Effects Change Cad PDF

EFFECTS OF BEHAVIOR CHANGE PROGRAM ON
PHYSICAL ACTIVITYAND PHYSICAL FITNESS

IN PATIENTS STATUS POST
CORONARY ARTERY BYPASS GRAFT SURGERY
WORARAT PHOTI
A THESIS SUBMITTED IN PARTIAL FULFILLMENT

OF THE REQUIREMENTS FOR
THE DEGREE OF MASTER OF NURSING SCIENCE
(ADULT NURSING)
FACULTY OF GRADUATE STUDIES
MAHIDOL UNIVERSITY
2009
COPYRIGHT OF MAHIDOL UNIVERSITY
Copyright by Mahidol University
iii
ACKNOWLEDGEMENTS
The success of this thesis can been attributed to the extensive support and
assistance from my major advisor, Asst. Prof. Napaporn Wanitkun and my co-advisor,
Assoc. Prof. Suvimol Kimpee and Dr. Taweesak Chotivatanapong. I deeply thank
them for their valuable advice and guidance in this research.
I would like to express my deep appreciation to Dr. Grit Leetongin for
external examiner of the thesis defense, his kindness and helpful guidance. I would
like to gratefully appreciate Assoc. Prof. Kanaungnit
Pongthavornkamol for her
constructive comments. Grateful acknowledge extend to all the experts for their
invaluable advice and comments on this thesis ,especially Prof. Karen B. Tetz for her
time in revising and polishing my English writing.
I wish to thank all experts for kindness in examining the research
instrument and providing suggestions for improvement.
I would like to thank all nurses and other health care team member at the
Chest Disease Institute for helping me to succeed in data collection. I am deeply
thankful to all patients for their cooperation to patients in my study.
I am grateful to all the lectures and staff of the Faculty of Nursing for
valuable advice and thanks also go to my older sister and friends in classmate master
program for their kind support.
Finally, I am grateful to my parents for their financial support, entirely
care, love, and believed in me. Thanks Mr. Nuttaphon for helped in any way you
could. The usefulness of this thesis I dedicate to my father, my mother and all the
teachers who have taught me since my childhood.
Worarat Photi
Fac. of Grad. Studies, Mahidol Univ.
Thesis / iv
EFFECTS OF BEHAVIOR CHANGE PROGRAM ON PHYSICAL ACTIVITY

AND PHYSICAL FITNESS IN PATIENTS STATUS POST CORONARY
ARTERY BYPASS GRAFT SURGERY
WORARAT PHOTI 4936723 NSAN/M
M.N.S. (ADULT NURSING)
THESIS ADVISORY COMMITTEE : NAPAPORN WANITKUN, Ph.D. (Adult Nursing),
SUVIMOL KIMPEE, M.ED., TAWEESAK CHOTIVATANAPONG, M.D.
ABSTRACT
This quasi-experimental study was designed to examine a Behavior Change
Program that would significantly impact physical activity and physical fitness in patients with
post coronary artery bypass graft surgery, who were admitted to the Central Chest Institute
during December 2008 May 2009.
The participants of this study were 73 patients following coronary artery bypass
graft surgery. There were patients in the control group (n=37) and the intervention group
(n=36). The two groups were matched by age and sex. Patients in the control group were fully
recruited first and then the intervention group was started on data collection two weeks later
to prevent contamination. Both groups received the cardiac rehabilitation program as usual
hospital care of the Central Chest Institute and the experimental group also participated in the
Behavior Change Program. The program was based on the specific constructs of the
Transtheoretical Model for only individuals in the preparation stage of readiness for physical
activity. Physical activity behavior (measured by expenditure of at least a moderate level of
physical activity) and physical fitness (measured by six-minute walking distance) were
assessed at pre- and post-intervention. Only daily steps were measured post- intervention. The
data were analyzed using MANOVA.
The results demonstrated that both groups had no difference in physical activity
and physical fitness pre-intervention (p>.05). Post-intervention, the intervention group had a
significantly higher level of physical activity and physical fitness than the control group
(p< 0.01).
These findings can be applied to improve physical activity and physical fitness
among patients who have had post-coronary artery bypass graft surgery and have potential
applications for other clinical settings.
KEY WORDS: BEHAVIOR CHANGE PROGRAM / CORONARY ARTERY

BYPASS GRAFT / PHYSICAL ACTIVITY /
TRANSTHEORETICAL MODEL
111 pages
Thesis / v
EFFECTS OF BEHAVIOR CHANGE PROGRAM ON PHYSICALA CTIVITY AND PHYSICAL

FITNESS IN PATIENTS STATUS POST CORONARY ARTERY BYPASS GRAFT SURGERY
4936723 NSAN/M
.. ()
: , Ph.D. (Nursing), , ..
( ), , ..
2551 2552
73
(37 ) (36 )
2

6
(
) ( 6 )
MANOVA

(p > .05)
(,
) ( 6 )
(p< 0.01).

111
vi
CONTENTS
Page
ACKNOWLEDGEMENTS
iii
ABSTRACTS (ENGLISH)
iv
ABSTRACTS (THAI)
LIST OF TABLES
viii
LIST OF FIGURE
ix
CHAPTER I
INTRODUCTION
Background and significance of the study
Research questions
Purpose of the research
Research hypothesis
Conceptual framework of the research
Scope of the study
Definition of terms
Expected benefits of the research
10
CHAPTER II
LITERATURE REVIEW
11
CHAPTER III
METHODOLOGY
37
Research design
37
Population and sampling
37
Setting
38
Instrument
38
Validity and reliability
42
Data collection
43
Protection of human right
47
Data analysis
48
vii
CONTENTS (cont.)
Page
CHAPTER IV
RESULTS
50
CHAPTER V
DISCUSSION
62
CHAPTER VI
CONCLUSION
69
REFERENCES
73
APPENDICES
Appendix A
The experts who validated the content of the

instruments.
93
Appendix B
Demographic data questionnaire.
94
Appendix C
Exercise Stages of Change questionnaire : ESC.
95
Appendix D
Community Health Activities Model Program for

Seniors
96
Activities Questionnaire for Older Adults: CHAMPS

Appendix E
Self-Efficacy for Overcoming Barriers to Exercise

questionnaire.
98
Appendix F
Questionnaire for evaluated patient perception of care.
Appendix G
Self liberation card
100
Appendix H
Brochures
103
Appendix I
Motto
105
Appendix J
Letter
106
Appendix K
Behavior Change Program guideline
107
Appendix L
Pedometers manual
109
Appendix M
Documentary Proof of Mahidol University Institutional

Review Board
BIOGRAPHY
99
110
111
viii
LIST OF TABLES
Table
1
Page
Physical Activity for Patients Received coronary Artery
Bypass Graft Surgery
25
The Behavior Change Program
46
Comparison of Demographic characteristics by Chi-square

and Mann-Whitney U test
Comparison of Socioeconomic Status Between Control and

Intervention Groups by Chi-square and Mann-Whitney U test.
51
52
Comparison of health behaviors : working physical activity,

diet control, smoking by Chi-square and Mann-Whitney U test
53
The Frequency and Percentage of Functional Class
54
Frequency and Percentage of Illness Conditions
55
Comparisons of Mean and standard deviation of Caloric

Expenditure of at Least Moderate Physical Activity Level
and Above, Daily Steps and Six-Minute Walking Distance
Between Intervention and Control Group at postintervention by MANOVA
Frequency and Percentage of Participants Perception of

Care quality
10
56
58
Comparing means and standard deviations of Self-efficacy

for Overcoming Barriers by t-test
60
ix
LIST OF FIGURES
Figure
Page
Conceptual framework of the research
The processes of the intervention
8
45
M.N.S. (Adult Nursing) / 1
CHAPTER I
INTRODUCTION
Background and Significance of the Study

Acute Coronary Syndromes (ACS) is the leading cause of death and
results in high hospital costs in Thailand (Bureau of Policy and Strategy, 2005) and the
United States (Anderson et al., 2007). Coronary Artery Bypass Graft (CABG) surgery
is a treatment that may be used for patients with ACS. The number of patients who
received CABG surgery in Thailand increased from 2,213 in 2005,to 3,063 in 2007
(The Society of Thoracic Surgeons of Thailand, 2007) and the total cost for coronary
artery bypass graft surgery is more than 140,000 bath per person. In the United States,
the number of patients with ACS increased and the cost for surgery and care increased
as well (Nilsson, Algotsson, Hoglund, Luhrs, & Brandt, 2004). Moreover, even though
the patients have already been surgically treated, it is likely that they will develop this
illness again unless they change their behaviors (Eagle et al., 2004). Physical activity
can reduce the recurrence of Acute Coronary Syndromes (ASCM, 2007).
The recommended minimum for physical activity was moderate physical
activities consuming about 3-6 METs 30 minutes of continued physical activity or the
sum of at least 30 min of intermittent exercise, five days per week. Moderate physical
activity levels were complementary in the production of health benefits (Haskell,
2007). Many studies demonstrated the benefits of physical activity and exercise. Both
physical activity and exercise decreased and prevented artherosclerotic heart disease.
A meta analysis of 51 intervention studies found that rehabilitation programs (exercise
only) reduced mortality rate by 27% (Jolliffe, Rees, Taylor, Thompson, Oldridge, &
Ebrahim, 2001). The six-minute walk test and quadriceps muscle strength test
improved significantly in patients who received a supervised exercise program
(Jonsdottira, Andersen, Sigurosson, & Sigurosson, 2006). An average increase in
HDL-C levels was 4.6%. Triglyceride and LDL-C were reduced by 3.7% and 5.0%
respectively (Thompson et al., 2003). Nowadays, even if physical activity and exercise
Worarat Photi
Introduction / 2
are supported, research has found that the majority of persons in the United States do
not engage in consistent physical activity for the recommended minimum 30 minutes
of moderate-intensity activity in most days of the week. In 2001, 54.6% of persons
did not have enough activity to meet the recommendations (Centers for Disease
Control and Prevention, 2003). In Thailand, a total of 45% of patients with ACS did
not have regular physical activity (Wanitkun, 2003).
There is not a simple way to motivate patients to regularly do physical
activities that are appropriate with their competency. Only providing knowledge and
skill about exercise is not sufficient to bring about continuous exercise for health.
(U.S. Preventive Services Task Force, 2006). Primary and secondary prevention
should be emphasized, including a focus on ways individual persons can improve
their abilities such as skill, motivation from their lifestyle, self- efficacy overcoming
barriers and self-monitoring. Readiness for behavior change or stages of change is
associated with a benefit and cost (pros and cons) analysis of behavior change
(Prochaska et al.,1994). The lifestyles and barriers of each person are different; hence,
they use different processes of change (Lowther, Mutrie, & Scott, 2007). Providing
one program for behavior change is not always effective for people at various stages of
readiness.
Literature review demonstrated that education technique (Kawchareanta,
2003), group support (Kaduang, 2004), self-efficacy enhancement (Jompong, 2003;
Leangchawengwong, 1998; Lipun, 1999), and
motivation promotion (Intaratool,
2005) were used for behavior change. These techniques included the same content
and details for every person. After the patients received the program, they could
change their behaviors. However, the literature review demonstrated that the
transtheoretical model (TTM) based activity promotion interventions are effective in
promoting activity adoption, initial results on longer term adherence are disappointing
(Adams, & White, 2003; Dallow & Anderson, 2003; Spencer, Malone, Roy, & Yost,
2006). The TTM was useful in explaining the longitudinal effects of exercise. After
one year, 60% of those in the intervention group were adopters compared to 16% of
those in the education program (Findorff, Stock, Gross, & Wyman, 2007).
Prior to the current research, cardiac rehabilitation program at the Central
Chest institute for physical activity enhancement of patients with ACS emphasized the
education technique for a group or person and then all of them received the same
content. This program was not developed in terms of appropriate individual lifestyle,
barriers, and readiness for changing behavior. The literature review demonstrated that
an effective program should be developed by a combination of psychotherapy and
behavior change, and it should motivate a change from risky behavior to healthy
behavior. The program development should emphasize the appropriate individual
persons style (Wanitkun, 2005) and readiness for change (Prochaska, Redding, &
Evers, 2002).
The conceptual framework of this study is based on the Transtheoretical
model which integrates behaviors and classifies individuals in respect to readiness for
behavior change. There are 5 stages of change which consist of precontemplation,
contemplation, preparation, action, and maintenance (Prochaska, Redding, & Evers,
2002; Wilson & Schlam, 2004). Based on the transtheoretical model, individuals in
each stage were assisted with various unique combinations of strategies or processes
to aid the patients in changing their behavior. Individuals in the contemplation stage
used dramatic relief, environmental reevaluation, (Prochaska, Redding, & Evers,
2002) consciousness raising, decisional balance, and self-efficacy overcoming barriers
(Kim, Hwangb, & Yoo, 2004), while individuals in the preparation stage used selfliberation (Prochaska, Redding, & Evers, 2002), reinforcement management, selfefficacy for overcoming barriers (Kim et al., 2004), environmental reevaluation, and
counter-conditioning (Tseng, Jaw, Lin, & Ho, 2003) for behavior change.
The literature review found that the transtheoretical model is effective for
behavior change in areas such as physical activity (Dallow & Anderson, 2003;
Griffin-Blanke, Dejoy, 2006; Plotnikoff, Brunet, Courneya, Birkett, Marcus, &
Whiteley, 2007; Titze, Martin, Seiler, Stronegger, & Marti, 2001; Woods, Mutrie, &
Scott, 2002) and exercise (Kim et al., 2004; Spencer, Malone, Roy, & Yost, 2006;
Tseng, Jaw, Lin, & Ho, 2003). An outcome of exercise and physical activity behavior
was measured with caloric expenditure and cardiorespiratory fitness (Kim et al., 2004;
Spencer, B, Malone, Roy, & Yost, 2006; Tseng et al., 2003; Spencer et al.,2006;
Tseng et al., 2003). Moreover, the transtheoretical model is effective for eating
behavior change ( Wilson & Schlam, 2004) and for use in behavior change that
involves more than one behavior (Kim, et al., 2004; Johnson, et al., 2006; McKee,
Worarat Photi
Introduction / 4
Bannon, Kerins, & FitzGerald, 2006; Prochaska, et al., 2007). Measured outcomes
include stress management (Tseng et al., 2003), fasting blood glucose level (Kim et
al.,
2004), and eating behavior (Johnson, Driskell,Johnson, Dyment, Prochaska,
Prochaska, et al., 2006; Wilson & Schlam, 2004).

