role in intention formation and should be excluded from motivational counselling. Such a conclusion would be short-sighted because all three patient groups whether motivated or not perceived an average of three personal risk factors. This finding should be considered an indicator

14 Phase III CR Motivation and Participation 231 that all patients are well informed and sensitised to their personal risks after phase II CR. Dropping out of the phase III CR programme after 6 month was considered a backward transition from the actional stage at T1 to nonparticipation at T2. This response was found in 21% of the former participants, which is consistent with previous research (Bjarnason-Wehrens, Kretschmann, Lang, et al. 1998; Budde and Keck 1999). On the basis of the HAPA assumptions and empirical findings, motivational factors should not play a role in this later process of health behaviour change (Lippke and Sniehotta 2003; Renner and Schwarzer 2005; Schuz, Sniehotta, Mallach, et al. 2009; Sniehotta, Luszczynska, Scholz, et al. 2005). In fact, our longitudinal results confirmed that dropouts and maintainers differed in neither their risk perception nor their outcome expectancies. Rather, it was postulated that volitional factors are important in this actional phase (Luszczynska and Schwarzer 2003; Renner and Schwarzer 2005; Scholz, Sniehotta, and Schwarzer 2005; Schwarzer, Schuz, Ziegelmann, et al. 2007; Sniehotta, Scholz, and Schwarzer 2005). In accordance with this assumption, our longitudinal results demonstrated that patients who dropped out of the phase III CR programme at T2 had lower intention and maintenance self-efficacy at T1. Moreover, they appeared to perceive also lower recovery self-efficacy at T1. Low intention and low maintenance self-efficacy at T1 were identified as the main predictors of CR dropout at T2 using a multivariate logistic regression analysis. Dropout from phase III CR programme participation after 6 months increased by 27% and 13% for every standard deviation decrease in participants (T1 actors ) intention and maintenance self-efficacy at T1. This finding is in accordance with the fact that maintenance of a new behaviour is not achieved through strong intention alone. Rather, it requires selfregulatory skills and strategies to cope successfully with barriers that occur after adopting the new behaviour as reflected by maintenance self-efficacy (Schwarzer 2008). Recovery self-efficacy was not predictive. This finding underlines the validity of both self-efficacy constructs and thereby supports the stage-specific differentiation of this important social cognitive factor. Recovery self-efficacy may reflect the confidence in strategies for readopting phase III CR programme participation as indicated by a study showing that recovery self-efficacy supports cardiac patients not in maintaining physical exercise, but in readopting it after a break (Scholz, Sniehotta, and Schwarzer 2005). Finally, our longitudinal results provide further evidence for stagespecific mindsets that characterise the different stage groups on their way to persistent health behaviour change. Volitional factors such as intention and maintenance self-efficacy thus differentiated the mindsets of actors who succeeded and failed to maintain persistent phase III CR programme participation. In line with the HAPA, this study suggests the following clinical implications: Phase III CR programme participation should be understood as a

15 232 B. Dohnke et al. dynamic process in which patients pass through different psychological stages. During these stages, certain mindsets cause them to step forward or backward on their way to persistent programme participation. Thus, a patient s psychological stage or mindset has to be diagnosed prior to every intervention. Interventions then should be tailored to that specific stage, resulting in higher motivation, higher adoption rates, and lower dropout rates. All patients should be informed about the health risks associated with their current lifestyle. When a patient is unmotivated and does not intend to participate in a CR programme (i.e., is in the nonintentional stage), positive consequences of CR participation in particular should be discussed to resolve this ambivalence and help form an intention. In addition, the barriers that prevent a patient from setting an intention should be clarified, and his or her confidence to overcome these barriers should be strengthened. Strengthening a patient s intention alone, however, may not be enough to support CR programme participation. For a patient who is motivated and intends to participate (i.e., is in intentional stage), counselling should focus on the personal and health-related benefits of CR programme participation. Primarily, however, it should clarify the barriers preventing a person from acting. Counselling should aim to qualify these and strengthen the behavioural competences necessary to act in the face of them. Counselling for a patient who already participates in a CR programme (i.e., is in actional stage) should promote self-reflection of the pros and behavioural competences associated with participation. With respect to behavioural competences (self-efficacy), barriers might be addressed that hinder the maintenance of CR participation and a patient s confidence strengthened to cope successfully with them. Some limitations, however, should be addressed in future research. First, CR intention and CR adoption were examined in a cross-sectional design 6 months after discharge from phase II CR. Given that patients can become informed, motivated, and supported to plan a phase III CR programme participation during phase II CR, future research should use a longitudinal design and assess social cognitive factors, including intention at discharge from phase II CR to study these early stages of health behaviour change. This extension would provide further information that could help better design patients counselling during phase II CR, thereby resulting in increased phase III CR programme motivation and higher adoption rates. Second, the difference in risk perception across all three stages was not significant. In order to draw final conclusions regarding patient motivation by risk communication in phase II CR, further research on the influence of risk perception on phase III CR motivation and participation is needed. Third, self-efficacy was the only volitional factor examined in addition to intention. Future research on CR adoption and dropout should include planning as a second promising factor to bridge the intention behaviour gap and

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