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HOPELESSNESS AND DEPRESSION IN MYOCARDIAL INFARCTION
By

Susan Lynn Dunn

A DISSERTATION

Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
College of Nursing

2005

ABSTRACT
HOPELESSNESS AND DEPRESSION IN MYOCARDIAL INFARCTION
By
Susan Lynn Dunn
Psychosocial factors, such as depression, have been identiﬁed as important
predictors of morbidity and mortality in individuals with coronary heart disease;
however, little research has been done examining hopelessness in this population. This
investigation examined the frequency and severity of hopelessness and depression
symptoms in the early recovery period after hospitalization for myocardial infarction
(M1), the relationship between hopelessness and depression symptoms, patient
characteristics leading to these two constructs, and the effect of hopelessness symptoms
on cardiac rehabilitation exercise participation and physical functioning post-MI. A
sample of 351 men and women who were hospitalized for M1 at ﬁve hospitals in central
Michigan were interviewed after discharge home (approximately 14 days) and at three
months after hospital discharge. Measures included the cognitive expectations factor of
the Beck Hopelessness Scale®, Center for Epidemiologic Studies- Depression Scale, a
cardiac rehabilitation exercise participation questionnaire, and the Activity Status Index.
Both hopelessness and depression symptoms were frequent and moderate to severe in a
portion of the sample at baseline and three months, yet depression symptoms
signiﬁcantly decreased from baseline to three months whereas hopelessness symptoms
did not. Hopelessness symptoms were strongly associated with symptoms of depression
at three months after hospital discharge. However, 10% of the sample had symptoms of

hopelessness but minimal or no symptoms of depression, while another 10% had

symptoms of depression but minimal or no hopelessness symptoms. There were some
differences in baseline patient characteristics leading to hopelessness symptoms versus
depression symptoms. In addition, baseline hopelessness symptoms were predictive of
not starting a hospital-based cardiac rehabilitation exercise program and of quitting a
hospital-based exercise program early, whereas depression symptoms had no such effect.
Both hopelessness and depression symptoms at baseline accounted for an independent
portion of variance in physical functioning at three months after hospital discharge. This
descriptive study is an important early step in the research of hopelessness symptoms
after an acute MI. Longitudinal modeling of the pathways among hopelessness
symptoms, depression symptoms, and health-related outcomes is needed to further
discern the relationship between hopelessness and depression symptoms, the distinction

of these two constructs, and their effects on post-MI outcomes.

This work is dedicated to all of the individuals with coronary heart

disease who I have been privileged to care for over the years.

iv

ACKNOWLEDGEMENTS

Barbara Given, Ph.D., R.N., FAAN, is especially recognized for her outstanding
guidance and support as Dissertation Committee Chairperson. Her high standards and
continual encouragement were essential to the success of this project.

Margaret Holmes-Rovner, Ph.D., is acknowledged for her guidance as a
Dissertation Committee member and as the leader of the HARP study team. Her
generosity in sharing the HARP study experience and data is most appreciated.

Audrey Gift, Ph.D., R.N., F AAN, and Linda Spence, Ph.D., R.N., Dissertation
Committee members, are recognized for their considerable guidance and support.

Linda Scott, Ph.D., R.N. is acknowledged for her assistance as a consultant to the
Dissertation Committee and for her ongoing support. Manfred Stommel, Ph.D., is
recognized for his assistance as a consultant to the Dissertation Committee. A

A special thank you to Anita Jablonski, Ph.D., RN, and Amy Hofﬁnan, M.S.N.,
R.N., for sharing the doctoral experience with me.

Most importantly, immeasurable gratitude is expressed to my husband, Randy,
and children, Matthew, Kristen, and Kara, for their unending support and encouragement.

Funding sources for this project include the National Institutes of Health, National
Institute of Nursing Research, Ruth L. Kirschstein National Research Service Award
(NR82972) (Dunn); Blue Cross Blue Shield of Michigan Foundation (Dunn); Sigma
Theta Tau, Kappa Epsilon Chapter-at-Large (Dunn); and AHRQ R01 grant (HSlOS31),

“Translating Research: Patient Decision Support/Coaching” (Holmes-Rovner).

TABLE OF CONTENTS

LIST OF TABLES ............................................................................ , ..... viii
LIST OF FIGURES .................................................................................. ix
CHAPTER 1
INTRODUCTION ........................................................................... 1
CHAPTER 2
CONCEPTUAL FRAMEWORK ............................................................. 12
The Literature Review for the Conceptual Model ...................................... 12
Hopelessness in the Literature ............................................................. 13
Depression in the Literature ................................................................ 20
Distinction of Hopelessness from Depression ........................................... 22
Antecedent Factors in the Literature ...................................................... 23
Exercise Participation in the Literature ................................................... 25
Physical Functioning in the Literature .................................................... 26
The Conceptual Model ...................................................................... 28
Model Application to Hopelessness and Depression after a MI ...................... 34
CHAPTER 3
THE STATE OF HOPELESSNESS RESEARCH ........................................... 36
Frequency, Severity, and Impact of Hopelessness ..................................... 36
Hopelessness, Exercise Participation, and Physical Functioning ..................... 40
Methodological Issues ...................................................................... 43
Avenues for Exploration in Hopelessness Research .................................... 45
CHAPTER 4
METHODOLOGY ............................................................................... 48
Design ......................................................................................... 48
Sample and Setting .......................................................................... 49
Operational Deﬁnitions ..................................................................... 53
Instruments .................................................................................. 54
Procedures .................................................................................... 64
Protection of Human Subjects ............................................................. 67
Data Analysis ................................................................................ 70
CHAPTER 5
RESULTS ........................................................................................ 76
Preliminary Analysis of Data .............................................................. 76
Research Question #1 ....................................................................... 78
Research Question #2 ....................................................................... 82
Research Question #3 ....................................................................... 95
Research Question #4 ........................................................................ 98

vi

CHAPTER 6

DISCUSSION ................................................................................. 1 12
Frequency and Severity of Hopelessness and Depression Symptoms. . .. . . . ..1 12
Relationship between Hopelessness and Depression Symptoms ................... 115
Predictors of Hopelessness Symptoms ................................................ 117
Effects of Hopelessness on Exercise Participation and Physical
Functioning ................................................................................ 118
Limitations ................................................................................. 122
Direct Implications for Future Nursing Research ..................................... 123
Additional Implications for Nursing Research ....................................... 130
Implications for Nursing Practice ...................................................... 132
Conclusion ................................................................................. 136

APPENDICES

MEASURES .................................................................................. 139

Antecedent Patient Factors .............................................................. 139
Baseline Self-Report Telephone Tool ............................................... 139

Chart Abstraction Form ............................................................... 141

Five Item Cognitive Expectations Factor of the Beck Hopelessness Scale® .. ..142
Center for Epidemiologic Studies- Depression Scale (CES-D) ................ . . 143
Cardiac Rehabilitation Exercise Participation Tool .............................. ... . .145
Activity Status Index (ASI) ............................................................. 148
REFERENCES ..................................................................................... 150

vii

LIST OF TABLES

Table 1. Characteristics of the Sample ....................................................... 51-52
Table 2. Description of Measures for the Study, Data Collection Points,

Number of Items, Score Ranges and Psychometric Properties. . . . . .........55
Table 3. Measures, Possible Ranges, Actual Ranges, and Scores ............................ 79
Table 4. Frequency and Severity of Hepelessness Symptoms Total

Scores and Depression Symptoms Range of Total Scores .......................... 80
Table 5. Correlations among Continuous Independent and Dependent

Variables ................................................................................... 83
Table 6. Correlations between Hopelessness Symptoms Total Score and

CES-D F actors/ Subscales and CES-D Items at Three Months ..................... 85
Table 7. Predictors of Three-month Depression Symptoms ................................ 87-89
Table 8. Correlations between Antecedent Variables and Baseline

Hopelessness Total Scores and Baseline Depression Total Scores ................. 92
Table 9. Predictors of Three-month Depression Factors/Subscales. . . . . .. . ......93-94
Table 10. Predictors of Three-month Hopelessness Symptoms ........................... 96-97

Table 11. Participation in Hospital- and Home-based Cardiac
Rehabilitation Exercise Programs .................................................... 100

Table 12 Cross-tabulation of Number of MI Patients who Participated in
Hospital- and Home-based Cardiac Rehabilitation Exercise at
Three Months after Hospital ........................................................... 101

Table 13. Predictors of Three-month Hospital-based Cardiac Rehabilitation
Exercise Participation ................................................................. 103

Table 14. Predictors of Three-month Home-based Cardiac Rehabilitation
Exercise Participation ................................................................. 104

Table 15. Predictors of Three-month Physical Functioning ............................. 107-109

viii

LIST OF FIGURES

Figure l. Continuum of Hopelessness and Hopelessness Depression................... . . . . . . . .24
Figure 2. Conceptual Model of the Study ........................................................ 29

Figure 3. Analytic Model of the Study ........................................................... 71

ix

Chapter 1
INTRODUCTION

Coronary heart disease (CHD) and depression are highly prevalent, comorbid
health problems associated with substantial morbidity and mortality. CHD is a leading
cause of mortality among American men and women (American Heart Association
[AHA], 2004), while depression affects 12% of women and 7% of men (National
Institute of Mental Health [NIMH], 2002). Depression symptoms tend to be more
prevalent in the CHD population than in the general population (Ariyo et al., 2000;
Frasure-Smith, Lesperance, & Talajic, 1993; Travella, Forrester, Schultz, & Robinson,
1994). This is particularly true after an acute CHD event, such as a myocardial infarction
(MI). Depression symptoms have been found predictive of increased morbidity (Levine et
al., 1996) and mortality (Barefoot et al., 2000; Erasure-Smith, Lesperance, & Talajic,
1995; Frasure-Smith et al., 2000; Travella et al.) following a MI.

A construct related to depression, but less well understood, is hopelessness. Its
role in recovery from heart disease events is potentially important, and previously under-
studied. Hopelessness has been associated with the presence of depression in individuals
coping with physical illness (Brietbart et al., 2000; Cochinov, Keith, Murray, & Landers,
1998; Lewis, Dennis, O’Rourke, & Sharpe, 2001; Northouse, Jeffs, Cracchiolo-Caraway,
Lampman, & Dorris, 1995; Northouse, Templin, & Mood, 2001; VanServellen, Sama,
Padilla, & Brecht, 1996; Watson, Haviland, Greer, Davidson, & Bliss, 1999). Symptoms
of hopelessness have been associated with increased risk of fatal and nonfatal CHD and
MI (Anda et al., 1993; Barefoot, Brummett, Helms, Mark, Siegler, & Williams, 2000;

Everson et al., 1996). However, no research has been found examining the frequency,

severity, and impact of hopelessness symptoms after hospitalization for a M1 or
describing the relationship between symptoms of hopelessness and depression after a MI.

Although relationships between CHI) and depression outcomes and between
symptoms of hopelessness and depression have been documented, minimal research has
been done to examine the relationships among hopelessness symptoms and outcomes of
CHD. Research has demonstrated that depressed MI patients are at greater risk of quitting
hospital- and home-based cardiac rehabilitation exercise programs than non-depressed
MI patients (Glazer, Emery, Frid, & Banyasz, 2002; Ziegelstein, Fauerbach, Stevens,
Romanelli, Richter, & Bush, 2000). In addition, depression symptoms have been
negatively correlated with physical functioning in CHD patients attending an outpatient
cardiac rehabilitation exercise program (Ades, Maloney, Savage, & Carhart, 1999;
Blumenthal et al., 1997). However, no research has been found examining the
relationships among hopelessness symptoms and cardiac rehabilitation exercise
participation or physical functioning post-MI.

This study was designed to answer the following questions:

1) What is the frequency and severity of hopelessness symptoms and
depression symptoms among post-MI patients at three-months after
hospital discharge?

2) What is the relationship between hopelessness and depression symptoms
among post-MI patients at three-months after hospital discharge?

3) For those post-MI patients who have hopelessness symptoms at three-
months after hospital discharge, what factors present at baseline are

predictive of their three-month hopelessness scores?

4) Are hopelessness symptoms at baseline. predictive of participation in
cardiac rehabilitation exercise and physical functioning among post-MI
patients at three-months after hospital discharge?

The purpose of Chapter 1 is to provide an overview of depression and
hopelessness in CHD. First, brief deﬁnitions of CHD and MI will be presented. Next,
deﬁnitions of both hopelessness and depression will be discussed. The frequency of CHD
and depression as comorbid problems will be presented. This will be followed by a
discussion regarding the associations between hopelessness and depression and the
relationship between hopelessness and CHD. Chapter 1 will conclude with a discussion
regarding cardiac rehabilitation exercise participation and physical functioning post-MI
and their relationships with depression and hopelessness. Chapter 1 will provide the
background for the development of the study’s conceptual ﬁ'amework, which is discussed
in Chapter 2.

Deﬁnitions of Coronary Heart Disease, Myocardial Infarction, and Acute
Coronary Syndrome

According to the American College of Cardiology (ACC)/American Heart
Association (AHA) Task Force on Practice Guidelines, coronary artery (heart) disease
(CHD) refers to the atherosclerotic narrowing of one of the coronary arteries (Braunwald
et al., 2002). CHD can lead to acute myocardial infarction (MI) or unstable angina.
Clinically, the diagnosis of a MI is typically made when there is a characteristic rise and
fall in cardiac biomarkers (e. g. troponin) indicative of myocardial necrosis, and may be
referred to as an enzyme-diagnosed M1 or biomarker-diagnosed MI (Braunwald et al.).

Depending on electrocardiogram ﬁndings, a MI may also be titled a ST elevation MI,

non—ST elevation M1, or non-Q wave MI. An MI may be diagnosed after the rise and fall
of cardiac biomarkers solely by ECG changes, and this is titled a late ECG-diagnosed MI.
Patients with unstable angina do not present with ST-segment elevation on their
electrocardiogram and do not release biomarkers indicative of myocardial necrosis into
the blood (Braunwald et al.).

Acute coronary syndrome is any constellation of clinical signs and symptoms
suggestive of MI or unstable angina. This syndrome includes patients with enzyme-
diagnosed MI, biomarker-diagnosed MI, ST elevation MI, non-ST elevation MI, non-Q
wave MI, late ECG-diagnosed MI, and unstable angina. The term acute coronary
syndrome is used prospectively to identify those patients at a time of initial presentation
who should be considered for treatment of acute M1 or unstable angina (Braunwald et al.,
2002)

Deﬁnitions of Hopelessness and Depression

Hopelessness is deﬁned in this proposal as a psychological response to a negative
event, consisting of a negative expectancy concerning one’s future and an expectation of
helplessness in changing one’s future (Abramson, Alloy, & Metalsky, 1989). According
to the Theory of Hopelessness Depression, hopelessness can be a precursor of depression
or can be independent of depression (Abramson et al.). Depression is deﬁned in this
proposal as the presence of depressed mood and/or loss of interest or pleasure in activities
in addition to several other depressive symptoms, including weight loss or gain, insomnia
or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings
of worthlessness or excessive guilt, diminished ability to think or indecisiveness, or

recurrent thoughts of suicide or death (American Psychiatric Association, 2000).

Depression and Coronary Heart Disease

Depression is the leading cause of disability Worldwide, with approximately 19
million American adults affected per year (N IMH, 2002; World Health Organization
[WHO], 2001). Coronary heart disease (CHD) is a leading cause of death in the United
States, with an estimated 12,400,000 Americans currently living with CHD (AHA, 2004).
CHD and depression are rightﬁilly identiﬁed as public health priorities by a number of
agencies. The WHO predicts heart disease and depression to be the top two leading
causes of disease burden in year 2020, while the NIMH identiﬁes the co-occurrence of
depression with CHD as a key research priority.

The prevalence of depression symptoms among individuals who have survived a
MI is estimated to be 16% to 28% (Ariyo et al., 2000; Frasure-Smith et al., 1993;
Travella et al., 1994). Major depression symptoms have been found in 26% of patients at
three—months, 21% at 6 months, 28% at nine months, and 16% at 12 months post-MI
(Travella et al.). The median duration of depression symptoms post-MI has been reported
as 4.5 months (Bush et al., 2001), while depression symptoms have been related to
mortality at four months (Travella et al.), six months (F rasure-Smith et al., 1993), twelve
months (Frasure-Smith et al., 2000), and eighteen months (Frasure-Smith et al., 1995)
post-MI. Depression symptoms, if left untreated, have been found to reoccur or be
persistent in CHD patients. In a study of 200 CHD patients, 17% were diagnosed with
major depression and 17% were diagnosed with minor depression (Hance, Carney,
Freedland, & Skale, 1996). Of those with major depression, 50% remained depressed
over a 12 month period or relapsed within the 12 months, while 42% of those with minor

depression subsequently developed major depression in the 12 month interval (Hance et

al.). Although the relationship between depression and CHD is well documented,
minimal research has been done to examine the relationship between CHD and
hopelessness. Additionally, the relationship between hopelessness and depression is not
well understood.
Hopelessness and Depression

Hopelessness has been related to depression in some studies, yet has been found
to be independent of depression in other studies. Hopelessness has been found to increase
vulnerability to a subtype of depression, titled hopelessness depression, in college
students (Alloy et al., 1999), outpatient psychiatric clients, and air force cadets (Joiner,
Steer, Abramson, Alloy, Metalsky, & Schmidt, 2001). Hopelessness, beginning as a
precursor, has been found to continue in conjunction with this subtype of depression in
some patients (Joiner et al.) (see Chapter 3 for further elaboration of hopelessness
depression). Hopelessness has also been identiﬁed as a mediator between depression
symptoms and social support in men with HIV (Johnson et al., 2001). Although baseline
hopelessness was predictive of increased depression in the study by Johnson and
colleagues, baseline depression was not found to be predictive of increased hopelessness.

Symptoms of hopelessness and depression have been related to suicidal ideation
in individuals with advanced terminal cancer (Cochinov et al, 1998) and suicidal ideation
and suicide in psychiatric patients (Beck, Steer, Beck, & Newman, 1993); however,
symptoms of hopelessness were found to be a more important and independent predictor
in both of these studies. In a study of terminally ill cancer patients, hopelessness
predicted desire for hastened death, independent of depression (Breitbart et al., 2000). A

study among stroke survivors found hopelessness related to long-term survival,

independent of depression (Lewis, Dennis, O’Rourke, & Sharpe, 2001). Hopelessness has
also been found predictive of hypertension, after adjusting for depression and CHD risk
factors (Everson, Kaplan, Goldberg, & Salonen, 2000). Though a fair amount of research
has been done examining hopelessness and depression in physically ill populations,
minimal work is reported in the literature examining hopelessness in individuals with
CHD.

Hopelessness and Coronary Heart Disease

Only a small number of studies have examined the relationship between
hopelessness and CHD. Of particular importance to this investigation are three large
studies that examined hopelessness in conjunction with CHD in cohorts followed over
varying lengths of time. In the National Health Examination F ollow-Up Study, the
relative risk of fatal CHD among 2,832 initially healthy American men and women for a
moderate level of hopelessness was 1.6 (95% conﬁdence interval: 1.0, 2.5) and for a
severe level of hopelessness was 2.1 (95% conﬁdence interval: 1.1, 3.9) (Anda et al.,
1993). The relative risk of nonfatal CHD for moderate and severe levels of hopelessness
were 1.3 (95% conﬁdence interval = 0.8 to 2.0) and 1.9 (95% conﬁdence interval = 1.0 to
3.6) respectively. Hopelessness was more strongly related to morbidity and mortality than
depression (Anda et al.).

In the Finnish Kuopio Ischemic Heart Disease study, high levels of hopelessness
were associated with cardiovascular mortality (n = 87) among 2,428 men (Everson et al.,
1996). The moderately hopeless men were at more than twice the risk (Relative Hazards
= 2.52 [95% conﬁdence interval: 1.52, 4.17] and the highly h0peless men at more than

three times the risk (Relative Hazards = 3.90 [95% conﬁdence interval: 2.14, 7.11]) of

death due to cardiovascular causes, compared with the low scorers on the hopelessness
scale. These relationships remained signiﬁcant after adjusting for biological, behavioral,
and socioeconomic risk factors, including depression (Everson et al.). Among men with
no known history of angina or MI (n =1820), those reporting high levels of hopelessness
were at signiﬁcantly increased risk for a ﬁrst-time MI (n = 95), relative to men scoring
low on the measure of hopelessness (Relative Hazards = 2.39 [95% conﬁdence interval:
1.35, 4.25]) (Everson et al.).

Finally, hopelessness was found to be a strong predictor of survival (345 deaths in
a sample of 921) in patients with signiﬁcant CI-[D hospitalized at Duke University
Medical Center, with an adjusted relative risk of 1.5 (p = 0.015), independent of
depression (Barefoot et al., 2000). However, no studies were found that examined the
frequency and severity of hopelessness after hospitalization for M1.

Although hopelessness aﬁer 3 MI has not been previously examined, the
psychological dynamics in response to other potentially life-threatening diseases may be
similar to that of a MI. In particular, individuals diagnosed with cancer or AIDS are
especially vulnerable to emotional distress. Symptoms of hopelessness have been
identiﬁed in 40% of men with cancer and AIDS, with higher levels of hopelessness
symptoms associated with poorer functional status (VanServellen et al., 1996). Higher
levels of hopelessness symptoms have also been associated with increased risk for relapse
or death in women with breast cancer (Watson et al., 1999) and have been identiﬁed as a

Predictor of suicidal ideation or desire for death in individuals with terminal cancer

(Breitbart et al., 2000; Cochinov et al., 1998). The frequency of hopelessness after a MI,

and impact of hopelessness on post-.MI outcomes, may be similar to those seen in
individuals with cancer and AIDS.
Exercise Participation

Cardiac rehabilitation exercise is an outcome of interest in the CHD population.
Evidence suggests that participation in a cardiac rehabilitation exercise program promotes
improved exercise tolerance (Balady, Jette, Scheer, & Downing, 1996; Marchionni et al.,
2003) and a reduction in mortality in individuals with CHD (Balady et al., 2000). Despite
the potential beneﬁts, studies over the past decade indicate that only 11% to 21% of
patients participate in an outpatient cardiac rehabilitation exercise program aﬁer a CHD
event (Ades, Waldmann, McCann, & Weaver, 1992; Blackburn et al., 2000).