Individuals in each stage used various processes; thus, stage matched
interventions can enhance the physical activity more than non stage matched
interventions (Dallow & Anderson, 2003). The participants in this study were patients
who received CABG surgery. They could not be treated by medication, and were
concerned about the importance of risk factor reduction, and cardiac rehabilitation
enhancement. They gained education about exercise or physical activity; thus, they
have learned about the cost of non physical activity. They received a cardiac
rehabilitation program from a physiotherapy team. Not all of them succeeded in
physical activity. Some patients did not change behavior or met the criteria. Likewise
some patients succeeded in changing their behavior but they did not regularly
participate in physical activity. Education alone cannot motivate patients to reach the
recommended physical activity level. This study developed the Behavior Change
Program for the patients in this group. The Behavior Change Program included selfliberation (Prochaska, Redding, & Evers, 2002), reinforcement management, selfefficacy overcoming barriers (Kim et al., 2004), environmental reevaluation, and
counter conditioning (Tseng et al., 2003).
Research Question
1. Does a Behavior Change Program have an effect on physical activities
(caloric expenditure of at least moderate physical activity level, and daily steps) of
CABG patients in the preparation stage?
2. Does a Behavior Change Program have an effect on physical fitness
(six-minute walking distance) of CABG patients in the preparation stage?
Purposes of the Study

1. To compare physical activities (caloric expenditure of at least moderate
physical activity level, and daily steps) of CABG patients in the preparation stage for
those who received a Behavior Change Program and those who received usual care.
2. To compare physical fitness (six-minute walking distance) of CABG
patients in the preparation stage for those who received a Behavior Change Program
and those who received usual care.
Research Hypotheses
1. The intervention group will have a significantly greater caloric
expenditure of at least moderate physical activity level when compare to, the control
group.
2. The intervention group will have a significantly higher number of daily
steps than the control group.
3. The intervention group will have a significantly longer six-minute
walking distance than the control group.
Conceptual Framework of the research

The conceptual framework of this study is based on the transtheoretical
model (TTM) which emerged from comparative analysis of leading theories of
psychotherapy and behavior change (Prochaska, & DiClemente, 1983). The TTM
consists of various stages of change, process of change, self-efficacy, and decisional
balance (Prochaska et al., 2002; Wanitkun, 2005). The TTM integrates behaviors to
classify individuals with respect to readiness for behavior change. So, individuals in
each stage use different strategies or processes, self - efficacy overcoming barriers,
and weight of the cost-benefit to aid them in changing their behavior. The TTM
construes change as a process-involving progress through a series of five stages:
Precontemplation, Contemplation, Preparation, Action, and Maintenance.
Worarat Photi
Introduction / 6
The decisional balance refers to the weight of the benefit and cost
consideration (pros and cons) of changing behavior. Individuals in each stage have
different benefit and cost considerations (Kim, 2007). The 10 processes of change are
the covert and overt activities that people use to progress through the stages.
(Prochaska et al., 2002). Self-efficacy overcoming barriers are combined with the
TTM. The meaning of self-efficacy overcoming barriers is the confidence in
overcoming the barriers to performing physical activity (Bandura, 1997 ).
The program in this study was developed for CABG patients in the
preparation stage. This group is concerned about the importance of risk factor
reduction and cardiac rehabilitation enhancement. This group received education about
exercise or physical activity; thus, they have learned about the cost of non physical
activity. They received a cardiac rehabilitation program by a physiotherapy team.
After surgery, the patient may have wounds. Manipulation of the chest cavity, and use
of retractors during surgery may all contribute to postoperative pain. They may also
experience anxiety and fear about self care post operation. They have barriers to
physical activity in their lifestyle. These factors lead to some patients being unable to
change behavior or meet the criteria. Other patients may succeed in changing their
behavior, but do not participate in regular physical activity. Thus, the Behavior
Change Program should be focused on appropriate individuals.
Persons in the
preparation stage were ready to begin physical activity. The goal is to reinforce and
increase physical activity behavior.
The Behavior Change Program focused on identified barriers to physical
activity and using processes of change for motivating the behavior change. This
program was composed of self liberation (Prochaska et al., 2002; Tseng et al., 2003),
counter-conditioning, stimulus control, environmental reevaluation(Tseng et al., 2003),
reinforcement management, and self-efficacy (Kim et al., 2004)for increasing physical
activity and physical fitness.
Self-efficacy for overcoming barriers to exercise is the confidence a person
feels about performing physical activities (Bandura, 1997). Persons with higher selfefficacy maintained physical activity level, perceived less effort in doing physical
activity, and reported more positive effects from physical activities (Prochaska et al.,
2002; Wanitkun, 2005). The Behavior Change Program increased patients self
efficacy by discussing their physical activity barriers and identifying strategies to

overcome the barriers, thus leading to increased physical activity. Counterconditioning skills are important to learn when trying to fit short bouts of moderately
intense physical activity into the day. These skills are important to guide patients who
are thinking about changing physical activity behavior (preparation stages) to proceed
to the action stage. Self-liberation represents making a firm commitment to changing
health behavior. Helping patients to set realistic personal activity goals is important to
guide physical activity behavior change. Environmental reevaluation included
consideration and assessment by persons about how the problem affects the social
environments and physics. Stimulus Control was control of causes that trigger the
behavioral problem, including removal of cues for unhealthy habits and addition of
prompts for healthier alternatives. Reinforcement Management provided rewards for
controlling or maintaining the physical activity.
These processes increased self-efficacy (Dallow & Anderson, 2003),
benefits consideration (pros) of physical activities (Fahrenwaldm & Walkerm, 2003)
and decreased cost consideration (cons) of exercise or physical activity (Griffin-Blake
& DeJoy, 2006).
Worarat Photi
Introduction / 8
Coronary artery bypass graft

surgery patients
in preparation stage
Not engage in
physical activity
because of
- Confidence a person
feels about performing
physical activities not
improved or
decreased.
- Benefit analysis of
physical activities not
improved or
decreased.
- Cost analysis of
physical activities
increased.
- Cannot combine
physical activities into
lifestyle.
Do engage regular
physical activity
because of Confidence a person
feels about
performing physical
activities was
increased.
- Benefit analysis of
physical activities
was increased .
- Cost analysis of
physical activities was
decreased.
- Can combine
physical activities into
lifestyle.
1.Physical activities
- Caloric expenditure
of at least moderate
physical activity level
not improve.
- Mean daily steps
not improve.
2. Physical fitness
- Six-minute walking
distance not improve.
1.Physical activities
- Caloric expenditure
of at least moderate
physical activity level
was increase.
- Mean daily steps
was increase.
2. Physical fitness
- Six-minute walking
distance was increase.
Normal pathway
Behavior Change Program

- Substitution of alternative behaviors
for the problem behavior :counterconditioning (Tseng, Jaw, Lin, & Ho,
2003).
- Consideration and assessment by
person of how the problem affects the
social environments and
physics :environmental reevaluation
(Tseng, Jaw, Lin, & Ho, 2003).
- Persons choice, commitment and
recommitment to change the
behavioral problems: self
liberation(Prochaska, Redding, &
Evers, 2002; Tseng, Jaw, Lin, & Ho,
2003).
- Control of situations and other
causes that triggers the problem
behavior: stimulus control (Tseng,
Jaw, Lin, & Ho, 2003).
- Provided rewards for controlling or
maintaining the healthy behavior:
reinforcement management (Kim,
Hwangb, & Yoo, 2004)
- Increased confidence a person feels
about performing physical activity:
self-efficacy (Kim, Hwangb, & Yoo,
2004)
The Behavior Change Program pathway
Figure 1 Conceptual framework of the research
Scope of the Study

This study aimed to examine the effect of a Behavior Change Program on
physical activities (caloric expenditure of at least moderate physical activity level,
daily steps) and physical fitness (six-minute walking distance) of CABG patients
compared with usual care. The participants in this study were patients who received
CABG and were admitted to Center Chest Institute. The data were collected during the
months from May 2008 to May 2009.
Definitions of Terms
Physical activity was defined as any bodily movement produced by
skeletal muscles that results in energy expenditure (Caspersen, Powell, & Christenson,
1985). The physical activity in this study was moderate physical activities that were
measured by
- Caloric expenditure of at least moderate physical activity
level per week can be measured by the Community Health Activities Model Program
for Seniors Activities Questionnaire for Older Adults (CHAMPS)
- Daily steps can be measured by a Pedometer.
Physical fitness was defined as a set of attributes that are either related
health or skill. The degree to which people have these attributes can be measured
with specific tests (Caspersen et al., 1985). There are four components that include
cardiorespiratory fitness, muscular strength and muscular endurance, flexibility, and
body composition (ACSM, 2007; Wisan & Rapeepol, 2548). In this study, physical
fitness refers to six-minute walking distance that can be measured by the six-minute
walk test.
Behavior Change Program was defined as a program based on the
transtheoretical model and literature review of physical activity change for CABG
patients in the preparation stage (Prochaska et al., 2002 ; Wilson & Schlam, 2004).
This program includes self-efficacy overcoming barriers, environmental reevaluation,
stimulus control, reinforcement management, counter-conditioning, and self liberation.
Duration of the Behavior Change Program was seven weeks.
Worarat Photi
Introduction / 10
Expected benefit of the research

1. The established program will be an effective nursing care to promote
physical activity behavior and to promote strengthening of physical fitness among
CABG patients who are in the preparation stage.
2. The strategies of the program will be a guideline for nurses in cardiac
units to implement for CABG patients who are in the preparation stage.
3. The findings will be preliminary knowledge for further study regarding
developing interventions appropriate for CABG patients in other stages of change and
patients with other diseases.
CHAPTER II
LITERATURE REVIEW
The purpose of this study was to examine the effects of the Behavior
Change Program on physical activities (caloric expenditure of at least moderate
physical activity level and above, daily steps) and physical fitness (six-minute walking
distance) among coronary artery bypass graft (CABG) patients compared with
receiving usual care. This chapter presents a review of theoretical content and related
concepts of interest regarding three topics as follows:
1. Acute Coronary Syndromes.
1.1 Definition and pathophysiology
1.2 Risk factors
1.3 Coronary artery bypass graft surgery
1.4 Recovery processes
2. Physical activity and physical fitness in patients with coronary artery
bypass graft.
2.1. Definition of physical activity and physical fitness
2.2. Method for measure physical activity and physical fitness
2.3. Benefit of physical activity
2.4. Physical activity and physical fitness of patients with
coronary artery bypass graft.
3. Changing health behavior based on the Transtheoretical Model.
3.1. Basic concept of transtheoretical model
3.2. Application of the Transtheoretical model to Behavior
Change Program for patients with coronary artery bypass graft
3.3. Effects of a Behavior Change Program on physical activity
and physical fitness
Worarat Photi
Literature Review / 12
1. Acute Coronary Syndromes.

1.1 Definition and Pathophysiology
Acute Coronary Syndrome with ischemic heart disease is a condition
resulting from atherosclerotic plaque accumulating on the internal walls of coronary
arteries. Narrowing arteries lead to decreased blood flow to cardiac muscle. The initial
event in coronary atherosclerosis is endothelial injury. The factor most described is
hypercholesterolemia. Low-density lipoprotein (LDL) cholesterol diffuses into the
coronary arteries; once oxidized, it induces a severe inflammatory reaction leading to
endothelial dysfunction. This disturbs the balance between the vasodilator and
antiproliferative agent nitric oxide, and the vasoconstrictor agent endothelin. Release
of chemotactic and growth factors also occurs, and inflammatory cells are attracted to
the site of atherosclerosis. Oxidized LDL is taken up by macrophages, leading to the
development of a lipid core surrounded by smooth muscle cells and fibrous tissue,
forming the atherosclerotic plaque. The narrowing arteries lead to decreased blood
flow to cardiac muscle in the affected area, causing insufficient blood supply and
insufficient oxygenation. Thus, they are characterized by an imbalance between
myocardial oxygen supply and demand (Anderson, 2007; Libby & Theroux, 2005;
Wenger, Helmy, Patel & Lerakis, 2005).
1.2 Risk factors
The exact cause of atherosclerotic plaque is yet unknown. However, it has
been found that factors associated with coronary artery disease can be divided into two
types.
1.2.1 Unmodified risk factors:
1. Age: The progress of fatty streak and fibrous plaque
increases with age. The prevalence of fatty streaks in the coronary arteries increases
with age. Between the ages of 2 to 15 years of age, approximately 50 percent of people
already have fatty streaks, while from 21 to 39 years of age, 85 percent of people have
fatty streaks. (Berenson et.al., 1998). Platelet aggregation activities increase with age.
The lipid composition of the platelet membrane changes in people of higher age
causees artherosclerosis (Korkushko, Sarkisov, Lishnevskaya & Gorbach, 2000).
2. Sex: Men develop this illness when they are 40 years old
and women develop it at 55 years of age. (Agingthai Institute, 2006). The prevalence
of Acute Coronary Syndrome in premenopausal females is lower than for males;

however, the prevalence of Acute Coronary Syndrome in postmenopausal females is
higher than for males (Alberta & Ruskina, 2001). The average rate of progression of
subclinical atherosclerosis in postmenopausal women was
lower in those taking
unopposed micronized 17b-estradiol (1 mg/d) group than in those taking the placebo
(-0.0017 mm/y vs 0.0036 mm/y ).The difference in average progression rates between
the placebo and estradiol groups was 0.0053 mm/y (Hodis et al., 2001).
3. Family history: Family history of myocardial infarction is
associated with thicker intima-media thickness (IMT). Persons with a family history of
myocardial infarction had significantly thicker intima-media thickness (IMT) than
persons with no family history (Stensland-Bugge, Bnaa & Joakimsen, 2001; JerrardDunne, et al., 2003) Positive family histories were independent predictors for redo
CABG (Odd ratio = 2.4) (Mennander et al., 2005).
1.2.2 Modified risky factors:
1. Hyperlipidemia: Fatty streak and fibrous plaque lesions in
the aorta and coronary vessels
were
associated with serum triglyceride
concentrations, and LDL cholesterol concentrations. (r = 0.50, 0.43 respectively)

(Berenson et al., 1998). The symptoms of inflammatory processes emerge at the same
time as atherosclerotic plaques accumulating on the internal walls of coronary arteries
(Libby, Ridker & Maseri, 2002) whose processes were
explained in the
pathophysiology of Acute Coronary Syndromes. A high serum triglyceride level ( 2

mmol/L) was an independent predictor for redo CABG and odd ratio was 1.6
(Mennander, Angervuori, Huhtala, Karhunen, Tarkka & Kuukasjarvi, 2005).
2. Smoking: A history of smoking is associated with coronary
artery and carotid artery disease (Ehtisham, Chimowitz, Furlan & Lafranchise, 2005).
The number of smokers increased in terms of the percentage of intimal surface
involved with fibrous plaques in the aorta (1.22% in smoker vs 0.12% in nonsmoker)
and fatty streaks in coronary vessels (8.27% in smoker vs 2.98% in nonsmoker)
(Berenson et al., 1998).
3. Hypertension: Hypertension was associated with coronary
artery and carotid disease (Ehtisham et al., 2005). The renin-angiotensin system
contributes to the pathogenesis of atherosclerosis. Angiotensin II may elicit
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inflammatory signals in vascular smooth muscle cells. The transcription factor NF-B
participates in most signaling pathways involved in inflammation (Altman, 2003).
4. Diabetes: Diabetes is a state of increased plasma
coagulability (Mooradian, 2003). Diabetic patients have impaired endotheliumdependent vasodilatation, hyper-coagulability, increased PAI-1 level in the arterial
wall with impaired fibrinolysis, decrease of endothelial nitric oxide synthase, and
increase of endothelin-1 (Altman, 2003). The study showed after a follow up of 7
years was done, that mortality in diabetic patients was higher than in non-diabetics
and for diabetic patients with no history of myocardial infarction (Haffner et al., as
cited in Altman, 2003).
5. Psychosocial: Systematic review demonstrated a moderate
association between depression, social support and psychosocial work characteristics
and CHD etiology and prognosis (Kuper, Marmot, & Hemingway, 2002). Anxiety and
depression were associated with the development of coronary artery disease (Januzzi,
Stern, Pasternak & DeSanctis, 2000). The mechanism was thought to be a reduction in
vagal tone and increase in susceptibility to ventricular fibrillation (Albert & Ruskina,
2001).
6. Physical activity: When leisure-time physical activity
increased, the risk of Acute Coronary Syndromes (ACS) decreased. Leisure-time
physical activity was divided into four levels based on the frequency of physical
activity in the survey. There were I get practically no exercise at all, I exercise
occasionally, I exercise once or twice a week, and I exercise vigorously at least
twice a week. Persons who were physically active at least twice a week had a 41%
low risk of developing ACS more than those who performed no physical activity
(hazard ratio=0.59) (Sundquist, Qvist, Johansson & Sundquist, 2005). An energy
expenditure of about 1600 kcal or 6720 kJ per week has been found effective in
halting the progression of coronary artery disease, and an energy expenditure of about
2200 kcal or 9240 kJ per week had been shown associated with plaque reduction in
patients with heart disease (Franklin, Swain & Shephard, 2003; Warburton, Nicol &
Bredin, 2006). Persons who reported less than 30 minutes a week of physical activity
at baseline had a risk ratio concerning subsequent mortality compared with 30 or more
minutes of physical activity a week (2.82 vs 2.15) (Martinson, O'Connor& Pronk,
2001).
1.3 Coronary artery bypass graft

