Social Support in Cardiac Rehabilitation Exercise Maintenance: Associations with Self-Efficacy and Health-Related Quality of Life

Social Support in Cardiac Rehabilitation ExerciseMaintenance: Associations with Self-Efficacy and

Health-Related Quality of Life1

Jennifer Woodgate2

Department of KinesiologyMcMaster University

Lawrence R. BrawleyUniversity of Saskatchewan

Christopher A. ShieldsAcadia University

This study examined whether cardiac rehabilitation (CR) maintenance exercise par-ticipants who were high and moderate in social support (SS) differed in their types ofself-efficacy and health-related quality of life, and whether SS was related to self-efficacy. Measures of SS, self-efficacy (i.e., walking, scheduling, in-class efficacy),and health-related quality of life (HRQL) were administered to 64 CR maintenanceexercise participants. A one-way, between-groups MANOVA was significant( p < .01), indicating that CR participants higher in SS reported significantly greaterself-efficacy and physical HRQL than did their moderate counterparts. In addition,social support predicted significant variance in task self-efficacy. The findingssuggest that differential perceptions of SS are related to differences in walking,in-class and scheduling self-efficacy, and the physical component of HRQL amongCR exercise maintainers.

Nonadherence to cardiac rehabilitation (CR) exercise programs has beenidentified as a major clinical and research problem (Burke, Dunbar-Jacob, &Hill, 1997; Dorn, Naughton, Imamura, & Trevisan, 2001). Over the past 20years, there have been numerous developments in exercise programs forcardiovascular disease (Dusseldorp, vanEldern, Maes, Meulman, & Kroaj,1999). A number of investigators have employed various behavioral andcognitive interventions within these programs to enhance compliance/adherence to rehabilitative therapy (Schneiderman, Antoni, Saab, & Ironson,2001). Whereas most psychosocial studies of CR adherence examine partici-pants during the initial, intensive phase of exercise therapy (Angove &

1All of the authors were at the Department of Kinesiology at the University of Waterloo atthe time of this study. The first author acknowledges the support provided by Social Sciences andHumanities Research Council (SSHRC) doctoral and postdoctoral fellowships. This article isbased on a portion of the first author’s M.Sc. thesis, under the supervision of the second author.

2Correspondence concerning this article should be addressed to Jennifer Woodgate, Depart-ment of Kinesiology, McMaster University, Hamilton, ON, Canada L8S 4K1. E-mail:[email protected]

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Journal of Applied Social Psychology, 2007, 37, 5, pp. 1041–1059.© 2007 Copyright the AuthorsJournal compilation © 2007 Blackwell Publishing, Inc.

mailto:[email protected]

Brawley, 2003; Dusseldorp et al., 1999), the maintenance of exercise behaviorrepresents an even greater public health challenge (Orleans, 2000; Rothman,2000). Although there have been some promising interventions that haveutilized behavior change strategies and demonstrated maintenance up to ayear in symptomatic older adults (King, Rejeski, & Buchner, 1998), we knowrelatively little about psychosocial factors that are associated with longerterm maintenance.

Wing (2000) underscored the need to examine individuals who appar-ently have achieved successful maintenance, and suggested observationalstudies of maintainers in order to understand the various factors thatcharacterize their maintenance. In addition, Orleans (2000) argued thatfuture research should assess the social processes that underlie successfulmaintenance (e.g., skills, support systems, motivations, barriers), particu-larly among special populations. The present study attempts to addressthese research recommendations by examining CR exercise participantswho successfully maintained their adherence to structured exercise therapy.For the present study, we consider maintenance beyond the 3-monthintensive training that is characteristic of programs that follow the Ameri-can Association of Cardiovascular and Pulmonary Rehabilitation(AACVPR, 1999).

Both the social support inherent to the delivery of CR and theself-efficacy related to rehabilitation have been identified as importantpsychosocial issues for investigation in CR (Berkhuysen, Nieuwland,Buunk, Sanderman, & Rispens, 1999; Dracup, 1994). However, to examinethese factors in maintenance CR, the social context of CR, as well asconceptual and measurement issues that concern social support requireconsideration.

