Objective: Physical activity is crucial in the treatment of cardiac disease. In addition to sociocognitive theories of behavior change, attitudinal ambivalence and nonconscious factors have also been demonstrated to predict physical activity. We propose an extension to the theory of planned behavior with a dual-systems approach including explicit and implicit attitudes, and different types of attitudinal ambivalence as moderators to predict the physical activity of patients after discharge from inpatient cardiac rehabilitation. Method: The sample comprised N = 111 cardiac patients who provided daily diary reports of intention, cognitive, affective, and implicit attitudes for 21 days after discharge (86% male, M age = 62, SD age = 11, n = 2,017 days). Daily moderate-to-vigorous (MVPA) and light (LPA) physical activity were measured using accelerometers. Five types of ambivalence were calculated. Analyses included Bayesian multilevel modeling. Results: Patients with more positive affective attitudes and more positive implicit attitudes had a higher intention. Higher ambivalence weakened the affective attitudes-intention relationship. On days with more positive implicit attitudes than usual, intention was lower, but only when ambivalence was low. Patients with higher ambivalence engaged in less MVPA. On days with extremely low ambivalence, implicit attitudes were negatively associated with tomorrow's MVPA. Patients with more positive affective attitudes engaged in more LPA, but only when their ambivalence was very low. On days with higher ambivalence than usual, the next day's LPA was shorter. However, another type of ambivalence showed the opposite effect. Conclusions: The results emphasize the importance of affective and implicit attitudes and ambivalence for the physical activity of cardiac patients.
1Theories of behaviour change and health behaviour change interventions are most often 2 evaluated in between-person designs. However, behaviour change theories apply to 3 individuals not groups and behavioural interventions ultimately aim to achieve within-person 4 rather than between-group change. Within-person methodology, such as N-of-1 (also known 5 as single case design), can circumvent this issue, though has multiple design-specific 6 challenges. This paper provides a conceptual review of the challenges and potential solutions 7 for undertaking N-of-1 studies in health psychology. Key challenges identified include 8 participant adherence to within-person protocols, carry-over and slow onset effects, 9 suitability of behaviour change techniques for evaluation in N-of-1 experimental studies, 10 optimal allocation sequencing and blinding, calculating power/sample size, and choosing the 11 most suitable analysis approach. Key solutions include involving users in study design, 12 employing recent technologies for unobtrusive data collection and problem solving by 13 design. Within-person designs share common methodological requirements with 14 conventional between-person designs but require specific methodological considerations. N-15 of-1 evaluation designs are appropriate for many though not all types of interventions. A 16 greater understanding of patterns of behaviours and factors influencing behaviour change at 17 the within-person level is required to progress health psychology into a precision science. 18 19 See Supplementary Material 1 for video abstract. 20 21 Keywords: N-of-1, single case study, within-person design, idiographic design 22In health psychology, there is currently no established tradition of N-of-1 studies 19 (Davidson et al., 2014;McDonald et al., 2017), meaning the design has been underused and 20 is often misunderstood in the field. While this idiographic design offers many advantages 21 over more traditional nomothetic approaches, it comes with its own challenges, some of 22 which are particularly pertinent to health psychology investigations. The purpose of this 23 paper is to review the key challenges for undertaking health psychology related N-of-1 24 research and provide potential solutions for resolving or minimising these and, in doing so,
Aims Cardiac rehabilitation plays a vital role in secondary prevention of cardiovascular patients. Female sex and higher age, however, are associated with non-referral to cardiac rehabilitation. Improving exercise capacity during cardiac rehabilitation is essential to reduce morbidity and mortality risks. The objective of this study was to closely examine the beneficial changes in exercise capacity of older patients of both sexes during cardiac rehabilitation and to identify the most important predictors of the change in exercise capacity. Method A sample of 13,612 patients (mean age = 69.10 ± 11.8 years, 63.7% men, 19% > 80 years) was analysed. Data were prospectively assessed from 2012–2018 in six Swiss in-patient cardiovascular rehabilitation clinics. Improvement in exercise capacity measured with the six-minute walking test represents the outcome variable. Univariate and multivariate analyses, as well as the random forest method were used to estimate variable importance. Results Mean improvement in the six-minute walking test was 113.5 ± 90.5 m (men = 118.7 ± 110.0; women = 104.4 ± 93.0, Cohen’s d = 0.16). The presence of heart failure, diabetes mellitus and psychiatric diagnoses was related to reduced but nonetheless clinically relevant six-minute walking test improvement. Random forest analysis suggests that baseline exercise capacity, age, time in rehabilitation and heart failure were the most important predictors for improvement in exercise capacity. Clinically relevant improvements in exercise capacity (>45 m) were also present into old age (85 years) and for both sexes. Conclusion As indicated by these results, efforts need to be increased to refer eligible patients to structured rehabilitation programmes, irrespective of patients’ age and sex.
This study highlights the importance and feasibility of studying adherence to multiple medications differentially, and in daily life. Future studies may use these measures to investigate within-person and between-medication differences in adherence.
This study emphasises the importance of examining health behavior change theories at both, the inter- and the intraindividual level.
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