Coronary artery bypass graft (CABG) surgery was indicated for patients
with Acute Coronary Syndromes to relieve symptoms, improve quality of life, and
prolong life. Coronary artery bypass was the construction of new pathways between
the aorta and coronary arteries beyond the obstructing lesion. Conduits used for
coronary artery bypass graft surgery were saphenous vein, internal mammary artery,
and radial artery. There were indications for CABG following ACC/AHA guidelines
(Anderson, 2007).
- Compelling anatomy, such as left main coronary artery disease (50%).
- Multivessel disease with or without depressed ejection fraction.
- Two-vessel disease, proximal left anterior descending lesion with
depressed ejection fraction < 50%.
- Coronary artery disease does not respond to medical treatment.
Coronary artery bypass graft is a major surgery. During cardiopulmonary
bypass blood is circulated by a pump to other organs of the body independent of
physiologic control and non pulsatile flow. This allows surgeons to operate on a still,
bloodless field. During manipulation of the heart, changes in hemodynamic stability
may cause many complications.
1. Cardiovascular
complication
The
majority
of
cardiovascular
complications were atrial fibrillation (AF). Atrial fibrillation occurs in 28.2% at 0 to

11 days after operation in patients who had CABG surgery (Zaman, 2000), and causes
longer lengths of stay. (Martin & Turkelson, 2006)
2. Renal complication The study by Stallwood, Grayson, Mills, & Scawn
(2004) revealed that 53 patients (2.4%) developed acute renal failure (ARF) following
CABG. Thirty-four patients (1.5%) developed ARF without requiring dialysis, while
19 patients (0.9%) who developed ARF required dialysis support. Acute renal failure
associated with effectiveness of cardiac output or hypotension. Therefore, renal
perfusion insufficiency. Cardiopulmonary bypass graft (CPB) represents a specific risk
factor (Martin & Turkelson, 2006). CPB results in reduced glomerular filtration rate,
reduced renal blood flow, and redistribution of blood flow from the cortex to the outer
medulla (Young & Dai, 2000).
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3. Respiratory complication. Pulmonary complications were among the

most frequently reported complications and occur in 33% of patients after coronary
artery bypass graft (CABG) surgery (Hulzebos, 2003). Pulmonary complications result
from cardiopulmonary bypass graft, length of surgery, resultant increase in the amount
of needed anesthetic agents, and pain (Martin & Turkelson, 2006).
4. Neuropsychological complication Patients who require coronary artery
bypass surgery are at an increased risk for neurological complications (Ganushchak,
Fransen, Visser, JongJos, & Maessen, 2004) Stroke can be caused by hypotension or an
embolic event during or after surgery. Manipulation of the aorta has been implicated in
embolic events (Engstrom, 2003). Most patients have confusion or unconsciousness
(Martin & Turkelson, 2006).
5. Gastrointestinal
complication.
The
range
of
gastrointestinal
complication occurrence was 0.12 to 2%. Complications included peptic ulcer,

perforated ulcer, pancreatitis, acute cholecystitis, bowel ischemia, diverticulitis, and
liver dysfunction. The nurse should monitor the patients bowel sounds, abdominal
distention, nausea, and vomiting. The intubated patient will have a nasogastric tube.
Placement and patency should be assessed as well as amount, color, and characteristics
of the drainage(Martin & Turkelson, 2006).
6. Pain The pain experienced by patients who receive coronary artery bypass
surgery results from tissue injury (nociceptive pain). The patient may have a median
sternotomy incision, leg incision, and radial incision. Manipulation of the chest cavity, use
of retractors during surgery, and electrocautery may all contribute to post-operative pain.
Other sources of pain include the removal of the chest tubes. This usually occurs 24 to 48
hours after operation (Martin & Turkelson, 2006).
7. Wound infection
The incidence of infection of sternal and leg
incisions after cardiac surgery was less than 3% (Martin & Turkelson, 2006).
1.4 Recovery in coronary artery bypass graft patients.

Recovery from an illness or surgery to normal life is a dynamic process
encompassing both biophysical and psychosocial components. Patients who received
coronary artery bypass graft had lower recovery before the operation and this
increased after the operation. Recovery at discharge was the lowest, then gradually
increased at 6 months after CABG (Lopeza, Yingb, Poonc & Wai, 2007). Autonomic
cardiovascular function including respiratory sinus arrhythmia, valsalva maneuver,
respiratory function and heart rate variability reached the lowest level 3-6 days after
surgery, returning to pre-surgery values at about 30-60 days postoperatively (Soares,
Moreno, Cravo & Nobrega, 2005). Mean energy expenditure after the operation was
28.87, 28.69, and 31.69 kcal/kg/day at 3, 6, and 12 months respectively. This study
showed that since 3 months after coronary artery bypass graft surgery, patients can
tolerate moderate physical activity (Barnason, et al., 2000). Psychological recovery
and depression levels increased or were stable at 1 week, then gradually decreased in
the 3rd and 6th month (Lopeza et al., 2007). Depression levels were the highest in pre
operation then gradually significantly decreased during the hospital stay, discharge,
and 6 weeks were the lowest respectively (Doering, Moser, Lemankiewicz, Luper &
Khan, 2005). The quality of life related to physical health, role-physical, social, bodily
pain, mental, vitality, and general health was
the lowest in pre operation, then
gradually increased in the 3rd and 6th month respectively (Barnason et al., 2000).
Recovery of patients who received coronary artery bypass graft surgery
differed. Risk factors associated with recovery were as follows:
1. Age: Older patients had low functional capacity compared
to younger patients (Pierson et al., 2003).
2. Sex: Men had higher physical functioning (Treat-Jacobson
& Lindquist, 2004), and functional capacity when compared to women (Pierson et al.,
2003). Women had more physical symptoms and side effects, including unstable
angina, congestive heart failure, and depressive symptoms in the six to eight weeks
after CABG surgery when compared to men (Vaccarino et al., 2003).
3. Depression: Postoperative depression has effects on
recovery from coronary artery bypass graft surgery. At discharge, patients with higher
depression reported poorer emotional health with physical recovery and achieved
shorter walking distances compared to patients with lower depression. Moreover, in
post CABG patients, higher depression was found to be associated with increased
infection, and impaired wound healing (Doering, Moser, Lemankiewicz, Luper &
Khan, 2005).
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4. Pain: Moreover, patients reported that they stayed in the

hospital with the longest period and experienced the most pain (Sarpy, Galbraith &
Jones, 2000).
5. Exercise: The study showed that patients who participated
in regular exercise had higher functional status (Treat-Jacobson & Lindquist, 2004)
and functional capacity than patients who did not participate in regular exercise
(Pierson et al., 2003).
2. Physical activity and Physical fitness of coronary artery bypass

graft surgery patients
2.1 Definitions of physical activity and physical fitness
Physical activity was defined as any bodily movement produced by
skeletal muscles that results in energy expenditure. The energy expenditure can be
measured in kilocalories. Physical activity in daily life can be categorized into
occupational, sports, conditioning, household, or other activities (Caspersen, Powell &
Christenson, 1985).
ACSM/AHA developed a new protocol to promote health
through an accessible exercise program. The recommended minimum was moderate

physical activities consuming about 3-6 METs 30 minutes of continued physical
activity or the sum of at least 30 min of intermittent exercise, five days per week or
vigorous-intensity 20 minutes per day, three days per week. Moderate and vigorous
intensity activities were complementary in the production of health benefits and a
variety of activities can be combined to meet 450-750 METs per week (Haskell,
2007).
Exercise was defined as a subset of physical activity that was planned,
structured, and repetitive and had as a final or an intermediate objective, the
improvement or maintenance of physical fitness (Caspersen et al., 1985).
Physical fitness was defined as a set of attributes that were either
related health or skill. The degree to which people have these attributes can be
measured with specific tests (Caspersen et al., 1985). There were
four components
which were cardiorespiratory fitness, muscular strength and muscular endurance,
flexibility, and body composition (ACSM, 2007; Kantarattanakool & Koonchon Na

Ayutthaya, 2005).
1. Cardiorespiratory fitness
Cardiorespiratory fitness was
aerobic fitness or aerobic
endurance related to the ability of performing large muscle, dynamic, moderate to high
intensity exercise for prolonged periods. Maximal oxygen uptake (VO2max) was
accepted as the criterion measure of cardiorespiratory fitness. Maximal oxygen uptake
is the product of maximal cardiac output and arterial-venous oxygen difference. Direct
measurement of VO2max was not feasible or desirable, so a variety of submaximal and
maximal exercise tests can be used to estimate VO2max (ACSM, 2007). Aerobic
fitness or aerobic endurance was measured by oxygen use per 1 kilogram per min
(ml/kg/min) or metabolic equivalent task [MET]. The mean of maximum ventilatory
oxygen comsumption (VO2 max) in males and females was
12 and 10 METs
respectively (Kantarattanakool & Koonchon Na Ayutthaya, 2005).

2. Muscular strength and muscular endurance
Muscular strength and muscular endurance are the ability of
the muscle to exert force and the muscles ability to continue to perform for successive
exertions or many repetitions. Muscular strength and muscular endurance are healthrelated fitness that prevent coronary artery disease, prevent osteoporosis, control type
2 diabetes, lower risk of injury, and promote weight management (Kantarattanakool &
Koonchon Na Ayutthaya, 2005).
3. Flexibility
Flexibility is the ability to move a joint through its complete
range of motion. It is important for athletic performance and the ability to carry out the
activities of daily life. Flexibility depends on a number of specific variables, including
distensibility of the joint capsule, adequate warm-up, and muscle viscosity.
Complicance of various other tissues affects the range of motion (Kantarattanakool &
Koonchon Na Ayutthaya, 2005).
4. Body composition
It is well established that excessive fat body is associated with
hypertension, type 2 diabetes, coronary heart disease, stroke, and hyperlipidemia. The
basic body composition can be expressed as the relative percentage of body mass that
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is fat and fat-free tissue using a two-compartment model. Body composition can be
estimated by both laboratory and field technique that vary in terms of complexity,
cost, and accuracy. The examples for estimated body composition are the
anthropometric method, body mass index, circumference, skinfold measurements, and
densitometry etc.
The indispensable components are cardiorespiratory fitness or aerobic
fitness. These components measure submaximal exercise capacity by various methods.
The literature review showed that the six minute walk test has been used to evaluate
cardiorespiratory fitness within programs for exercise or physical activity
enhancement in coronary artery disease (Jonsdottira, et al., 2006; Solway, Brooks,
Lacesse & Thomas, 2001; Wright, Khan, Gossage & Saltissi, 2001; Kawchareanta,
2003; Intaratool, 2005). Even though the test was considered submaximal, it may
result in near maximal performance for those with low fitness levels or disease.
Several multivariate equations are available to predict peak oxygen consumption from
the 6 minute walk test (Kantarattanakool, 2005; ACSM, 2007).
2.2 Physical activity and physical fitness measurements.

2.2.1 Physical activity measurements.
There are varieties of methods available to measure physical
activity such as self-report, behavioral observation, and electronic monitors (Laporte,
Monotoyee, & Caspersen, 1985). Self-report methods are self-administered or
interviewer-administered recall questionnaires, activity logs, diaries, or proxy reports.
Physical activity can be measured in terms of type, intensity, duration, and frequency.
The data from self-report questionnaires are calculated to reflect the rate of energy
expenditure during physical activity. Physical activity levels are generally expressed in
METS. Self-report measures of physical activity have been widely used in survey
studies (Brownson, Eyler, King, Brown, Shyu, & Sallis, 2000) and intervention studies
(Allison, & Keller, 2000).
A literature review demonstrated exercise self-report is needed to assess
frequency, intensity, and duration of physical activity to define the dose-response
association between physical activity and health outcomes (Sallis, & Saelen, 2000). In
this study, physical activity was measured using the Community Healthy Activities
Model Program for Seniors Activities Questionnaire for Older Adults (CHAMPS).
The CHAMPS questionnaire was developed in 2001 for use with older adults . This
questionnaire was translated into Thai language by using a back-translation processes
and evaluated in terms of content validity by Wanitkun (2003). Construct validity of
the relationship between caloric expenditure computed from a list of activities of
CHAMPS was measured, and intention to exercise was assessed by the Exercise
Stages of Change. There were significant differences in caloric expenditure during all
physical activities (F4396=13.41,p< 0.001) and those engaging in moderate to vigorous
physical activities (F4360 = 17.81, p < 0.001) among the 5 stages.
The CHAMPS questionnaire was composed of 39 items. There were 37
items for assessing intensity, frequency, and duration of activities. Three questions
were asked regarding each activity: was the activity done? Yes/No if yes, two
questions of frequency and duration were asked. There was one item for other
activities and 1 item for recheck. The exact number or frequency of a particular
activity was reported. All physical activities were reported into frequency per week
and estimated caloric expenditure per week of physical activity (Stewart, et al., 2001).
However, there was also a method for evaluating physical activity which used a
pedometer.
Pedometers objectively measure ambulatory activities throughout the day
in the form of step counts. They are tools for monitoring and motivation in physical
activity interventions. Pedometers are easy to use and relatively inexpensive compared
with other motion sensors. The pedometer has been applied to motivate physical
activities in adults (Stovitz, VanWormer, Center, & Bremer, 2005), older (Wellman,
Kamp, Kirk-Sanchez, & Johnson, 2007), and type 2 diabetes patients (Tudor-Locke,
Myers, Bell, Harrisd, & Rodgere, 2002). Moreover, the pedometer has been applied to
measurement of physical activities in a community sample of working women (Speck,
& Looney, 2001), and men and women aged 2574 years (Sequeira, Rickenbach,
Wietlisbach, Tullen, & Schutz, 1995).
2.2.2 Physical fitness measurements.
Physical fitness was measured from the six minutes walk test
[6MWT]. The objective of the six minutes walk test was to cover the greatest distance
in the period lasting six minutes. VO2 max could be estimated from the equation. The
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six minutes walk test has been used to evaluate cardiorespiratory fitness within some
clinical patients such as those with congestive heart failure and pulmonary disease. It
has also been widely used for preoperative and postoperative evaluation and for
measuring the response to therapeutic interventions for pulmonary and cardiac disease.
The distance of one meter walk was measured by using oxygen 0.1 ml per body
weigh 1 kilogram. The method for administering the six minute walk test was as
follows: (American Thoracic Society, 2002).
1. Prepare the equipment and location for six minute walk
test. The equipment included a countdown timer, a chair that can be easily moved
along the walking course, mechanical lap counter, worksheet on a clipboard, a source
of oxygen, sphygmomanometer, telephone, automated electronic defribrillator. The
location was indoor, along a long, flat, straight course. The walking course must be 30
meters in length. A 100 fit hallway is, therefore, required. The length of the corridor
should be marked every 3 meters.
2. The patient should sit to rest on a chair, located near the
starting position for at least 10 minutes before the test starts. During this time, check
for contraindications, measure pulse and blood pressure, and make sure that clothing
and shoes are appropriate. Pulse oximetry is optional. If it is performed, measure and
record baseline heart rate and oxygen saturation.
3. Instruct the patient about objects and methods of this test.
4. Set the lap counter to zero and the timer to six minutes.
Move to the starting point where the patient is waiting to start. You should also stand
near the starting line during the test. Do not walk with the patients.
5. Do not talk to anyone during the walk. Each minute, tell
the patients the following You are doing well. You have minutes to go
6. For the post test, measure vital signs and oxygen
saturation.
7. Record the additional distance covered (the number of
meters in the final partial lap) using the markers on the wall as distance guides.
Calculate the total walking distance, rounding to the nearest meter, and record it on the
worksheet.
2.3 Benefit of physical activity
Physical activity has been classified using the MET intensity as follows:
light (< 3 METs), moderate (3-6 METs), and vigorous (> 6 METs) (Ainsworth, 2000).
Regular exercise has both direct and indirect beneficial effects on the severity for coronary
atherosclerosis and recovery after an operation.
2.3.1 Antiatherogenic effect. Physical activity was associated
with less severe CAD, larger coronary luminal diameters, and reduced progression of
atherosclerosis. These beneficial effects seem to be due to the attenuation of coexisting
risk factors by exercise. These include the following reduction of adiposity,