Social Support and the Social Context of Cardiac Rehabilitation

During CR, participants are presented with several challenges requiringthe acquisition of novel skills, including coping with the symptoms of heartdisease and learning exercise behaviors. Understanding the social environ-mental context in which rehabilitation occurs is important in counteringnonadherence to treatment regimens and facilitating rehabilitation programdelivery (Meichenbaum & Turk, 1987). The inherent provision of socialassistance and support from both rehabilitation staff and other participantsin the CR program (e.g., social integration, guidance) may be useful toindividuals as they strive to become self-efficacious in their adjustment,acquisition of new skills, and adherence to their exercise regimen (Dracup,1994; Ewart, 1995; Kulik, Mahler, & Moore, 1996).

1042 WOODGATE ET AL.

CR program advocates emphasize that understanding social support isimportant (Anderson, Deshaies, & Jobin, 1996) in order to facilitate a suc-cessful intervention (Dracup, 1994). However, a frequently ignored possibil-ity is that participants could view the provision of support as low or negative(Berkhuysen et al., 1999; Chogahara, O’Brien Cousins, & Wankel, 1998). Infact, social support is not always related to health behaviors (Berkman,Blumenthal, Burg et al., 2003; Smith, Fernengel, Holcroft, Gerald, &Marien, 1994). Given the paucity of research on maintaining health-relatedperceptions and behavior (Bandura, 2004; Rothman, 2000), it should not beassumed that social support is positive among maintainers. Clearly, evidenceof the level of social support among rehabilitation exercise maintainers isneeded.

Surprisingly, the identification of social support, which is an inherent partof CR exercise program interventions, is problematic. Many studies that haveexamined social support and CR exercise have conceptual and measurementproblems similar to those found in the general social support literature andits exercise counterpart (Shields, Angove, & Brawley, 2003). These problemsare that most assessments of social relationships are neither theoreticallygrounded nor empirically validated (Rook & Underwood, 2000; Shumaker &Czajkowski, 1994). We attempt to address these limitations by using theo-retically based measures and evidence-based measurement recommendations(Willis & Shinar, 2000) in order to determine whether social support appearsto be meaningful to maintenance CR participants.

Self-Efficacy Relationships

An added benefit of social support is that its provision can be a source ofself-efficacy information. According to self-efficacy theory (Bandura, 1997),social support may be a source of efficacy information because individualsinfer the extent of their capabilities from interactions in their social environ-ment (e.g., directly via verbal persuasion) and social comparisons with others(e.g., indirectly via vicarious experience). In fact, Ewart (1995) asserted thatsources of efficacy information are integral components of well designed CRprograms.

High self-efficacy appraisals can enhance CR participants’ coping behav-iors, affect, and exercise participation (Ewart, 1995; Lemanski, 1990;McAuley & Mihalko, 1998). Specifically, self-regulatory self-efficacy (e.g.,specific confidence about behaviors leading to program attendance or carry-ing out daily lifestyle activity) has been shown to have a reliable associationwith CR exercise adherence (Blanchard, Rodgers, Courneya, Daub, &Knapik, 2002; Woodgate, Brawley, & Weston, 2005). Furthermore, partici-

SOCIAL SUPPORT AND EXERCISE MAINTENANCE 1043

pation in a socially enriched CR exercise program has been related toimproved task self-efficacy (e.g., specific confidence in behaviors that occurduring the exercise bout), compared to standard CR (Carlson et al., 2001).