Patient factors predictive of decreased participation in an outpatient cardiac
rehabilitation program include increased age (Ades et al, 1992; Blackburn et al., 2000),
female gender (Ades et al., Blackburn et al.), lower education (Ades et al.), and decreased
leﬁ ventricular function (Blackburn et al.). Research has found increased depression
(Glazer et al., 2002; Ziegelstein, et al., 2000) and a history of depression (Ades et al.) as
another predictor of decreased exercise participation. A reciprocal relationship is evident
in that depression has also been found signiﬁcantly reduced in CHD patients participating
in a structured outpatient cardiac rehabilitation exercise program as compared to those
who did not participate (Blumenthal et al., 1997; Milani & Lavie, 1998). Health care
provider and health care system factors predictive of decreased participation in cardiac
rehabilitation exercise include the strength of the physician’s recommendation and the
patient’s commute time (Ades et al.; Barber, Stommel, Kroll, Hohnes-Rovner, &

McIntosh, 2001). Moreover, of those who participate in an outpatient cardiac

rehabilitation exercise program, 25% to 50% discontinue within six months and less than
25% continue exercise at home (Harlan, Sandler, Lee, Lam, & Mark, 1995). Little
research has been done which examines home-based cardiac rehabilitation exercise.
Findings suggest that depression symptoms are negatively related to participation in
home exercise (Ziegelstein et al.).

No research was found examining the relationship between hopelessness
symptoms and participation in cardiac rehabilitation exercise. However, attitude and
perceived behavioral control have been found to explain a proportion of variance in
exercise intention and subsequent adherence in a sample of patients attending a structured
outpatient cardiac rehabilitation program (Blanchard et al., 2003) and in a sample of 30 to
60 year old men in the community (Nguyen, Potvin, & Otis, 1997). Hopeless individuals
have a negative attitude toward the future and perceive little control in changing the
future (Abramson et al., 1989). A post-MI patient suffering from hopelessness may not be
able to identify a purpose in exercising. Consequently, a hopeless post-MI patient may
have little intent on starting an exercise program or may have poor adherence to a
program once it is started.

Physical Functioning

Physical functioning is another outcome of interest in the CHD population.
Decreased physical functioning in patients with CHD has been associated with female
gender, increased age, decreased aerobic exercise capacity, decreased leg and arm
strength, and increased comorbidity (Ades et al, 1999). Increased depression symptoms
have also been negatively related to physical functioning in CHI) patients beginning an

OUIPatient cardiac rehabilitation exercise program (Blumenthal et al., 1997). These same

10

patients were evaluated after three months of exercise and a decrease in depression
symptoms was correlated with improvement in physical functioning (Ades et al.).
Moreover, baseline depression scores accounted for approximately 10% of the variance
associated with decreased aerobic capacity in a sample of patients attending a structured
outpatient cardiac rehabilitation exercise program, controlling for demographic variables
and adherence (Glazer et al., 2002). Because hopelessness symptoms have been
associated with poorer ﬁmctional status in men with cancer and AIDS (VanServellen et
al., 1996), hopelessness symptoms may be correlated with physical functioning post-MI.
However, no research was found examining the relationship between hopelessness
symptoms and physical functioning in a CHD population.
Chapter Summary

The purpose of this investigatidn was to describe the symptoms of hopelessness
and depression following a M1, the relationship between hopelessness and depression
symptoms, patient characteristics leading to these two constructs, and the effect of
hopelessness symptoms on cardiac rehabilitation exercise participation and physical
functioning post-MI. The conceptual model of the proposed study, developed from a
review of the psychology, nursing, and medical literature, will be presented in Chapter 2.
Chapter 3 focuses on the present state of hopelessness research and the signiﬁcance of the
current study. The design, key variables, measures, procedures, protection of human
subjects, and an overview of data analysis will be presented in Chapter 4. Chapter 5 will
present the results of the study. Chapter 6 will provide a discussion, including limitations

of the study and implications for nursing research and practice.

11

Chapter 2
CONCEPTUAL FRAMEWORK

The complex relationship between coronary heart disease (CHD) and one’s
psychological status is not fully understood. The prevalence, severity, and impact of
depression after a MI have been well documented. However, the relationship between
hopelessness and depression is not well understood and the ﬁequency, severity and
impact of hopelessness after a MI have not been previously examined. The purpose of
this chapter is to present a conceptual model for the study that describes the relationships
among hopelessness, depression, and select patient outcomes after a MI. A review of
literature that provided the foundation for the development of the conceptual model will
ﬁrst be discussed with a focus on the relationship between hopelessness and depression
and the distinction between these two concepts. Next, the conceptual model and the
relationships among its concepts as reported in the psychology, nursing, and medical
literature will be presented. This chapter will conclude with a summary of how the
conceptual relationships apply to hopelessness and depression after a MI.
The Literature Review for the Conceptual Model

A review of the literature was completed to identify relationships among
hopelessness, depression, and select patient outcomes (i.e. cardiac rehabilitation exercise
participation and physical frmctioning) after 3 MI. The Cumulative Index to Nursing and
Allied Health Literature (CINAHL), MEDLINE, and PsychINFO® databases were
searched (1983-2005) using the key words and terms ‘hopelessness,’ ‘hopelessness and
heart disease,’ ‘hopelessness and depression,’ ‘depression and heart disease,’ ‘exercise

and heart disease,’ ‘physical functioning and heart disease,’ ‘recovery and heart disease,’

12

and ‘rehabilitation and heart disease.’ The purpose of this literature review was to
identify works that focused on the concepts of hopelessness, depression, CHD, and
outcomes of CHD. Literature was reviewed over a twenty—year period to understand the
historical development of the concepts; however, particular attention was given to
published works within the past ﬁVe years. Conceptual, theoretical, and empirical
writings were reviewed to discern the applicable concepts and potential relationships
present with hopelessness and depression after a MI. Secondary articles were reviewed to
identify primary theoretical and conceptual sources; however, only primary sources were
cited. The literature searches produced works by authors in the disciplines of psychology,
nursing, and medicine. Because the greatest breadth and depth of the conceptual and
theoretical literature related to hopelessness was found in the psychology literature, and
some of the work in psychology differs from the work in nursing and medicine, the works
of each of the three disciplines are discussed separately in this chapter.
Hopelessness in the Literature

The concept of hopelessness is used in a variety of ways by both lay people and
healthcare professionals. The word hopeless in lay Western society often refers to a
negative situation that is futile or has no hope, such as a terminal illness, addiction, or
poor marital relationship. This use of the word hopeless focuses on a negative outcome
and a sense of helplessness. In contrast, another common use of the term hopeless in
Western society is the phrase “hopeless romantic,” referring to people who are incurable
of their romantic tendencies. This phrase focuses on helplessness; however, does not
necessarily refer to expectations of a negative outcome. The Merriam- Webster Collegiate

Dictionary (2003) identiﬁes hopelessness as the noun associated with the adjective

13

hopeless. Hopeless is deﬁned as having no expectation of good or success (despairing);
not susceptible to remedy or cure; incapable of redemption or improvement; giving no
ground for hope (desperate); and incapable of solution, management, or accomplishment
(impossible). A synonym offered in the dictionary’s deﬁnition is “impossible” (Merriam-
Webster’s Collegiate Dictionary). This deﬁnition focuses on a negative affect and
helplessness.

The psychology literature. Hopelessness is used by the discipline of psychology in
differing ways. Hopelessness has been deﬁned by the American Psychiatric Association
(APA) as a pervasive pessimism about the future (2000). Hopelessness is used as a
symptom of several depressive disorders in the APA’s Diagnostic and Statistical Manual
of Mental Disorders (DSM I V-T R); however, the DSM I V-T R does not classify
hopelessness as a unique category for therapy.

In contrast, many psychology researchers use hopelessness as a distinct concept.
Beck’s cognitive perspective states that hopelessness results from irrational and distorted
thoughts (1967). Beck further describes hopelessness as a system of negative
expectancies concerning one’s self and one’s future life (Beck, 1967). Beck and
colleagues describe negative outcome and helplessness expectancies with three
dimensions (Beck, Weissman, Lester, & Trexler, 1974). The cognitive dimension is
comprised of negative future expectations, such as thoughts that include a dark, vague, or
uncertain future. The affective dimension consists of negative feelings about the future,
including lack of hope, enthusiasm, or faith. The motivational dimension includes
m‘v’gative thoughts and feelings toward changing the future (Beck et al., 1974), such as not

being able to make things better.

14

Another psychological perspective, titled the Theory of Hopelessness Depression,
deﬁnes hopelessness as both a negative outcome expectancy and a helplessness
expectancy (Abramson et al., 1989). Abramson and colleagues use hopelessness as a
distinct concept in examining hopelessness as a precursor to a subtype of depression,
called hopelessness depression. Abramson and colleagues note a sequence of causal
events that lead to distorted thoughts and hopelessness. This sequence begins with the
perception of a life event as negative and an expectation that one can do nothing to
change the event or its consequences. Individuals make inferences at this point, which
contribute to whether they become hopeless. Inferences include (a) cause, (b)
consequences, and (c) characteristics about oneself. Hopelessness is more likely to occur
if a person has a negative cognitive style where the person makes negative inferences
regarding the causes and consequences of life events and their ability to change the event
(Abramson et al.).

According to both Abramson et al. (1989) and Beck (1967), hopelessness can be
generalized (i.e. a trait) or circumscribed (i.e. a state). Individuals with trait hopelessness
exhibit chronic negative outcome expectancy about many areas of their life. Individuals
with state hopelessness exhibit negative outcome expectancy about a limited area or
event in their life (Abramson et al.), such as an unexpected crisis or acute illness. The
severity of hopelessness in a person at any point in time may be explained by both stable
individual differences (i.e. trait) and varying individual differences (i.e. state) (Abramson
et 31-; Beck). However, an individual with trait hopelessness may be more susceptible to
state hopelessness than an individual without a pre-existing hopelessness trait (Abramson

et 3”- Abramson and colleagues suggest that trait hopelessness may produce more

15

severe symptoms than the symptoms caused by state hopelessness, and that trait
hopelessness symptoms will likely require long-term cognitive therapy. State
hopelessness is more likely to produce less severe symptoms of a temporary nature and
may be successfully treated with short-term cognitive interventions. Despite the
conceptual differentiation of trait versus state hopelessness, there has been no distinction
in operationalizing the two types of hopelessness in the literature.

In summary, hopelessness as a concept is used by the discipline of psychology in
a variety of ways. Some psychologists use hopelessness as a symptom of depressive
disorders (APA, 2000) while others in the ﬁeld of psychology view hopelessness as a
distinct concept (Abramson et al., 1989; Beck et al., 1974) that may or may not serve as a
precursor to a subtype of depression (Abramson et al.). Finally, some psychologists
describe the intensity of hopelessness in a given person at a given point in time as having
either trait or state characteristics or a combination of trait and state hopelessness
characteristics (Abramson et al.; Beck, 1967). Although measures to distinguish trait and
state hopelessness do not currently exist, the severity of hopelessness can be assessed and
treated accordingly with long-term or short-term cognitive interventions.

The nursing literature. The concept of hopelessness is not as well described in
the nursing literature as in the psychology literature. Nurses who use the North American
Nursing Diagnosis Association (NANDA) (1996) nursing process and documentation
systems use hopelessness as a nursing diagnosis in their practice. Despite the fact that
hopelessness is used as a nursing diagnosis, deﬁnitions of hopelessness vary in the
nursing literature. NANDA deﬁnes hopelessness as “a subjective state in which a person

sees limited or no alternatives or personal choices available and is unable to mobilize

16

energy on his/her behalf” (NANDA, 1996, p. 69). This deﬁnition, similar to that of
Abramson et al. (1989), focuses on helplessness expectancy; however, it does not address
expectations of a negative outcome. Deﬁning characteristics of the NANDA
hopelessness diagnosis include passivity, decreased verbalization, decreased affect and
verbal cues such as despondent content, sighing or saying, “I can’t.” Minor deﬁning
characteristics include lack of initiative, decreased response to stimuli, turning away or
shrugging, closing eyes, decreased appetite, increased or decreased sleep, and lack of
involvement in care (NANDA). Although verbal cues have been found to be a critical
component of the NANDA hopelessness diagnosis (Bruss, 1988), several of the
remaining characteristics are considered in psychology literature to be symptoms of
depression, including decreased affect, lack of initiative, decreased appetite, and
increased or decreased sleep (APA, 2000).

Hopelessness has been deﬁned by one group of nurse researchers as “. . .a feeling
of despair and discouragement; a thought process that expects nothing, and a behavioral
process in which the person attempts little or takes inappropriate action” (Farran, Herth,
& Popovich, 1995, p. 25). F arran and colleagues describe hopelessness as a state or trait
and as a trajectory with four attributes: (a) experiential (i.e. discouragement and despair,
loss of energy, perceived lack of resources, feeling entrapped, or the expectation that
desired outcomes will not occur); (b) relational (i.e. absence of relationships with others
who can help, disbelief/lack of expectation that others can help, inability to trust others,
or social withdrawal); (c) transcendent (i.e. disbelief in a spiritual power, inability to
perceive transcendent help, or over-reliance in a spiritual power); and (d) behavioral (i.e.

difﬁculty thinking, realizing alternatives, or setting goals, or ineffective action) (F arran et

17

al.). The description of hopelessness by Farran et al., based on a literature review and the
researchers’ own experiences and research, is similar to that of NANDA (1996) and
Abramson et al. (1989) in emphasizing a helplessness expectancy and similar to
Abramson et al. by incorporating a negative outcome expectancy. However, several
characteristics identiﬁed by F arran et al. are recognized by the APA (2000) as depression
symptoms, including discouragement, despair, loss of energy, social withdrawal, and
impaired thinking.

A limited number of concept analyses in nursing have addressed hopelessness
attributes. Campbell’s (1987) analysis deﬁned four hopelessness attributes, namely
negative future expectations, loss of control over the future, passive acceptance of the
futility in planning goals, and emotional negativism. An analysis of hopelessness,
helplessness, and powerlessness by Drew (1990) concluded that the three concepts are
qualitatively different in nature and that hopelessness is primarily a trait. A grounded
theory study by Kylma, Vehvilainen-Julkunen, and Lahdevirta (2001) deﬁned
hopelessness as passivity and a giving up in the face of belief in a non-existing future.
Although the analyses by Campbell, Drew and Kyhna et al. addressed negative and
helplessness expectancies, they did not strive to differentiate hopelessness from
depression. In contrast, Bartlett sought to examine hopelessness and depression using the
Hybrid Model of Concept Development (1994) and descriptive research (1999). Bartlett
concluded that the differentiation of hopelessness ﬁ'om depression was impossible and
that hopelessness should not be considered a NANDA diagnosis (1999). However,
Bartlett’s ﬁndings were limited by the concept analysis strategy used, small sample size,

and restricted use of correlational analysis.

18

Nursing literature further supports a negative life event as an antecedent to
hopelessness. NANDA describes a perceived or actual stressor or loss for an individual as
an antecedent of hopelessness, including a prolonged activity restriction creating
isolation, a failing physiological condition, long-term stress, abandonment, or a loss of
belief in transcendent values/God (1996). Similarly, F arran et a1. (1995) identiﬁed
negative intrapersonal, interpersonal, and environmental/sociological experiences as
antecedents, Drew (1990) described stress as an antecedent, and Campbell (1987)
identiﬁed a negatively perceived event or a series of failures to reach a desired goal as
antecedents to hopelessness. The nursing literature does not support distorted thoughts as
an antecedent to hopelessness in the physically ill. This may be due to the fact that when
physically ill individuals judge their illness as negative and out of their control, it is often
an accurate appraisal.

Although it is commendable that the nursing discipline has recognized
hopelessness as an important concept by identifying it as a NANDA (1996) nursing
diagnosis, it is apparent that deﬁnitions of hopelessness in the nursing literature differ
from one another and differ from deﬁnitions provided in the psychology literature. The
deﬁnition by NANDA lacks the key characteristic of a negative outcome expectancy. The
NANDA deﬁnition and deﬁnition by Farran et al. (1995) also contain characteristics
considered by psychologists as symptoms of depression. An accurate, consistent
deﬁnition of the concept of hopelessness is needed in nursing to adequately assess its
presence in individuals and to intervene appropriately.

The medical literature. Although hopelessness is not typically used as a concept

or category for diagnosis or therapy in medicine, hopelessness has been gaining attention

19

over the past decade as a variable in selected medical studies. Hopelessness was deﬁned
in one of these medical studies as a feeling of sadness and discouragement, the presence
of excess problems, and questioning if anything is worthwhile (Anda et al., 1993).
Another medical study described hopelessness as the feeling of impossibility in reaching
goals and a disbelief that things will change for the better (Everson et al., 1996; Everson
et al., 2000). While several of the characteristics described in these medical studies are
hopelessness attributes, feelings of discouragement and sadness are considered by APA
(2000) as depression symptoms. As in nursing, an accurate and consistent deﬁnition of
hopelessness is needed in medicine to identify its presence in individuals and to treat
individuals accordingly.

In summary, hopelessness as a concept is deﬁned by several disciplines, namely
psychology, nursing, and medicine. Overall, psychology, nursing and medicine agree that
hopelessness consists of negative expectations concerning one’s ﬁrture and negative
thoughts toward changing one’s outcomes in the future. Symptoms of hopelessness as
described by psychology, nursing, and medicine include thoughts of a negative, vague or
uncertain ﬁrture; lack of hope, enthusiasm or faith; an expectation of limited choices; an
expectation of not being able to make things better; and verbal cues such as “I can’t.”
Because hopelessness is conceptualized as a distinct concept in some of the literature, as
a Symptom of depression in other literature, and as a cause of depression in yet other
writings, a review of depression in the literature is also needed.

Depression in the Literature
The concept of depression is used in the literature to refer to a range of mood

disorders that can be diagnosed using standardized criteria. Depression may be used to

20

describe any disorder ranging from a sad mood, psychological distress related to a
negative mood state, major depression, or a biochemical disorder (APA, 2000).
Depression is diagnosed using the Diagnostic and Statistical Manual of Mental Disorders
(DSM-I V-T R) (APA). Major depression is deﬁned by the APA as the presence of
depressed mood and/or loss of interest or pleasure in activities most days over two weeks
in addition to the presence of four of the following: weight loss or gain, insomnia or
hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of
worthlessness, hopelessness, or guilt, decreased ability to think or indecisiveness, or
recurrent thoughts of death or suicidal ideation or attempts.

The heterogeneous components of depression are further described in the
literature with respect to both symptoms and cause. Symptoms of depression have been
described using sub—concepts/sub-scales or factors of depression. Factor analytic studies
using the Center for Epidemiologic Studies- Depression Scale (CES-D) have validated a
four-factor structure of depression (Radloff, 1977; Sheehan, F iﬁeld, Reisine & Tennen,
1995), namely (1) depressed affect/mood (blues, depressed, lonely, cry, sad), (2) lack of
well-being/positive affect (good, hopeful, happy, enjoy), (3) somatic and retarded activity
(bothered, appetite, effort, sleep, get going), and (4) interpersonal (unfriendly, dislike).

Etiology of depression has also ﬁgured prominently in the deﬁnitions of a subtype
of depression, titled hopelessness depression. A causal chain of hopelessness depression
begins with a life event that is perceived as negative. This is followed by inferences about
the Cause, consequences, and self. These inferences will most likely lead to hopelessness

When the person believes that the negative consequence is important, unlikely to change,

and affects many areas of life. It has been hypothesized that hopelessness, if left

21

untreated, can lead to hopelessness depression (Abramson et al., 1989). Because
hopelessness as a concept is present in the APA (2000) deﬁnition of depression, and
because it is hypothesized that there is a causal relationship between hopelessness and
depression, further distinction of hopelessness from depression is warranted.
Distinction of Hopelessness ﬁom Depression

There are areas of agreement and disagreement in the literature regarding the
distinct attributes of hopelessness and depression and the relationship between the two
concepts. Ambiguity related to the distinct characteristics of hopelessness and depression
may be attributed in part to similar characteristics found in the two conditions. The
psychomotor retardation, lack of voluntary responses, loss of energy, and fatigue or sleep
disturbances seen in people with depression (APA, 2000) can resemble the helplessness
expectancy seen in hopelessness. The depressed mood, sadness, apathy, loss of interest in
activities, indecisiveness, or suicidal thoughts seen with depression (APA) can be similar
to the negative expectancy evident in hopelessness.

Further uncertainty regarding the relationship between the two concepts may be
due to different perspectives of the two entities. According to the APA, depression can
range from a temporary grief response to a persistent psychiatric disorder and includes
the presence of depressed mood and/or loss of interest or pleasure in activities, in
addition to several other potential symptoms including hopelessness. This
conceptualization of hopelessness as a symptom of depression supports Beck’s theory of
depression (1967). In contrast, Abramson et al. (1989) have conceptualized hopelessness

as a precursor to a subtype of depression (i.e. hopelessness depression), not as a symptom

22

of depression. Abramson et al. recognize that hopelessness, beginning as a precursor,
may continue at times in conjunction with this subtype of depression.

In examining hopelessness and depression in response to physical illness, the
distinction of each concept and their relationship to each other may be best viewed on a
continuum (Dunn, 2005). Depression often occurs as a grief response to a past event,
such as a physical illness, and includes distinct attributes or symptoms. In contrast,
hopelessness is focused on expectations about the future. Hopelessness occurs in
response to a negative event, such as a physical illness, and includes speciﬁc symptoms.
The continuum of the relationship between hopelessness and hopelessness depression
attributes is depicted in Figure 1. According to Figure 1, hopelessness and depression can
be distinct diagnoses or hopelessness can lead to hopelessness depression.

In summary, hopelessness and depression are closely related concepts. The
negative outcome and helplessness expectancies seen in hopelessness may resemble the
depressed affect/mood and retarded activity seen in depression. Hopelessness may further
lead to a subtype of depression. Because the two concepts are closely related, it is
imperative to examine the frequency and severity of each concept, the relationship
between the two concepts, and to further identify their antecedents and consequences.
Antecedent Factors in the Literature

Patient demographics and patient history have been examined as potential
antecedent factors for depression, hopelessness, cardiac rehabilitation exercise, and
physical functioning. Depression has been found more common in CHD patients who are
0f female gender (Anda et al., 1993; Barefoot et al., 2000; Mendes de Leon et al., 2001;

Travella et al., 1994; Watkins et al, 2003), decreased age (Barefoot et al.; Watkins et al.),

23

PAST 4— —————————————————————————————— 9 FUTURE

 

Physical
Illness

 

Hopelessness Depression

 

 

Hopelessness

 

 

 

 

0 Negative feelings and
expectations about
one’s future

0 Negative thoughts and
feelings towards
changing future

 

 

 

 

Smptoms
0 Thoughts of a dark,

vague, or uncertain
future

0 Lack of hope,
enthusiasm, or faith

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choices

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can’t”

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Sadness
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Lack of energy,
fatigue, or sleep
disturbances
0 Lack of initiation of
voluntary responses
- Psychomotor
retardation
. Suicidality
o Hopelessness
(as an antecedent
and subsequent

symptom)

 

Figure l. Continuum of Hopelessness and Hopelessness Depression

24

 

 

non-married status (Anda et al.) or socially isolated (Watkins et al.), less educated
(Watkins et al.), with decreased income (Barefoot et al.), and with a history of depression
(Lesperance et al., 1996). Both non-Caucasian race (Anda et al.) and Caucasian race
(Watkins et al.) have been associated with depression in CI-[D patients. One study that
examined potential antecedent variables to hopelessness and depression found no
demographic variables as antecedents to hopelessness (Barefoot et al.).