particularly in those with excessive upper body and abdominal fat, elevated plasma
triglycerides, with an increase in HDL cholesterol levels and Improvement in insulin
sensitivity and glucose use and reduction in risk of type 2 of diabetes.
2.3.2 Antithrombotic effect. Exercise training favorably
affects this process, in particular the fibrinolytic system. Exercise for six months in
healthy older patients resulted in a significant improvement in hemostatic indices, with
a reduction in plasma fibrinogen levels, an increase in mean tissue plasminogen
activator, an increase in active tissue plasminogen activator, and a reduction of
plasminogen activator inhibitor.
Short and long term exercise affects platelet
activation. Platelet activation is important for the pathophysiological mechanisms of

unstable coronary syndrome and acute MI. Short-term exercise can lead to increased
platelet activity, and long-term exercise may abolish or reduce this response.
2.3.3 Endothelial function. The vascular endothelium plays
an important role in the regulation of arterial tone and local platelet aggregation, in
part through the release of endothelium-derived relaxing factors, that prevent coronary
artery disease. Emerging evidence suggests that aerobic exercise improves endothelial
function.
2.3.4 Autonomic Function. The balance between sympathetic
and parasympathetic activity modulates cardiovascular activity. In coronary artery
disease was found over sympathetic nervous system that associated heart disease
(Fletcher, et al., 200; Kantarattanakool & Koonchon Na Ayutthaya, 2005). Exercise
training is associated with a relative enhancement of vagal tone, improved heart rate
recovery after exercise, and reduced morbidity in patients with cardiovascular disease
(Rosenwinkel, Bloomfield, Arwady, & Goldsmith, 2001). Long-term endurance
training significantly influences how the autonomic nervous system controls heart
function. Endurance training increases parasympathetic activity and decreases
sympathetic activity in the human heart at rest (Carter, Banister, & Blaber, 2003).
2.3.5 Anti-Ischemic Effects. There were a number of
mechanisms by which endurance exercise training may improve the relative balance
between myocardial oxygen supply and demand and thereby result in an anti-ischemic
effect. Increased metabolic capacity and improved mechanical performance of the
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myocardium were well-substantiated adaptations to endurance exercise training.

Lower heart rate and systolic blood pressure during submaximal exertion reduce
myocardial work, thereby reducing myocardial oxygen demands and coronary blood
flow requirements. Among patients with CAD, this allows a greater absolute workload
to be accomplished before reaching the ischemic threshold. In addition, heart rate
slowing with training allows more time during diastole for coronary blood flow to
perfuse the myocardium.
2.3.6 Antiarrhythmic Effects. Exercise traininginduced
improvement in the myocardial oxygen supply-demand balance and concomitant
reduction in sympathetic tone and catecholamine release was postulated to attenuate
the risk of ventricular fibrillation. This may explain the lower rate of sudden cardiac
death observed in physically active men with known or suspected CAD or a high risk
of CAD (Fletcher, et al., 200; Kantarattanakool & Koonchon Na Ayutthaya, 2005;
Agingthat Institute, 2006)
Low intense exercise training has also been associated with an
improvement in health status. The minimum training intensity recommended for
patients with heart disease is generally 45% of heart rate reserve. An energy
expenditure of about 1600 kcal (6720 kJ) per week has been found to be effective in
halting the progression of coronary artery disease, and an energy expenditure of about
2200 kcal (9240 kJ) per week has been shown to be associated with plaque reduction
in patients with coronary heart disease (Franklin, Swain & Shephard, 2003; Warburton
et al., 2006).
Coronary artery bypass graft surgery patients who regularly do exercise or
physical activity can reduce recurrent coronary artery disease. A part of core
components of cardiac rehabilitation/secondary prevention programs is physical
activity counseling and exercise training (Balady, et al., 2007). Coronary artery bypass
surgery patients receive surgery and a cardiac rehabilitation exercise program. This
program met three times a week, for a total of 36 sessions. The intervention group
showed a significantly lower resting heart rate (77.46+/-9.49 versus 92.31+/-10.18
bpm) and a significantly higher recovery of heart rate over one min (16.38+/-6.32
versus 11.38+4.81 bpm) compared with the control group (Tsai, et al., 2004). Persons
who engaged in regular exercise had a higher functional status (Treat-Jacobson &
Lindquist, 2004) and a higher functional capacity higher when compared to persons
who did not exercise (Pierson et al., 2003).
2.4 Physical activities and physical fitness of patients who received

coronary artery bypass surgery after discharge.
Patients who received coronary artery bypass surgery after discharge can
start physical activity as follows: (Kantarattanakool & Koonchon Na Ayutthaya,
2005):
Table 1 Physical Activity for Patients Received coronary Artery Bypass Graft
Surgery
Week
First week
Activities
- Do light work around the house (such as sweeping, or feeding pet)
- Walk leisurely for exercise or pleasure 5 minutes, two time per day
Second
- Walk leisurely for exercise or pleasure 10 minutes, two time per day
week
- Do light work around the house (such as dish washing, preparing

food or cooking)
- Do light gardening (such as watering plants)
- Lift less 3 kilogram
Third week
- Walk leisurely for exercise or pleasure 15-20 minutes, two time

per day
- Do light work around the house
- Do light work around the house, laundry by washing machine ,
preparing food or cooking
- Do light gardening
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Table 1 Physical Activity for Patients Received coronary Artery Bypass Graft
Surgery (Continue).
Week
Activities
Fourth week
- Walk fast or briskly for exercise 20-25 minutes, two time per day
- Do light work around the house
- Do light gardening
Fifth to
- shopping, sweep leaves
sixth week
- Ride a bicycle (general)

- Lift 3-5 kilogram 3-5 kilogram
- Walk fast or briskly for exercise 25-30 minutes, one to two time
per day
Sixth to
- gardening, planting, digging sandbox
twelve week - Home activities (such as washing windows, cleaning gutters or

scrubbing floors inside home)
- Activities about lawn and garden (such as digging, spading, raking)
- Walk fast or briskly for exercise least 30 minutes, one to two time
per day
Cardiorespiratory fitness was a part of physical fitness evaluated for
patients who received coronary artery bypass surgery. Cardiorespiratory fitness was
measured from the six minute walk test (Jonsdottira, et al., 2006; Solway, Brooks,
Lacesse & Thomas, 2001; Wright, Khan, Gossage & Saltissi, 2001; Kawchareanta,
2003; Intaratool, 2005). Results of the six minute walk test were measured 1-2 days
before discharge.
3. Effects of Behavior Change Program based on Transtheoretical

Model on physical activity and physical fitness
3.1 Transtheoretical Model and applied to behavioral change.
The transtheoretical model developed in 1970 to 1980 emerged from a
comparative analysis of leading theories of psychotherapy and behavioral change.
Based on the transtheoretical model, individuals in each stage use various unique
combinations of strategies or processes to aid them in changing their behavior. The
strengths of the transtheoretical model were sensitivity to level of readiness,
incremental change over time, and specific interventions for each stage. Moreover,
behavior change was a dynamic processes that occurred either progressively or in a
relapsing pattern. These theories consist of various stages of change, processes of
change, decisional balance, and self-efficacy for overcoming barriers (Prochaska,
Redding & Evers, 2002; Wanitkun, 2005).
3.1.1 Stages of Change: SC
The stage construct was important because it represents a
temporal dimension. The Transtheoretical Model construes change as a processinvolving progress through a series of six stages (Prochaska, Redding & Evers, 2002)
- Precontemplation is the stage in which the person does not
intend to change according to the recommended behavior, usually measured as the
next six months. A person may be in this stage because they were uninformed or under
informed about the consequences of their behavior, they may have tried to change a
number of times and became demoralized about their abilities to change. Both groups
tend to avoid information, talking, or thinking about their high-risk behaviors.
- Contemplation is the stage in which persons intend to
change within the next six months. They start to recognize that it is necessary to
change, and are aware of the pros of changing but also acutely aware of the cons. This
group is not ready for traditional action-oriented programs. They need more support
regarding motivation and self-confidence in order to move to action, and they have not
made a commitment to take action yet.
- Preparation is the stage in which persons intend to take
action within a month. They have participated in some exercise, but have not met the
criteria yet. This group has a plan of action such as talking to their physician, joining a
health education class, consulting a counselor, buying a self-help book, or relying on a
self-change approach.
- Action is the stage where the person has obviously modified
his/her behavior within the past six months. He/she has regularly exercised but less
than 6 month; therefore, relapse might happen in this group.
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- Maintenance is the stage in which the person has been

exercising regularly for more than six months. They are less tempted to relapse and
increasingly more confident that they can continue their changes.
- Termination is the stage in which persons have no
temptation to engage in a sedentary lifestyle and have full self-efficacy for engaging in
regular exercise for more than 5 years. They are sure they will not return to their old
unhealthy behavior as a way of coping.
Persons in different stages of change have different behaviors. A
comparison of lifestyle between the precontemplation stage and the action stage
showed that persons in the action stage had significantly higher exercise, vegetable
and fruit consumption compared to the person in the precontemplation stage. While
persons in the action stage had significantly lower smoking and alcohol consumption
when compared to persons in the precontemplation stage (Lam, et al., 2006).
3.1.2 Decisional balance
The decisional balance concept is comprised of a cost-benefit
analysis of a behavior change at that time, derived from Janis and Manns (1977)
model decision making. The original version includes four categories of pros
(instrumental gains for self and for others and approval from self and from others), and
four categories of cons (instrumental costs to self and to others and disapproval from
self and from others) (Prochaska, Redding & Evers, 2002; Wanitkun, 2005). From the
literature review, it was found that eventually only the Pros and Cons subscales were
used, and many studies confirm two factors of decisional balance (Prochaska, Redding
& Evers, 2002; Wanitkun, 2005).
The study indicated that pros scores were lower during the
precontemplation and contemplation stages compared to the action and maintenance
stages, while cons scores were higher during the precontemplation and contemplation
stages compared to the action and maintenance stages (Kim, 2007).
3.1.3 Self-efficacy
Self-efficacy was derived from Banduras Social Cognitvie
theory (1997). Self-efficacy is the situation-specific confidence that people have that
they can cope with high-risk situations without relapsing to their unhealthy or high-
risk behaviors. The method for increasing self-efficacy was information, including
enactive mastery experience, vicarious experience, verbal persuasion, and physiological
and
affective
states. Self-efficacy for overcoming barriers to exercise is the
confidence a person feels about performing physical activities. (Bandura,1997).

Persons with higher self-efficacy maintained physical activity levels, perceived less
effort in doing physical activity, and reported more positive effects from physical
activities ( Prochaska, Redding & Evers, 2002; Wanitkun, 2005).
There were six barriers of physical activity that
included negative effects, which were excuse making, exercising alone, inconvenient
to exercise, resistance from others, and bad weather. The study indicated that selfefficacy increased during the precontemplation and to the action and maintenance
stages (Wanitkun, 2003; Kim, 2007).
3.1.4 Processes of change
Processes of change were the process that persons use to
progress through the different stages of change, and provide important guides for
intervention programs (Prochaska, Redding & Evers, 2002). The processes were also
categorized into two factors: experiental and behavioral processes.
The experiental processes were as follows:
- Consciousness raising increased awareness about causes,
consequence, and cures for details of behavioral problems. The person attempted to
seek new information and gain understanding and feedback about the problem.
- Self-reevaluation was combined both emotional and cognitive
assessments of values by persons with respect to the unhealthy behavior.
- Environmental Reevaluation was consideration and assessment
by persons of how the problem affects the social environments and physics.
- Social Liberation was awareness, and acceptance by
persons of alternative, and problem-free life styles in the society.
- Dramatic relief was initially produced and increased
emotional experiences occurred, often involving intense emotional experiences related
to the problem behavior.
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The behavioral processes were as follows:

- Counter-condition was alternative behaviors for the
unhealthy behavior.
- Helping Relationship was combined with trusting, accepting,
caring, and utilizing the support during attempts to change the unhealthy behavior.
- Reinforcement Management was provided rewards for
controlling or maintaining the healthy behavior.
- Self-liberation was the persons choice, commitment and
recommitment to change the behavioral problems.
- Stimulus Control was control of causes that trigger the
behavioral problem, including removal of cues for unhealthy habits and addition of
prompts for healthier alternatives.
Using the processes of change differentiated at different stages
of exercise behavior. There were significantly differences in conscious raising, self
revaluation,
counter-conditioning,
helping
relationship,
stimulus
control,and
reinforcement management across the stage of change(Kim, 2007). The study of

Tseng (2003) showed scores for self-reevaluation, self-liberation, and counterconditioning increased from the pre-contemplation stage to the preparation stage and
from the preparation stage to the maintenance stage. However, consciousness raising,
social liberation, reforcement management, and helping relationships should be used
for earlier stages (precontemplation stage to preparation stage). In contrast, dramatic
relief, environment reevaluation and stimulus control should be used for later stages
(preparation stage to stage maintenance) (Tseng, Jaw, Lin & Ho, 2003).
The Transtheoretical model has been applied successfully in behavior
change for people, including smokers (Narkarat, 1997),
children, teens, senior
citizens, work sites, medical patients (Spencer, Malone, Roy & Yost, 2006), obese
women (Dallow & Anderson, 2003) menopausal women (Chitima, 2003) adults,
sedentary adults, women (Adams & White, 2003) diabetes patients (Jackson,
Asimakopoulou & Scammell, 2007; Kim, Hwang & Yoo, 2004)) and cardiac
rehabilitation patients (McKee, Bannon, Kerins & FitzGerald, 2006).
The study by Spencer, Malone, Roy & Yost (2006) demonstrated

application of the Transtheoretical model in exercise behavioral programs for children,
teens, senior citizens, medical patients, sedentary adults, and obese women, and a
range of intervention programs lasting from about 2 weeks to 2 years. Stage matched
interventions appear to be effective in promoting exercise (Spencer, Malone, Roy &
Yost, 2006). Adams & White (2003) studied 16 intervention programs for
adults.These programs had a time range of about 1 time to 2 years. This study revealed
that stage matched interventions based on the Transtheoretical model are more
effective than non-stage matched interventions (Adams & White, 2003).
The Transtheoretical model has been applied in behavior change for
medical patients. Kim, Hwangb & Yoo (2004) evaluated a stage-matched intervention
(SMI) for promoting exercise in Korean patients with type 2 diabetes, and the range of
intervention programs was 12 weeks. This study found the stage of change in the
intervention groups increased, whereas that of the control group did not change.
Physical activity levels in the intervention group increase (+14.78 METs x h/week),
whereas the control group did not change significantly (+0.39 METs x h/week). In the
intervention group FBS and HbA1C decreased (-17.18 mg/dl, , and -0.88% respective),
whereas in the control group FBS and HbA1C increased (+10.61 mg/dl, and +0.41%
respective) (Kim, Hwangb & Yoo, 2004). Jackson, Asimakopoulou & Scammell
(2007) studied the effects of a program to promote physical activity based on the
Transtheoretical model in 34 patients with type 2 diabetes. The intervention group
received a physical activity leaflet and one by one interview with a dietitian a week
after their routine appointment, and measured their physical activity level at baseline
and after 6 weeks. This study showed that physical activity levels in the intervention
group were greater than in the control group (Jackson, Asimakopoulou & Scammell,
2007).
Additionally, the transtheoretical model has been applied in behavior
change for coronary artery disease patients. McKee, Bannon, Kerins & FitzGerald
(2006) studied the effects of the Behavior Change Program. The program was used for
patients with coronary artery disease. The program undertook phase III of cardiac
rehabilitation for the patients, and lasted for 14 weeks. This program demonstrated that
there were significant improvements in the stage of change by the end of the program
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and over the next six months when compared to patients before entering the program
(McKee, Bannon, Kerins & FitzGerald, 2006).
Chitima (2003) studied an exercise program for menopausal women in
Chiang-Mai province. The range of the intervention was eight weeks. They compared
caloric expenditure, knowledge, exercising behavior, HDL level, and LDL, VO2 max
between pre and post exercise program. They found that after participants received
the exercise program, they had significantly higher mean scores than prior to
participating in the exercise program. Sittipreechachan (2005) studied the effect of the
Trantheoretical model application on low back pain prevention among workers in
sanitary production factories. The intervention lasted for 12 weeks. In comparing
knowledge about preventing low back pain pre and post intervention in the
intervention group and control groups, they found that after participants received the
intervention they had significantly higher mean scores than before receiving the
intervention. Moreover, they found that following the intervention, the participants in
intervention group had significantly higher knowledge about preventing low back pain
than those in the control group. Narkarat, (1997) studied the effects of a smoking
Behavior Change Program on smoking in middle school students. The length of
intervention was 10 weeks. When comparing attitude, perceived risks and effect of
smoking, and smoking behavior between pre and post smoking Behavior Change
Program, researchers found that those in the intervention group had significantly
higher attitude, perceived risks and effects of smoking, and outsmoking behavior than
before receiving the smoking Behavior Change Program. The students in the
intervention group also had higher significantly higher attitude, perceived risks and
effects of smoking, and rate of outsmoking behavior than those in the control group.
However, there are few studies that look at how to promote exercise in persons with
chronic disease by using this framework in Thailand.
3.2 Application of transtheoretical model to Behavior Change