Quality-of-Life Relationships

In addition to self-efficacy enhancement, it has been demonstrated that asocially enriched group exercise environment may improve participants’ feel-ings of enjoyment and health-related quality of life (Brawley, Rejeski, &Lutes, 2000; Turner, Rejeski, & Brawley, 1997). A review (Rejeski &Mihalko, 2001) has suggested that enjoyable experiences with physical activ-ity may be related to older adults’ overall quality of life in both asymptomaticand symptomatic samples. In the CR setting, health-related quality of life(HRQL) has been identified as a salient outcome of exercise rehabilitation(Beniamini, Rubenstein, Zaichkowsky, & Crim, 1997; Focht, Brawley,Rejeski, & Ambrosius, 2004). For example, CR participants’ repeated expo-sure to a supportive exercise program characterized by social integration withpeers and instructor feedback may bolster their adherence. In turn, exerciseadherence could improve participants’ physical functioning and reduce theirperceptions of pain (i.e., enhanced HRQL). Thus, the relationship betweensocial support and HRQL among adherent CR participants is examined inthe present study of maintainers. In addition, we are interested in whetherdifferences in HRQL will be observed among maintenance CR participantswho are higher and lower in their ratings of social provisions.

Is CR Maintenance Exercise Psychologically Habitual?

Among asymptomatic exercisers, it has been suggested that social-cognitive influences on maintenance exercise are not as pronounced as wheninitiating exercise. It is presumed that exercise becomes habitual with lessdeliberate decision making about adherence, and that psychosocial variablesmay contribute less to the prediction of behavior (e.g., McAuley & Blissmer,2000). However, recent evidence has suggested that social support and self-regulatory efficacy act as determinants of long-term physical activity partici-pation in relatively healthy older adults (McAuley, Jerome, Elavsky,Marquez, & Ramsey, 2003).

Maddux (1997) argued that the assumption that individuals who main-tain their exercise function “mindlessly” does not take into account manyexamples of individuals who have conscious awareness and volitional controlover many maintenance health behaviors (e.g., flossing teeth, going for a


walk, resistance training, swimming at 5 a.m.). These individuals must makedecisions in order to self-regulate their maintenance behavior. Thus, in thecase of symptomatic individuals (e.g., maintenance CR participants), con-scious forethought and planning would seem to be necessary for their main-tenance of rehabilitation exercise. Surprisingly, little attention has been paidto the examination of the social cognitions of CR maintenance participantswho engage in ongoing self-regulation for successful disease management(Clark, 2003). The present study constitutes an attempt to address an iden-tified maintenance research need (Wing, 2000) by examining the nature of therelationships between social support, self-efficacy, and HRQL among long-term maintenance CR participants who are engaged in physical activity.

The first purpose of the present study is to determine if maintenanceparticipants who are higher and lower in social support differ in theirwalking, in-class self-efficacy, scheduling self-efficacy, and health-relatedquality of life. The second purpose is to examine the nature of the relation-ships between social support, self-efficacy, and HRQL among maintenanceCR participants. In order to accomplish both purposes, theoretically basedmeasures and evidence-based measurement recommendations (Willis &Shinar, 2000) are used to address the social support of maintenance CRparticipants.

Method

Participants

Study participants were post-myocardial infarction (MI) patients whowere engaged in long-term exercise maintenance. The 64 volunteer partici-pants (M age = 65 years, SD = 10.14) were recruited from two highly similar,well established cardiac rehabilitation programs in two different communi-ties and settings (i.e., hospital and university). The sample was predominantlymale (n = 59; 92.2%), which is representative of the demographics for therespective CR programs. In addition, the mean tenure of maintenance par-ticipation in the CR programs was 3 years (SD = 28 months). The vastmajority of participants were married (86%), while 14% were single, divorced,or widowed.

Inclusion criteria were that participants first had to have successfullycompleted the intensive phase of a CR program and, second, to be engagedin the maintenance rehabilitation program for no less than 6 months (i.e.,initial CR program exercise therapy is 12 weeks; AACVPR, 1999). In addi-tion, they could not have experienced a recurrence of an MI. Attendance wasmonitored continuously as a check on their maintenance adherence rate for


the month prior to and following the administration of study measures.Adherence rates for each month were 77% and 74%, respectively.