Decreased participation in outpatient cardiac rehabilitation exercise has been
associated with increased age (Ades et al, 1992; Blackburn et al., 2000), female gender
(Ades et al., Blackburn et al.), lower education (Ades et al.), decreased left ventricular
function (Blackburn et al.), and history of depression (Ades et al.). Decreased physical
functioning in patients with CHD has been associated with female gender, increased age,
decreased aerobic exercise capacity, decreased leg and arm strength, and increased
comorbidities (Ades et al, 1999).

Exercise Participation in the Literature

Participation in cardiac rehabilitation exercise is deﬁned in a variety of ways in
the literature. Some authors have focused on adherence to recommended exercise by
measuring self-reported regular exercise (Ziegelstein et al., 2000). Other authors have
deﬁned participation in cardiac rehabilitation exercise as adherence to the number or
percentage of exercise appointments kept while the patient was enrolled in an outpatient
cardiac rehabilitation exercise program (Glazer et al., 2002; Hershberger, Robertson &
Markert, 1999). Still others have deﬁned participation as adherence by measuring the
percentage of outpatient exercise sessions attended divided by the number of exercise

sessions prescribed (Blanchard et al., 2003) or the actual exercise behaviors divided by

25

the individual’s exercise intention (Konradi & Lyon, 2000). Others have deﬁned cardiac
rehabilitation exercise participation as the frequency of supervised on-site exercise plus
the frequency of off-site independent exercise of 30 minutes or more per session
(Carlson, Johnson, Franklin & Vanderlaan, 2000).

Although hopelessness post-MI has not been previously examined, hopelessness
may have a negative effect on cardiac rehabilitation exercise participation. Hopeless
individuals have negative and helplessness expectancies about changing ﬁrture outcomes
(Abramson et al., 1989). Thus, individuals with hopelessness may not be able to identify
a purpose in participating in exercise if they believe that the exercise will not make a
difference in their outcome.

Physical Functioning in the Literature

Physical functioning is deﬁned and measured in a variety of ways. Some
researchers deﬁne and measure physical functioning as strictly the self-reported
functional performance during a range of activities from low (i.e. dressing) to strenuous
(i.e. running) levels (Ades et al., 1999; Bamason, Zimmerman, Anderson, Mohr-Burt &
Nieveen, 2000). Rej eski and colleagues (2002) measured physical ﬁmctioning with both
functional performance and ftmctional capacity measures, namely the peak or average
metabolic equivalency (MET) level during activity or exercise, the total distance covered
in feet during a treadmill test, and with a self-reported physical ﬁmctioning measure.
Other researchers integrate elements of both functional performance and functional
capacity in one’s self-reported ability to perform various activities ranging from activities

of daily living to strenuous exercise, with the conversion of these to MET levels

26

(Bairey—Merz et al., 2000; Hlatky et al., 1989; Rankin, 2002; Yates, Price-Fowlkes &
Agrawal, 2003).

Hopelessness has not been examined in relationship to physical functioning post-
MI; however, it may potentially negatively affect physical functioning. A hopeless
individual has negative and helplessness expectancies about changing future outcomes
(Abramson et al., 1989). Thus, a hopeless individual may not feel capable of physically
functioning and may believe that it will not make any difference in their outcome.

In summary, a review of literature was completed focusing on the concepts of
hopelessness, depression, cardiac rehabilitation exercise participation, and physical
functioning. Hopelessness is defrned in the literature as a negative expectation concerning
one’s future and an expectation of helplessness in changing one’s future outcomes.
Depression, as a closely related concept, is deﬁned in the literature as an affective or
mood disorder. By deﬁnition, hopelessness may lead to a subtype of depression.
Participation with cardiac rehabilitation exercise is deﬁned in the literature as the number
or percentage of exercise appointments kept while the patient is enrolled in an outpatient
cardiac rehabilitation exercise program or independent home exercise program,
sometimes in relationship to a prescription for exercise. Physical functioning is identiﬁed
and defrned in the literature as either functional performance or capacity during a range
0f activities.

Because hopelessness has not been previously examined in the post-MI recovery
Period, a conceptual model is needed to illustrate the concepts of interest and their
relationships. The conceptual deﬁnitions for the proposed study will also be discussed in

the conceptual model section of this chapter.

27

The Conceptual Model

The conceptual model of the study is presented in Figure 2. This model is based
on Abrarnson’s Theory of Hopelessness Depression (Abramson et al., 1989). The study
focuses on selected relationships depicted in the model. Speciﬁcally, the relationships
portrayed by solid arrows were examined, while relationships portrayed by broken arrows
were not a focus in the study (a separate analytic model will be discussed in Chapter 4).

The conceptual model presents the relationships among antecedent patient factors,
the perceived negative life event (MI), hopelessness symptoms, depression symptoms,
participation in cardiac rehabilitation exercise, and physical ﬁmctioning. Although each
of these concepts was discussed in the preceding literature review section of this chapter,
the following section is presented to theoretically deﬁne each of the concepts and their
role in the conceptual model. ‘

Antecedent patient factors. Antecedent patient factors are deﬁned in the study as
those variables that are potential precursors to the negatively perceived MI event, to
symptoms of hopelessness and depression, and to physical functioning and cardiac
rehabilitation exercise participation. The relationship between the antecedent patient
factors and the negative life event (i.e. MI) was not a focus of this study and was not
examined. However, antecedent patient factors were used in the study to describe the
sample, in the prediction of hopelessness symptoms, and as control variables in
predicting cardiac rehabilitation exercise participation and physical functioning.
Antecedent patient factors of interest include age, gender, race, marital status, presence of

caregiver, history of depression, history of prior MI, assignment to control or

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29

experimental group in the larger study from which this sample was taken (see further
discussion pages 29-30), and disease severity.
Participants in the study were male and female adults age 21 years and older.

Race was differentiated by self-report as falling into the following groups: Caucasian,
Hispanic or Latino, American Indian/Alaska Native, Asian, Native Hawaiian or other
Paciﬁc Islander, Black or African American, more than one race, or unknown or not
reported. Marital status was differentiated as married, separated, divorced, widowed, and
never married. The presence of a caregiver was deﬁned in the study as the presence or
absence of someone who could help the patient with any type of care after being in the
hospital. The caregiver could be formal (e. g. a nurse or nurse’s aide) or informal (e. g. a
family member). History of depression was deﬁned for the study as a self-report as to
whether the person had ever been diagnosed or treated for depression. A history of MI
was deﬁned as a self-report as to whether the person had ever been diagnosed or treated

for a heart attack prior to the current hospitalization and current MI.

The sample for this study came from the AHRQ-funded project (HS 10531),
entitled, “Patient Decision Support and Coaching Project”, referred hereafter as the Heart
Aﬁer Hospital Recovery Planner (HARP) study. Participants in the HARP study were
randorrrized to a control or experimental group. Those in the experimental group received
a six-session program delivered over the telephone by a trained health educator. The
HARP study intervention adapted a relapse prevention model smoking cessation program
for use with the multiple risk factors of CHD, including smoking, physical activity, diet,
StreSS, and compliance with medications. Those in the control group received standard

Care.

30

Disease severity, deﬁned in the study as left ventricular ejection fraction post-MI
while the patient was still hospitalized, is recognized in the conceptual model as an
antecedent to a perception of the MI as a negative life event. It was hypothesized in the
study that patient understanding of a decreased ejection ﬁ'action, or self-reported
symptoms resulting from a decreased ejection fraction, could be related to a patient’s
negative perception of a MI event. The effect of decreased ejection ﬁaction on a patient’s
negative perception of a MI could thus potentially affect hopelessness symptoms. It was
also recognized that severity of disease may be directly related to physical functioning
and cardiac rehabilitation exercise participation. Subjects in the HARP study may have
received any form of medical or surgical treatment, including coronary artery bypass
surgery or angioplasty; however, ejection fraction was used for the measurement of
disease severity.

Hopelessness. Hopelessness was deﬁned for the study as a negative expectancy
concerning one’s future, including expectations of helplessness in changing one’s ﬁrture
(Abramson et al., 1989). Hopelessness was deﬁned for the study as either a state or trait;
however, data related to hopelessness symptoms prior to the M1 were not available and
therefore state and trait hopelessness could not be differentiated in this study. Symptoms
of hopelessness include: thoughts of a dark, vague or uncertain ﬁrture; lack of hope,
enthusiasm, or faith; expectations of limited choices; expectations of not being able to
make things better; and cues such as “I can’t”.

Hopelessness can be prompted by a life event, such as a MI, which the individual
attributes as negative (Abramson et al., 1989). Hopelessness is more likely to occur if a

person believes that the negative consequence is important, unlikely to change, and

31

affects many important areas of one’s life (Abramson et al.). People who exhibit a
negative cognitive style are more likely to make negative inferences (Abramson et al.).
For example, a person diagnosed with an acute MI would likely perceive this as a
negative event. If the person believed that they were leading a fairly healthy lifestyle
prior to the event, the person might infer that he or she has little control over the cause. If
family members have historically died due to MI, the person may infer that the MI is not
preventable or that death is imminent. If the individual is a smoker who has failed at
attempts to quit the habit, the person may infer that he or she will be unsuccessful at
smoking cessation.

It was recognized in the study that antecedent patient factors may serve as
predictors of hopelessness and this was examined. It was also recognized that
hopelessness and depression symptoms are likely related to each other and the strength of
this potential relationship, as well as the independence of these two variables in
relationship to other predictors and outcomes were examined. However, based on the
work of Abramson and her colleagues (1989) it was hypothesized in the study that
hopelessness symptoms can be independent of depression symptoms or be a precursor of
depression symptoms. Hopelessness symptoms were thus examined as predictive of
depression symptoms. Hopelessness symptoms were also used as a predictor of cardiac
rehabilitation exercise participation and physical functioning, controlling for depression
symptoms.

Depression. The conceptual model recognizes that increased depression
symptoms can be related to a MI event, as described in the earlier literature review. The

deﬁnition of depression for the proposed study is the presence of depressed mood and/or

32

loss of interest or pleasure in activities most days over two weeks in addition to the
presence of four of the following: weight loss or gain, insomnia or hypersomnia,
psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness,
hopelessness, or guilt, decreased ability to think or indecisiveness, or recurrent thoughts
of death or suicidal ideation or attempts (APA, 2000). It is recognized that one
component of depression may be a subtype of depression titled hopelessness depression
(see Chapter 3 for further elaboration of hopelessness depression); however, hopelessness
depression could not be speciﬁcally examined in this study. Instead, in examining the
relationship between hopelessness and depression, hopelessness was examined as a
predictor of depression. It is also recognized that antecedent patient factors may be
predictive of depression symptoms, although this was not a focus in this study.
Depression symptoms potentially have an affect on cardiac rehabilitation exercise
participation and physical functioning. Level of depression symptoms was used as a
control variable in this study in predicting cardiac rehabilitation exercise participation
and physical functioning.

Cardiac rehabilitation exercise participation. Participation in cardiac
rehabilitation exercise was deﬁned in the study as self-reported participation in a
hospital- and/or home-based cardiac rehabilitation exercise program. Exercise
participation was used as an outcome variable. It was hypothesized in the study that a
higher level of hopelessness symptoms would be predictive of a lower level of cardiac
rehabilitation exercise participation. Although it is recognized in the conceptual model
that symptoms of depression can directly affect cardiac rehabilitation exercise

Participation, this was not a focus in the study. It is recognized in the model that physical

33

functioning can affect cardiac rehabilitation exercise participation in that someone with
decreased physical functioning may be less capable of participating in cardiac
rehabilitation exercise. It is also recognized that cardiac rehabilitation exercise
participation may have an effect on physical functioning in that someone with decreased
participation in exercise may have decreased physical capability. However, the bi-
directional relationship between physical functioning and cardiac rehabilitation exercise
participation was not a focus in this study.

Physical functioning. Physical functioning was deﬁned in the study as one’s self-
reported ability to perform various activities ranging from activities of daily living to
strenuous exercise. It was used as an outcome in the study. It was hypothesized in the
study that a high level of hopelessness symptoms would be predictive of a lower level of
physical functioning. The model also recognizes that symptoms of depression can
directly affect physical functioning, although this was not a focus of the study.

Model Application to Hopelessness and Depression after a MI

The psychological status of a person in the post-MI recovery period is complex
and not well understood. The examination of the conceptual relationships in this study
was intended to increase this understanding. The antecedent patient factors were
examined to help identify sub-groups of individuals who are at risk for hopelessness
symptoms post-MI. An analysis of the relationship between hopelessness and depression
Symptoms was completed to help clarify the distinction between these two closely-related
Concepts. Finally, the examination of hopelessness symptoms as a predictor of cardiac

rehabilitation exercise participation and physical functioning was completed to

34

potentially offer new information as to the role of hopelessness in affecting patient
outcomes post-MI.
Chapter Summary

The purpose of the study, research questions, and conceptual framework have
been presented in Chapters 1 and 2. Chapter 3 will describe in greater detail the current
state of hopelessness research with the CHD population and will focus on gaps in the
literature. Chapter 4 will discuss the speciﬁc design and methodology of the study, while

Chapter 5 and 6 will present the results and discussion.

35

Chapter 3
THE STATE OF HOPELESSNESS RESEARCH

Over the past several decades hopelessness research has focused on providing a
better understanding of populations with mental illness, especially as related to
depression, suicidal ideation, and suicide. More recently, hopelessness research has
contributed to an increased understanding of the connection between emotional status and
physical illness. However, there are gaps in the hopelessness literature for physically ill
population groups, including those individuals in the post-MI recovery period. In this
chapter, a summary and critique of hopelessness research in psychology, nursing and
medicine from the mid-19805 to the present will be discussed. First, research ﬁndings
related to the frequency, severity and impact of hopelessness will be discussed. Next,
methodological issues of existing hopelessness research will be presented. The chapter
will conclude with a discussion regarding the avenues of hopelessness research yet to be
explored and the potential signiﬁcance of this study.
Frequency, Severity and Impact of Hopelessness

Psychology researchers have examined hopelessness in psychiatric inpatient and
outpatient populations for several decades. Early research focused primarily on the
relationships among hopelessness, depression, and suicidal ideation or ultimate suicide.
Hopelessness has frequently been reported as a stronger correlate of suicidal ideation
(Beck & Steer, 1993; Wetzel, Margulies, Davis & Karam, 1980) and eventual suicide
(Beck, Brown, Berchick, Stewart & Steer, 1990; Beck, Steer, Kovacs & Garrison, 1985)

than depression.

36

More recent studies in psychology have focused on the relationship between
hopelessness and a subtype of depression, titled hopelessness depression. According to
Abramson et al. (1989), hopelessness is more likely to occur if a person has a negative
cognitive style where the person makes negative inferences regarding the causes and
consequences of life events. Research examining college students has shown that an
increased negative cognitive style is related to increased levels of hopelessness, which
can serve as a precursor to a subtype of depression (Alloy et al., 1999). Several other
studies have found that a negative cognitive style is more strongly correlated with
symptoms of hopelessness depression than with symptoms of other types of depression
(Alloy & Clements, 1998; Alloy, Just & Panzarella, 1997; Joiner, 2001; Joiner, et al.,
2001)

There is limited research in nursing that has examined hopelessness as a distinct
concept. These studies have examined the NANDA (1996) diagnosis of hopelessness and
its deﬁning characteristics. A content validity study examining the deﬁning
characteristics of hopelessness identiﬁed verbal cues as critical to the nursing diagnosis
of hopelessness, but did not ﬁnd passivity, decreased verbalization, or decreased affect as
signiﬁcant to the hopelessness nursing diagnosis (Bruss, 1988). A study by Wake,
Fehring, and Fadden (1991) reported that nurses from various countries differed in their
ratings of how well each deﬁning characteristic of the NANDA diagnosis of hopelessness
represented the concept. A grounded theory study by Kyhna and colleagues (2001)
deﬁned attributes of hopelessness as passivity and a giving up in the face of belief in a
non-existing future. Finally, Bartlett’s descriptive research (1999) concluded that the

differentiation of hopelessness from depression was impossible and that hopelessness

37

should not be considered a NANDA diagnosis. However, Bartlett’s ﬁndings were limited
by a small sample size and the sole use of correlational analysis.

In recent years the breadth of hopelessness research in nursing and medicine has
expanded to examining the outcomes of hopelessness in medically ill populations. Many
of these studies have examined hopelessness as a correlate or predictor of morbidity and
mortality. A number of these studies have focused on hopelessness as independent from
depression. These studies are applicable to the current study in that the psychological
dynamics in response to any life-threatening illness may be similar to that of a MI. In
particular, individuals diagnosed with cancer or AIDS are at high risk for emotional
distress. In one nursing study, symptoms of hopelessness were identiﬁed in 40% of men
with cancer or AIDS, with higher levels of hopelessness associated with poorer
functional status in these populations (VanServellen et a1. 1996). In other nursing
studies, higher levels of hopelessness symptoms were associated with higher distress
levels in women undergoing breast biopsy (Northouse et al., 1995) and poorer adjustment
to breast disease in women during the ﬁrst year following diagnosis (Northouse et al.,
2001)

Medical studies have found that higher levels of hopelessness symptoms are
related to increased risk for relapse or death in women with breast cancer (Watson et al.,
1999) and predictive of suicidal ideation in individuals with terminal cancer, independent
of depression (Cochinov et al., 1998). In another prospective medical study of terminally
ill cancer patients, hopelessness and depression were positively correlated to desires for
hastened death, although hopelessness provided independent contributions and had no

interaction effect with depression (Breitbart et al., 2000). Menon, Campbell, Ruskin, and

38

Hebe] (2000) examined a group of elderly medically ill veterans and found that increased
hopelessness was related to decreased desire for life-saving treatments, independent of
depression. Finally, a study among stroke survivors found hopelessness related to long-
term survival, independent of depression (Lewis et al., 2001). Although this hopelessness
research has not focused on post-MI populations, it is assumed that the psychological
response to a MI is similar to other life-threatening illnesses and that there is a potential
relationship between hopelessness and post-MI health outcomes.

Of particular interest to the current research are a limited number of large medical
studies within the past decade that have examined the relationship between hopelessness
in conjunction with CHD in cohorts over time. In the National Health Examination
F ollow-Up Study, the risk of fatal and nonfatal CHD among initially healthy men and
women was higher for those participants with moderate and severe levels of hopelessness
(see detailed description in Chapter 2), with hopelessness more strongly related to
morbidity and mortality than depression (Anda et al., 1993). In the Finnish Kuopio
Ischemic Heart Disease study, risk of death due to cardiovascular causes was doubled
among men with moderate hopelessness scores while cardiovascular mortality risks
tripled among men who had high hopelessness scores (see description in Chapter 2), aﬁer
adjusting for depression (Everson et al., 1996). In a third cohort study, hopelessness was
found to be a strong predictor of survival in patients with signiﬁcant CHD, independent
of depression (see Chapter 2 description) (Barefoot et al., 2000). No research was found
examining the frequency, severity, or impact of hopelessness after a MI.

The biopsychosocial relationship between hopelessness and CHD outcomes is not

ﬁrlly understood. However, hopelessness may be similar to depression in its pathogenesis

39

of CHD and related outcomes. Depression has been associated with higher serum
cholesterol levels (Ledochowski, 2003), inflammatory risk markers (Miller, 2003), higher
glucocorticoids (Musselman, 1998), and elevated serotonin levels (Whyte, 2001), all of
which can potentially have vasoconstrictive or atherogenesis properties. In addition,
depressed individuals are at greater risk for ventricular arrhythmias (Carney, 2003;
Lauzon, 2003; Shiotani, 2002). Hence, depression symptoms have potential to inﬂuence
post-MI outcomes. Whether hopelessness may also affect post-MI outcomes is currently
unknown.
Hopelessness, Exercise Participation, and Physical Functioning
Health outcomes of particular interest in the post-MI population include
participation in cardiac rehabilitation exercise and physical ﬁrnctioning. Participation in
exercise leads to improved exercise tolerance (Balady et al., 1996; Marchionni et al.,
2003) and a reduction in mortality in individuals with CHD (Balady et al., 2000). No
research was found examining the relationship between hopelessness symptoms and
cardiac rehabilitation exercise participation. Similarly, no research was found examining
hopelessness in any disease condition in relationship to adherence to healthy lifestyle
recommendations. However, attitude and perceived behavioral control have been found
to explain a proportion of variance in exercise intention and subsequent adherence in
both a sample of patients attending a structured outpatient cardiac rehabilitation program
(Blanchard et al., 2003) and in a sample of 30 to 60 year old men in the community
(Nguyen et al., 1997). Additionally, hopeless individuals have negative and helplessness

expectancies about changing future outcomes (Abramson et al., 1989) and therefore

40

individuals with hopelessness may be unable to identify a purpose in exercise
participation if they do not believe it will make a difference in their outcome.

Depression, as a concept closely related to hopelessness, has been found to be
predictive of cardiac rehabilitation exercise participation in a number of studies. A
history of depression prior to hospitalization for M1 or coronary artery bypass surgery
was predictive of decreased participation in an outpatient cardiac rehabilitation program
in a multivariate analysis of 226 American men and women age 62 to 92 years (Ades et
al., 1992). In a study examining 204 American men and women post-MI, hospitalized
patients who had symptoms of mild, moderate, or major depression reported lower
adherence to regular exercise at four months after discharge (Ziegelstein et al., 2000). A
smaller study sample (n = 46) in a structured outpatient cardiac rehabilitation program
found depression to have a signiﬁcant negative inﬂuence on adherence to exercise
(Glazer et al., 2002).

Participation in an outpatient cardiac rehabilitation exercise program has also
been shown to decrease depression. A study following 107 men and women with CHD
and myocardial ischemia over a four-month period of time found that depression was
signiﬁcantly reduced among participants in the exercise program as compared to those
who did not participate (Blumenthal et al., 1997). A sample of 268 CID patients age 65
or more years who participated in a 12-week outpatient cardiac rehabilitation exercise
program showed a signiﬁcant decrease in depression at the completion of the program
(Milani & Lavie, 1998). Because hopelessness is closely related to depression, and

because hopeless individuals have negative and helplessness expectancies about

41

changing their future outcomes, hopelessness may be related to cardiac rehabilitation
exercise participation.

Although no research was found examining the relationship between hopelessness
symptoms and physical functioning in a CHD population, hopelessness symptoms have
been associated with poorer functional status in men with cancer and AIDS
(V anServellen et al., 1996) and may be correlated with physical frmctioning post-MI. In
addition, depression symptoms have been negatively related to physical functioning in
CHD patients. In a study examining 303 CHD patients in an outpatient cardiac
rehabilitation program, increased depression was found to be a signiﬁcant predictor of
decreased baseline physical functioning (r = -0.022, r2 = 0.05, p < 0.001) (Ades et al.,
1999). In the study by Ades et al., the best determinant of improvement in physical
functioning after rehabilitation exercise was the baseline physical functioning score;
however, the best training-related correlate of improved physical functioning was a
decrease in depression (r = 0.36, I] = 0.13, p < 0.001) (Ades et al.). Baseline depression
scores have been found to account for approximately 10% of the variance associated with
decreased aerobic capacity in patients attending a structured outpatient cardiac
rehabilitation program, controlling for demographic variables and adherence (Glazer et
al., 2002). Since hopelessness symptoms have been associated with poorer functional
status in other illness populations, and the related concept of depression has been
correlated with decreased physical functioning in subjects with CHD, hopelessness may
be associated with decreased physical functioning post-MI.