Program for CABG patients
The stage matched intervention for behavioral change that is based on the
Transtheoretical model is more effective than a non-staged intervention (Adams &
White, 2003). The Transtheoretical model has been applied in behavior change for
people who have a readiness for change. Theprocesses of change used for behavior
change in the preparation stage were self liberation with choices and commitment to
change. It was believed that one can change and tell other persons (Prochaska,
Redding & Evers, 2002; Tseng, Jaw, Lin & Ho, 2003). Kim, Hwangb & Yoo (2004)
studied the use of processes of change for behavioral change in older persons. This
study
showed
that
participants
used
self-reevaluation,
counter-conditioning,
environmental reevaluation processes during pre-contemplation to preparation, and

preparation to action. While environmental reevaluation and stimulus control
processes were used during preparation to action (Tseng, Jaw, Lin & Ho, 2003),
decisional balance and self efficacy were used to develop the exercising program for
Korean participants with type 2 diabetes. This study revealed that the intervention
group compared to the control group showed significant improvements in stages of
change for exercising behavior, physical activity levels, and reductions in FBS and
HbA1c (Kim, Hwangb & Yoo, 2004).
Marcus, et al.(2007) studied delivery channels, telephone, print and
control, to determine whether one was more effective in promoting physical activities.
At six months, both telephone and print arms significantly increased in minutes of
moderate intense physical activities compared with the control arm, with no
differences between the telephone and print arms. At 12 months, the number of
moderate intensity minutes of physical activity for the print participants was
significantly higher than for both telephone and control participants (Marcus, et al,
2007).
The literature review concerning methods of intervention included
telephone, computer, and print-based materials, including brochures, posters, reports,
manuals. Most interventions incorporated more than one method of delivery (Spencer,
Malone, Roy & Yost, 2006). Exercising Behavior Change Programs ranged in length
from 1 session to 2 years (Conn, Minor, Burks, Rantz & Pomeroy, 2003). The
majority of developed programs for behavioral change based on the transtheoretical
model had a range of 2 weeks to 2 years (Spencer, Malone, Roy & Yost, 2006).
Criteria for diagnosis of unstable angina were based on the duration and
intensity of angina as graded according to The Canadian Cardiovascular Society
Grading Scale (Anderson, 2007)
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Class 1 Ordinary physical activity does not cause. Angina occurs with
strenuous, rapid, or prolonged exertion at work or recreation.
Class 2 Slight limitation of ordinary activity. Angina occurs on walking
or climbing stairs rapidly walking uphill; walking or stair climbing after meal; in cold,
in wind, or under emotional stress; or only during the few hours after awakening.
Angina occurs on walking more than 2 blocks on the level and climbing more than 1
flight of ordinary stairs at a normal pace and under normal conditions.
Class 3
Marked limitations of ordinary physical activity. Angina occurs
on walking 1 to 2 blocks on the level and climbing 1 flight of stairs under normal
condition and at a normal pace.
Class 4 Inability to carry on any physical activity without discomfort.
Angina symptoms may be present at rest.
Cardiac patients may be further stratified regarding safety during exercise
using published guidelines (AACVRP, 2003). Risk stratification criteria from the
AACVPR were presented following:
1. Characteristics of patients at high risk for exercise participation.
1.1 Presence of complex ventricular dysrhythmias during
exercise testing or recovery.
1.2 Presence of angina or other significant symptoms.
1.3 High level of silent ischemia (ST depression 2 mm)
during exercise testing or recovery.
1.4 Presence of abnormal hemodynamics with exercise testing
or recovery.
1.5 Ejection fraction < 40%.
1.6 History of cardiac arrest or sudden death.
1.7 Complex dysrhythmias at rest.
1.8 Complicated myocardial infarction or revascularization
procedure.
1.9 Presence of congestive heart failure.
1.10Presence of signs or symptoms of post event/ post
procedure ischemia.
1.11Presence of clinical depression.
2. Characteristics of patients at moderate risk for exercise participation
2.1 Presence of angina or other significant symptoms
2.2 Mild to moderate level of silent ischemia during exercise
testing or recovery (ST segment depression < 2 mm from baseline)
2.3 Functional capacity < 5 METs
2.4 Rest ejection fraction 40% to 49%
3. Characteristics of patients at lower risk for exercise participation
3.1 Absence of complex ventricular dysrhythmias during
exercise testing and recovery
3.2 Absence of angina or other significant symptoms
3.3 Presence of normal hemodynamics during exercise testing
and recovery
3.4 Functional capacity 7 METs
3.5 Resting ejection fraction 50%
3.6 Uncomplicated myocardial infarction or revascularization

procedure
3.7 Absence of complicated ventricular dysrhythmias at rest
3.8 Absence of congestive heart failure
3.9 Absence of signs or symptoms of posteven/postprocedure
ischemia
3.10Absence of clinical depression.
3.3 Effects of Behavior Change Program on physical activity and
physical fitness.
Programs for persons in the preparation stage included substitution of
alternative behaviors for the problem behavior (counter-conditioning), consideration
and assessment by the person of how the problem affects the social environments and
physics (environmental reevaluation) (Tseng, Jaw, Lin, & Ho, 2003), the persons
choice, commitment and recommitment to change the behavioral problems (self
liberation) (Prochaska, Redding, & Evers, 2002; Tseng, Jaw, Lin, & Ho, 2003),
control of situations and other causes that trigger the problem behavior(stimulus
control),
provided
rewards
for
controlling
or
maintaining
the
healthy
behavior(reinforcement management) (Prochaska, Redding, & Evers, 2002), and

increased confidence a person feels about performing physical activity(promote selfefficacy overcoming barriers) (Kim, Hwangb, & Yoo, 2004). This program increased
self-efficacy (Dallow & Anderson, 2003), readiness for change (Kim, Hwangb &
Yoo, 2004; McKee, Bannon, Kerins & FitzGerald, 2006; Woods, Mutrie & Scott,
2002), and decreased cost consideration (cons) of exercise or physical activity
(Griffin-Blake & DeJoy, 2006).
Readiness for change increased associated with
increased benefits consideration (pros) of physical activities and self-efficacy, while

the cost consideration of physical activities was decreased (Fahrenwaldm & Walkerm,
2003).
The CABG patients have gained education about exercise or physical
activity. They have learned about the cost of non physical activity and concern about
the importance of risk factor reduction, and cardiac rehabilitation enhancement. After
surgery patients have pain, anxiety, and fear about self care. Some patients could not
change behavior or meet the criteria, likewise some patients may succeed in changing
their behavior but they do not practice regular physical activity. These patients are in
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the preparation stage since they intended to take action within a month or participate in
some exercise, but they have not met the criteria yet. Other program emphasized
education and skill for physical activity. The education and skill can not motivate
physical activity in everybody, so they need to help them develop some additional
strategies for increasing their activity level. The TTM describes a dynamic process
whereby individuals at different stages use different processes to consider and adopt
new behaviors. Interventions specifically targeted at an individuals stage of change
are more effective in promoting that change (Prochaska, et al., 1993; Oldenburg, et al.,
1999; Peterson, Aldana, 1999). Thus, a Behavior Change Program was developed
based on the TTM for participants in the preparation stage who received CABG
surgery and is. The participants were in a low risk group because of being in
functional class 1 or 2.
CHAPTER III
METHODOLOGY
Research Design
This study was a quasi-experimental study with two group comparison.
The purpose of this study was to compare the effects of a Behavior Change Program
on physical activities (caloric expenditure of at least moderate physical activity level,
daily steps) and physical fitness (six-minute walking distance) with usual care.
Population and Sampling

The participants in this study comprised adult and elderly participants aged
35 years old or older who underwent CABG at the Chest Disease Institute, Ministry of
Public Health, Nonthaburi. Many studies demonstrated that age (Pierson, et al., 2003).
and gender (Vaccarino, et al., 2003; Treat-Jacobson & Lindquist, 2004) were related to
postoperative quality of recovery and incidence of the disease. To take these into
consideration during sampling, the ratios of gender and age in both groups were
assigned as follows:
- The male to female ratio was 3:1
- The ratio of age less than 60 years to 60 years and older was 1:2
The inclusion criteria for the eligible participants of this study were as
follows:
1. First experience of CABG.
2. Participants intention of participating in physical activity was in the
preparation stage as measured by Exercise Stage of Change questionnaire.
3. Literacy to collaborate with the Behavior Change Program.
4. Receiving the cardiac rehabilitation program and making the postoperative
follow-up appointment with Chest Disease Institute.
Worarat Photi
Methodology / 38
The exclusion criteria for this study were as follows:

1. Having limited ability to exercise such as arthritis, gout, or disability.
2. Uncontrolled chronic illness within the last 6 months before the
surgery.
3. Unavailable telephone communication.
The termination criteria of this study were as follows:

1. Unable to contact as appointed during the program
2. During the program, the health conditions were getting worse as
demonstrated by severe dyspnea, or chest pain etc.
The sample size was calculated by Power analysis (Polit, 2008). The
number of effect size was .7 calculated from the average of Dallow & Andersons
study (2003) and Wanitkunstudy (2003). The power of 0.80 for main effect and =
0.05 were chosen. The calculated sample size was 32 participants with adding 4
participants for attrition rate of 10% from previous research study (ref); total sample
size was 36 participants per group
Setting
The setting for this study was the 7/9 unit of the Chest Disease Institute,
Ministry of Public Health, Nonthaburi during December 2008 May 2009. This unit
is a pre and postoperative cardiac unit for adult and elderly patients. After the surgery,
patients are usually admitted to the intensive cardiac care unit and return to the ward
within 2-3 days.
Research Instruments
The research instrument consisted of four parts:
Part 1. Screening instrument.
The screening instrument was the Exercise Stages of Change questionnaire
(ESC) representing the individuals readiness for changing exercising behavior. The
questionnaire was developed by Wanitkun for patients with coronary artery disease
(2003) and changed the word from exercise to physical activity based on the results
of testing the feasibility of a physical activity program. It was a single question using a
five stage response-choice with criteria of regular physical activity accumulating three
10-minute or one 30-minute or more in most days of the week at a level that increases
your breathing rate and causes you to break a sweat. To answer this question,
participants selected an answer suitable for their physical activitys intention. The
question was Do you do physical activity regularly according to the definition
mentioned above?. The answers were no intention to did physical activity
regularly for more than 6 months. The questionnaire is in the appendix .
To
categorize a participant into the preparation stage, his/her answer was no, I intended
to begin physical activity regularly in the next 30 days.
Part 2. Intervention component

2.1 Self-Efficacy for Overcoming Barriers to Physical Activity
questionnaire.
The Behavior Change Programs aim was to find some solution for
overcoming barriers to a physically active lifestyle. To achieve the aim, all barriers
were assessed. The Self-Efficacy for Overcoming Barriers to Exercise questionnaire
was developed by Wanitkun (2003) to measure cardiac patients confidence to perform
exercise when facing obstacles. Like ESC, the word for exercise was changed to
physical activity.
The questionnaire had 23 items with six scales of excuse making,
exercising alone, access to equipment, resistance from others, and bad weather. The
answers used a 5-points Likert scale from 0 = not at all confident to 4 = completely
confident to regularly perform physical activity.
2.2 Behavior Change Program, including as follows:

- A booklet (intervention guideline).
- A brochure consisted of effects of non physical activity, choices of
physical activity, barriers of physical activity and methods for overcoming barriers.
Worarat Photi
Methodology / 40
- A self-liberation card, the content consisted of setting a goal of physical

activity.
- A motto for motivating physical activity.
- A summary letter, the content consisted of physical activity level
(enough or not enough) and barriers to physical activity.
Part 3. Data collection instruments

3.1 Demographic data questionnaire
A demographic characteristics questionnaire gathered information about
demographic and medical conditions. The demographic characteristics questionnaire
consisted of 13 items that gathered information such as age, gender, education, living
situation, employment status, marital status, weight, height, health habits of low-fat
diet consumption, previous or current working characteristics (choice ranging from
sedentary working to highly physical active), and history of smoking. The medical
condition section consisted of 16 items. Answers were in a Yes/No format related to
chronic illness history
3.2 Community Health Activities Model Program for Seniors

Activities Questionnaire for Older Adults: CHAMPS
The Community Health Activities Model Program for Seniors Activities
Questionnaire for Older Adults was the instrument used for measuring caloric
expenditure.
The questionnaire was developed by Wanitkun for patients with
coronary artery diseases (2003). The modified CHAMPS questionnaire was found to
fit for assessing Thai middle-aged and older adults. The CHAMPS consisted of 39
items for assessing weekly frequency, intensity, and duration of activities that persons
have done during the past month. Three questions were asked about each activity: was
the activity done? Yes/No if they engaged in an activity, two questions of duration
and frequency were asked. The exact number of frequency of a particular activity was
reported. The duration of the activity was identified by an exact number of hours and
reported on a 6 point Likert scale (less than 1 hour, 1-2.5 hours, 3-4.5 hours, 5-6.5
hours, 7-8.5 hours, and 9 or more hours). All physical activities were reported,
including duration and frequency per week and estimated caloric expenditure per week
in physical activity (Stewart, et al., 2001).
3.3 Six minute walk test :6MWT

A 6-minute field performance test (six minute walk test) was developed to
evaluate the level of physical fitness in severely impaired patients. This test used a
watch and a sphygmomanometer for measures the distance that a participant can
quickly walk on a flat surface in a period of 6 minutes. It evaluates the global and
integrated responses of all the systems involved during exercise such as pulmonary
and cardiovascular systems. The six minute walk test was a part of cardiac
rehabilitation at the Chest Disease Institute. Vital signs, distance, and abnormal signs
and symptoms were recorded.
3.4 Pedometer
A pedometer (OMRON HJ 005) was used for measuring the number of
daily steps. Participants received the manual as shown in appendix. The participants
had to attach the pedometer at the waist since they awoke, and wore it throughout the
day until they went to sleep. This recorded the number of daily steps. The record of
this study took three days to gather the data (one holiday and two working days). The
mean of three-days step recording demonstrated physical activity.
Part 4. The instrument for reassess intervention.