Measures

Consistent with the study’s first purpose, we describe the process that wasused to select a social support measure relevant to the specific context of CRand exercise. Social support investigators have been urged to ensure that theirsocial support measure is congruent with the unique needs of their studypopulation (Lakey & Cohen, 2000), and the importance of sound psycho-metric indexes has been advised for accurate measurement. Inasmuch as theuse of many social support measures in previous CR and exercise studies hasbeen problematic (Shields et al., 2003), we paid particular attention to con-gruency issues, as well as the methods and practices of previous socialsupport research with older adult exercisers (e.g., Courneya & McAuley,1995; Cutrona & Russell, 1987; Duncan, McAuley, Stoolmiller, & Duncan,1993).

Duncan, McAuley et al. (1993) advocated further specificity in the assess-ment of social support within the exercise domain. Specifically, these authorsexamined the relative influence of general social support (e.g., outside theexercise group) and specific social support (e.g., inside the exercise group) oncontinued exercise program participation. They found that general supportfrom a variety of social networks was not predictive of exercise adherence.Consequently, sole reliance on global social support measures tapping avariety of sources may not be a wise research strategy. Thus, because we wereconcerned primarily with forms of support provided by the CR group,respondents rated the extent to which their current social relationships withinthe CR program (e.g., instructors, staff, volunteers, other participants) weresupplying each of the social support provisions (Duncan, Duncan, &McAuley, 1993; Litt, Kleppinger, & Judge, 2002). Accordingly, we brieflyoutline the background and rationale for our social support measurement toillustrate improvements.

Social Provisions Scale

The Social Provisions Scale (SPS; Cutrona & Russell, 1987) was devel-oped to assess several different social provisions or functions identified byWeiss’s (1974) theoretical framework. The scale measures an individual’sperceived social support and captures the six social support provisions ofguidance, attachment, social integration, reassurance of worth, reliable alli-


ance, and opportunity for nurturance. The SPS has been used previously witholder adults (Mancini & Blieszner, 1992), as well as with other individualsconfronting chronic and acute stressors (Cutrona & Russell, 1987). In orderto capture aspects of social support that might be relevant within the CRcontext, we followed the recommendations of Willis and Shinar (2000). Theyadvocated the use of a well tested social support measure (i.e., SPS).

In the present study, we employ a domain-specific version of the SPS(Cutrona & Russell, 1987) that is appropriate for the CR exercise context.For example, the original SPS item “Other people do not view me as com-petent” was modified to read “Other people do not view me as a competentparticipant in the cardiac rehabilitation exercise program.” Willis and Shinar(2000) recommended the inclusion of new items designed to capture specificaspects of the stressor characteristics (e.g., coronary heart disease symptoms)and to support the specific needs of the study population. Thus, an additionalsocial provision scale previously utilized with CR participants—symptom-oriented integration—was included in the social provisions battery (Rejeski& Brawley, 1996).

Subscale descriptions and psychometrics. For the present study, the com-plete social support measure consisted of a total of seven subscales (i.e., thesix context-specific, original SPS scales, plus the CR program specificsymptom-oriented integration scale). Each of the six initial social supportprovisions was assessed with four items: two that described the presence ofthe provision, and two that described the absence of the provision. Symptom-oriented integration consisted of one positive and two negatively phraseditems. Negatively phrased items were reverse-scored. For all scales, each itemwas scored on a 4-point scale ranging from 1 (strongly disagree) to 4 (stronglyagree).

We examined the responses and internal consistencies of all scales todetermine (a) reliability of items to the scale concept; and (b) relevance of theCR-oriented modification of scales to maintenance participants. This wasconsidered prudent, as previous investigations of the scales have indicatedthat some social provisions are not reliable or meaningful to specific samples(Cutrona & Russell, 1987). In fact, two of the seven subscales were notinternally consistent, based on data from CR participant responses and, thus,were excluded (i.e., social integration and reassurance of worth, as < .60). Abrief description of each of the five remaining internally consistent socialprovision scales follows.