In summary, hopelessness has been found to be prevalent and severe in

individuals with psychological and physical illnesses. Hopelessness has also been found

42

to have signiﬁcant impact on health outcomes, although the biopsychosocial relationship
between hopelessness, CHD, and related health outcomes is unknown. The frequency,
severity, and impact of hopelessness post-MI have not been previously examined.
Although increased depression has been found to decrease cardiac rehabilitation exercise
participation and physical functioning in CHD patients, and increased hopelessness has
been found to be predictive of decreased physical functioning in patients with other life
threatening illnesses, the impact of hopelessness on the post-MI outcomes of cardiac
rehabilitation exercise participation and physical functioning is not known.
Methodological Issues

Hopelessness studies over the past 30 years have used a variety of methodological
approaches. A number of study designs have been cross—sectional in nature (Beck et al.,
1993; Cochinov et al., 1998; Joiner et al., 2001; Northouse et al., 1995; VanServellen et
al., 1996), allowing for an examination of the association between variables, but limited
in their ability to examine changes over time or to contribute to the understanding of
causation. Other studies have used a longitudinal design (Anda et al., 1993; Beck et al.,
1985; Everson et al., 1996; Everson et al., 1999; Lewis et al., 2001; Northouse et al.,
2001; Watson et al., 1999), permitting some examination of change over time.

Hopelessness studies in the ﬁeld of psychology that have focused on its
relationship to depression, suicidal ideation, or ultimate suicide in psychiatric inpatients
and outpatients have used fairly large sample sizes, ranging from approximately 200 to
2,000 participants (Beck et al., 1990; Beck, et al., 1993; Becket al., 1985; Wetzel et al.,
1980). Studies that have focused on hopelessness as a precursor to hopelessness

depression in college students have also employed moderate to large samples (i.e. 110 to

43

5,500 participants) (Alloy & Clements, 1998; Alloy et al., 1997; Joiner et al., 2001). One
study examining hopelessness depression as a distinct subtype of depression used a large
sample of 1,500 Air Force cadets and 3,000 psychiatric outpatients (Joiner et al.).

Hopelessness research in nursing and medicine has focused on both the
relationship between hopelessness and morbidity and mortality in physically ill
populations as well as causality between hopelessness and health outcomes. These studies
have used a wide range of sample sizes. Correlational studies have employed small (i.e.
30 per group) (V anServellen et al., 1996) to moderately large (i.e. 200 to 300 per group)
(Cochinov et al., 1998; Northouse et al., 1995) sample sizes. Studies focusing on
causality have used moderate to large sample sizes, ranging from 130 (Northouse et al.,
2001) to 2,500 (Anda et al., 1993; Everson et al., 1996).

The Beck Hopelessness Scale® (BHS®) (Beck et al., 1974) is the most widely
used hopelessness tool in psychology research. Although the 20-item BHS® is
commonly used in nursing research (Northouse et al., 1995; Northouse et al., 2001;
VanServellen et al., 1996), much of the hopelessness research done in medicine has
employed subscales of other psychosocial measures to examine hopelessness. In fact,
many of the hopelessness instruments used in medicine have been one- or two-item
measures. A two-item hopelessness scale (i.e. “I feel that is impossible to reach the goals
I would like to strive for” and “The future seems to me to be hopeless, and I can’t believe
that things are changing for the better”) was used in the Kuopio Ischemic Heart Disease
Study (Everson et al., 1996; Everson et al., 2000). In the National Health Examination
Follow-up Survey hopelessness was measured by the single item, “Have you felt so sad,

discouraged, hopeless or had so many problems that you wondered if anything is

44

worthwhile?” from the full four-item depression subscale of the General Well-Being
Schedule (Anda et al., 1993). Hopelessness has also been examined in a sample of
patients with advanced terminal cancer by using one pessimism item from the Beck
Depression Inventory and one discouragement/pessimism/hopelessness item from the
Schedule for Affective Disorders and Schizophrenia (Cochinov et al., 1998). It is
doubtful that these measurement subscales with so few items capture the
multidimensionality of hopelessness.
Avenues for Exploration in Hopelessness Research

Research is needed to describe the frequency and severity of hopelessness
symptoms in the post-MI population as this is currently unknown. In particular, research
is needed in the initial recovery period after the MI as this is the time period when the
myocardial tissue heals and transition back to baseline activities occurs. An examination
of predictors of hopelessness symptoms in post-MI patients is also needed in an effort to
identify those patients at highest risk for hopelessness. An analysis of the relationship and
distinction between hopelessness and depression symptoms is warranted as interventions
for these two concepts may differ. Additionally, the relationship between hopelessness
symptoms and the outcomes of cardiac rehabilitation exercise participation and physical
functioning is warranted as these are two important post-MI outcomes already known to
be affected by the closely related concept of depression.

The current study is intended to ﬁll some of the gaps in hopelessness research in
the post-MI population by examining the frequency and severity of hopelessness
symptoms and depression symptoms among post-MI patients three-months after hospital

discharge, potential predictors of hopelessness, and effects of hopelessness on exercise

45

participation and physical functioning (see conceptual model in Figure 2). This
information will contribute to the practitioner’s understanding of the pervasiveness and
severity of hopelessness symptoms in the early post-MI recovery period, those post-MI
patients at greatest risk for hopelessness symptoms, and the effects that hopelessness
might have on post-MI outcomes. Ultimately this knowledge may be used as a foundation
for potential interventions to prevent or treat hopelessness symptoms and to improve
exercise participation and physical ﬁrnctioning in those individuals who are hopeless
post-MI.

The present study additionally analyzes the relationship between hopelessness and
depression symptoms in post-MI patients and attempts to further differentiate
hopelessness from depression by examining baseline hopelessness symptoms as an
independent predictor of cardiac rehabilitation exercise participation and physical
functioning at three-months after hospital discharge (see conceptual model in Figure 2).
This information will add to the body of knowledge related to hopelessness and
depression and may serve as a catalyst for further hopelessness-depression research in the
MI population. Study ﬁndings may contribute to clariﬁcation of both the conceptual and
operational deﬁnitions of hopelessness and serve as a foundation for further hopelessness
research.

In summary, it is anticipated that this study will begin to ﬁll the knowledge gap in
existing hopelessness research related to the post-MI population, contributing to the
knowledge base of nursing and other health disciplines caring for M1 patients. Because
there is no existing research related to hopelessness post-MI, this study will additionally

lay the groundwork for future research aimed at more in-depth examination of

46

 

hopelessness symptoms in the post-MI recovery period. This study and future research
may eventually serve as a foundation for understanding the biopsychosocial relationship
between hopelessness, CHD, and related health outcome and in designing effective
interventions that prevent or treat hopelessness symptoms and promote cardiac
rehabilitation exercise participation and optimal physical functioning of the MI patient.
Chapter 1 and 2 served to provide the background, research questions and
conceptual model for the proposed study. Chapter 3 has presented the current state of
hopelessness research, gaps in the literature, and avenues for future exploration. The
methodology of the study will be discussed in Chapter 4. Chapters 5 and 6 will present

the results of the study and discussion of the ﬁndings.

47

Chapter 4
METHODOLOGY

Methodology of the study will be presented in this chapter. First the study’s
design, sample and setting will be discussed. This will be followed by a description of the
operational deﬁnitions and measurement of the key variables. Data collection and
procedures to protect the rights of human subjects will be then discussed. Finally, a
description of the data analysis procedures will be presented.
Design

A descriptive research design using data from two waves of a three wave panel
study was used in this study. Predictors were examined using baseline data and outcomes
were examined using three month data, to answer the following research questions:

1) What is the frequency and severity of hopelessness symptoms and depression
symptoms among post-MI patients at three-months after hospital discharge?

2) What is the relationship between hopelessness symptoms and depression
symptoms among post-MI patients at three-months after hospital discharge?

3) For those post—MI patients who have hopelessness symptoms at three-months
after hospital discharge, what factors present at baseline are predictive of their
three-month hopelessness scores?

4) Are hopelessness symptoms at baseline predictive of participation in cardiac
rehabilitation exercise and physical functioning among post-MI patients at three-
months after hospital discharge?

The conceptual deﬁnitions of key variables were presented in Chapter 2. This

research focused on a description of hopelessness and depression symptoms and the

48

relationship between hopelessness symptoms to outcomes in the initial recovery period
after a MI, as these have not been previously examined. It is recognized that these
variables can change over time and should also be examined at intervals beyond three-
months.

Sample and Setting

The sample for this study came from the AHRQ-funded project (HSlOS31),
entitled, “Patient Decision Support and Coaching Project,” referred hereafter as the Heart
Aﬁer Hospital Recovery Planner (HARP) study. Dr. Margaret Holmes-Rovner, Principal
Investigator for the HARP study, granted permission to this investigator to use the HARP
study data. The major aim of the HARP study was to test the effects of a brief six-session
program delivered to patients with acute coronary syndrome (ACS) after hospital
discharge. The HARP intervention was delivered to patients over the telephone by a
trained health educator. The HARP study intervention adapted a relapse prevention
model smoking cessation program for use with the multiple risk factors of smoking,
physical activity, diet, stress, and compliance with medications. The HARP study
enrolled subjects ﬁ'om January 14, 2002 through April 13, 2003 at ﬁve mid- to large-size
community hospitals in two central Michigan communities.

A total of 721 subjects who were approached during their hospitalization for ACS
consented and were enrolled in the HARP study. A total of 527 subjects (26.9% attrition)
were contacted by telephone in their homes approximately two weeks after hospital
discharge (M = 14.1 days, SD = 9.6) and completed structured baseline interviews.
However, only 513 of the baselined subjects had a conﬁrmed discharge diagnosis of

ACS. Of these, 431 subjects completed three-month telephone interviews (attrition

49

between baseline and three months = 16%). A comparison of demographic characteristics
between the enrolled subjects and those interviewed at baseline and three months
indicated no signiﬁcant differences, with the exception of a difference in mean age
between the enrolled (M = 69.96 years, SD = 14.80) and baseline (M = 61.16 years, SD =
12.96) subjects.

For the purposes of this investigation, only those subjects with a conﬁrmed
diagnosis of M1 at discharge were used in the analysis. A total of 351 subjects with a
conﬁrmed diagnosis of MI completed interview data at three months. Table 1
summarizes characteristics of the 351 subjects. Gender and race distributions were typical
of MI (American Heart Association [AHA], 2004). Based on estimated incidence rates by
the AHA, it was anticipated that one-third of participants would be under age 65 years.
However, 67.5% of study participants were under 65 years of age at time of enrollment
into the study, with a mean of 60 years (SD = 11.3) and a range of 32 to 99 years.
Twenty-one percent of subjects reported a history of diagnosis or treatment for
depression, which is comparable to previous research (i.e. 16-28%) (Ariyo et al., 2000;
Frasure—Smith et al., 1993; Hance et al., 1996). Twenty-nine percent of subjects reported
a history of MI, which is less than the national average (i.e. 41%) (AHA). It is unknown
why only 22% of subjects (n = 75) responded to the presence of caregiver item; however,
due to the low response rate, this item was not used in the study. An average ejection
fraction of 50% indicated fairly well preserved left ventricular function in this group,
possibly related to the younger age of the sample and lower percentage of subjects with a

history of prior MI.

50

Table 1

Characteristics of the Sample

 

Characteristic n %
Gender
Female 123 35
Male 228 65
Race
Non-Hispanic Caucasian 300 86
Aﬁican-American 37 11
Hispanic Caucasian 8 2
American Indian 6 2
Marital status
Married 252 72
Separated 9 3
Divorced 40 11
Widowed 41 12
Never married 9 3
'istory of diagnosis or treatment for depression
Yes 73 21
No 275 78
Don’t know 3 1

 

51

 

Table 1 (continued)

 

 

 

 

Characteristic n %
History of prior heart attack
Yes 102 29
No 246 70
Don’t know 3 1
Presence of caregiver
Yes 59 1 7
No 16 5
Group assignment
Intervention 1 78 5 1
Control 173 49
n M (SD) (Range)
Age 351 60 (11) 32-99
Disease Severity
Ejection fraction (percent) 305 50 (13) 15-90

 

52

Data were used from both the intervention and control groups of the HARP study.
Subjects were fairly well distributed between intervention (51%) and control (49%) arms
of the study. Demographic characteristics did not differ signiﬁcantly between the two
study arms, with the exception of age. Subjects in the intervention group were slightly
younger (M = 58.49, SD = 10.65) than those in the control group (M = 60.96, SD = 11.90)
(t = 2.05, df= 349, p = 0.04). There were no signiﬁcant differences in the levels of
hopelessness symptoms between the intervention (M =1 .66, SD = 1.52) and control (M =
1.51, SD = 1.55) groups prior to the intervention (t = 0.91, df= 349, p = 0.37).
Intervention and control group assignment was used as a control variable in the study.
Operational Definitions

Operational deﬁnitions of the current study’s key variables are presented below.
First, operational deﬁnitions for hopelessness symptoms and depression symptoms will
be presented. Next, the antecedent patient factors will be operationally deﬁned. Finally,
the operational deﬁnitions for the dependent variables, cardiac rehabilitation exercise

participation and physical functioning, will be discussed.

Hopelessness symptoms. The patient’s report of negative outcome expectancies

and helplessness expectancies (Beck, et al., 1974).

Depression symptoms. Depressed affect/mood, absence of well-being/positive

affect, somatic/vegetative activity, and interpersonal factors as reported by the patient

(Radloff, 1977).

Antecedent patient factors. The patient’s self report of age, gender, race, marital
status, presence of caregiver, history of depression, and history of prior MI. Control or

experimental group assignment is deﬁned as the randomization assignment as

53

documented on the study questionnaire by HARP study personnel. Disease severity is
operationally deﬁned as the patient’s left ventricular ejection fraction as recorded in the
patient’s chart.

Cardiac rehabilitation exercise participation. The patient’s self report of
participation in a hospital-based outpatient cardiac rehabilitation exercise program and/or
a home-based cardiac rehabilitation exercise program.

Physical functioning. The patient’s report of his or her ability to perform various
activities of daily living (Hlatky, et al., 1989).

The operationalization of the key study variables is further discussed below by
summarizing the instruments for the study and their relative psychometric properties.
Instruments

Interview instruments to measure hopelessness symptoms and depression
symptoms will be discussed ﬁrst. Next, the measures for the antecedent patient factors
will be presented. Finally, the instruments to measure the dependent variables (i.e.
cardiac rehabilitation exercise participation and physical ﬁrnctioning) will be described.
A summary of the measures for the study is presented in Table 2, including the research
question(s) addressed by each measure, collection point(s), number of items, score
ranges, and psychometric properties. Copies of all measures appear in the Appendices.

Beck Hopelessness Scale® Cognitive Expectations Factor. The patient’s
hopelessness symptoms were measured in the study using the cognitive expectations
factor of the full Beck Hopelessness Scale® (BHS®) (Beck et al., 1974). The full BHS®

is a 20-item true/false scale that is based on three dimensions of hopelessness:

54

 

 

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Em as Exeseﬁxo Legend

55

(a) affective, (b) motivational, and (c) cognitive expectations (Beck et al., 1974). Alpha
coefﬁcients of 0.93 for patients who attempted suicide (Beck et al., 1974), 0.84 for
suicidal elderly patients (Beck et al., 1974), and 0.73 for women prior to breast biopsy
(Northouse et al., 1995) have been reported with the BHS®. Content validity was
established in Beck’s original work (Beck etal., 1974). Criterion-related validity has
been demonstrated in correlating the BHS® with other measures of mood disorders
(Beck, Steer, Beck, & Newman, 1993). Construct validity has been conﬁrmed by
comparing BHS® scores with clinical ratings of hopelessness patients hospitalized for
attempted suicide (r = 0.62) and medical outpatients (r = 0.74). Factor analytic studies
have conﬁrmed the three scale factors. The BHS® has demonstrated good sensitivity and
fair speciﬁcity (Beck et al., 1974).

Use of the full 20-item BHS® would have been optimal; however, it was
determined that the addition of 15 more items to an already lengthy battery of instruments
would have created excessive burden for study participants. The 5-item true/false

expectations factor was selected for consistency with the Theory of Hopelessness
Depression, which deﬁnes hopelessness as negative outcome and helplessness
expectancies (Abramson et al., 1989). The expectations factor, items 4, 7, 8, 14, and 18 of
the BHS® (see sample items in Appendix), includes anticipations regarding what life will
>e like in the future (Beck et al., 1974). Reliability of the expectations factor has not been
:ported in the literature; however, item-total correlations for the factor’s ﬁve items have
en reported as 0.39, 0.72, 0.63, 0.62, and 0.51 respectively in a population of outpatient

:l inpatient psychiatric patients (Beck et al.). An internal consistency (KR-20) of 0.66

56

was reported in the HARP study pilot of CHD patients, with item-total correlations for
the factor’s ﬁve items of .21, .62, .32, .55, and .51 respectively.

For the current study reliability of the hopelessness factor was examined both
before and after imputation of missing values. A more conservative approach is taken by
reporting the lesser of these values (i.e. before imputations). In the current study, an
internal consistency (KR-20) of 0.71 was found at baseline, with item-total correlations
of 0.35, 0.58, 0.36, 0.51, and 0.58 respectively. An internal consistency (KR—20) of 0.75 i.-
was found at three months, with item-total correlations of 0.37, 0.63, 0.42, 0.55, and 0.66 E:
respectively. The internal consistency values of the scale at baseline (0.71) and three
months (0.75) are acceptable (Nunnally & Bernstein, 1994) and similar to reliability
found in previous research with physically ill subjects using the full BHS® (a = 0.73)
(Northouse et al., 1995). It was determined that the alpha coefﬁcient of the baseline scale
could not be improved if any item was deleted, while the alpha coefﬁcient for the three
month scale could be slightly improved (or = 0.76) if item #4 was deleted. However, the
importance of the item’s contribution to the overall operational deﬁnition was deemed
more important than the slight improvement in reliability. It was also recognized that
items #7, 8, and 14 had lower item-total correlations in this sample of MI patients as
compared to mentally ill populations (Beck et al., 1974), yet items #4 and #18 had similar
or higher item-total correlations respectively in the MI sample as compared to mentally
ill populations.

Validity of the cognitive expectations factor of the BHS® is limited in the
literature and is not available in the Beck Hopelessness Scale® Manual (Beck & Steer,

1993). Sensitivity and speciﬁcity of the cognitive expectations factor of the BHS® is also

57

not available. This is recognized as a limitation in the present study. Criterion-related
validity was examined in the current study by correlating the ﬁve-item cognitive
expectations factor with the one hope item within the absence of well-being/positive
affect factor/subscale of the CES-D at both baseline and three months. The strength of the
correlation between the hopelessness total score and absence of hope item from the CES-
D was fairly weak at both baseline (r = 0.47) and three months (r = 0.45). The lack of a
strong relationship between the hopelessness score and lack of hope item could indicate
that the ﬁve-item cognitive expectations factor may not be a valid measurement of lack of
hope or hopelessness. Perhaps more importantly, the fairly weak correlation between the
hopelessness and lack of hope scores may indicate that hopelessness is not a polar
opposite of lack of hope.

Content validity was examined by reviewing the literature to examine the degree
to which the ﬁve-item cognitive expectations factor of the BHS® covers the domain of
hopelessness in a MI population. Hopelessness is deﬁned as a negative expectancy
concerning one’s future, including expectations of helplessness in changing one’s future
(Abramson et al., 1989). The content of the ﬁve questions included in the cognitive
expectations factor of the BHS® are summarized in sample items reproduced with
permission of the Publisher, Harcourt Assessment, Inc. (see Appendix). Items #7 and #18
focus on a negative expectancy of the future, while item #14 focuses on a helplessness
expectancy toward the future. Items #4 and 8, which had the lowest item-total
correlations, are not as clearly focused on negative and helplessness expectancies.
Instead, items #4 and 8 might be better described as focusing on the constructs of an

external locus of control or “luck”.

58

In examining content validity further, hopelessness can be prompted by a life
event, such as a MI, which the individual attributes as negative (Abramson et al., 1989).
Hopelessness is more likely to occur if a person believes that the negative consequence is
important, unlikely to change, and affects many important areas of one’s life (Abramson
et al.). A MI is commonly perceived as an important negative event that affects a
person’s lifestyle in several respects, including changes in diet, exercise, and smoking
habits. Additionally, a patient with a MI is typically educated that the resulting
myocardial damage is permanent and CHD is a chronic disease process. The patient with
a MI learns that there should be a life-long focus on prevention of further disease, future
MI, and cardiovascular death. Therefore, a MI would be expected to be attributed as a
negative life event that could potentially lead to hopelessness.

Hopelessness symptoms were measured at baseline and three-months after
hospital discharge using the ﬁve items of the cognitive expectations factor of the BHS®.
A total score was calculated by adding the scores for the ﬁve items. A total score thus
ranged from 0 (low) to 5 (high). For the current study, the ﬁve-item instrument was
scored as a continuous scale to test associations between study variables. A cut-off score
indicative of the presence of hopelessness has not been established for the ﬁve-item
factor. However, a score of 9 or more on the full 20—item BHS® has been associated with
a signiﬁcant risk of suicide (Beck et al., 1990). For the current study, a cut-off score of 3
or higher was considered indicative of moderate to severe levels of hopelessness for the
‘ ﬁve-item scale. A cut-off score of 3 was selected as it is similarly proportionate to the
cut-off of 9 or more on a 20-item scale and 3 is a half-way point between the possible

scores of 0 to 5.