4.1 Questionnaire for evaluated participants perception of care.
The aim of the Behavior Change Program was to change non physical
activity to active physical activity. The questionnaire for evaluating participants
perception of care consisted of 10 items. It evaluated perceptions of the participants
about the Behavior change program that emphasized participant centered and
individual respect care.
Worarat Photi
Methodology / 42
Content validity and reliability.

1. Content validity.
Before its implementation, a panel of experts validated the
content of this program and the questionnaires. These experts consisted of two
cardiologists, a cardiac rehabilitation nurse, a nurse specialist in coronary artery
bypass graft care, and a physical activity specialist.
The CHAMPS questionnaire had a content validity index, each
item was 0.6 1.0, and the total content validity index was 0.91. The Self-Efficacy for
Overcoming Barriers to Exercise questionnaire had a content validity index, each item
was 0.81.0, and the total content validity index was 0.98. The questionnaire for
evaluating participants perception of care had a total content validity index was 1.0.
The Behavior Change Program and Exercise Stages of Change questionnaire had
suggestions about wording. Suggestions from these five experts were incorporated in
the final revision of these questionnaires.
The final Behavior Change Program was implemented by two
focus group discussions. Each focus group had 6-7 persons. The researcher asked the
participants following guiding question about understanding and recommendation of
details and appropriateness. Suggestions from these participants were incorporated in
the revision of the Behavior Change Program and questionnaires.
2. Reliability
The final questionnaire implemented in the trial study with 30
qualified CABG participants in the Chest Disease Institute. The Self-Efficacy for
Overcoming Barriers to Exercise questionnaire showed that cronbachs alpha
coefficients were 0.86 and 0.88 in questionnaires that evaluated participants
perception of care. The participants answered the items in the CHAMPS
questionnaire in the same way.
Data Collection
The eligible participants were recruited into the study in the preoperation
phase. Collecting data from the control group was done before the intervention group.
During the initial contact with the participants, the researcher explained the purpose
and the procedures of the study, including possible risks and benefits, to the subjects
who met the inclusion criteria and agreed to participate were requested to sign
informed consent forms.
After signing the consent form, each participant was interviewed before
the operation and the first data collection by questionnaire. Completion of the
questionnaires was estimated to require approximately 15-20 minutes. The processes
of intervention and data collection are shown in figure 2 and table 1. After standard
treatment at the hospital, the process of intervention was performed by the researcher
as shown in the appendix.
The intervention group engaged in a 7 week Behavior Change Program.
The program was divided into two sessions within hospital admission and at home
following discharge. Participants received tailored materials which addressed an
individuals specific problems and concerns. The tailored materials should be more
likely to stimulate change in three sections. The first sections during hospital stay
contained information to motivate the participants to consider the effects of non
physical activity on family or cousins, and how to combine physical activity into their
lifestyle. The second session motivated the participants to evaluate and analyze
barriers to physical activity, and shared how to find methods for overcoming barriers,
supported methods for combining physical activity with the participants lifestyles and
the participants specific elected methods. The third session comprised assessing the
goal of the third contact, shared stimulus control removing reminders or cues to engage
in unhealthy behaviors and adding cues or remainders to engage in the healthy
behaviors, and helped the participants to make a firm commitment to change. The
participants received a commitment card. In addition, the participants received
brochures, a self liberation card and motto.
At the first week and fourth week after discharge, the participants in the
intervention group were contacted by telephone to motivate them and find barriers to
physical activity, and to support the methods that the participants elected and to
Worarat Photi
Methodology / 44
analyze how well the participants plans worked, removing reminders or cues to
engage in non physical activity and adding cues or reminders to engage in physical
activity.
At the first follow up or second week after discharge, the participants in
the intervention group were contacted by the researcher to assess the goal of the first
telephone follow up. The researcher assessed their commitment to change, and
identified methods for combining physical activity into the participants lifestyle. This
also provided an opportunity for the researcher to applaud the participants progress
and assess their willpower to continue physical activity.
Data regarding the expenditure of at least moderate physical activity level
and above, and six minute walking distance were collected twice. Once at preintervention (1 day after discharge or discharge day) and again at post-intervention
(second follow up). The daily steps were collected one time at post-intervention
(second follow up).
After confirming their eligibility for the study and standard treatment at
the hospital, the pretest interviews were scheduled for the control group. The pre-test
and post-test were 7 weeks apart, so the duration of the study was the same as that of
the intervention group.
CABG participants in preparation stage
Intervention group (n = 35)
Control group (n = 36)
Explain the study

1-2 day before operation
Preoperation
Explain the study

Intervention phase
1st contact
1-2 days after discharge
from intermediate care
1st contact
1-2 days after discharge
from intermediate care
Admission in
hospital
2nd contact
Discharge day
2nd contact
6-7 days after operation
3rd contact
Discharge day
1st telephone interview

1 week after discharge
4th contact
First follow up
During stay at home

4 weeks after discharge
Evaluation phase
1st telephone for evaluation
Sent pedometer
6-7 weeks after discharge

Sent pedometer
6-7 weeks after discharge
Evaluate
Contact for evaluation
Second follow up

Second follow up
Figure 2 The processes of intervention
Worarat Photi
Methodology / 46
Table 2 The Behavior Change Program
Control group
Intervention group
Contact to explain the purpose and the Contact to explain the purpose and the
procedures of the study (15-20 min.)
procedures of the study (15-20 min.)
- Introduction, Inform consent
- Introduction, Inform consent
Answer
demographic
and
SOC -Answer
demographic
questionnaire
questionnaire
1st contact (10 min.)
1st contact (10 min.)
1-2 days after discharge from intermediate 1-2
days
after
and
SOC
discharge
from
care
intermediate care
- Answer SEOBE questionnaire
- Answer SEOBE questionnaire
- Usual care
- Behavior change program

2nd contact (10-15 min.)
-
6-7 days after operation

- Behavior Change Program
2nd contact (10-15 min.)
3rd contact (10-15 min.)
Discharge day
Discharge day
- Usual care
- Answer CHAMPS questionnaire
- Answer CHAMPS questionnaire
- Test Six Min. Walk Test
- Test Six Min. Walk Test

(10-15 min.) 1 week after discharge

4th contact (10-15 min.)
First follow up (2 week after discharge)

Table 2. The Behavior Change Program (Continue).
Control group
Intervention group
2nd telephone interview (10-15 min.)
-
4 weeks after discharge

(10-15 min.) 6-7 week after discharge
(10-15 min.) 6-7 week after discharge
- Details provided for use of pedometer
- Details provided for use of pedometer
Sent pedometer
Sent pedometer
(15-20 min.) Contact for evaluation (15-20 min.)
Second follow up
Second follow up
- Answer SEOBE, CHAMPS, and evaluate - Answer SEOBE, CHAMPS, and evaluate
nurse questionnaire
nurse questionnaire
- Six Minutes Walk Test
- Six Minutes Walk Test
Protection of Human Subjects

1. The investigator submitted a letter of introduction from the Graduate
School of Mahidol University and the thesis proposal was submitted to the Ethical
Committee and the director of Chest Disease Institute, Ministry of Public Health by the
investigator. After gaining permission from Ethical Committee and the director of the
Chest Disease Institute, Ministry of Public Health , the investigator submitted a letter
of introduction from the Graduate School of Mahidol university to the Director of the
Chest Disease Institute to request data collection.
2. After permission from the director of the Chest Disease Institute,
Ministry of Public Health had been granted, the researcher met the head of the 7/6, 7/7
and 7/9 units, OPD, 6/2 and 6/3 units, and cardiac rehabilitation unit to explain the
objectives and methods of data collection.
3. The researcher made the first contact and she introduced herself to the
subjects, then described the purpose and procedures of the study, including the length
of the Behavior Change Program, possible risks and benefits to the subject. To
Worarat Photi
Methodology / 48
maintain confidentiality, numbers were assigned to identify the subjects and their
information was kept in a locked file during the study. After the subject listened to and
read the information sheet, a signed consent was obtained from those subjects who met
the inclusion criteria and agreed to participate. The subjects were free to refuse to
answer any questions they preferred not to discuss and were allowed to ask questions
or stop the interview at any time.
4. A code number on the questionnaires was applied to protect
confidentiality. The participants were informed that the researcher would not identify
their names or other data in any published reports of this research. All hard copies of
questionnaires and notes were kept in a locked file cabinet, which only the researcher
could access. All signed consent forms were kept in a separate locked location.
Data Analysis
The data were analyzed as follows:
1. Frequency, mean and percentage were used to analyze demographic
characteristics and health condition.
2. A comparison of demographic characteristics and medical condition
between intervention group and control group were done by using chi-square.
3. Test significance of differences of physical fitness (six-minute walking
distance) between intervention group and control group at pre-intervention were done
by using independent t-test.
4. Test the significance of differences of physical activities (caloric
expenditure of at least moderate physical activity level, daily steps) and physical
fitness (six-minute walking distance) between the intervention group and the control
group at post-intervention were done by using MANOVA.
5. Testing the significance of differences in self-efficacy for overcoming
barriers and the perceptions of participants between the intervention group and the
control group at post-intervention were done by using an independent t-test.
Assumption of MANOVA
1. The dependent variable for MANOVA should be measured on a scale
that is ratio-level or internal level.
2. There was a multivariate normal distribution
3. There was a correlate between dependent variable (0.5 - 0.8).
4. The MANOVA assumes that each dependent variable will have similar
variance for all groups.
Worarat Photi
Results / 50
CHAPTER IV
RESULTS
The purpose of this study was to examine the effects of a Behavior Change
Program on physical activities (measured by caloric expenditure of at least moderate
physical activity level and above and daily steps) and physical fitness (measured by
six-minute walking distance) among coronary artery bypass graft (CABG) patients
who participated in the Behavior Change Program following their surgery. They were
compared with CABG patients who were treated with usual care following their
surgery. The results are presented in three sections: demographics, hypothesis testing,
and evaluation of the intervention process.
Part 1 Demographic Characteristics

Seventy-three participants were recruited into this study. There were 36
and 37 participants in the intervention and control groups, respectively. No
participants refused to participate in this study. Two participants were terminated from
the study (one participant of each group) because their hospitalization lasted longer
than five weeks. Thirty-five participants in the intervention group completed the
program and follow-up testing.
The demographic characteristics of the participants are presented in the
Table 3. Their age ranged from 48 to 84 years with a mean of 64.26 years in the
intervention group (SD = 8.92) and 45 to 81 years with a mean 62 years in the control
group (SD = 9.01). The majority of both intervention and control groups were male
(71.4% and 61.1%, respectively), older (62.9% and 58.3%, respectively), overweight
60% and 50%, respectively), education in element and lower (68.6% and 63.9%,
respectively), married (77.1 and 86.1%, respectively), retired or unemployed (48.6 and
63.9%, respectively), and had enough income but no savings (62.9 and 50%,
respectively).
Table 3 Comparison of Demographic characteristics by Chi-square and MannWhitney U test.

Characteristics
Intervention Group
(n = 35)
Control Group
(n = 36)
Male
25
71.4
22
61.1
Female
10
28.6
14
38.9
< 60 years
13
37.1
15
41.7
60 years
22
62.9
21
58.3
Normal 18.5-22.9
14
40.0
18
50
Overweight 23
21
60.0
18
50
Married
27
77.1
31
86.1
Single, Widow and Divorce
22.8
12.9
Spouse and children
16
45.7
22
61.1
Spouse
22.9
25.0
Children
11.4
8.3
Spouse and other relative
11.4
2.8
Other relatives
8.6
Alone
2.8
Gender
Ageb
BMI
Marital statusd
Living situation
(2 (1,71) = 0.844, p > 0.05). b(2 (1,71) = 0.152, p > 0.05).
(2 (1,71) = 0.717, p > 0.05). d (2 (1,71) = 1.430, p > 0.05).
Table 3 presents demographic characteristics of the intervention and

control groups. There were no statistically significant differences in demographics
between the intervention and control groups at p-value greater than 0.05.
Worarat Photi
Results / 52
Table 4 Comparison of Socioeconomic Status Between Control and Intervention

Groups by Chi-square and Mann-Whitney U test.
Characteristics
Intervention Group
Control Group
(n = 35)
(n = 36)
Employed
18
51.4
13
36.1
Retired or unemployed
17
48.6
23
63.9
Element and lower
24
68.6
23
63.9
High school
14.3
22.2
Vocational education
14.3
11.1
Bachelor degree or higher
2.8
2.8
- Not enough
13.9
- Enough but no saving
22
62.9
18
50
- Have more than need
2.9
5.6
- Having some extra money to save
12
34.3
11
30.6
Employment statuse
Educationf
Incomeg
(2 (1,71) = 1.129, p > 0.05). f (z = -0.528, p > .05.). g (z = -0.254, p > .05)
Table 4 presents the socioeconomic status of the intervention and control

groups. There were no significant differences in education (z = -0.254, p > .05) and
income (z = -0.528, p > .05.) between intervention and control groups.
Table 5 Comparison of health behaviors: working physical activity, diet control, and
smoking, by Chi-square and Mann-Whitney U test
Characteristics
Intervention
Control
Group
Group
(n = 35)
(n = 36)
- Mainly sitting with slight arm movement
18
51.4
16
44.4
- Sitting or standing with some walking
10
28.6
16.7
17.1
22.2
2.9
16.7
Yes
31
88.6
33
91.7
No
11.4
8.3
No
15
42.8
14
38.9
Yes
20
57.2
22
61.1
Previous or current working characteristics a
- Walking and heavy manual work often

requiring handling of materials weighing
over 20 kgs
- Walking with some handling of materials
generally weighing less than 20 kgs
Diet control b
History of smoking c
(2 (3,71) 4.962, p > 0.05). b (z = -0.434, p > .05.).
(2 (1,71) = 2.859, p > 0.05).
Their working behaviors were mostly working in a sitting position with

slight arm movement (51.4%of intervention group and 44.4 % of control group). The
majority of both groups had diet control (88.6% and 91.7 %, respectively), and
smoking experience (57.2% and 61.1%, respectively). There were no statistically
significant differences in health behaviors: working physical activity, diet control,
smoking between control and intervention groups at p-value greater than 0.05.
Worarat Photi
Results / 54
Table 6 The Frequency and Percentage of Functional Class

Functional class
Intervention Group
Control Group
(n = 35)
(n = 36)
Class 2
14.3
25
Class 3
18
51.4
16
44.4
Class 4
12
34.3
11
30.6
Class 1
20
22.2
Class 2
25
71.4
25
69.4
Class 3
8.6
8.4
Pre operation a
Post operation b
(2 (2,71) = 1.290, p > 0.05). b (z = -0.201, p > .05.).
In the Preoperative period, the majority of participants were markedly

limited in daily activities to provide self-care for themselves (85.7 % of the
intervention group and 75 % of the control group). After surgery, their functional
abilities were mostly better; most of them were able to take care themselves (791.4 %
of the intervention group and 91.6 % of the control group). There were no significant
differences in functional class between the intervention and control groups in both pre
(z = -0.805, p > .05.) and post-surgery (z = -0.201, p > .05.) at p-value greater than
0.05.
Table 7 Frequency and Percentage of Illness Conditions