Guidance is support in the form of advice or information (a = .70).Attachment involves emotional closeness and may provide a sense of secu-rity (a = .89). Reliable alliance items include tangible aid and assistance(a = .79). Items on the opportunity for nurturance subscale entail the oppor-tunity to feel needed (a = .81). Finally, symptom-oriented integration (i.e.,


the new provision) taps support drawn from group members’ similarity inmedical condition (a = .83). As reflected by internal consistency values,these scales were reliable in the context of the CR program sample (a > .70;Nunnally, 1978).

Total SPS score. Willis and Shinar (2000) suggested that when subscalecorrelations indicate a common social support construct, it would be appro-priate to combine individual provisions and use them as a total SPS measureof perceived support. In fact, Cutrona and Russell (1987) consistently utilizeda total SPS score to successfully predict physical and psychological outcomeswith study populations confronting chronic and acute stressors. Finally, thispractice has been followed also in studies of exercising adults, where onlythose scales that were correlated and theoretically relevant were combined(e.g., Courneya & McAuley, 1995; Duncan, Duncan et al., 1993).

Based on recommendations from this literature, we followed similar pro-cedures to refine our measure. The three social provisions that were signifi-cantly correlated (range of rs = .41–.59, ps < .05) were guidance, reliablealliance, and symptom-oriented integration. Opportunity for nurturance andattachment were not included because of their nonsignificant correlations( ps > .05) with the other three scales or with each other.

Consistent with the practice in the aforementioned studies, a total socialsupport score was created from the three subscales that were psychometri-cally sound and related. Each subscale score was summed and divided by thenumber of items, creating three subscale scores ranging from 1 to 4 that arerepresentative of the measure’s 4-point scale. The total social support scorecontaining three subscales could range from 3 to 12, with higher scoresindicating greater perceived social support (MSPS total = 9.88, SD = 1.27). Thetotal social support measure was relevant for the exercise and CR context andwas internally consistent (a = .77; Nunnally, 1978).

Self-Efficacy

Major reviews of exercise-related self-efficacy have recommended that inorder to assess the construct properly, investigators should employ specificityin its measurement and utilize multiple indicators of self-efficacy (McAuley &Mihalko, 1998; McAuley, Pena, & Jerome, 2001). Consistent with theserecommendations, we utilized three published, exercise-related self-efficacymeasures that were adapted to reflect the CR program context (Dawson &Brawley, 2000; DuCharme & Brawley, 1995; Woodgate & Brawley, in press).Both task (i.e., in-class and walking) and self-regulatory (i.e., scheduling)self-efficacy were assessed. Each of the following self-efficacy scales employeda confidence scale ranging from 0% (not at all confident) to 100% (completely


confident), consistent with recommendations published in the aforemen-tioned reviews.

Walking self-efficacy. The measure of walking self-efficacy assesses par-ticipants’ degree of confidence in performing a walking task using a hierar-chical scale of increased duration. Participants indicated their confidence towalk briskly for 5-min increments (from 15 to 40 min). A mean of these sixitems represents walking self-efficacy. This measure was internally consistent(Cronbach’s a = .78; Nunnally, 1978).

Scheduling self-efficacy. The six-item measure of scheduling self-efficacyassesses participants’ confidence in their ability to self-regulate various orga-nizational and scheduling tasks with respect to CR program attendance(DuCharme & Brawley, 1995). A sample item is “Organize time and respon-sibilities around each cardiac rehabilitation exercise session during the next 4weeks.” The confidence ratings were summed and divided by 6 to yield amean scheduling self-efficacy score ranging from 0% to 100%. Good internalconsistency of the measure in this study was evident (a = .96; Tabachnick &Fidell, 2001).

In-class self-efficacy. The measure of in-class self-efficacy consists ofseven items adapted from Dawson and Brawley (2000) to reflect specificaspects of the center-based classes in the CR program. A sample item is“Complete the aerobic/cardio component of my cardiac rehabilitation exer-cise session without breathing too heavily.” The mean of the seven statementsrepresents in-class self-efficacy. Cronbach’s alpha for the measure was .90,reflecting good internal consistency (Tabachnick & Fidell, 2001).