59

C en ter for Epidemiologic Studies-Depression Scale. Depression symptoms were
measured using the Center for Epidemiologic Studies-Depression Scale (CBS-D)
(Radloff, 1 977) at baseline and three-months after hospital discharge. The CBS-D is a 20-
item screening instrument designed to measure current level of depression symptoms.
Each response is scored from zero to three. A total score is calculated by adding the item

scores together, with a total range of scores from zero (low) to 60 (high). Alpha
coefﬁcients of 0.85 to 0.95 have been found in general, psychiatric, and medically ill
populations (Arean & Miranda, 1997; Radloff). Alpha coefﬁcients (prior to imputation of
missing values) were 0.84 at baseline and 0.86 at three-months in the current study. The
CBS-D has demonstrated content, criterion-related, and construct validity in a variety of
groups, including the general community, psychiatric patients (Radloff), and CHD
patients (Blumenthal et al., 1997). Conﬁrmatory factor analyses have validated four
subscales: (1) depressed affect/mood, (2) absence of well-being/positive affect, (3)
somatic activity, and (4) interpersonal subscales (Radloff; Sheehan, F iﬁeld, Reisine &
Tennen, 1995). The CES-D has demonstrated good sensitivity and speciﬁcity (Radloff).
Data provided by the CES-D may be presented as a dichotomous measure, continuous
measure, or grouped by factor scores (Lyness, Noel, Cox, King, Conwell, & Caine,
1997). A cut-off total score of 16 or above is commonly considered a positive screen for
depression symptoms (Radloff). The CES-D was used for the current study as a
continuous measure of depression symptoms. For descriptive purposes, total scores of 16
or greater were viewed as indicative of moderate to severe levels of depression.
Antecedent patient factors. Antecedent patient factors, including age, gender,

race, marital status, presence of caregiver, history of depression, history of prior MI,

60

intervention versus control group assignment, and disease severity (i.e. ejection ﬁ'action)
were collected at baseline using selected items from a demographic questionnaire and
chart abstraction form developed for the HARP study. The majority of these items were
treated as dichotomous or categorical variables. Due-to the small number of subjects in
the non-Caucasian categories, race was categorized as Caucasian and non-Caucasian.
Because there were a relatively small number of subjects in non-married categories,
marital status was categorized as married and non-manied. Age was treated as a
continuous variable.

Disease severity was measured by left ventricular ejection fraction (LVEF). The
presence of left ventricular dysfunction in the post-MI period has been recognized as an
important determinant of increased morbidity and mortality. Early studies showed that
there is an inverse relationship between LVEF and mortality post-MI, with events
increasing dramatically in post-MI patients with LVEF less than 40% (Gottlieb,
McDermott, & Eberly, 1992; Multicenter Postinfarction Research Group, 1983). More
recently, LVEF has been found to be an independent predictor of major adverse events '
post-MI, including heart failure, new ischemic cardiovascular events, and death (Richards
et al., 2003).

The degree of LVEF impairment is commonly assessed using the measurement of
left ventricular ejection fraction (LVEF) percent. LVEF most commonly ranges from O to
approximately 65% (Stempien-Otero & Weaver, 1998). LVEF has been used as a
continuous or categorical variable in a number of recent studies (Carney et al., 2001;
ENRICHD Investigators, 2001; Frasure-Smith et al., 1995; F rasure-Smith et al., 2000).

A common categorization of LVEF is < =35% and >36% (Frasure-Smith et al., 1995;

61

Frasure-Smith et al., 2000). For the Harp study the percent of LVEF was taken as
documented on a cardiac catheterization or echocardiogram report post-MI during the
subject’s hospitalization. LVEF could not be obtained for every patient in the current
study as some did not undergo cardiac catheterization or echocardio gram procedures.
LVEF values were thus grouped into three categories for analysis: 1) 15-34%, 2) 35%
and above, and 3) no available information. This allowed for the ordinal nature of the
data to be maintained, yet no subjects were excluded from analysis. Although the
measurement of left ventricular ejection fraction (LVEF) percent should be similar
between cardiac catheterization and echocardiogram tests (Stempien-Otero & Weaver,
1998), it is recognized that the two different methods, in addition to the various
equipment used at ﬁve different hospitals, may have potentially affected the reliability of
this measure.

Cardiac rehabilitation exercise participation. Data related to participation in
exercise was collected at three months after hospital discharge. Participation in cardiac
rehabilitation exercise has been measured in a variety of ways in studies, including self-
reported adherence to recommended regular exercise (Ziegelstein et al., 2000), the
number or percentage of exercise appointments in an outpatient cardiac rehabilitation
exercise program (Glazer et al., 2002; Hershberger, Robertson & Markert, 1999), the
percentage of outpatient exercise sessions attended divided by the number of exercise
sessions prescribed (Blanchard et al., 2003), the actual exercise behaviors divided by the
individual’s exercise intention (Konradi & Lyon, 2000), and the frequency of on-and off-
site exercise of 30 minutes or more per session (Carlson, Johnson, Franklin &

Vanderlaan, 2000). However, a reliable and valid tool related to hospital— and home-

62

based cardiac rehabilitation exercise participation was not found in the literature.
Consequently, participation in cardiac rehabilitation exercise was examined using self-
report questions from a 12-item questionnaire developed for the HARP study. The HARP
study exercise measure was developed based on a review of the literature and discussions
with experts in cardiac rehabilitation exercise and post-MI adherence. This tool provided
data regarding physician recommendation for exercise and patient follow-through in
starting and maintaining hospital- or home-based cardiac rehabilitation exercise. Analysis
allowed for the possibility that subjects may exercise in both hospital- and home-based
settings. Validity and reliability could not be established for this tool and it is recognized
that the performance of this tool may be a limitation to the study.

Physical functioning. Physical functioning was examined using the Activity
Status Index (ASI) (Hlatky et al., 1989), a 12-item scale designed to measure functional
capacity of cardiovascular patients based on the patient’s ability to perform activities of
daily living. The A81 was developed to correlate with peak oxygen uptake as one
criterion of functional status. Each response, scored from one to four, is weighted based
on known metabolic cost of each activity (Hlatky et al., 1989). Composite scores are
added and can range from 0 (low) to 58.2 (high). Mean ASI scores for patients with CHD
have ranged from 20.0 to 21.6 for patients awaiting bypass surgery or angioplasty
respectively (Hlatky et al., 1989). A median ASI score of 19 has been found in patients
20 days post-MI and a score of 35 in patients one year post-MI (Hlatky, et al., 1997).
Mean ASI scores of 21 .9 for Caucasian women and 14.4 for African-American women
have been found one year post-MI (Rankin, 2002). Reliability of the ASI has been

determined using Cronbach alpha in patients with angina pectoris (or = 0.98) (Beckman,

63

Barefoot, Haney, Williams, & Mark, 1994) and in women recovering from M1 (or = 0.80
to 0.88) (Rankin). An alpha coefﬁcient (prior to imputation of missing values) of 0.80
was found at three-months in the current study.

Validity of the ASI instrument has been conﬁrmed by examining Spearman
correlations of the A81 and other established physical functioning instruments with peak
oxygen uptake capacity in two samples. Correlations with the ASI were higher in the two
samples (0.81 and 0.58 respectively) than correlations using the Canadian Cardiovascular
Society Classiﬁcation (of 0.58 and 0.49 respectively) and the Speciﬁc Activity Scale
(0.67 and 0.30 respectively) (Hlatky et al., 1989). The A81 has shown sensitivity in
discriminating between patients with and without congestive heart failure and history of
MI (Nelson, Hemdon, Mark, Pryor, Califf, & Hlatky, 1991), although serial change has
not been assessed (Coyne & Allen, 1998). For the current study the ASI was used as a
continuous measure at three-months after hospital discharge.

The study design, sample and setting, and operationalization and measurement of
key study variables for the study have been presented. A discussion related to recruitment
and data collection will follow. Finally, content related to human subject protection and a
description of data analysis will be presented.

Procedures

Recruitment. Research nurses identiﬁed potential participants’ names by
reviewing daily laboratory report summaries for elevated cardiac enzyme levels (i.e.
troponin). These reports were reviewed and destroyed on-site at the hospitals. After the
research nurse determined eligibility, she met with patients during their hospitalization to

provide a description of the study, discuss expectations, explain the patients’ rights,

64

obtain written consent, and enrolled the patients. The research nurse obtained written
informed consent for the overall HARP study from the patients during their
hospitalization. Patients consented to the current study as part of the HARP study
consent.

Data collection. Baseline and three month data were collected by trained research
staff at the Ofﬁce for Survey Research (OSR) at the Institute for Public Policy and Social
Research (IPPSR) at Michigan State University (MSU). The research staff of OSR has
training and expertise in providing survey data collection capacity to MSU, state
government, other units of government, nonproﬁt organizations, and the private sector for
basic or applied research. Such surveys provided by OSR include needs assessments,
epidemiological studies, opinion surveys, client feedback surveys, social or economic
impact studies, and political polls. Five members of the OSR research staff were trained
as designated HARP study interviewers. The OSR research staff collected data for the
HARP study after the patient’s discharge home, at baseline (M = 14.1 days, SD = 9.6)
and three months after hospital discharge via self-report telephone interviews. The OSR
research staff than transferred data to the HARP study Principal Investigator via a
password-protected computer disk. Trained research nurses completed chart abstraction
via a review of each patient chart in the medical records department of each hospital.

Inclusion and exclusion criteria. The HARP study enrolled individuals who were
admitted to an acute care hospital with a diagnosis of acute coronary syndrome (ACS).
Individuals" could be enrolled whether it was a ﬁrst-time diagnosis of ACS or if they had
a prior history of ACS. ACS is deﬁned as any group of signs and symptoms suggestive of

acute MI, ST elevation MI, non-ST elevation MI, enzyme-diagnosed MI, biomarker-

65

diagnosed MI, late electrocardiogram (ECG) diagnosed MI, and unstable angina
(Braunwald et al., 2002). The term ACS is used at the time of initial presentation in the
acute care setting to identify patients that should be considered for treatment. Clinically,
the diagnosis of a MI is typically made when there is a characteristic rise and fall in
cardiac biomarkers (e.g. troponin) indicative of myocardial necrosis (Braunwald et al.).
In most unstable angina patients, their signs and symptoms reﬂect the same underlying
process as acute MI (i.e. myocardial ischemia resulting from signiﬁcant underlying
coronary heart disease) (Braunwald et al.).

Criteria for inclusion of patients into the HARP study consisted of the following:
1) working diagnosis of ACS in the medical record, 2) a documented serum Troponin I
level of 2 1.5 ng/ml during hospitalization, and 3) age 21 years or older. Exclusion
criteria included: 1) inability to speak English or to complete study interviews or 2)
anticipated discharge to a non-home setting. Only patients with a conﬁrmed diagnosis of
M1 were included in the current study. A diagnosis of MI was conﬁrmed from chart
abstraction using documented discharge diagnoses.

Age inclusion. Eligible adults age 21 years and older were enrolled in the HARP
study. Individuals under the age of 21 years were excluded as it is extremely rare for an
individual under 21 years to suffer a MI. In addition, the sample would not contain
enough participants of this age group to identify signiﬁcant relationships and recovery
from a MI may vary substantially for an individual less than 21 years of age. It was
anticipated that one-third of participants would be under age 65 years (AHA, 2004);
however, 67.5% of study participants were under 65 years of age at time of enrollment

into the study, with a mean of 60 years (SD = 11.3) and a range of 32 to 99 years.

66

 

Gender inclusion. Eligible male and female adults were enrolled in the HARP
study. AHA incidence rates indicate that only one-third of MI patients will be female
(AHA, 2004). Females, including women of childbearing age, were subsequently actively
recruited for the HARP study through personal contact with trained nurse interviewers. In
the current study 35% of subjects were female.

Minority inclusion. Eligible adults of any race were enrolled in the HARP study.
Racial minority groups were actively recruited into the study through the use of personal
contact by trained research nurses. Non-Caucasian participants were differentiated via
interview by the following groups: Hispanic or Latino, American Indian/Alaska Native,
Asian, Native Hawaiian or other Paciﬁc Islander, Black or Aﬁican American, more than
one race, unknown, or not reported. In the current study 14.5% of subjects were non-
Caucasian (i.e. black/African American, Hispanic White, and American Indian).
Protection of Human Subjects

Data sources. Data were obtained for the HARP study from individually
identiﬁable living human subjects in the form of self—report phone questionnaires and
medical record data. The sample for the current research came from the HARP study. The
doctoral student was given permission from Dr. Margaret Holmes-Rovner, Principal
Investigator of the HARP study, to use the data. The doctoral student is not associated
with the subjects in any way. Subjects were not compensated for participation in the
HARP study or for the current study. Subjects did not incur any additional expense as a
result of their participation in HARP study or the current study. Data for the current study

were obtained speciﬁcally for research purposes.

67

 

Participants’ HARP study consent forms were kept in a locked ﬁle cabinet. The
completed questionnaires and chart abstraction forms were identiﬁed only by a numerical
code and were kept in a separate locked ﬁle. HARP study data from the paper
questionnaires and chart abstraction forms was entered into a SPSS computer program on
a password-protected computer. A master list linking names with case study
identiﬁcation numbers was kept on a password-protected computer. Data for the current
project was provided to the doctoral student on a computer disc, which was password-
protected. Data for the current study came from the following measures: 1) Beck
Hopelessness Scale® (BHS®) cognitive expectations factor (Beck et al., 1974), 2) Center
for Epidenriologic Studies-Depression Scale (CBS-D) (Radloff, 1977), 3) antecedent
patient factor questions ﬁom the demographic questionnaire and chart abstraction form,
4) cardiac rehabilitation exercise questionnaire, and 5) Activity Status Index (ASI)
(Hlatky et al., 1989). All information obtained from subjects was identiﬁed by case study
identiﬁcation number only. All data for the current study will be published in aggregate
form, without agency or individual names or identiﬁcation. All data will be kept at MSU
for a minimum of seven years after the completion of the study.

Institutional Review Board. The HARP study has Institutional Review Board
approval through each of the ﬁve enrolling hospitals and through the University
Committee on Research Involving Human Subjects (UCRIHS) of Michigan State
University (MSU), including approval for use of the measures used in the current study.
The current study has approval through the UCRIHS of MSU. The doctoral student has
adhered to all mechanisms for the protection of human subjects. The doctoral student has

maintained human subject certiﬁcation administered by UCRIHS.

68

 

Potential risks. Because the current research was descriptive in nature, there was
minimal risk to subjects. There has also been minimal risk to participants involved in the
HARP study. Participants in the HARP study may have potentially become fatigued
during the interviews; however, every attempt was made by the HARP study staff to limit
the length of the interview. Participants may have felt apprehensive sharing information
regarding symptoms of hopelessness and depression. The IPPSR OSR research staff did
not have access to subjects’ depression or hopelessness scores. However, the interviewers
were trained to acknowledge subjects’ feelings and to refer subjects to their physicians if
needed. If the interview became fatiguing or distressing to the participant, the interviewer
concluded the interview immediately. Data were sent from the IPPSR OSR research staff
to the HARP study staff in large batches and so there was a signiﬁcant delay before
depression and hopelessness scores could be calculated by HARP study staff. Because of
the delay in acquiring the depression and hopelessness total scores, and because
depression and hopelessness can be transient in nature, subjects were not contacted by
HARP study staff for elevated depression or hopelessness scores. Any adverse events
noted by the IPPSR OSR staff during phone interviews with subjects were reported
promptly to the HARP study Principal Investigator.

Participants were informed that they could withdraw from the HARP study at any
time, without loss of beneﬁts they would otherwise be entitled to and without penalty to
their health care. A request by any subject to withdraw his/her consent for the HARP
study and to discontinue participation in the study was honored promptly and
unconditionally. Participants were also provided (verbally and in writing) with the names

and phone numbers of the Principal Investigator for the HARP study and the Chairperson

69

 

of the MSU Institutional Review Board (UCRIHS). Breach of conﬁdentiality was an
additional risk for participants in the current study; however, strict provisions to prevent
this have been in place.

Potential beneﬁts. There may or may not have been direct beneﬁts to the
participant involved in the HARP study and current study. Participants may have
experienced a therapeutic beneﬁt through self-reﬂection or sharing their thoughts and
feelings during the HARP study interviews. Individuals who suffer a MI in the future
may beneﬁt from the knowledge gained from the current study and future research—based
interventions targeted to meet their needs. Although there was a chance that no new
knowledge may have been gained from the current study, the risk was small compared to
the potential knowledge that may have been gained.

Data Analysis

Data for the current study was analyzed using descriptive statistics and selected
inferential statistics, namely regression. See Figure 3 for the analytic model of the study.
SPSS ® version 12.0 statistical software package was used for analysis. Tests were two-
tailed with level of signiﬁcance set at 0.05 for all tests. Steps for analysis are presented
here. First, preliminary descriptive statistics were completed to analyze the data for
normality, frequency, and patterns of missing data. Strategies to manage missing data
were evaluated and appropriate imputation techniques were used. Finally, analysis of the

research questions for the study was addressed in the following manner:

70

 

Antecedent Patient
Factors
0 Age
0 Gender
0 Race
0 Marital status
0 Caregiver presence
0 History of depression
0 History of prior MI
0 Control or
experimental
group assignment
0 Disease severity

 

 

 

 

‘ Hopelessness-
Symptoms

 

Cardiac
Rehabilitation
Exercise
Participation

 

 

 

 

I

 

 

Depression
Symptoms

 

 

 

 

 

Note. Dashed [-----] lines will be examined as control variables.

Figure 3. Analytic model of the study

71

-----------------------------------

 

Physical
Functioning

 

 

 

Question #1. The ﬁrst research question asked, “What is the frequency and
severity of hopelessness symptoms and depression symptoms among post-MI patients at
three-months after hospital discharge”? The proportion of subjects who expressed at least
one hopelessness symptom or one depression symptom was estimated within a 95%
conﬁdence interval. For those who experienced at least one symptom, the mean and
standard deviation of the number of hopelessness and depression symptoms were
estimated at a 95% conﬁdence interval. The proportion of subjects with a hopelessness
total score of 3 or greater and/or a CES-D total score of 16 or greater was also reported. ll.
The examination of frequency was limited in this sample in that ﬁequency was reported
only for those subjects who met eligibility criteria and who remained in the sample at
three months.

Question #2. The second question posed, “What is the relationship between
hopelessness symptoms and depression symptoms among post-MI patients at three-
months after hospital discharge”? The correlation between the BHS® cognitive
expectations factor total score for hopelessness symptoms at three months and the
CES-D total score for depression symptoms at three months was examined using the
Pearson R correlation. The relationship between hopelessness an depression symptoms
was further examined using cross-tabulation by categorizing the CES-D total scores into
two groups and the hopelessness scores into two groups. In addition to answering the
research question, the relationship between hopelessness and depression symptoms was
investigated further by examining the correlation between the hopelessness symptoms
total score and each of the CES-D factors/subscales at three months. The linear

relationship between the hopelessness symptoms total score at baseline and depression

72

symptoms total score at three months was also assessed with multiple regression,
controlling for antecedent patient variables and depression symptoms at baseline, using
the following model:

Expected value (depression symptoms at three-months) = Bo + B1 (gender) + B2

(race) + B3 (marital status) + B4 (age) + B5 (disease severity) + B6 (history of

depression) + B; (history of MI) + B3 (control or experimental group assignment)

+ B9 (depression symptoms at baseline) + B10 (hopelessness symptoms at r

baseline)+ ZBij (where X,- = other covariates)

Question #3: The third research question inquired, “For those post-MI patients
who have hopelessness symptoms at three-months after hospital discharge, what factors
present at baseline are predictive of their three-month hopelessness scores? The
relationship between the antecedent patient factors and the hopelessness symptoms total
score at three months was evaluated with multiple regression, controlling for
hopelessness symptoms at baseline, using the following model:

Expected value (hopelessness symptoms at three-months) = Bo + B1

(hopelessness symptoms at baseline) + B2 (race) + B3 (marital status) + B4 (age)

+ B5 (disease severity) + B6 (history of depression) + By (history of MI) + B3

(gender) + B9 (control or experimental group assignment) + ZBJ-Xj (where XJ- =

other covariates)

Question #4: The fourth question asked, “Are hopelessness symptoms at baseline
predictive of participation in cardiac rehabilitation exercise and physical ﬁmctioning

among post-MI patients at three-months after hospital discharge?

73

The linear relationship between hopelessness symptoms at baseline and physical
functioning at three months was evaluated with multiple regression, using the following
model, controlling for antecedent patient variables and depression symptoms at baseline:

Expected values (physical functioning at three-months) = Bo + B1 (gender) + B2

(race) + B3 (marital status) + B4 (age) + B5 (disease severity) + B6 (history of

depression) + B7 (history of MI) + B3 (control or experimental group assignment)

+ B9 (hopelessness symptoms at baseline) + BIO (depression symptoms at

baseline) + ZBij (where Xj = other covariates)

The extent to which hopelessness symptoms at baseline predict cardiac
rehabilitation exercise participation at three months was examined using a multinomial
logit regression model. This model was selected because there was no ordering to the
values of exercise participation.

In summary, this study is one of the ﬁrst to describe the relationship between
hopelessness and depression symptoms after a MI and to examine the frequency, severity,
and impact of hopelessness symptoms aﬁer a MI. This research also helps to clarify the
distinction between hopelessness and depression symptoms, to identify subgroups at risk
for hopelessness symptoms post-MI, and to identify the effect of hopelessness symptoms
on cardiac rehabilitation exercise participation and physical functioning. This study will'
contribute to the knowledge base of nursing and other health disciplines as related to
hopelessness research in the post-MI population. This research may additionally lay the
groundwork for future research regarding the relationship and/or distinction of
hopelessness and depression symptoms, predictors of hopelessness symptoms, and the

effects of hopelessness symptoms post-MI, with an ultimate goal of designing effective

74

interventions to prevent or treat hopelessness symptoms and promote exercise and
optimal physical functioning. Chapter 5 will present the results of this study. Chapter 6

will discuss study limitations and implications for nursing research and practice.

75

’1.-

Chapter 5
RESULTS

This descriptive study was designed to describe the frequency and severity of
hopelessness and depression symptoms, the relationship between hopelessness and
depression symptoms, predictors of hopelessness symptoms, and effects of hopelessness
symptoms among patients in the early recovery period after a MI. This study used data
from two waves of a three wave panel study. Results of the study will be presented in this
chapter. Analysis of data for normality, frequency, and patterns of missing data will be
discussed, including strategies used to manage missing data. Analysis of the research
questions will then be presented.
Preliminary Analysis of Data

Normality. Continuous variables, namely age, hopelessness symptoms, depression
symptoms, and physical functioning, were examined for normality of distribution. Age
was found to be fairly normally distributed. Total hopelessness scores at baseline and
three months were positively skewed with negative kurtosis, but at an acceptable level for
analysis (Nunnally & Bernstein, 1994). Depression total scores at baseline and three
months were positively skewed with positive kurtosis, but these were also at an
acceptable level for analysis (Nunnally & Bernstein). Finally, the physical functioning
composite score at three months was positively skewed with negative kurtosis, but at an
acceptable level for analysis (Nunnally & Bernstein).

Frequencies and missing data. The data were examined for frequency and
patterns of missing data. Antecedent patient factor variables were complete, with the

exception of three subjects (1%) who did not know if they had a history of prior MI, three

76

 

subjects (1%) who did not know if they had a history of depression, 46 subjects (13%)
who had no documented ejection fraction, and 286 (88%) subjects who did not answer
the caregiver item (see Table l in Chapter 4). The values for history of MI and history of
depression were not imputed in that there were no other variables in the data set that
could be used for the estimation of these missing values. Ejection fraction values were
not imputed in that no other variables were available that could be used for estimation of
the missing ejection fraction values. In addition, the lack of documented ejection fraction
was expected in that some subjects would not have had a heart catheterization or
echocardiogram during their hospitalization. Therefore, absence of documented ejection
fraction was used as a category for analysis, allowing for the ordinal nature of the data to
be maintained. Due to the high proportion of missing values (88%) for the caregiver item,
this item could not be imputed (Nunnally & Bernstein, 1994) and was excluded from
further analysis.