Health conditions
Intervention Group
Control Group
(n = 35)
(n = 36)
Heart failurea
20
8.3
Arrhythmiab
22.9
18
50
2.9
5.6
17
48.6
22
61.1
Dyslipidemiae
23
65.7
32
88.9
Hypertensionf
22
62.9
24
66.7
Heart history
Comorbidities
Chronic renal diseasec
Diabetes mellitus
(z = -1.108, p > .05.).b (z = -2.627, p < .01.). c (z = -0.561, p > .05.)
(z = -0.580, p > .05.). e (z = -2.302, p < .05). f (z = -0.090, p > .05.)
Most of participants in this study had more than one comorbidity. The
majority of comorbidities were dyslipidemia, hypertension and diabetes mellitus
(65.7%, 62.9%, 48.6% in intervention group and 88.9%, 66.7%, 61.1% in control
group, respectively). The number of participants with arrhythmia and dyslipidemia in
the control group was significantly greater than those in intervention group (22.9%,
65.7% in the intervention group and 50%, 88.9% in the control group, respectively).
A Mann-Whitney U test was conducted to evaluate the presence of illness conditions
between the two groups. There were significant differences in the incidence of
arrhythmia (z = -2.627, p < .01.) and dyslipidemia (z = -2.302, p < .05.) between the
intervention and control groups at p-value less than 0.01.
Worarat Photi
Results / 56
Part 2 Hypothesis testing

Table 8 Comparisons of Mean and standard deviation of Caloric Expenditure of at
Least Moderate Physical Activity Level and Above, Daily Steps and SixMinute Walking Distance Between the Intervention and Control Group at
post-intervention by MANOVA
Variable
Min
Max
Mean
SD
Intervention group
35
315.1
1696
893.6
410.8
Control group
36
289.4
1408
637.9
293.3
Intervention group
35
2230
3881
2810
424.8
Control group
36
1639
3799
2418
431.9
Intervention group
35
256
498
353.9
59.53
Control group
36
195
416
298
53.22
0.13
10.54
< 0.01
0.18
14.82
< 0.01
0.20
17.57
< 0.01
1. Physical activity
1.1 Caloric expenditure of at
least moderate physical
activity level and above
(Kilocalories /week )
1.2 Daily Steps (steps)
2. Physical fitness
2.1 Six-minute walking
distance (meter)
The participants in both groups were not able to do any physical activity of
at least moderate level and above at pre intervention. The daily steps were not
measured at pre intervention. Based on the routine care of the Chest Disease Institute,
the six-minute walking distance was measured as a pre-discharge physical fitness
measure. At pre-discharge, the six-minute walking distance for the intervention group
ranged from 165 to 375 meters and from 160 to 375 meters for the control group.
There were no significant differences in the six-minute walking distance between the
control and intervention groups (t69 = 1.128, p > 0.05). In comparing pre and post for
both the intervention and control groups, the caloric expenditure of at least moderate
physical activity level and above of both groups significantly increased (t34 = -13.784,
p < 0.01, t35 = -13.852, p < 0.01, respectively). In comparing pre and post for both the
intervention and control groups, the six-minute walking distance () of
both groups
significantly increased (t34 = 8.177, p < 0.01, t35 = -12.786, p < 0.01, respectively).
The caloric expenditure of at least moderate physical activity level and
above increased more for the intervention group than for the control group. There were
significant differences in caloric expenditure of at least moderate physical activity
level and above between the intervention and control groups after the intervention
(Wilks Lambda = 0, F (5,69) = 10.543, p < 0.01, partial eta square = 0.133). The sixminute walking distance of those in the intervention group increased more than for
those in the control group after the intervention. There were significant differences in
six-minute walking distance between the intervention and control groups at post
intervention (Wilks Lambda = 0, F (5,69) = 17.569, p < 0.01, partial eta square =
0.203 ). The daily step was not measured pre intervention. There were significant
differences in daily steps between the intervention and control groups at post
intervention (Wilks Lambda = 0, F (5, 69)= 14.822, p < 0.01, partial eta square =
0.177).
Participants in the intervention group performed greater physical activities
and had better physical fitness than participants in the control group at six weeks after
discharge as presented mean in Table 7.
There were statistically significant
differences between the control and intervention groups in caloric expenditure of at

least moderate physical activity level and above, daily steps, and six-minute walking
distance at six weeks after discharge.
Worarat Photi
Results / 58
Part 3 Evaluation of Intervention process

To establish that the aforementioned changes were effects of the Behavior
Change Program, a process evaluation was conducted. Table 6 presented participants
perceptions of care in the intervention group and the control group.
Table 9 Frequency and Percentage of Participants Perception of Care quality.
Number (Percent)
Item
Intervention Group
Control Group
(n = 35)
(n = 36)
Yes
No
Yes
No
35 (100)
0 (0)
36(100)
0 (0)
0.0
1.0
35 (100)
0 (0)
32(88.9)
4 (11.1)
-2.016
0.04*
32 (91.4)
3 (8.6)
31(68.1)
5(13.9)
-0.703
0.48
35 (100)
0 (0)
35(97.2)
1 (2.8)
-0.986
0.32
31 (88.6)
4 (11.4)
24(66.7)
12(33.3)
-2.193
0.03*
32 (91.4)
3 (8.6)
23(63.9)
13(36.1)
-2.757
1.The Nurse talked to you

about methods for
increasing physical
activity.
2. You received a
questionnaire about
physical activity methods.
3. The Nurse provided a
list of things you could
do for improved physical
activity.
4. The Nurse provided
specific advice for your
own methods to improve
physical activity.
5. Nurse shared with you
about setting specific
objectives for managing
health problems.
6. Nurse asked you to
participate in planning
care.
<0.01
Table 9 Frequency and Percentage of Participants Perception of Care quality

(Continue).
Number (Percent)
Item
Intervention Group
Control Group
(n = 35)
(n = 36)
Yes
No
Yes
No
33 (94.3)
2 (5.7)
26(72.7)
10(27.8)
-0.277
0.04*
32 (91.4)
3(8.6)
32(88.9)
4 (11.1)
-0.356
0.72
34 (97.1)
1(2.9)
31(68.1)
5(13.9)
-1.659
0.97
35 (100)
0 (0)
35(97.2)
1 (2.8)
-0.986
0.32
7. The Nurse helped

participants to plan the
method of health care for
every day.
8. The Nurse helped you to
adjust your situation so
that you could get
physical activity.
9. The Nurse talked
about other persons who
also could help
participants to manage
health problems such as;
nurse, cardiac
rehabilitation team, etc.
10. The Nurse planned to
contact you after
discharge to see how are
you doing
Table 9 presents the frequency and percentage of participants perception of

care quality. The perception of care quality score mean in the intervention group was
19.43 points (SD = 0.88) and 18.86 points (SD = 1.33) in the control group at post
intervention.
There were no significant differences in perception of care quality
between the intervention and control groups (z = -2.049, p > .05.) at post intervention.
However, participants in the intervention group perceived that they got
better care than the control group in the following areas: collaborating and setting
Worarat Photi
Results / 60
specific goals for managing their own health problems, asking participants to think
about methods of health care, and helping participants to plan the method of health
care for every day. There were also significant differences in sharing or collaborating
to set specific objectives for managing health problems (z = -2.193, p < .05.), asking
participants to participate in planning methods of health care (z = -2.757, p < .001.)
and helping participants to plan methods of health care for every day (z = -0.277, p <
.05.) between the intervention group and the control group. These results demonstrated
that the Behavior Change Program applied some processes of change including
counter-conditioning, environmental reevaluation, self liberation, stimulus control,
reinforcement management and self-efficacy for overcoming barriers for motivating
participants to set a specific goal, think and plan about methods to reach to the goal of
physical activity.
Table 10 Comparing means and standard deviations of Self-efficacy for Overcoming
Barriers by t-test
Variable
Pre intervention
Post intervention
Mean
SD
Mean
SD
- Intervention group
45.6
13.41
48.11
11.82
- Control group
30.44
16.06
30.6
15.17
Self efficacy overcoming

barriers score
Table 10 presents means and standard deviations of self-efficacy for

overcoming barriers. The score of self-efficacy for overcoming barriers ranged from
17 to 85 for intervention group and 2 to 70 for the control group at pre intervention.
There were significant differences in self efficacy for overcoming barriers between
the intervention and control groups at pre intervention (t(69) = 4.311, p < 0.01). The
intervention group self efficacy overcoming barriers scores ranged from 24 to 85
points with a mean of 48.11 points (SD = 11.82) while in the control group scores
ranged from 3 to 70 with a mean 30.6 points (SD = 15.17) at post intervention. There
was one participant in the intervention group and ten participants in the control group
who had decreased self efficacy for overcoming barriers score at post intervention.
The intervention group had significant differences in self-efficacy for overcoming
barriers when compared to the control group at post intervention (t(69) = 5.585, p <
0.01).
The intervention group had a significantly greater difference in selfefficacy for overcoming barriers between pre and post-intervention (t(34) = 5.158, p
< 0.01). However, no significant difference was found in the control group (t(35) = 1.390, p > 0.05). The intervention group had a significantly greater difference (D
difference) in self-efficacy for overcoming barriers between pre and post-intervention
when compared to the control group(t(69) = 5.203, p < 0.01).
In summary, there were statistically significant differences between the
control and intervention groups in caloric expenditure of at least moderate physical
activity level and above, daily steps, and six-minute walking distance at post
intervention. Moreover, participants in the intervention group perception of care
quality and self efficacy scores were higher than for those in the control group. The
results demonstrate that physical activity and physical fitness were increased because
of the Behavior Change Program.
Worarat Photi
Discussion / 62
CHAPTER V
DISCUSSION
The purpose of this study was to examine the effects of a Behavior Change
Program on physical activities (caloric expenditure of at least moderate physical
activity level , daily steps ) and physical fitness (six-minutes walking distance) among
coronary artery bypass graft (CABG) patients compared with usual care. The number
of participants was a total of 71 adult patients with CABG (35 in the intervention
group and 36 in the control group) at Central Chest Institute, Ministry of Public
Health, Nonthaburi. The results are discussed in terms of characteristics of the sample
and hypothesis testing.
Demographic Data
No participants in either group in this study dropped out. Meta-analysis of
Hausenblas, Carron, and Mack (1997) demonstrated that individuals have the greatest
commitment to exercise when they hold favorable beliefs about exercise and believe
that they can successfully perform the behavior. This represents persons in the
preparation stage who have a strong commitment to pursue an active lifestyle.
Collaborating on specific goal setting with individual patients decreased the drop out
rate from the failure to reach goals and expectations, particularly within the first 6
months of starting an exercise program (Dishman, 1988). A behavior change program
helps individuals have realistic expectations about exercise outcomes, increasing their
confidence in overcoming their own barriers; therefore, a person believes that they
can successfully perform physical activities and reach goals.
Many studies demonstrate age and sex effects on physical activity. Men
have been found to have higher physical functioning (Treat-Jacobson & Lindquist,
2004), and functional capacity than women (Pierson et al., 2003). Moreover, women
have more physical symptoms and side effects, including unstable angina, congestive
heart failure, and depressive symptoms in the six to eight weeks following CABG
surgery than men (Vaccarino, Lin, Kasl, Mattera, Roumanis, Abramson, et al., 2003).
Many studies demonstrate gender differences in the incidence of CAD (Alberta &
Ruskina, 2001; Hodis, Mack, Lobo, Shoupe, Sevanian, Mahrer, et al., 2001;
Leelahakul, Chavalitnitikul, Leelahakul, Puthadejakum and Pasunant, 2003) and
physical activity (Weiss, O'Loughli, Platt, & Paradis, 2007). Older persons have a
higher absolute risk estimation for coronary artery disease (CAD) than younger adults
(Berenson, Srinivasan, Bao, Newman, Tracy & Wattigney, 1998; Korkushko,
Sarkisov, Lishnevskaya & Gorbach, 2000); in addition, age is associated with activity
and the recovery process. Older patients have lower functional capacity when
compared to younger patients (Pierson, Norton, Herbert, Pierson, Ramp, Kiebzak, et
al., 2003). In this study, the researcher
took this into consideration in terms of
sampling assignment of the control and intervention groups; thus, the majority of both
groups were male, and 60 year of age or older.
Being overweight has a negative effect on the level of physical activity
behavior during leisure-time (Trost, Owen, Bauman, Sallis, & Brown, 2002; Weiss, O'
Loughli, Platt, & Paradis, 2007; Godi, Blanger-Gravel, & Noli, 2008). Marital status
is associated with physical activity (Trost, Owen, Bauman, Sallis, & Brown, 2002) and
is a predictor of physical activity (Ransdell, Wells, 1998). Smoking and past exercise
behavior are associated with physical activity (Trost, Owen, Bauman, Sallis, &
Brown, 2002). The intervention and control groups were similar in
terms
of
demographics, socioeconomic status, health behaviors, functional class, and illness

conditions. However, there were significant differences between the two groups in
terms of illness conditions (arrhythmia and dyslipidemia) at baseline. The sample for
this study may represent the target population in terms of factors related to physical
activity.
Hypotheses testing
The outcomes of this study were physical activities (measured by caloric
expenditure of at least moderate physical activity level, daily steps) and physical
fitness (measured by six-minutes walking distance). A further discussion of the
research hypotheses follows:
Worarat Photi
Discussion / 64
1. The intervention group will have a significantly greater caloric

expenditure of at least moderate physical activity level when compared to the
control group.
After the Behavior Change Program, the intervention group had a
significantly greater caloric expenditure of at least moderate physical activity level
when compared to the control group at 6 weeks post-operation (p<0.01). The Behavior
Change Program motivated participants to engage in physical activity by using
specific processes of change and self-efficacy for overcoming barriers. The program
focused on increasing their confidence in overcoming their own barriers; therefore, a
person feels confident to perform physical activities. Not only that, the researcher
stimulated participants problem solving to overcome their barriers to exercise.
Persons with higher self-efficacy maintain physical activity levels, perceived less
effort in doing physical activity, and reported more positive effects from physical
activities (Prochaska, Redding & Evers, 2002). Many studies demonstrate the effect of
applying self-efficacy from the Self- efficacy theory on exercise or physical activity
(Saesue, 2003; Jompong, 2003). The study by Kim (2007) demonstrated that selfefficacy significantly increases from preparation to the action. The study by Saesue
(2003) demonstrated that exercise behavior significantly increased after participating
in self-efficacy enhancement. The study by Jompong (2003) showed that the different
mean scores for self-efficacy and health behavior in the experimental group (received
self-efficacy enhancement) were significantly higher than those in the control group
(received routine instruction).
The researcher used the process of change to motivate physical activity
by individual intervention. A process of change of behavior change program includes
substitution of alternative behaviors for the problem behavior: counter-conditioning,
consideration and assessment by persons of how the problem affects their social
environments and physics: environmental reevaluation (Tseng, Jaw, Lin, & Ho, 2003),
persons choice, commitment and recommitment to change the behavioral problems :
self liberation (Prochaska, Redding, & Evers, 2002; Tseng, Jaw, Lin, & Ho, 2003),
control of situations and other causes that trigger problem behavior : stimulus control
(Tseng, Jaw, Lin, & Ho, 2003), and provides rewards for controlling or maintaining
the healthy behavior: reinforcement management (Kim, Hwangb, & Yoo, 2004). Many
studies demonstrate that people can move from preparation to action by using these
processes. A study by Kim (2004) applied self liberation and reinforcement
management for the preparation stage and demonstrated a significant increase in
exercise behaviors in the intervention group for patients with type 2 diabetes when
compared to the control group. Scores for counter conditioning, reinforcement
management, and self-liberation increased from the preparation stage to the
maintenance stage (Wadsworth, & Hallam, 2007). A study by Tseng (2003) showed
scores for environmental reevaluation, self-liberation, stimulus control, and counterconditioning increased from the preparation stage to the maintenance stage; moreover,
findings provide guidance in developing stage-matched interventions. Interventions
for the preparation stage included counter conditioning, environmental reevaluation,
self liberation, and stimulus control.
All
participants
received
cardiac
rehabilitation
program.
Recommendations of cardiac rehabilitation include that patients who received CABG