Health-Related Quality of Life

Participants’ perceived quality of life was assessed with the RAND36-Item Health Survey (SF-36; Ware & Sherbourne, 1992). This 36-itemquality-of-life measure is comprised of two norm-based composite scales(mental health and physical function) and eight subscales (physical func-tioning, bodily pain, role limitations resulting from physical healthproblems, role limitations resulting from personal or emotional problems,emotional well-being, social functioning, energy/fatigue, and generalhealth perceptions). Higher scores reflect a more favorable perceivedhealth state.

Composite measures of the SF-36 are reported frequently as health out-comes in major reviews of CR (e.g., Dusseldorp et al., 1999) and older adults(e.g., Rejeski & Mihalko, 2001). In the present study, both the SF-36 com-posites and the specific subscales were examined. Cronbach’s alpha indicatedacceptable internal consistency for all subscales, as well as the physical


function and mental health composites (range = .80–.93; Nunnally, 1978;Tabachnick & Fidell, 2001).

Demographics and Informed Consent

Demographic information was gathered about gender, age, duration ofinvolvement in the maintenance CR program, and marital status. Informedconsent documents with approval and study endorsement from the partici-pating programs and from university research ethics boards were provided.All participants were assured of the confidentiality of their responses and thatthey could withdraw from the study at any time without obligation orconcern about their maintenance CR participation. The study questionnaireswere completed following the CR program class, either individually or insmall groups (< 6 participants) at the CR program site under the supervisionof the study researcher.

Results

To examine the possibility that differences in participant characteristicscould be a function of participating in the two different CR programs, aone-way between-groups MANOVA procedure was conducted. The resultsindicate that there were no significant CR site differences among study par-ticipants for any of the social cognitive and behavioral variables or for anydemographics (Wilks’s l = .787, p > .05). Thus, participants from both siteswere pooled to form a common sample for all subsequent statistical analyses(N = 64).

Social Support Group Differences

In order to examine whether maintenance participants perceived differentamounts of efficacy and HRQL, we considered those participants who heldthe more extreme views of social support from their CR program. Therationale for the extreme groups procedure was that if social support isassociated with social cognitions such as self-efficacy, then individuals mostlikely to exhibit characteristic differences in these cognitions would be thosemost extreme in their perceived social support. Moreover, an observation ofcharacteristic differences among maintenance CR participants would suggestthat while maintainers adhere to regular physical activity, they are not homo-geneous in their perceptions.


However, if differences in individual social cognitive characteristics didnot manifest themselves among extreme group participants, it is unlikely thatthey would be observed in the entire sample, although the larger samplewould offer greater statistical power.3 Thus, we conducted an examination ofsocial cognitive differences among participants higher and lower in socialsupport using extreme groups comparisons. This extreme groups analysis hasbeen useful in previous research studying the physical activity behavior ofboth symptomatic and asymptomatic samples (e.g., fibromyalgia, Culos-Reed & Brawley, 2000; healthy adults, Gyurcsik & Brawley, 2000).

To create the extreme groups, individuals in either the higher (M = 11.04,n = 22) or the moderate (M = 8.57, n = 21) tertile of total perceived socialsupport (i.e., top and bottom third of the distribution) were used. We thenverified that these extreme groups were truly different in their level of totalsocial support on the basis of a significant univariate F test (F = 81.07,p < .001) in order to proceed with further analyses.

After meeting the independent groups criteria, we subsequently per-formed a one-way between social support groups MANOVA comparing thethree efficacy measures, the HRQL subscales, and the HRQL physical func-tion and mental health composites. The overall MANOVA was significant,F(13, 26) = 3.28, Wilks’ l = .379, p < .01. While a number of univariate Ftests indicated that the majority of dependent measures were significant, therewere a number of nonsignificant findings.