Frequencies were then examined for hopelessness symptoms, depression
symptoms, physical ﬁmctioning, and exercise items. Missing responses for the ﬁve-item
cognitive expectations factor of the Beck Hopelessness Scale® (BHS®) at baseline and
three months, the Center for Epidemiologic Studies- Depression Scale (CES-D) at
baseline and three months, and for the Activity Status Index at three months, had been
previously imputed by a Harp study investigator using regression substitution. For the
regression substitution, CES-D regression imputations were limited to a maximum of 4
items (out of 20), so that total scores were based on original responses to at least 16
items. BHS® regression imputations were limited to a maximum of two out of five items.

Less than 2% of the cases for all variables required regression imputation. PRELIS 2 ®, a

77

data preparation program associated with LISREL 8.70 ® software, was used by the
doctoral student for further imputation of data. According to Joreskog & Sorbom (1996)
the PRELIS 2 ® missing data estimation procedure (hot-deck method) was an appropriate
imputation method to use for one remaining case with three out of ﬁve missing BHS®
items and one remaining case with all missing CES-D items. Finally, the cardiac
rehabilitation exercise questionnaire was examined for frequency and missing values.
Three subjects did not answer the item related to physician referral to a hospital-based
exercise program, while one other subject did not answer the item related to physician
referral to a home-based exercise program. No other variables in the data set could be
used for estimation of these missing values and so these four subjects were excluded from
analysis of the exercise variable.
Research Question #1 .' What is the frequency and severity of hopelessness symptoms and
depression symptoms among post-MI patients at three-months after hospital discharge?
Hopelessness symptoms. The measure scores, including possible ranges, actual
ranges, means and standard deviations for each of the continuous measures in the study,
are presented in Table 3. Hopelessness symptoms were measured at baseline and three
months after hospital discharge using the ﬁve-item cognitive expectations factor of the
BHS®. A total score for the cognitive expectations factor of the BHS® can range from 0
(low) to 5 (high). The average baseline hopelessness score was 1.6 (SD = 1.5) while the
average three month hopelessness score slightly decreased to 1.5 (SD = 1.6) (see Table
3). However, the average three-month hopelessness total score did not statistically differ
from the average hopelessness total score at baseline (t = .95, df= 350, p = 0.34).

Although the average hopelessness total scores were only 1.6 and 1.5 at baseline and

78

Table 3

Measures, Possible Ranges, Actual Ranges, and Scores (11 =351)

 

 

 

Measure Possible Actual Actual Baseline Three
range baseline three month score month score
range range Mean (SD) Mean (SD)

Five-item 0 to 5 O to 5 O to 5 1.6 (1.5) 1.5 (1.6)

BHS ’

CES-D O to 60 0 to 48 O to 45 12.6 (9.7) 9.5 (9.5) T

A81 0 to 58.2 NA 0 to 58.2 NA 25.2 (17.4) j
Note. Five-item BHS = Five item cognitive expectations factor of Beck Hopelessness ‘

Scale®; CES-D = Center for Epidemiologic Studies— Depression Scale; ASI = Activity
Status Index

79

Table 4
Frequency and Severity of Hopelessness Symptoms Total Scores and Depression

Symptoms Range of Total Scores

 

Baseline (n = 351)

 

 

 

Hopelessness symptoms Depression symptoms
Total score 11 (%) Range of n (%)

at each score total scores at each range
0 104 (29.6) 0 to 15 239 (68.1)
1 101 (28.8) 16 to 20 43 (12.3)“
2 55 (15.7) 21 to 30 47 (13.4)”
3 44 (12.5)* 31 to 60 22 (6.3)"
4 20 (5.7)*
5 27 (7.7)*

 

Note. * = 25.9% of subjects with score 2 3, ** = 32% of subjects with scores 2 16

 

Three Months (11 = 351)

 

 

Hopelessness symptoms Depression symptoms

Total n (%) Range of n (%)

score at each score total scores at each range
0 108 (30.8) 0 to 15 271 (77.2)
1 113 (32.2) 16 to 20 33 (9.4)M
2 50 (14.2) 21 to 30 32 (9.1)**
3 30 (8.5)* 31 to 60 15 (4.3)"
4 19 (5.4)*
5 31 (8.8)*

 

 

Note. * = 22.7% of subjects with score 2 3, ** = 22.8% of subjects with scores 2 16

80

three months respectively, 26% of subjects reported a baseline hopelessness total score of
3.0 or greater, while 23% of subjects reported a three-month hopelessness total score of
3.0 or greater (Table 4). A history of hopelessness was not collected in this study and so
it is not known whether a subject’s hopelessness was a chronic/pre-existing trait or a state
in response to the MI event.

Depression symptoms. Depression symptoms were measured at baseline and three
months after hospital discharge using the CES-D. A total score for the CES-D can range
from 0 (low) to 60 (high). As seen in Table 3, the average baseline depression score was
12.6 (SD = 9.7), while the average depression score at three months signiﬁcantly
decreased to 9.5 (SD = 9.5) (t = 7.18, df= 350, p = 0.00). As depicted in Table 4,
approximately 32% of subjects reported a depression total score of 16 or greater at
baseline while 23% reported a score of 16 or greater at three months. The CES-D
factors/subscales were examined to further explain the signiﬁcant decline in depression
symptoms from baseline to three months. The mood/depressed affect factor signiﬁcantly
decreased from 3.7 (SD = 4.2) at baseline to 2.6 (SD = 3.6) at three months (t = 5.99, df=
350, p = 0.00). The somatic/vegetative factor also signiﬁcantly decreased from 6.8 (SD =
4.86) at baseline to 5.0 (SD = 4.4) at three months (t = 8.04, df= 350, p = 0.00). The
absence of well-being/positive affect factor and interpersonal factor did not signiﬁcantly
decrease from baseline to three months.

In summary, both hopelessness and depression symptoms were prevalent and
moderate to severe in a portion of the sample at three months after hospital discharge.
However, depression symptoms signiﬁcantly decreased from baseline to three months

whereas hopelessness symptoms did not. There was high variability in the total scores of

81

 

 

both hopelessness and depression symptoms at baseline and three months in this sample.
The high variability is likely due in part to the skewness and kurtosis of the distributions,
as discussed earlier. Therefore, the mean scores may not accurately summarize the I
distribution of scores for this sample.

Research Question #2: What is the relationship between hopelessness symptoms and
depression symptoms among post-MI patients at three-months after hospital discharge?

Correlations among continuous independent and dependent variables were
examined to identify potential covariance (see Table 5). All correlations were signiﬁcant
at the 0.01 level. As expected, there was a strong correlation (deﬁned as r 2 0.60)
between hopelessness variables over time and depression variables over time. There was
a moderate correlation (deﬁned as r = 0.30 to 0.59) between baseline hopelessness and
baseline depression (r = 0.52) and three month depression (r = 0.52). There was a
moderate correlation between three month hopelessness and baseline depression (r =
0.49) and a strong correlation between three month hopelessness and three month
depression (r = 0.65).

In examining Table 5 more closely, the proportion of variance shared by baseline
and three month hopelessness and depression scores ranged from 0.24 to 0.42 (computed
by squaring the correlations). The variance remaining that is not shared by baseline and
three month hopelessness and depression scores is therefore 0.58 to 0.76, which supports
some distinction between the two constructs.

It was recognized that the moderate to strong correlations between hopelessness
and depression symptoms (r = 0.49 to 0.65) may be an indicator of multicollinearity

(vonEye & Schuster, 1998). Other indicators of potential multicollinearity were closely

82

Table 5

Correlations among Continuous Independent and Dependent Variables

 

BHS base BHS 3 mos CES-D base CES-D 3 mo A81 3 mo

 

BHS base 1.00

BHS 3 mo 0.62" 1.00

CES-D base 0.52" 0.49“ 1.00

CBS-D 3 mo 0.52MI 0.65” 0.67** 1.00

A81 3 mo -0.29""" -O.32** -0.36** -0.48** 1.00

 

Note. ** p<0.01

BHS base = Five-item factor of Beck Hopelessness Scale® at baseline; BHS 3 mo = ﬁve-
item factor of Beck Hopelessness Scale® at 3 months; CBS-D base= Center for
Epidemiologic Studies- Depression Scale (CES-D) at baseline; CES-D 3 mo= Center for
Epidemiologic Studies- Depression Scale (CES-D) at 3 months; A81 3 mo= Activity
Status Index at 3 months

83

examined. Tolerance levels were analyzed in all regression analyses that included
hopelessness and depression symptoms. The tolerance levels for hopelessness and
depression in these regression models ranged from 0.67 to 0.71, indicating mild
collinearity (vonEye & Schuster). The following indicators of multicollinearity were not
found: 1) Large changes in parameter estimates when a variable is added or removed, 2)
Predictors known to be important do not carry statistically signiﬁcant prediction weights,
3) The sign of a predictor is counterintuitive or illogical, 4) Wide conﬁdence intervals for
parameter estimates for predictors known to be of importance, and 5) Large variance
inﬂation factors (vonEye & Schuster). Because some collinearity was expected between
hopelessness and depression symptoms, and multicollinearity was diagnosed as mild, no
countermeasures to multicollinearity were deemed necessary (vonEye & Schuster).

The relationship between hopelessness and depression symptoms at three months
was examined more thoroughly by studying the correlations between the hopelessness
total score and each of the CES-D factors/subscales at three months. As seen in Table 6,
the hopelessness total score was strongly associated with the mood/depressed affect
factor (r = 0.62) and moderately associated with the absence of well-being/positive affect
(r = 0.53) and the somatic (r = 0.51) factors at three months. The hopelessness total
score was only mildly correlated with the interpersonal factor (r = 0.19) at three-months.

Further examination of each of the three-month CES-D items showed that three-
month hopelessness was most highly correlated with items ﬁ'om the mood and lack of
well-being factors/subscales (r = 0.45 to 0.52), namely items commonly referred to as

9’ ‘6

“blues,” “depressed,” “fearful,” “failure,” “lonely, sad,” “happy,” and “hopeful” (see

84

Table 6
Correlations between Hopelessness Symptoms Total Score and CES-D

Factors/Subscales and CES-D Items at Three Months

 

 

 

 

 

CES—D CES- D Items Correlation with hopelessness
Factors/Subscales symptoms total score
Depressed 0.62"
affect/mood
3- Blues 0.45“
6- Depressed 0.52“
9- Failure 0.48”
10— Fearful 0.45"
14- Lonely 0.49"
17- Crying 0.34M
18- Sad 0.45"
Absence of 0.53“
well-being/
positive affect 4- Good 0.24"
8- Hopeful 0.45"
12- Happy 0.47"
16- Enjoyed 0.37”
Somatic/vegetative 0.5 1 **
1- Bothered 0.35"
2- Appetite 0.20“
5- Mind 0.32"
7- Effort 0.37"
11- Sleep 0.37"”I
13- Talked 0.31"
20- Get going 0.35"
Interpersonal 0.19"
15- Unfriendly 0.11*
19- Dislike 0.21"

 

Wore. **p< 0,01, *p< 0,05

85

Table 6). It is interesting to note that the total hopelessness score was only moderately
correlated with the absence of hope item on the CES-D (r = 0.45), suggesting that hope
and hopelessness may not be polar opposites. To examine whether the CES-D items that
were highly correlated with the hopelessness total score at three months may potentially
serve as a “hopelessness factor”, a total score was formed from the eight CES-D items.
The total score based on the eight CES-D items showed a similar correlation with the
hopelessness total score (r = 0.66) as compared to the correlation found with the 20-item
depression total score at three months (r = 0.65).

The relationship between hopelessness and depression symptoms was further
examined at three months using cross-tabulation by categorizing the CES-D total scores
into two groups (i.e. O to 15 and 16 to 60) and the hopelessness total scores into two
groups (i.e. 0 to 2 and 3 to 5). Of the total sample (n = 351), 10% (n = 34) had depression
symptoms but little or no hopelessness symptoms, while 10% (n = 34) had symptoms of
hopelessness but little or no depression. Those who had both depression and hopelessness
symptoms totaled 13% (n =46). Of the total sample, 67% (n = 237) had little or no
depression symptoms and little or no hopelessness symptoms at three months.

In keeping with the theory of hopelessness depression, which conceptualizes
hopelessness as a potential precursor to hopelessness depression (Abramson et al., 1989),
hierarchical regression was used to examine the linear relationship between hopelessness
symptoms at baseline and depression symptoms at three months. Step one of the
regression model examined the inﬂuence of antecedent variables (i.e. age, gender, race,

marital status, history of depression, history of MI, treatment group, and disease severity)

86

Table 7

Predictors of Three-month Depression Symptoms

 

 

Steg Variable B t Tolerance
1
Age (in years) 0.00 0.09 0.92
Gender (1 = male, 0 = female) -2.29 -2.10* 0.89
Race (1 = Caucasian, 0 = non-Caucasian) -l .98 -l .39 0.96
Marital status (1 = married, 0 = non-married) -2.02 -1.75 0.90
History of depression (1 = yes, 0 = no) 2.59 3.87* 0.97
History of heart attack (1 = yes, 0 = no) 0.12 0.19 0.97
Group assignment (1 = intervention, 0 = control) 012 -0.12 0.97

Disease severity (reference = 0-35)
36 and above (1 = 36+, 0 = 0-35) -0.26 -0.18 0.57

No EF information (1 = no EF, 0 = 0-35) -0.03 -0.02 0.59

 

Model R2 = 0.08
F ofR2 ‘ 3.38 (9, 350), p = .00
Observed power = 1.0
Partial eta squared = 0.85
Note. *p< 0.05

87

Table 7 (continued)

 

 

Steg Variable B t Tolerance
2

Age (in years) 0.03 0.78 0.92
Gender (1 = male, 0 = female) 068 -0.80 0.88
Race (1 = Caucasian, 0 = non-Caucasian) -0.85 -0.77 0.95
Marital status (1 = married, 0 = non-married) -0.42 -0.47 0.89
History of depression (1 = yes, 0 = no) 1.49 2.85“ 0.96
History of heart attack (1 = yes, 0 = no) -0.03 -0.07 0.97
Group assignment (1 = intervention, 0 = -0.53 -0.69 0.97
control)

Disease severity (reference = 0-35)

36 and above (1 = 36+, 0 = 0-35) 0.03 0.02 0.57
No EF information (1 = no EF, 0 = 0-35) 1.61 1.09 0.58
Baseline depression (CES-D total) 0.62 15.20“ 0.93

 

Model R2 = 0.45

F ofRz = 28.21 (10, 350), p = 0.00
Observed power = 0.15

Partial eta squared = 0.98

 

Note. *p< 0.05
CES-D = Center for Epidemiologic Studies- Depression Scale

88

Table 7 (continued)

 

 

Step Variable B t Tolerance
3

Age (in years) 0.02 0.70 0.92
Gender (1 = male, 0 = female) -1.11 -1.35 0.87
Race (1 = Caucasian, 0 = non-Caucasian) -0.90 -0.85 0.95
Marital status (1 = married, 0 = non-married) 0.14 0.16 0.88
History of depression (1 = yes, 0 = no) 1.49 298* 0.96
History of heart attack (1 = yes, 0 = no) -0.04 -0.09 0.97
Group assignment (1 = intervention, 0 = -0.79 -0.06 0.96
control)

Disease severity (reference = 0-35)

36 and above (1 = 36+, 0 = 0-35) 0.43 0.39 0.56
No EF information (1 = no EF, 0 = 0-35) 1.58 1.12 0.58
Baseline depression (CBS-D total) 0.49 10.81 * 0.69
Baseline hopelessness 1.55 5.50* 0.71

(F ive-item BHS total)

 

Model R2 = 0.50

F ofRz = 30.60 (11, 350), p = 0.00
Observed power = 0.13

Partial eta squared = 0.99

 

Tote. *p< 0.05
CES-D = Center for Epidemiologic Studies- Depression Scale; BHS = Beck
Hopelessness Scale®

89

on three-month depression symptoms. As depicted in Table 7, female gender and history
of depression were the only antecedent variables predictive of three-month depression
symptoms. Step one of the model was signiﬁcant; however, it accounted for only 8% of
the variance in depression symptoms. Examination of unconstrained and constrained
models showed that each individual predictor offered a signiﬁcant contribution to the
model. Additionally, examination of residuals showed that residuals were fairly normally
distributed. Tolerance levels for all variables (with the exception of the dummy-coded
ejection fraction variables) ranged from 0.89 to 0.97, indicating that the variables are
relatively independent of each other. Observed power was high and there was a large
effect size (see Table 7).

The baseline depression symptoms total score was added as a control variable in
the next step of the hierarchical regression analysis. As indicated in Table 7, the baseline
depression score was predictive of three month depression in this model. History of
depression also remained predictive, whereas female gender did not. This model was
signiﬁcant, accounting for 45% of the variance in three month depression symptoms
score. Analysis of unconstrained and constrained models showed that each predictor
provided a signiﬁcant contribution to the model. Additionally, examination of residuals
showed that residuals were fairly normally distributed. Tolerance levels for this step of
the model were appropriate. Observed power was low (0.15); however, there was a large
effect size (partial eta squared = 0.98) to contribute to the effect signiﬁcance.

The baseline hopelessness symptoms total score was added in step three of the
model. As depicted in Table 7, the addition of the baseline hopelessness score further

helped to explain 5% of the variance in the three month depression score. This signiﬁcant

90

change in variance was evident despite mild correlations between antecedent variables
and the baseline hopelessness symptoms total score (see Table 8). Both baseline
depression and baseline hopelessness total scores were predictive of three month
depression. History of depression also remained a predictor. The model was signiﬁcant
and accounted for 50% of variance in the three month depression symptoms score.
Examination of unconstrained and constrained models showed that each predictor offered
‘ a signiﬁcant contribution to this model. Residuals were fairly normally distributed.
Tolerance levels for baseline depression and baseline hopelessness were 0.69 and 0.71
respectively in this model, indicating mild collinearity of the two variables with other
independent variables in the model. Observed power was low (0.13); however, there was
a large effect size (partial eta squared = 0.99) to contribute to the effect signiﬁcance.

To analyze hopelessness symptoms as a predictor of three month depression
symptoms more closely, multiple regression with a simultaneous entry of predictor
variables was used to examine what is most predictive of each .of the four
factors/subscales of the CBS-D at three months. Based on ﬁndings from the previous
regression analysis, predictors included gender, history of depression, baseline
hopelessness, and baseline depression. As shown in Table 9, female gender was a
signiﬁcant predictor for the mood/depressed affect factor. History of depression was a
predictor for the somatic factor. Baseline hopelessness was a predictor for all four factors,
while baseline depression was a predictor for the mood/depressed affect, somatic, and
lack of well-being/positive affect factor. The models accounted for 40% of the variance

in the somatic/vegetative factor, 6% of the variance in the interpersonal factor, 25% of

91

 

Table 8
Correlations between Antecedent Variables and Baseline Hopelessness Total Scores and

Baseline Depression Total Scores

 

 

Antecedent Variable Correlation with Correlation with
Baseline Hopelessness Baseline Depression
Total Scores Total Scores
Age 0.02 -0.01
(in years)
Gender -0.04 -0. l 7“

(1= male, 0= female)

Race -0.03 -0.07
(1= Caucasian, 0= non-Caucasian)

Marital status -0.17** -0.15**
(1= married, 0= non-married)

History of depression 0.06 0.14"
(1: yes, 0= no)

History of heart attack 0.03 0.02
(1= yes, 0= no)

Group assignment 0.05 0.02
(1= intervention, 0= control)

_Ejection fraction (in percent) -0.l3* -0.01
Note. **p< .01, *p<.05

92

Table 9
Predictors of Three-month Depression F actors/Subscales

Variable B t

Tolerance

Interpersonal Factor

Gender (1 = male, 0 = female) 0.10 1.08 0.97
History of depression (1 = yes, 0 = no) 0.08 1.35 0.98
Baseline hopelessness (F ive-item BHS) ‘ 0.07 2.33“ 0.73
Baseline depression (CBS-D) 0.01 1.66 0.70

 

Model R2 “ 0.06

F of R2 = 5.05 (4, 350), p =0.00
Observed power = 1.0

Partial eta squared = 0.83

Mood/Depressed Affect Factor

Gender (1 = male, 0 = female) 078 -2.30* 0.97
History of depression (1 = yes, 0 = no) 0.20 0.91 0.98
Baseline hopelessness (F ive-item BHS) 0.57 4.73* 0.73

0.70-

 

Baseline depression (CBS-D) 0.19 9.61 *

Model R2 " 0.42
F of R2 = 62.22 (4, 350), p =0.00
Observed power = 1.0
iartial eta squared = 0.74
Note. *p< 0.05
F ive- item BHS = Five item Beck Hopelessness Scale® total score

93

Table 9 (continued)

 

Variable B t Tolerance

Somatic/Vegetative Factor

Gender (1 = male, 0 = female) -0.55 -1.42 0.97
History of depression (1 = yes, 0 = no) 1.01 406* 0.98
Baseline hopelessness (Five-item BHS) 0.43 3.09* 0.73
Baseline depression (CES-D) 0.22 9.63“ 0.70

 

Model R2 = 0.40

F of R2 " 57.48 (4, 350), p = 0.00
Observed power = 1.0

Partial eta squared = 0.66

Lack of Well-being/Positive Affect

 

Factor
Gender (1 = male, 0 = female) -0.01 -0.06 0.97
History of depression (1 = yes, 0 = no) 0.23 1.41 0.98
Baseline hopelessness (Five-item BHS) 0.48 522* 0.73
Baseline depression (CES-D) 0.07 5.02* 0.70

 

Model R2 = 0.25

F of R2 = 29.30 (4,350)*

Observed power = 1.0

Partial eta squared = 0.72

Note. I"p< 0.05

Five- item BHS = Five item Beck Hopelessness Scale® total score

94

the variance in the lack of well-being/positive affect factor, and 42% of the variance in
the mood/depressed affect factor. Analysis of unconstrained and constrained models
showed that each individual predictor offered a signiﬁcant contribution to the model.
Residuals were fairly normally distributed. All tolerance levels were at an acceptable
level, with tolerance levels for baseline depression and baseline hopelessness indicating
mild collinearity (0.79 and 0.73 respectively in all four models). In each model the
observed power was high (1.0), with moderate effect sizes in each model (0.66 to 0.83)
(see Table 9).

