Date of Award


Document Type


Degree Name

Doctor of Philosophy (Ph.D.)

Institution Granting Degree

The Ohio State University

Cedarville University School or Department


First Advisor

Karen Ahijevych


Health and environmental sciences, Social sciences, illness representation, cardiac rehabilitation, older adults


Coronary heart disease (CHD) is the number one cause of mortality and disability in the United States (U.S.). The burden of CHD disproportionately impacts the older adult population of the U.S. in relation to mortality, disability, and economic cost. Greater than 55% of acute myocardial infarction deaths and 86% of CHD deaths occur in adults who are 65 years of age or older. The estimated direct and indirect cost of CHD in the U.S. for 2007 is $151.6 billion. Research studies are needed to address the increasing burden of CHD among the older adult population.

The secondary prevention of CHD may be effectively promoted through cardiac rehabilitation utilization. Cardiac rehabilitation programs are effective and safe for older adult CHD patients. Older adult patients who participate in cardiac rehabilitation receive significant benefits such as a 15% to 28% reduction in all-cause mortality, 26% to 31% reduction in cardiac mortality, improved physical function, reduction in cardiac risk factors, and increased quality of life. Unfortunately, cardiac rehabilitation utilization rates among older adults are significantly lower than utilization rates among younger adults. Only 6.6% to 53.5% of eligible adults 65 years or older in the U.S. participate in cardiac rehabilitation. Poor cardiac rehabilitation utilization among older adults is of great concern given the established benefits associated with cardiac rehabilitation participation.

Research efforts have identified a variety of factors that influence older adult participation in cardiac rehabilitation. Patient understanding of the purpose and benefits of cardiac rehabilitation (representation of cardiac rehabilitation) and the patient's perceived meaning of CHD (illness representation) have been recognized as important targets for interventions to improve cardiac rehabilitation utilization rates among older adults. The purpose of this dissertation was to develop, pilot test, and evaluate the effectiveness of a tailored illness representation intervention to increase cardiac rehabilitation utilization among older adults. Three manuscripts are presented in this dissertation document.

Illness representations of CHD are more likely to be inaccurate among older adults, as compared to younger adults. Medically inaccurate illness representations of CHD are concerning because they are associated with poor cardiac rehabilitation utilization and are inconsistent with the secondary prevention of CHD. The first manuscript reviews the literature related to representations of cardiac rehabilitation and CHD among older adults. From this review of literature, a preliminary self-regulatory model of cardiac rehabilitation utilization is proposed to guide the development of tailored interventions to increase cardiac rehabilitation utilization among older adults.

Inaccuracies within illness representations of CHD have been positively modified through a three session illness representation intervention during hospitalization in adults 65 years of age or younger with an acute myocardial infarction (AMI). Positive changes in illness representations were maintained three months post hospital discharge in that study. It is unknown whether inaccuracies within illness representations of CHD might also be modifiable among older adults. If inaccuracies within illness representations of CHD among older adults are also modifiable, it is possible that cardiac rehabilitation utilization would increase in this population.

The second manuscript reports a complete, detailed description of the research design, tailored illness representation intervention, study procedures, and results of the present pilot study with implications for future research. The tailored illness representation was delivered during a single post hospital discharge home telephone session using a scripted protocol. The intervention was based upon the individual patient assessment of CHD illness representation during hospitalization for an AMI, angioplasty, stent, or coronary artery bypass graft surgery. Cardiac rehabilitation utilization rates in this pilot study were considerably higher than the national level. Sixty-seven percent of intervention group participants and 74% of control group participants attended at least one cardiac rehabilitation session. The majority of participants in the intervention and control group completed 75% or more of their prescribed cardiac rehabilitation program. Two significant predictors of cardiac rehabilitation utilization emerged in relation to illness representations of CHD: cyclical timeline and consequence dimensions. The final logistical model included two variables, cyclical timeline and consequence, and explained 34% of the variance in cardiac rehabilitation utilization.

The third manuscript reports recruitment outcomes of the present pilot study with discussion. Strategies to improve older adult participation in research during hospitalization are provided in this brief methodological report. Ninety-four older adults with CHD were referred for eligibility screening and 72 participants were enrolled. Eighty-two percent of the older adults who were screened for eligibility were enrolled during the 15 months of recruitment. A lack of interest in completing study-related paperwork and not feeling well were the most common reasons provided for non-participation. Collaboration with the inpatient cardiac rehabilitation clinicians during the recruitment process was an important contributor to our successful recruitment efforts. This manuscript provides guidance and suggestions for consideration by researchers who are interested in recruiting older adults for studies during hospitalization.

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.



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