Using Cohen’s (1992) recommendation for statistical model reduction toobtain power in the face of relatively small samples and multiple dependentmeasures, we trimmed the nonsignificant effects from the omnibusMANOVA model and reanalyzed (Tabachnick & Fidell, 2001). Thistrimmed MANOVA model was also significant, F(8, 34) = 3.04, Wilks’l = .575, p < .01, h2 = .425, power = .906. Univariate follow-up F testsrevealed numerous differences (see Table 1). All effects were in the samedirection (i.e., higher social support group had higher mean scores on allvariables), with p values ranging from .0001 to .029. The higher total socialsupport group had significantly greater in-class self-efficacy, F(1) = 17.47,p < .0001; scheduling self-efficacy, F(1) = 5.66, p < .022; and walking efficacy,F(1) = 5.86, p < .02, than did the lower social support group. This was alsothe case for the physical function HRQL composite, F(1) = 7.77, p < .008;and the HRQL subscales of physical role limitations, F(1) = 9.44, p < .004;energy, F(1) = 9.78, p < .003; pain, F(1) = 5.11, p < .029; and general healthstatus, F(1) = 6.22, p < .017.

3The extreme groups method produces a more conservative test of hypothesized groupdifferences because statistical power is reduced when only extreme groups are analyzed.


Social Support, Self-Efficacy, and HRQL Relationships

Self-efficacy. Correlational analyses revealed that several individualsocial support subscales were significantly related to indexes of self-efficacy.Specifically, in-class self-efficacy was correlated positively with guidance(r = .28), reliable alliance (r = .35), and symptom-oriented integration(r = .28). In addition, walking self-efficacy was significantly correlated withsymptom-oriented integration (r = .34). The combined total support indexwas significantly correlated with in-class self-efficacy ( p < .01). However,attachment and opportunity for nurturance were not significantly correlatedwith self-efficacy ( ps > .05).

In order to test whether total social support would predict multipledimensions of self-efficacy, three multiple regression analyses were conductedusing the R2 adjusted estimate to control for inflation (Tabachnick & Fidell,

Table 1

Means for High and Moderate Total Social Support Groups

Variable

High Moderate

M SD M SD

Walking self-efficacy*a 76.75 22.85 59.44 28.47In-class self-efficacy**a 94.35 6.40 78.56 17.94Scheduling self-efficacy*a 92.27 8.10 82.29 19.63Physical HRQL**a 52.35 5.58 45.54 9.75Physical role limitations**a 90.91 22.55 54.17 46.38Energy**a 71.60 15.15 56.67 16.45Pain**a 87.05 17.69 71.67 19.87General health status*a 72.99 21.24 55.83 24.21Mental HRQL 55.35 9.54 51.23 9.60Physical functioning 84.09 19.43 75.56 15.99Emotional role limitations 90.91 23.42 83.33 28.59Emotional well-being 86.91 17.64 78.00 15.17Social functioning 89.77 20.28 84.72 15.79

Note. High social support group, n = 22; moderate social support group, n = 21.HRQL = health-related quality of life.aVariable included in trimmed MANOVA model.*p < .05. **p < .01.


2001). Total social support significantly predicted 8% of the variance forin-class efficacy (R2 adj. = .078, p < .014), which is a small- to medium-sizedeffect (Cohen, 1992). No other significant self-efficacy predictions wereobserved. This is not surprising since in-class efficacy (i.e., confidence toperform exercises within the program) corresponded most with the totalsocial support measure (i.e., support from individuals within the program).

HRQL. Correlational analyses reveal that total social support was sig-nificantly related to the physical function HRQL composite (r = .25, p < .05).Total social support significantly predicted 8% of the variance for in-classefficacy (R2 adj. = .045, p < .05), which is a small effect (Cohen, 1992).