In summary, there was a moderate correlation between hopelessness and
depression, yet some distinction was evident between the two concepts. There was a
moderate amount of variance not shared by the two variables. In addition, there was a
portion of the sample that had either hopelessness symptoms but no symptoms of
depression or depression symptoms but no symptoms of hopelessness. Finally, baseline
hopelessness accounted for a small amount of variance in three-month depression.
Question #3: F or those post-MI patients who have hopelessness symptoms at three—
months aﬂer hospital discharge, what factors present at baseline are predictive of their
three-month hopelessness scores?

Hierarchical regression was used to examine the linear relationship between
antecedent patient factors and the hopelessness symptoms total score at three
months, controlling for hopelessness symptoms at baseline. Although the hopelessness
scale range is limited from one to ﬁve, theoretically the construct of hopelessness is
continuous in nature and was analyzed as such (vonEye & Schuster, 1998). As illustrated

in Table 10, a non-married status and history of depression were predictive of

95

Table 10

Predictors of Three-month Hopelessness Symptoms

 

 

Step Variable B t Tolerance
1

Age (in years) -0.01 -l .23 0.89
Gender (1 = male, 0 = female) -0.04 -0.22 0.90
Race (1 = Caucasian, 0 = non-Caucasian) -0.06 -0.27 0.95
Marital status (1 = married, 0 = non-married) -0.67 -3.47* 0.90
History of depression (1 = yes, 0 = no) 0.48 2.34* 0.95
History of heart attack (1 = yes, 0 = no) 0.18 0.94 0.94
Group assignment (1 = intervention, 0 = 0.04 0.25 0.97
control)

Disease severity (reference = 0-35)
-0.01 -0.03 0.56
36 and above (1 = 36+, 0 = 0—35)
0.10 0.32 0.58 4
No EF information (1 = no EF, 0 = 0-35)

 

Model R2 = 0.07
F of R2 = 2.70 (9, 344), p = 0.00
Observed power = 0.99
Partial eta squared = 0.86
Note. *p< 0.05

96

Table 10 (continued)

 

 

Step Variable B t Tolerance
2

Age (in years) —0.01 -1.65 0.89
Gender (1 = male, 0 = female) -0.09 -0.60 0.90
Race (1 = Caucasian, 0 = non-Caucasian) 0.01 0.05 0.95
Marital status (1 = married, 0 = non-married) -0.34 -2.15* 0.88
History of depression (1 = yes, 0 = no) 0.10 0.58 0.93
History of heart attack (1 = yes, 0 = no) -0.05 -0.32 0.93
Group assignment (1 = intervention, 0 = -0.11 -0.85 0.96
control)

Disease severity (reference = 0-35)

36 and above (1 = 36+, 0 = 0-35) 0.15 0.76 0.56
No EF information (1 = no EF, 0 = 0-35) 0.25 0.97 0.58
Baseline hopelessness 0.61 13.74“ 0.92

(F ive-item BHS total)

 

Model R2 = 0.40

F em2 = 22.68 (10, 344), p = 0.00
Observed power = 0.99

Partial eta squared = 0.99

 

Note. I"p< 0.05
BHS = Beck Hopelessness Scale®

97

hopelessness symptoms at three months in step one of the model. Step one of the model
was signiﬁcant but accounted for only 7% of the variance in three-month hopelessness
symptoms. An examination of the unconstrained and constrained models showed that
each predictor offered a signiﬁcant contribution to the model and residuals were fairly
normally distributed. All tolerance levels were at an acceptable level (with the exception
of the dummy coded ejection fraction variables). Observed power was high and there was
a large effect size (see Table 10).

Step two of the model added baseline hopelessness, which was found to be a
signiﬁcant predictor of hopelessness at three months. Non-married status also remained a
predictor, while history of depression was no longer a signiﬁcant predictor in this step of
the model. Step two of the model was signiﬁcant and explained 40% of the variance in
three—month hopelessness. Review of unconstrained and constrained models indicated
that each predictor offered a signiﬁcant contribution to the model. Examination of
residuals showed fairly normal distributions and all tolerance levels remained at an
acceptable level. Observed power remained high and there continued to be a large effect
size (see Table 10). In summary, a non-married status was the only factor predictive of
hopelessness symptoms at three-months in this study.

Question #4 .° Are hopelessness symptoms at baseline predictive of participation in
cardiac rehabilitation exercise and physical functioning among post-MI patients at three-
months after hospital discharge?

Cardiac rehabilitation exercise participation. Subjects responded to a series of
questions about physician recommendation and follow-through regarding participation in

cardiac rehabilitation exercise. These responses were divided into ﬁve categories for both

98

hospital- and home-based exercise (see Table 11). A total of 56% of subjects (n = 194)
reported that hospital-based exercise was not recommended to them by their physician,
while approximately 30% of subjects (n = 106) stated that home-based exercise was not
recommended. Of the 153 subjects who reported receiving a referral for hospital-based
exercise, 63% of these (n = 96) actually'started ahospital-based exercise program (i.e.
were either currently attending, had completed, or quit the program early). Participation
in a hospital-based exercise program was self-reported and was not validated. Of the 244
subjects who reported receiving a referral for a home-based exercise program, 88% of
these (n = 214) followed through and started a home-based program (i.e. were currently
attending, had completed, or quit the program early). Approximately 10% (n = 24) of
those who reported a referral to home-based exercise stated that they “completed” the
program or “quit early”, when home based exercise is typically recommended as a
permanent lifestyle change. Participation in home-based exercise was self-reported and
could not be validated. As seen in a cross-tabulation analysis of the cardiac rehabilitation
exercise data (Table 12), hospital- and home-based exercise were not mutually exclusive.
A proportion of subjects indicated participation in both exercise programs. A proportion
of subjects also did not participate in either type of exercise program.

The extent to which hopelessness symptoms at baseline predict cardiac
rehabilitation exercise participation at three months was examined using multinomial
logit regression. A multinomial regression model was selected because there was no
ordering to the values of exercise participation. Participation in both a reported physician-
recommended hospital-based exercise program and in a reported physician-recommended

‘ home-based exercise programs was examined. Categories of participation in a hospital-

99

Table 11

Participation in Hospital— and Home-based Cardiac Rehabilitation Exercise Programs

 

 

Categories of Hospital-based cardiac Home-based cardiac
participation rehabilitation exercise rehabilitation exercise
program (n = 348) program (11 = 350)
n (%) n (%)
Recommended by 47 (13.5) 190 (54.3)
physician and
currently attending
Recommended by 36 (10.3) 8 (2.3)
physician and
completed
Recommended by 13 (3.7) 16 (4.6)
physician but '
quit early
Recommended by 57 (16.4) 30 (8.6)
physician but
not started
Not recommended by 195 (56.0) 106 (30.3)
physician

 

100

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101

and home-based cardiac rehabilitation exercise program included: 1) current participation
in a physician-recommended exercise program; 2) completion of a physician-
recommended exercise program; 3) starting a physician-recommended exercise program,
but quitting it early; 4) not ever starting an exercise program that had been recommended
by a physician; and 5) no physician recommendation received for an exercise program.
Current participation in a physician-recommended exercise program was used as the
reference category in the two regression models. Baseline hopelessness symptoms were
entered as a covariate in the models. To further examine the distinction of hopelessness
and depression symptoms, baseline depression symptoms were also entered as a covariate
in the model.

Participation in hospital-based exercise was examined ﬁrst. As shown in Table
13, subjects with increased levels of baseline hopelessness symptoms were 1.57 times
more likely to never start a physician-recommended hospital-based exercise program than
to be currently attending a program at three months after hospital discharge. Additionally,
subjects with increased levels of baseline hopelessness symptoms were 1.6 times more
likely to quit a recommended hospital-based exercise program early. In contrast, baseline
depression symptoms were not predictive of any of the hospital-based exercise categories
in this model. Goodness of ﬁt tests showed that the model adequately ﬁt the data and
likelihood ratio tests indicated that the effect of baseline hopelessness signiﬁcantly
contributed to the model (22 = 12.33, df= 4, p = 0.02).

As illustrated in Table 14, there were no statistically signiﬁcant ﬁndings related to
baseline hopelessness symptoms as a predictor of participation in a home-based cardiac

rehabilitation exercise program. However, one value that approached signiﬁcance should

102

Table 13

Predictors of Three-month Hospital-based Cardiac Rehabilitation Exercise Participation

 

Dependent Variable: Hospital-Based Cardiac Rehabilitation Exercise Participation at
Three Months after Hospital Discharge (n = 348)

 

Exercise Categories
(reference category:

 

currently attending) Predictors Adjusted OR 95% CI p values
Completed a Hopelessness 1.10 0.77-1.57 0.614
recommended
program Depression 1 .02 0.96-1.07 0.550
Quit a recommended Hopelessness 1.60 1.01-2.55 0.046
program early

Depression 1.01 0.94-1.09 0.754
Program was Hopelessness 1.57 1.15-2.14 0.005
recommended, but
did not start Depression 1.01 0.96-1.05 0.851
Program was not Hopelessness 1.17 0.89-1.53 0.258
recommended

Depression 1 .00 0.96-1.04 0.934

 

Note. hopelessness = baseline hopelessness symptoms; depression = baseline depression
symptoms; OR = odds ratio; CI = conﬁdence interval

103

Table 14
Predictors of Three-month Home-based Cardiac Rehabilitation Exercise Participation

Dependent Variable: Home-Based Cardiac Rehabilitation Exercise Participation at
Three Months after Hospital Discharge (n = 350)

Exercise Categories
(reference category:

 

currently attending) Predictors Adjusted OR 95% CI p values
Completed a Hopelessness 1.08 0.63-1.85 0.779
recommended
program Depression 1 .00 0.92-1.09 0.999
Quit a recommended Hopelessness 0.96 0.64-1.44 0.841
program early

Depression 1.01 0.95-1.07 0.734
Program was Hopelessness 1.03 0.76-1.38 0.870
recommended, but
did not start Depression 1.00 0.95-1.05 0.965
Program was not Hopelessness 1.17 0.98-1.40 0.080
recommended

Depression 1.01 0.98-1.04 0.616

 

Note. hopelessness = baseline hopelessness symptoms; depression = baseline depression
symptoms; OR = odds ratio; CI = conﬁdence interval

104

be mentioned. Those subjects with increased levels of baseline hopelessness symptoms
showed more of a tendency to report not receiving a physician recommendation for
home-based exercise than to be currently participating in a home-based exercise program
at three months after hospital discharge (p = 0.08). There were no signiﬁcant ﬁndings
related to baseline depression symptoms and home-based exercise participation
categories. Goodness of ﬁt tests showed that the model adequately ﬁt the data.

Physical functioning. Physical functioning was measured at three months after
hospital discharge using the Activity Status Index (ASI). Physical functioning was used
as a dependent variable in the study. A composite score for the ASI can range from 0
(low) to 58.2 (high). As seen in Table 3, the average physical functioning score was 25.2
(SD = 17.4), which reﬂects a fairly high functioning level as compared to previous
research with CHD patients (Hlatky et al., 1989; Hlatky, et al., 1997; Rankin, 2002).

There was a weak (deﬁned as r < 0.30) negative correlation between baseline
hopelessness and three-month physical functioning (r = -0.29) and a moderately strong
negative correlation between three-month hopelessness and three-month physical
functioning (r = -0.32) (see Table 5). Physical functioning at three months was also
moderately negatively correlated with depression at baseline and three months (r = -0.36
and —0.48 respectively).

The linear relationship between hopelessness symptoms at baseline and physical
functioning at three months was evaluated using hierarchical regression. Antecedent
variables were entered in step one of the model. Baseline hopelessness symptoms were
added in step two. To further examine the distinction between hopelessness and

depression, baseline depression symptoms were added in step three of the model.

105

As depicted in Table 15, increased age, female gender, history of depression, and
history of a prior MI were all signiﬁcant predictors of decreased physical functioning at
three months in step one, two, and three of the model. An increased level of baseline
hopelessness was a signiﬁcant predictor of decreased physical functioning at three
months in step two of the model and remained a signiﬁcant predictor in step three.
Increased level of baseline depression symptoms was a signiﬁcant predictor of decreased
physical functioning at three months in step three of model. Step one of the model
accounted for 25% of the variance, while the addition of baseline hopelessness in step
two increased the explanation of variance to 29%. The addition of depression symptoms
in step three of the model increased the explanation of variance further to 32%. All steps
of the model were signiﬁcant. Review of unconstrained and constrained models showed
that each individual predictor offered a signiﬁcant contribution to the model.

Examination of residuals showed fairly normal distribution in all models.
Tolerance levels for baseline hopelessness and baseline depression were 0.70 and 0.67
respectively, indicating mild collinearity of the two variables with other independent
variables in the model. Tolerance levels for all other variables were appropriate.
Observed power was high (0.82) in step one of the model, but decreased in steps two and
three to 0.41 and 0.32 respectively. However, there was a large effect size in all three
models (see Table 15).

In summary, baseline hopelessness symptoms were predictive of subjects never
starting a physician-recommended hospital-based exercise program and were also

predictive of subjects quitting a hospital-based program early. Hopelessness symptoms

106

Table 15

Predictors of Three-Month Physical Functioning

 

 

Step Variable B t Tolerance
1

Age (in years) -0.36 -4.86* 0.89
Gender (1 = male, 0 = female) 8.43 4.64* 0.90
Race (1 = Caucasian, 0 = non-Caucasian) 2.99 1.26 0.95
Marital status (1 = married, 0 = non-married) 2.34 1.21 0.90
History of depression (1 = yes, 0 = no) -9.54 -4.62* 0.95
History of heart attack (1 = yes, 0 = no) -5.67 -3.04* 0.94
Group assignment (1 = intervention, 0 = -2.13 -1.27 0.97
control)

Disease severity (reference = 0-35)
4.35 1.77 0.56
36 and above (1 = 36+, 0 = 0-35)
2.09 0.66 0.58
No EF information (1 = no EF, 0 = 0-35)

 

Model R2 = 0.25
F ofR2= 12.10 (9, 344), p = 0.00
Observed power =0.82
Partial eta squared = 0.77
Note. *p< 0.05

107

Table 15 (continued)

 

 

Step Variable B t Tolerance
2
Age (in years) -0.37 -4.97* 0.89
Gender (1 = male, 0 = female) 8.63 4.89* 0.90
Race (1 = Caucasian, 0 = non-Caucasian) 2.70 1.16 0.95
Marital status (1 = married, 0 = non-married) 0.97 0.51 0.88
History of depression (1 = yes, 0 = no) -7.95 -3.91* 0.93
History of heart attack (1 = yes, 0 = no) -4.76 -2.61* 0.93
Group assignment (1 = intervention, 0 = -1.49 -0.91 0.96
control)
Disease severity (reference = 0-35)
36 and above (1 = 36+, 0 = 0-35) 3.71 1.55 0.56
No EF information (1 = no EF, 0 = 0-35) 1.50 0.49 0.58
Baseline hopelessness -4.65* 0.92

(F ive-item BHS total)

-2.52

 

Model R2 = 0.29

F ofR2 = 13.73 (10, 344), p = 0.00
Observed power = 0.41

Partial eta squared = 0.95

Note. *p< 0.05
BHS = Beck Hopelessness Scale®

108

Table 15 (continued)

 

 

Step Variable B t Tolerance
3
Age (in years) -0.38 -5.13* 0.89
Gender (1 = male, 0 = female) 7.55 4.31“ 0.88
Race (1 = Caucasian, 0 = non-Caucasian) 2.03 0.89 0.94
Marital status (1 = married, 0 = non-married) 0.72 0.39 0.87
History of depression (1 = yes, 0 = no) -6.39 -3.l4* 0.89
History of heart attack (1 = yes, 0 = no) -4.74 -2.66* 0.93
Group assignment (1 = intervention, 0 = -1.48 -0.92 0.96
control)
Disease severity (reference = 0-35)
36 and above (1 = 36+, 0 = 0-35) 3.80 1.62 0.56
No EF information (1 = no EF, 0 = 0-35) 0.60 0.20 0.58
Baseline hopelessness -1.35 -2.22* 0.70
(Five-item BHS total)
Baseline depression (CES-D total) -0.38 -3.89"' 0.67

 

Model R2 = 0.32

F ofR2= 14.38 (11, 344), p = 0.00
Observed power = 0.32

Partial eta squared = 1.0

Note. *p< 0.05
BHS = Beck Hopelessness Scale®; CES-D = Center for Epidemiologic Studies-
Depression Scale

109

also accounted for a signiﬁcant amount of variance in predicting decreased physical
functioning.

In conclusion, the results of the study have been presented in this chapter. Study
ﬁndings have shown a relationship between hopelessness and depression symptoms, but
also some distinction between the two concepts. Both hopelessness and depression
symptoms were found to be prevalent and moderate to severe in a portion of the sample
in the early stages of the post-MI recovery period. Depression symptoms signiﬁcantly
decreased from baseline to three months after hospital discharge whereas hopelessness
symptoms did not. A strong correlation was identiﬁed between symptoms of
hopelessness and depression at three months after hospital discharge. However, a small
percentage of subjects were identiﬁed who had symptoms of hopelessness but little or no
symptoms of depression. There was an additional small percentage of subjects who had
symptoms of depression but little or no hopelessness. In addition, baseline hopelessness
accounted for a small amount of variance in three-month depression. Predictors of
hopelessness symptoms were also examined and a non-married status was found to be a
signiﬁcant predictor of hopelessness at three months, but marital status was not predictive
of depression at three months. Finally, the effect of hopelessness symptoms on select
patient outcomes was examined. Increased baseline hopelessness symptoms were
predictive of not starting a hospital-based cardiac rehabilitation exercise program and of
quitting a hospital-based program early, whereas depression had no such effect.
Additionally, both hopelessness and depressions symptoms at baseline accounted for

independent proportions of variance in physical functioning at three months. In Chapter 6

110

an interpretation of the study ﬁndings, study limitations and implications for nursing

research and practice will be presented.

lll

Chapter 6
DISCUSSION

Depression and CHD are rightfully identiﬁed as public health priorities by the
World Health Organization (2001) and the National Institute of Mental Health (2002).
The presence of depression symptoms after a CHD event is well documented (Ariyo et
al., 2000; Frasure-Smith et al., 1993; Travella et al., 1994). However, the complex
relationship between CHD and other psychological factors is not fully understood.
Hopelessness has been associated with depression in individuals coping with a variety of
physical illnesses (Brietbart et al., 2000; Cochinov et al., 1998; Lewis et al, 2001;
Northouse et al., 1995; Northouse et al., 2001; VanServellen et al., 1996; Watson et al.,
1999). However, there has been minimal research done to describe hopelessness in
individuals with CHD.

This descriptive study was designed to describe symptoms of h0pelessness and
depression following a M1, the relationship between hopelessness and depression
symptoms, predictors of hopelessness symptoms, and how symptoms of hopelessness
might affect cardiac rehabilitation exercise participation and physical functioning post-
MI. This chapter will present an interpretation of the study ﬁndings, study limitations and
implications for nursing research and practice.

Frequency and Severity of Hopelessness and Depression Symptoms

This study examined the frequency and severity of hopelessness and depression
symptoms in patients following a MI. Similar to ﬁndings in the literature (Ariyo et al.,
2000; Barefoot et al., 2000; Bush et al., 2001; Frasure-Smith et al., 2000), depression

symptoms were frequent and moderate to severe in a portion of this sample of post-MI

112

patients. Also similar to reports in the literature (Frasure-Smith et al.; Hance et al., 1996;
Travella et al., 1994), depression symptoms in this study signiﬁcantly decreased from
baseline (i.e. average 14 days) to three months after hospital discharge. While 32% of
subjects reported a CES-D total score of 16 or greater at baseline, this decreased to 23%
at three months. The percentage of subjects with depression symptoms at three months
post-MI (23%) still remained above what is typically seen in American men (7%) and
women (12%) in the general population (N IMH, 2002). .

Examination of the CES-D factors/subscales from baseline to three months
showed a signiﬁcant decrease in two factors, namely the somatic factor and
mood/depressed affect factor. The high frequency and severity of somatic symptoms at
baseline likely reﬂect the physical signs and symptoms experienced by many post-MI
patients (e. g. lack of appetite, difﬁculty sleeping, difﬁculty concentrating, lack of energy,
etc.). These somatic symptoms are often secondary to side effects from new medications
or related to activity restrictions in the early post-MI recovery period. The high frequency
and severity of depressed mood symptoms at baseline likely reﬂects a grief response that
can occur in reaction to a cardiac diagnosis and experience of hospitalization. A decrease
in somatic symptoms at three months may be related to the common removal of activity
restrictions approximately 4-6 weeks post-MI, an improved response to increased activity
and exercise, and adaptation to medications. The resolution of mood symptoms may be
related to a reduction in grief and fear as physical symptoms resolve and the individual

returns to work or other previous activities of daily living.

113

Research ﬁndings over the past ﬁve years indicate a prevalence of mild to severe
hopelessness in physically ill populations, including patients with stroke (Lewis et al.,
2001), hypertension (Everson et al., 2000), cancer (Brietbart et al., 2000; Northouse et al.,
2001; Northouse et al., 2002; Watson etal., 1999), and those who are generally medically
ill (Menon et al., 2000). No previous research was found examining the frequency and
severity of hopelessness after a MI. In this post-MI sample, hopelessness symptoms were
prevalent and moderate to severe in a portion of subjects at both baseline and three
months after hospital discharge. The average hopelessness total score at baseline was 1.6
(SD = 1.5) and did not signiﬁcantly decrease at three months (M = 1.5, SD = 1.6) (t =
0.95, df= 350, p = 0.34). While 26% of subjects reported a baseline hopelessness total
score of 3.0 or greater at baseline, this only decreased to 23% at three months.

In contrast to depression, there was a persistence of moderate to severe
hopelessness symptoms in approximately one-quarter of the subjects at three months
post-MI. This persistence in hopelessness reﬂects an ongoing negative outlook and sense
of helplessness toward the future. The future likely remains uncertain for many MI
patients who are faced with a new cardiac diagnosis, a number of recommended lifestyle
changes, and an uncertain prognosis (i.e. state hopelessness). Although a MI typically
heals by three months and patients have typically returned to work and other previous
activities, most patients continue to be faced with changes related to diet modiﬁcations,
exercise, weight loss, smoking cessation, stress reduction, and medication adherence. A
number of individuals may continue to struggle with these lifestyle changes, including
being less successful with the changes than they had hoped, leaving them with thoughts

and feelings of hopelessness. The persistence in hopelessness may also reﬂect a

114

patient’s habitual outlook toward many areas of life (i.e. trait hopelessness). However,
state hopelessness could not be differentiated from trait hopelessness in this study due to
the absence of data related to hopelessness symptoms before the MI.
Relationship between Hopelessness and Depression Symptoms

The relationship between hopelessness and depression symptoms in the early
recovery period after a MI was investigated. Findings were similar to earlier reports in
the literature which have found hopelessness related to depression, yet distinct in some
respects from depression. In past research, hopelessness was found to increase
vulnerability to a subtype of depression (i.e. hopelessness depression) (Alloy et al., 1999;
Joiner et al., 2001). Hopelessness has also been identiﬁed as a mediator between
depression symptoms and social support (Johnson et al., 2001). Symptoms of
hopelessness and depression have been related to suicidal ideation in medically ill
individuals (Cochinov et al, 1998) and psychiatric patients (Beck et al., 1993); however,
symptoms of hopelessness have been found to be a more important and independent
predictor of suicide than depression (Beck et al.; Cochinov et al.). Hopelessness has
predicted desire for hastened death, independent of depression (Brietbart et al., 2000) and
has been found to be related to long-term survival, independent of depression (Lewis et
al., 2001). Finally, hopelessness has been found predictive of hypertension, after
adjusting for depression and CHD risk factors (Everson et al., 2000).