surgery can fast or briskly walk for exercise at least 30 minutes, five days per week
(Kantarattanakool & Koonchon Na Ayutthaya, 2005) at 6 weeks post-operation.
Stewart, et al. (2001) calculated caloric expenditure from the frequency and duration
of walking.. The criteria of caloric expenditure that emphasized walking was 6211089 kcal per week. The intervention and control groups reached criteria based on this
recommendation. However, the intervention group had a significantly greater caloric
expenditure of at least moderate physical activity level when compared to the control
group. The researcher performed individual intervention to help the participants set
realistic personal activity goals and to guide physical activity behavior change;
moreover, the researcher emphasized walking and encouraged other physical activity.
The results were consistent with other studies based on the
Transtheoretical model. The Transtheoretical model has been applied to physical
intervention for obese, sedentary women (Dallow, Anderson, 2003), to promote an
exercise behavior program for patients with type 2 diabetes (Kim, Hwangb & Yoo,
2004), lifestyle physical activity intervention for sedentary employees (Titze, Martin,
Seiler, Stronegger, & Marti, 2001), and an exercise education intervention program
based on the Transtheoretical model was used with adults and older women (Shirazi,
Worarat Photi
Discussion / 66
et al., 2007). All findings demonstrate that the energy expenditure of the intervention
group was significantly higher than for the control group at post intervention.
2. The intervention group will have significantly higher number of

daily steps than the control group.
significantly higher number of daily steps than the control group at 6 weeks postoperation with the statistic level of significance at p-value less than 0.001. These
findings support the research hypotheses.
The pedometer was used as a motivation technique and for self
monitoring. The literature review demonstrated that the pedometer was perceived as a
novel and highly useful motivator, a direct source of feedback, and a readily available
memory prompt and reminder (Tudor-Locke, Myer, 2000). The pedometer can be used
as a tracking device, a feedback tool, and as a motivator (Catrine, 2002). The
pedometers reflect cumulative bouts of activity, and thus are responsive to even small
increases in walking (Tudor-Locke, 2001). Using a pedometer gives them the
opportunity to set and reach goals regarding their physical activity. As pedometer use
was only one of the strategies promoted during this multi-component intervention, it
was interesting to find that it was associated with an observed increase in step counts.
(Cocker, KBourdeaudhuij, Brown, & Cardon1, 2009).
It is possible that patients in this study had more interest in trying out a
pedometer; however, major studies use a pedometer and other strategies to promote
physical activity. The study by Araiza, et al. (2006) used pedometers and instructed
participants to walk at least 10000 steps per day 5 or more days per week. Subjects in
the active group significantly increased physical activity, whereas there was no change
in the physical activity of the control group (Araiza, Hewes, Gashetewa, Vella, &
Burge, 2006). Croteau (2004) used a combination of behavioral techniques
(pedometer-based and intervention) to promote daily steps.
Results indicate a
significant increase in average daily steps from baseline to after the program.
The increase in regular physical activity may be due to the behavior
change program applying the Transtheoretical Model. Processes of behavior change
were described in hypothesis 1. This program emphasized walking; thus, daily steps
increased. The results were consistent with a study by Baker, & Mutrie (2005) in
which the intervention group received a behavior change program applying the
Transtheoretical Model with monitoring by pedometer while the control group
received only a pedometer. The results demonstrated that the intervention group had a
significantly higher number of daily steps than the control group (Baker, & Mutrie,
2005).
3. The intervention group will have a significantly longer six-minute

walking distance than the control group.
significantly longer six-minute walking distance than the control group at 6 weeks
post-operation with the statistic level of significance at p-value less than 0.001. These
findings supported the research hypotheses.
Cardiac rehabilitation programs were originally introduced to facilitate
recovery from acute cardiac events. Exercise and physical activity were a part of
cardiac rehabilitation programs. The goals of cardiac rehabilitation have been to
promote recovery following an acute illness such as a cardiac event, by improving
physical outcomes and functional status of the patient and encouraging early return to
work. The instrument used to assessfunctional capacity was the 6-minute walk test
(Goble, & Worcester,1999). The 6-minute walk test was a useful measure of
functional capacity, targeting people with at least moderately severe impairment. It has
been widely used for measuring the response to therapeutic interventions for
pulmonary and cardiac disease (American Thoracic Society, 2002; Enright, 2003;
Opasich, et al., 2004).
Many studies measure cardiorespiratory fitness by the 6-minute walk test.
A study by Jancik (2001) demonstrated that the intervention group (received exercise
program) had a maximal oxygen uptake significantly greater than the control group at
p-value 0.05 (Jancik et al., 2001). The study by Yu, Li, Ho, & Lau, (2003)
demonstrated that exercise can promote maximal oxygen uptake. The intervention
group (received cardiac rehabilitation program) had a significantly greater maximal
oxygen uptake than the control group at p-value 0.001 (Yu, Li, Ho, & Lau, 2003). The
Verrill, Barton, Beasley, Lippard, & King, 2003 study looked at effects of cardiac
Worarat Photi
Discussion / 68
rehabilitation in coronary artery disease. As aforementioned, the findings of this study

demonstrated that the intervention group had a significantly longer six minute walking
distance than the control group at p-value 0.001 (Verrill, Barton, Beasley, Lippard, &
King, 2003).
Patients with coronary artery bypass graft surgery who were in
intervention group had an increase in their physical activity level; hence, the physical
fitness (six-minute walking distance) was increased (American Thoracic Society,
2002; ACSM, 2007). Physical activity affects large coronary luminal diameters,
reduces
progression
of
atherosclerosis,
balances
between
sympathetic
and
parasympathetic activity modulating cardiovascular activity, and improves endothelial

function in coronary artery bypass graft patients (Fletcher, et al., 2000; ACSM, 2007).
A benefit of regular physical activity is improved myocardial contraction, increased
stroke volume, and decreased heart rate at rest; moreover, exercise promotes lower
myocardial oxygen demand and improvemes myocardial oxygen supply, leading to
increased cardiac output (Franklin, Swain & Shephard, 2003; Warburton et al., 2006).
This process causes increased maximal oxygen uptake. The increased maximal oxygen
uptake results in a longer six-minute walking distance (ACSM, 2007).
This result was consistent with the Shirazi, et al. (2007) study where the
Transtheoretical model was applied to an exercise education intervention program for
adults and older women, the results demonstrate significantly higher mean scores for
physical fitness in the intervention group when compared to the control group (Shirazi,
et al., 2007).
In summary, participation in the intervention group increase physical

activity behavior (measured by expenditure of at least moderate physical activity
level) and physical fitness (measured by six-minute walking distance) more than the
control group because they received behavior change program. The behavior change
program individual intervention ; moreover, motivated participants to engage in
physical activity by using specific processes of change and self-efficacy for
overcoming barriers.
CHAPTER VI
CONCLUSION
The summary of the study

This research was a quasi-experimental study with two group comparison.
The purpose of this study was to examine the effects of a Behavior Change Program
on physical activities (caloric expenditure of at least moderate physical activity level
and above, daily steps) and physical fitness (six-minute walking distance) among
coronary artery bypass graft (CABG) patients compared with usual care. The criteria
for participants were adult patients who were 35 years old or older who had undergone
their first CABG. The number of participants totaled 73 adult patients with CABG (36
in the intervention group and 37 in the control group) at Central Chest Institute,
Ministry of Public Health, Nonthaburi. The data were collected during November
2008 to May 2009.
The research instruments were divided into 3 parts: 1) Screening
instrument. 2) Intervention component and 3) Data collection instruments.
1) After hospital admission, the patients were recruited by the inclusion
criteria and assigned into either group based on ratio of age and sex. The patients in
both groups answered the questionnaire before the intervention group received the
Behavior Change Program.
2) The researcher collected data in the control group and then the
intervention group was started on data collection for prevent contamination. Both
group received the usual care at the Chest Disease Institute and the experimental group
also participated in the Behavior Change Program.
3) The intervention group received the intervention for 6 weeks, which
included the recovery phase in hospital and their stay at home. Patients received
brochures, a motto, letter and pedometer. After a 6 week period (second follow up),
the patients in both groups answered the questionnaire again and recorded a six-minute
walking distance.
Worarat Photi
Conclusion / 70
4) Physical activity behavior (measured by expenditure of at least

moderate physical activity level) and physical fitness (measured by six-minute
walking distance) were assessed at pre intervention. At post intervention, physical
activity behavior (measured by expenditure of at least moderate physical activity level
and above, and daily steps) and physical fitness (measured by six-minute walking
distance) were assessed as the outcomes of this study.
5) The mean scores for the six-minute walking distance were compared
between the intervention and control groups at pre-intervention by using a T-test.
6) The mean scores for the caloric expenditure of at least moderate
physical activity level, daily steps and six-minute walking distance were compared
between the intervention and control groups post behavior change program, by using
MANOVA.
The results of this study can be summarized as follows:

The age of the patients ranged from 45 to 84 years, with a mean age of
64.68 years for the intervention group (SD = 9.36) and 62.30 years for the control
group (SD = 9.07). The majority of the patients in both groups were married, lived
with their spouse and children, completed primary school, were retired or unemployed,
and had enough income but no savings. The physical activities level for most of the
patients was mainly sitting with slight arm movement. The majority of the pre and
post operation functional class was class 3 and 1 respectively.
There were no significant differences between the control and intervention
groups in terms of demographics , socioeconomic status, health behaviors, functional
class, illness conditions and outcome; however, there were significant differences
between the control and intervention groups in term of illness condition (arrhythmia
and dyslipidemia) at baseline (p < 0.05). After the Behavior Change Program, there
were significant differences between the control and intervention groups in terms of
caloric expenditure of at least moderate physical activity level (p < 0.001), and sixminute walking distance (p < 0.001), and daily steps (p < 0.001).
Implications and recommendations

Implications for nursing practice
The Behavior Change Program could change physical activity behavior
and achieve a higher physical activity and physical fitness. Patients received telephone
follow-up and contact after discharge. They helped motivate physical activity and
helped solve physical activity problems. The nurses who implemented the intervention
should be trained by experts and have a booklet guideline. The duration for the
intervention each time was less than 20 minutes because it does not interfere with
usual care.
Implications for nursing education

Education management should incorporate this program with the specific
curricula of advanced nursing practice related to behavioral change. It will greatly
enhance the health education skill of nursing students and allow them to properly learn
and use physical activity to facilitate the rehabilitation of patients with CABG. In
addition, the Behavior Change Program can be used to improve health education of
patients with chronic disease.
Implication for nursing research

It was necessary to evaluate the effect of the Behavior Change Program
over 3 months, 6 months and 1 year in order to confirm that the patients complied with
regular behavior. It is recommended that any who will be implementing this program
arrange the Behavior Change Program based on the Transtheoretical model for other
patients, and assess differences in readiness for change.
Limitations of the study

There were several limitations to this study as follows:
1. The data collection a method in this study assigned the sample into both
groups following ratios of age and sex. A repeated study with randomization is
therefore recommended.
Worarat Photi
Conclusion / 72
2. There were significant differences between the control and intervention

groups in term of arrhythmia and dyslipidemia at baseline.
3. The Behavior Change Program was applied to patients at the Chest
Disease Institute. This program can be applied to other hospitals with appropriate
circumstances because the program was implemented at only one setting.
4. Only a small size effect was found for group differences in participants
overall achievement.
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.
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.
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. ,
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Worarat Photi
Appendices / 92
APPENDICES
APPENDIX A
(Content validity)

.

7/9
Worarat Photi
Appendices / 94
APPENDIX B
DEMOGRAPHIC DATA QUESTIONNAIRE
:
1. .......................................
10.
..............................
..........................
2.
3.
13.
...............................................
...............................................
4.
/
/
...............................................
APPENDIX C
Exercise Stages of Change questionnaire : ESC
5
()

..........................................................
.........................................................................................................................................................

5
,
6
, 6
, 6
Worarat Photi
Appendices / 96
APPENDIX D
Community Health Activities Model Program for Seniors Activities
Questionnaire for Older Adults: CHAMPS
1
4 X
2
X

3
4 X

1
2

2
1
Worarat Photi
Appendices / 98
APPENDIX E
Self-Efficacy for Overcoming Barriers to Exercise questionnaire
1.
99
0
1
2
2.
99
0
1
2
3.
99
0
1
2
4.
99
0
1
2
5.
99
0
1
2
99
0
1
2
23.
........

3
3
3
3
3
4
4
4
4
4
APPENDIX F
Questionnaire for evaluated patient perception of care
1
1.
10.
Worarat Photi
Appendices / 100
APPENDIX G
..............................................................................
Worarat Photi
Appendices / 102
APPENDIX H
(1)
Worarat Photi
Appendix / 104
(2)
APPENDIX I
Angsana new 86
Worarat Photi
Appendix / 106
APPENDIX J
.............................................
..............................................

1.
.................../\
(........................................)

APPENDIX K

1. (self-efficacy
overcoming barriers)
2. (reinforcement management)
5: 2 (6
) 15-20
-

-
(CHAMPS)
(Stages of change)
-
(Self-efficacy overcoming
barriers)
- 6 minutes walk test
Worarat Photi
Appendix / 108
APPENDIX L
.
.
.
.
.
.
.
.
.
.
Worarat Photi
Appendix / 110
APPENDIX M
.
.
.
.
.
.
.
.
.
.
.
Fac of Grad. Studies, Mahidol Univ.
BIOGRAPHY
NAME
Miss Worarat Photi
DATE OF BIRTH
28 April 1982
PLACE OF BIRTH
Nakhonpathom, Thailand
INSTITUTION ATTENDED
Thammasat University, 2000-2004

Bachelor of Nursing
Mahidol University, 2006-2009
Master of Nursing Science
(Adult nursing)
POSITION & OFFICE
2009 Present, Instructor at The Thai Red Cross

College of Nursing, Bangkok.
2004 2006, Surgical Intensive Care Unit,
Thammasat Hospital, Pathumthani.
HOME ADDRESS
11/1 Moo. 5 T.Lampaya Banglen

Nakhonpathom, Thailand 73130
Tel. 08-9794-1718
E-mail: wora_g@hotmail.com
EMPLOYMENT ADDRESS
The Thai Red Cross College of Nursing 1873

Praram 4 Road, Pathumwan Bangkok
10330

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EFFECTS OF BEHAVIOR CHANGE PROGRAM ON

PHYSICAL ACTIVITYAND PHYSICAL FITNESS

A THESIS SUBMITTED IN PARTIAL FULFILLMENT

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EFFECTS OF BEHAVIOR CHANGE PROGRAM ON PHYSICAL ACTIVITY

KEY WORDS: BEHAVIOR CHANGE PROGRAM / CORONARY ARTERY

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EFFECTS OF BEHAVIOR CHANGE PROGRAM ON PHYSICALA CTIVITY AND PHYSICAL

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Background and significance of the study

Purpose of the research

Conceptual framework of the research

Scope of the study

Expected benefits of the research

Population and sampling

Validity and reliability

Protection of human right

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The Behavior Change Program

Comparison of Demographic characteristics by Chi-square

Comparison of Socioeconomic Status Between Control and

Comparison of health behaviors : working physical activity,

The Frequency and Percentage of Functional Class

Frequency and Percentage of Illness Conditions

Comparisons of Mean and standard deviation of Caloric

Frequency and Percentage of Participants Perception of

Comparing means and standard deviations of Self-efficacy

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motivation promotion (Intaratool,

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2004), and eating behavior (Johnson, Driskell,Johnson, Dyment, Prochaska,

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