Discussion

Although social support is deemed an important facet of cardiac rehabili-tation exercise therapy programs (Dracup, 1994), identification of the formsof social support provided as an inherent part of these programs has not beenexamined reliably (Shields et al., 2003; Shumaker & Czajkowski, 1994).Moreover, few studies have examined social support within the context ofCR exercise maintenance. In this study, we specifically addressed some of theproblems of social support measurement in previous studies of exercise andCR by carefully following both recommendations made relative to socialsupport measurement and previous evidence for specific populations. Inaddition, whereas the study of maintenance has been advocated (Rothman,2000; Wing, 2000), most psychosocial research attention in the CR literaturehas been devoted to exercise initiation. Specifically, research examining thesocial cognitions of long-term maintainers has been advocated because we donot understand the social cognitions and behavioral strategies used by suchindividuals to achieve their maintenance of a lifestyle change (Bandura, 2004;Orleans, 2000; Wing, 2000). Thus, the results of the present investigationprovide some initial insight into the psychosocial relationships and differ-ences among long-term maintenance CR program participants.

Regarding social cognitive differences, participants perceiving high socialsupport from the maintenance CR program reported greater self-efficacy andphysical status HRQL than did those who perceived moderate socialsupport. High support participants had stronger self-efficacy beliefs intheir self-regulatory abilities (i.e., schedule exercise sessions) and task-relatedabilities (i.e., walking, performing in-class exercise activities) than did theirmoderate support counterparts.

A similar pattern of results emerged for several physical HRQL indices.Those individuals who were higher in perceived social provisions expressedgreater energy, less pain, better health status, and fewer physical role limi-


tations than did participants who perceived only moderate levels of socialprovisions. However, it is worth noting that participants who adhered butreported only moderate levels of CR program social provisions expressedHRQL levels significantly below their counterparts, and these values weresimilar to the asymptomatic norms for their age group (SF-36; Ware,1993).

Collectively, the various social cognitive and HRQL differences observedin the present study suggest that long-term maintenance CR participants arenot a homogeneous group. It is evident that there are individual differencesfor participants who have adhered to their CR program for an average of 3years. Thus, the idea that maintenance participants can be treated in commonfashion with the expectation of long-term success should be avoided, andcontinued assessment of participants’ beliefs about their maintenance abili-ties is necessary (Rothman, 2000).

For most health behaviors that we maintain, we are aware that thesebehaviors are under our volitional control (Maddux, 1997). Indeed, thesebehaviors really are customary routines requiring mindful forethought andplanning for maintenance. As such, mindless habituation is not a character-istic of maintenance CR (Maddux, 1997). Among this maintenance sample,CR participants reported differential perceptions of social support from thegroup and efficacy to schedule, perform program exercises, and walk. Fur-thermore, maintainers were differentially satisfied with their physical healthstatus (as suggested by HRQL differences). For example, a CR participantwho perceived moderate social support from the program was likely to be lessconfident in his or her ability to attend the program sessions and reportedpoorer physical functioning. A possible implication of these findings is thatmore tailored CR program social support may be necessary for long-termmaintenance participants.

It also was demonstrated that specific social provisions were related to CRparticipants’ self-efficacy appraisals. Perceptions of guidance, reliable alli-ance, and symptom-oriented integration explained significant variance inmaintenance participants’ confidence to perform various aspects of thecenter-based CR exercise classes. Because social support may serve as asource of efficacy information (Bandura, 1997), this association warrantsfurther attention in future intervention studies in which specific forms ofsocial support might be varied and compared.

In conclusion, the chronic nature of cardiovascular disease, coupledwith age-related comorbidities, presents a host of challenges for olderadults who must maintain lifestyle changes in physical activity required byCR (Brawley, Rejeski, & King, 2003; Clark, 2003). Do those who perceiveless social support also doubt their ability (self-efficacy) to deal with thechallenges of maintaining long-term physical activity change? We will only


know the answer to such questions by continuing to examine older adultswho, while confronting other chronic problems that often are associatedwith aging, continue successful exercise maintenance. Future study of main-tenance of physical activity as a means of countering the chronic problemsassociated with the inactivity of older age has been recommended (Brawleyet al., 2003; Wing, 2000). This study represents an initial step towardserving that need.

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Social Support in Cardiac Rehabilitation Exercise Maintenance: Associations with Self-Efficacy and Health-Related Quality of Life