"Too Much of a Good Thing?" Examination of Proxy Reliance and Gender in Adherence to Cardiac Rehabilitation
McMahon, Casey J 1992-
With 1.4 million Canadians living with heart disease, cardiac rehabilitation (CR) programs are considered an essential component of the healthcare system and the overall care of patients following a cardiac incident (Daly et al., 2002). The exercise therapy component of cardiac rehabilitation (CR) not only aids improvements in physical function, but also assists participants in their return to work and everyday life activities. Although CR helps to reduce patients’ risk of future cardiac events, exercise adherence is suboptimal in CR programs and continues to decline following program completion. The decline of self-managed (SM) exercise following CR suggests patients may be unprepared for maintaining the exercise that initially lowered their cardiac risk. One psychological factor that may contribute to the issue of non-adherence to SM-exercise is CR participants’ reliance on CR staff, known as proxy reliance. Staff function as agents to assist and guide participants, however a downside to strong patient management is the potential over-reliance on CR staff. Over-reliance may contribute to participants’ inability to SM-exercise following CR completion. This phenomenon can be understood through the agency aspect of Bandura’s social-cognitive theory (SCT; Bandura, 1986). Individuals who enlist a proxy develop efficacy beliefs for their proxy, known as proxy efficacy (Bandura, 1997). Although proxy efficacy can help build one’s own personal sense of efficacy for behaviour (i.e., SM-exercise), the dilemma of proxy reliance becomes apparent the more the proxy is used (SCT; Bandura, 1997). Bandura (1997) suggests reliance upon high levels of assistance from a proxy may actually reduce individuals’ opportunities for mastery experiences, resulting in an inability to develop self-regulatory behaviour (Shields & Brawley, 2007). Using Bandura’s (1986) SCT, the primary purpose was twofold. The first purpose of the present study was to examine social-cognitive and behavioural differences over time among individuals with high proxy reliance. Further, CR participants high and low in proxy reliance were also compared relative to social-cognitive and behavioural variables. Bandura (1997) has also noted differences in relinquishing control between men and women, with women more willing to yield control to others who they believe can manage the situation better. Additionally, women are often underrepresented in CR programs and have been identified as the most vulnerable to attrition (Sedlak & Humphries, 2016). To date, no research has investigated potential gender differences in proxy reliance. Also, given that gender differences have been observed in CR exercise adherence literature, the secondary purpose was to explore participants' CR entry characteristics, proxy reliance, and adherence. The study design was prospective observational. Eighty-nine CR participants (Mage = 64.5, 32.6% female) who agreed to participate were followed over a usual care 12-week CR program, and for one-month of self-management post-CR. Participants completed measures of proxy reliance, self-regulatory efficacy (SRE) for scheduling and planning exercise (SP), SRE SM-exercise options (SRE-SMO), anticipated persistence for SM-exercise, exercise difficulty, and volume of SM-exercise. Assessments were completed at multiple time points throughout the course of study participation. Individuals with high proxy reliance had a significant decline in their persistence for SM-exercise from the end of CR to one-month following the end of the CR program. One-month post-CR, their number of SM-exercise options also differed. Significant differences were also found between individuals high and low in proxy reliance for volume of SM-exercise and number of SM-exercise options. A noticeable post-CR decline was found in both high and low proxy individuals’ SRE-SP and persistence. Comparisons between men and women indicated no differences in proxy reliance and no differences in study adherence. The exploration of baseline gender differences in health variables indicated that women reported significantly greater anxiety at the start of CR and a greater number of comorbidities. Exploration of baseline gender differences regarding social-cognitive variables indicated women had lower SRE-SP, greater exercise difficulty, and fewer SM-exercise bouts. Health variable differences were similar to those found in previous gender-based literature (e.g., Oosenbrug et al., 2016). Regarding primary study purposes, results follow Bandura’s theorizing regarding the dilemma of proxy reliance. A risk of decline in exercise self-management was evident for those who rely more on CR staff. Individuals with high proxy reliance exhibit greater difficulty in self-managing exercise post-CR. Findings of the present study not only provide questions for future research but also potential implications for training of CR staff.
DegreeMaster of Science (M.Sc.)
CommitteeGoodridge, Donna; Gyurcsik, Nancy; Spink, Kevin; Farthing, Jon
Copyright DateJune 2017