No previous research was found examining the relationship between hopelessness
and depression symptoms in post-MI patients over time. In this post-MI sample,
hopelessness symptoms were found to be moderately correlated to depression symptoms

at baseline (r = .52), yet more strongly correlated to depression symptoms at three months

115

(r = .65). It may be that hopelessness symptoms are more strongly related to persistent
symptoms of depression, than depression symptoms of a transient nature. Hopelessness
symptoms may also have a tendency to be more strongly related to. depression symptoms
over time, or to lead to depression symptoms (i.e. hopelessness depression) over time, as
is hypothesized by the conceptual model for the current study (Abramson et al., 1989).
Further examination of the relationship between hopelessness and depression symptoms
found that baseline hopelessness symptoms accounted for an additional 5% of variance in
three month depression symptoms, aﬁer controlling for antecedent variables and baseline
depression symptoms. This small amount of variance was evident despite small
correlations that existed between the antecedent variables and baseline hopelessness
symptoms (see Table 8).

Of the total sample of post-MI patients in this study, 10% had a moderate to
severe level of hopelessness symptoms while having minimal or no symptoms of
depression at three months post-MI. These subjects had minimal or no depressed mood or
somatic symptoms, yet had negative expectations and a sense of helplessness toward their
future. Another portion of the sample (10%) had a moderate to severe level of depression
symptoms, but minimal or no hopelessness symptoms at three months post-MI. These
subjects exhibited depressed mood and somatic symptoms, yet had no or little
helplessness or negative expectancy toward their future. This supports previous research
where hopelessness symptoms were found to be independent of depression symptoms
(Barefoot et al., 2000; Cochinov et al., 1998; Everson et al., 1996). Yet, 13% of the
sample exhibited symptoms of both hopelessness and depression. These subjects

expressed depressed mood, somatic symptoms, helplessness and negative expectancy

116

toward their future. These ﬁndings support previous research suggesting that
hopelessness can lead to a sub-type of depression (i.e. hopelessness depression) (Alloy et
al., 1999; Alloy & Clements, 1998; Alloy, Just & Panzarella, 1997; Joiner, 2001; Joiner,
et al., 2001) and may at times occur in conjunction with depression (Abramson et al.,
1989). Finally, of the total sample, 67% had neither depression nor hopelessness
symptoms at three months.

Of some additional interest in this investigation, the hopelessness total score was
only moderately correlated to the lack of hope item on the CES-D. This indicates that
hopelessness and hope may not be polar opposites. These ﬁndings suggest that a reversed
hope item on a larger depression tool may not be an appropriate proxy for hopelessness.

In summary, these ﬁndings suggest that a moderate to strong relationship is
present between hopelessness and depression symptoms in the early recovery period after
a MI; however, some distinction between the two variables exists. Further examination of
the distinction between the two variables was done by analyzing the predictors of
hopelessness and depression symptoms and will be presented next. The outcomes of both
h0pelessness and depression symptoms were also examined and will be discussed.
Predictors of Hopelessness Symptoms

This study examined age, gender, race, marital status, history of depression,
history of prior MI, study group assignment, and disease severity as potential predictors
of hopelessness symptoms at three months. No previous research was found examining
any of these variables as antecedents to hopelessness. In the current study, a non-married
status (i.e. divorced, separated, widowed, or never married) was the only predictor of

hopelessness symptoms at three months, when controlling for baseline hopelessness.

117

Married individuals may be more likely to have other people in their home who they feel
responsible for and therefore have a greater sense of purpose and control in their life.
Married people may also have greater access to support (e. g. emotional, social, physical,
and economic) thus promoting a more positive expectation of the future. Previous
research with heart failure patients has shown that family involvement in patient
education and counseling improves understanding of recommended treatment regimens
and adherence to regimens, especially among those who are married (Ni, Nauman,
Burgess, Wise, Crispell, & Hershberger, 1999).

In contrast to the study ﬁndings related to marital status and hopelessness
symptoms, marital status was not predictive of depression symptoms at three months
post-MI. The only predictor of three-month depression symptoms was a history of
depression. This ﬁnding supports previous research that has found depression history
related to increased symptoms of depression after a CHD event (Lesperance et al., 1996).
In summary, the results of the current study identiﬁed different predictors for three-
month hopelessness and depression symptoms, offering some evidence of a distinction
between hopelessness and depression symptoms post-MI.

Effects of Hopelessness on Exercise Participation and Physical Functioning

Exercise participation. A physician referral is needed for a patient to begin a
hospital-based cardiac rehabilitation exercise program. Approximately 44% of the
subjects in this study reported receiving such a referral, while approximately 28% of the
total subjects reported having started a hospital-based exercise program at three months.
However, thirteen subjects who started a hospital-based exercise program quit the

program “early”, making for a participation rate of approximately 27%. This is higher

118

than participation rates found in earlier studies (11 to 21%) (Ades et al., 1999; Blackburn
et al., 2000), although the current study’s data was self-reported and could not be
validated.

Baseline hopelessness was examined in this study as a predictor of participation in
hospital-based cardiac rehabilitation exercise at three months. The current study found
that subjects with increased levels of baseline hopelessness symptoms were
approximately one and a half times more likely to never start a recommended hospital-
based exercise program than to be currently attending a program at three months.
Subjects were also approximately one and a half times more likely to quit a hospital-
based exercise program early than to be currently attending a program at three months.
This ﬁnding supports related research where attitude and perceived control have
explained a proportion of variance in exercise intention and adherence in patients
attending a hospital-based cardiac rehabilitation program (Blanchard et al., 2003).
Hopeless individuals have a negative attitude toward the future and perceive little control
in changing the future. It may be that a hospital-based cardiac rehabilitation exercise
program is perceived as requiring too much time, effort, and cost to a hopeless person
who is already feeling pessimistic about the future and helpless in changing future
outcomes. In addition, a hopeless individual may feel more helpless in a structured group
setting where they might be compared to others’ achievements and outcomes.

Baseline depression was also examined as a predictor of hospital-based exercise
participation in this study. Baseline depression was not predictive of hospital-based
exercise participation in this sample, which contradicts previous research ﬁndings

(Glazer et al., 2002; Ziegelstein et al., 2000). The current ﬁndings showing hopelessness

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symptoms, but not depression symptoms, as predictive of participation in hospital-based
exercise suggest some differentiation of hopelessness and depression symptoms post-MI.

Home-based cardiac rehabilitation exercise programs have become increasingly
popular in recent years due to cost and time constraints. In spite of the growing
popularity, participation in home-based cardiac rehabilitation exercise has not been
widely studied. Approximately 70% of subjects in this study reported receiving a
physician referral for a home-based exercise program, while 61% of the total sample
reported having started such a program. A greater percentage of patients reported
receiving a referral for home-based exercise (70%) as compared to a referral to a
hospital-based exercise program (44%). Although these referrals could not be validated,
it is likely that physicians were making more referrals to home-based exercise due to a
variety of factors, including cost to the patient, time constraints, and driving distance to a
hospital-based exercise facility. More patients also followed through on a referral to
home-based exercise than a referral to a hospital-based program likely due the
convenience and low cost associated with a home-based exercise program.

The current study did not ﬁnd either hopelessness or depression symptoms as
predictive of home-based exercise participation. This contradicts one literature source
that suggested depression symptoms as being negatively related to home-based exercise
participation (Ziegelstein et al.). However, ﬁndings in the current study suggested that
subjects with increased levels of baseline hopelessness symptoms may have less of a
tendency to receive a physician recommendation for home-based exercise than to be
currently participating in a home-based exercise program three months post-MI. This

may be related to a hopeless person not hearing or understanding a referral for home-

120

based exercise. It may also be due to a physicians’ hesitancy to recommend home
exercise when an individual is already expressing a negative attitude about the future and
expressing little perceived control in changing the future.

Physical functioning. The present study examined baseline hopelessness
symptoms as predictive of physical functioning at three months. No research has been
found examining the relationship between hopelessness and physical functioning in a
CHD population. In the current study, the average physical functioning score (M: 25.2,
SD = 17.4) indicated a moderately high level of physical functioning post-MI as
compared to previous studies with CHD patients (Hlatky et al., 1989; Hlatky, et al., 1997;
Rankin, 2002). In the present study, baseline hopelessness symptoms were a signiﬁcant
predictor of decreased physical functioning at three months, explaining 4% of the
variance in physical functioning beyond what was already accounted for by antecedent
patient factors. This small amount of variance was signiﬁcant despite that fact that there
were small correlations between baseline hopelessness symptoms and antecedent
variables (see Table 8). Although small, the proportion of variance in physical
functioning accounted for by hopelessness symptoms supports previous cross-sectional
research that found hopelessness symptoms associated with decreased physical
functioning in men with cancer and AIDS (VanServellen et al., 1996).

Baseline depression symptoms explained an additional small amount of variance
(3%) in physical functioning, after controlling for symptoms of baseline hopelessness.
This is in agreement With previous ﬁndings in the literature that have identiﬁed increased
depression as related to decreased physical ﬁrnctioning (Blumenthal et al., 1997) and

decreased aerobic capacity (Glazer et al., 2002). Although the additional variance in

121

physical functioning explained by depression symptoms beyond what was already
explained by hopelessness was small, it further supports some distinction between
hopelessness and depression symptoms in this post-MI sample.

Limitations

While this study contributes to an improved understanding of hopelessness and
depression symptoms post-MI, the ﬁndings from this study must be considered in
association with the study limitations. It is recognized that the use of the complete 20-
item Beck Hopelessness Scale® (BHS®) (Beck et al., 1974) may have been optimal for
the study. However, it was determined that the addition of 15 more items to an already
lengthy battery of tests would potentially create excessive burden for study participants.
The reliability of the BHS® cognitive expectations factor was closely examined during
this study and deemed acceptable (see the instruments section of Chapter 4). Thus, the
ﬁve-item BHS® cognitive expectations factor may have potential as a screening tool for
hopelessness symptoms in the CHD population. The validity of the cognitive
expectations factor of the BHS® was also previously unknown, and was not determined
in this study. This is recognized as a limitation.

The instrument used to measure participation in cardiac rehabilitation exercise
must also be mentioned as a study limitation. Although the instrument measured exercise
participation in those subjects who had received a physician referral for exercise, the
instrument did not examine exercise participation for those subjects who did not get a
physician referral. It is likely that little information would have been gained regarding
hospital-based exercise participation in that a hospital-based program requires a physician

referral. However, important information may have been gained regarding those subjects

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participating in a home-based exercise program who reported no physician referral, as
this type of exercise can be done without physician recommendation. In addition, the
cardiac rehabilitation exercise tool included the category, “completed a home-based
exercise program”. Home-based exercise is considered a permanent lifestyle change and
so completion of home-based exercise is essentially identical to another category,
“quitting the exercise early”. Reliability and validity of the cardiac rehabilitation exercise
tool is unknown, and this is recognized as a limitation to the study.

Of the 721 subjects who consented and were enrolled in the HARP study, only
513 subjects with ACS completed baseline interviews and 431 completed three month
interviews. Although the demographics were similar in these groups, there was a
signiﬁcant decrease in mean age from the enrollment sample to baseline sample. This
attrition and difference in age is recognized as a limitation. Consequently, study results
may not be generalizable to those MI patients over 65 years of age.

Direct Implications for Future Nursing Research

Despite its limitations, this study has important implications for future nursing
research. This is the ﬁrst known study to examine hopelessness symptoms in the early
recovery period after hospitalization for M1. Study results can serve as a catalyst for
future hopelessness research with M1 populations.

Frequency of hopelessness and depression symptoms. As expected, depression
symptoms were frequent and severe at baseline in a portion of the sample and
signiﬁcantly decreased at three months. In particular, this study found signiﬁcant
reductions in the mood/depressed affect and somatic factor scores. Further research

related to the frequency and severity of the four factors of the CES-D later in the MI

123

recovery period is warranted. Whether the mood/depressed affect and somatic factors
continue to decrease beyond three months post-MI needs further investigation. Additional
examination of the interpersonal and absence of well-being/positive affect factors and
whether they persist, increase, or decrease beyond three months is also of interest.

In this post-MI sample, hopelessness symptoms were frequent and moderate to
severe in a portion of the sample at baseline and did not signiﬁcantly decrease at three
months. These ﬁndings are consistent with the study’s conceptual model based on the
theory of hopelessness depression, which states that hopelessness can be prompted by a
negative life event (Abramson et al., 1989). Further examination of hopelessness
symptoms at later points in the post-MI recovery period is needed to determine if these
symptoms remain constant, increase, or decrease beyond three months post-MI. In
addition, a longitudinal analysis of the ﬁve-item hopelessness scale’s individual items
may provide further information as to whether it is the negative expectancy, helplessness
expectancy, or some other unknown component of hopelessness that may be most
persistent in the post-MI patient.

It is unknown in this study if hopelessness symptoms were present in some
subjects prior to the MI. Earlier research has found hopelessness to be a predictor of fatal
and nonfatal CHD (Anda et al., 1993; Barefoot et al., 2000; Everson et al., 1996). The
differentiation of trait hopelessness from state hopelessness may help to explain the
persistence of hopelessness in this sample. Because a tool is not currently available to
assess trait versus state hopelessness, subjects would need to be asked about their history
of speciﬁc hopelessness symptoms prior to the MI event, in addition to current symptoms

of hopelessness. The development of an instrument to assess trait hopelessness would

124

include a history of negative and helplessness expectations, while current hopelessness
symptoms would need to be examined to assess state hopelessness. It is recognized that a
combination of both trait and state hopelessness may be present in some individuals.

This study used the cognitive expectations factor of the BHS® to assess
hopelessness. The cognitive dimension is comprised of thoughts that include a dark,
vague, or uncertain ﬁrture and thoughts of helplessness. Future research with post-MI
patients should also include the affective and motivational dimensions of the BHS®. The
affective dimension consists of negative feelings about the future, including lack of hope,
enthusiasm, or faith. The affective factor may prove to be more highly correlated with
depression symptoms. The motivational dimension includes negative thoughts and
feelings toward changing the future (Beck et al., 1974). The motivational dimension may
better capture subjects’ sense of helplessness, provide additional insight into exercise
participation and physical functioning post-MI, and be more amenable to therapeutic
interventions than the cognitive or affective dimensions.

Relationship between hopelessness and depression symptoms. This study found
hopelessness symptoms to be moderately correlated to depression symptoms at baseline,
yet more strongly correlated to depression symptoms at three months. Hopelessness
symptoms were most highly related to the mood/depressed affect factor of the CES-D at
three months, despite a signiﬁcant reduction in the mood/depressed affect factor from
baseline to three months but no signiﬁcant decrease in hopelessness symptoms over this
same period of time. Additionally, baseline hopelessness accounted for an additional 5%
of the variance in three month depression, after controlling for antecedent variables and

baseline depression. These ﬁndings suggest that although a relationship exists between

125

hopelessness and depression symptoms post-MI at three months after hospital discharge,
some distinction between the two variables is present. It is expected that a moderate to
strong correlation, with some distinction between the two concepts, would continue
further into the post-MI recovery period and this requires further research. It is also
hypothesized that hopelessness may lead to depression in some individuals, versus
depression leading to hopelessness. However, the nature of the relationship between
hopelessness and depression symptoms cannot be established by regression techniques.
In addition, the presence of mild multicollinearity with hopelessness and depression
symptoms should be controlled in future investigations. The nature of the relationship
between the two concepts would be better analyzed longitudinally using more extensive
modeling techniques, which could also better control for collinearity.

Of the total sample of post-MI patients in this study, 10% had a moderate to
severe level of hopelessness symptoms, yet had minimal or no symptoms of depression.
Similarly, another 10% of the sample had a moderate to severe level of depression
symptoms, but minimal or no hopelessness symptoms. It is unknown if these differences
between hopelessness and depression symptoms continue, decrease, or increase later in
the post-MI recovery period. Additional research is needed to assess these differences
beyond three months.

The current study did not ﬁnd a strong correlation between the ﬁve-item
hopelessness total score and a reverse-scored hope item from the depression scale. This
ﬁnding would discourage the use of a reversed hope item as a substitute for hopelessness
in a CHD population. Future research related to hopelessness and hope variables in the

MI population would be of interest. Examination of the affective and motivational

126

dimensions of hopelessness may better assess subjects’ negative feelings about the future
and sense of helplessness. The affective factor of the BHS® includes a lack of hope item.
In addition, the examination of other variables similar to hopelessness is warranted,
including pessimism or the absence of optimism, and perceived locus of control.

Predictors of hopelessness symptoms. In the current study, a non-married status
was a predictor of hopelessness symptoms at three months. This relationship should be
examined at later points in the recovery period. Additionally, further speciﬁcation of non-
married status is needed (i.e. widowed, divorced, separated, never married) using a larger
sample size with larger marital status sub-groups. It is not known which non-married
status might increase hopelessness symptoms or how a non-married status increases
hopelessness symptoms. Therefore, other related variables warrant investigation,
including presence of others in the home, presence of others in one’s life to assist with
caregiving, and social support.

Although a number of antecedent variables were evaluated as predictors of
hopelessness, whether or not these antecedent variables are predictive of hopelessness
symptoms further in the recovery period is unknown and warrants further investigation.
Other possible predictors should also be examined in future research, including
educational level, employment status, smoking history, alcohol history, illicit drug use
history, medication history, and co-morbid health conditions. The effect of antecedents
on all dimensions of hopelessness is warranted, including cognitive, affective, and
motivational dimensions.

Hopelessness as a predictor of outcomes. The current study found that subjects

with increased levels of baseline hopelessness symptoms were approximately one and a

127

half times more likely to never start a recommended hospital-based cardiac rehabilitation
exercise program than to be currently attending a program at three months. Subjects were
also approximately one and a half times more likely to quit a hospital-based exercise
program early. It may be that a hospital-based cardiac rehabilitation exercise program is
perceived as requiring too much time, effort, and cost to a hopeless person who is already
feeling pessimistic about the future and helpless in changing future outcomes. In addition,
a hopeless individual may feel more helpless in a structured group setting where they
might be compared to others’ achievements and outcomes. Additional research is needed
to examine the potential effect of hopelessness symptoms on participation in hospital-
based cardiac rehabilitation exercise, especially related to perceived barriers to hospital-
based exercise and patient’s thoughts related to a group exercise setting. Ongoing
encouragement from a health care provider should also be assessed to determine the
impact that this may have on a patient quitting a hospital-based program early.

Results from the current study also suggested that subjects with increased
hopelessness symptoms reported lower physician recommendation for home-based
cardiac rehabilitation exercise. Further research is warranted to evaluate how
hopelessness symptoms might affect the patient-physician interaction. In particular, both
patient and physician perceptions of a recommendation and the differentiation of a
physician’s “order” for a hospital- or home-based exercise program versus the
physician’s level of encouragement to attend such programs would be of interest. A
recommendation to start a home-based exercise program also needs further investigation,

including an assessment of participation in a home-based program beyond three months.

128

Future research is also needed to identify other variables that may impact a MI
patient’s decision to participate in a hospital- or home-based exercise program. Other
potential predictors include psychological, social, economic, agency/system, and health-
illness variables. Although depression symptoms were not found predictive of hospital-
or home-based exercise in this study, ﬁrrther research is needed to validate these ﬁndings.

A valid and reliable tool is needed for future research of hospital- and home based
cardiac rehabilitation exercise participation. Because hospital- and home-based exercise
programs differ in several respects, two different tools may be needed. These tools must
capture the initial recommendation for exercise by a health care provider, including the
strength of this recommendation. They must also capture ongoing encouragement by a
health care provider in addition to ongoing encouragement and support by the post-MI
patient’s signiﬁcant others. Barriers to participation in exercise must be identiﬁed,
including psychological, social, economic, agency/system, and health-illness variables.
The average amount of exercise per week should be assessed, in addition to type of
exercise being performed.

In the current study, both baseline hopelessness and depression symptoms were
found to be signiﬁcant predictors of decreased physical functioning at three months. It is
recognized that decreased physical functioning may also be predictive of increased
hopelessness and depression symptoms. Future research examining the modeling of the
pathways among hopelessness symptoms, depression symptoms, and physical
functioning would help to discern these potential reciprocal relationships and better
deﬁne how hopelessness symptoms, depression symptoms, and physical functioning may

potentially respond to therapeutic intervention.

129

Finally, it is unknown how hopelessness symptoms may affect other post-MI
outcomes. Symptoms of hopelessness have been associated with increased risk of fatal
and nonfatal CHD and MI (Anda et al., 1993; Barefoot et al., 2000; Everson et al., 1996).
How hopelessness may affect morbidity and mortality after a MI event is unknown and
requires further investigation. The current study identiﬁed increased hopelessness
symptoms as predictive of decreased hospital-based exercise participation. How
hopelessness symptoms might affect adherence to other lifestyle recommendations is
unknown. Research is needed to evaluate the effect of hopelessness symptoms on
adherence to a heart-healthy diet, weight reduction, smoking cessation, and compliance
with prescribed medications. Because increased hopelessness symptoms were also found
predictive of increased depression symptoms and decreased physical functioning, it
would also be of interest to examine the effect of increased hopelessness symptoms on
post-MI patients’ quality of life.

Additional Implications for Nursing Research

Conceptualization of hopelessness. The discipline of nursing has recognized
hopelessness as an important concept for a number of years. However, conceptual
deﬁnitions of hopelessness differ in the nursing literature and differ from deﬁnitions
found in the psychology literature. A common conceptual model of hopelessness in
physical illness is needed. This model should include the antecedents, attributes, and
consequences of hopelessness speciﬁc to physical illness, the differentiation of state and
trait hopelessness, and how physical illness may impact both state and trait hopelessness.
It is imperative that the model include both the distinction of hopelessness and depression

symptoms, as well as the relationship between the two concepts. Testing of the

130

conceptual model would be essential to either validate or support reﬁnements to
NANDA’s (1996) conceptualization of hopelessness.

Measurement of hopelessness. Research to evaluate existing hopelessness tools
for their use in physical illness is needed. In particular, it must be determined if the
dimensions/ factors found in the widely used Beck Hopelessness Scale® (i.e. cognitive
expectations, affective, and motivational dimensions) (Beck et al., 1974) are applicable to
physically ill patients. Hopelessness at times may be a justiﬁable response to a negative
event out of a person’s control; however, hopelessness has potential to affect the quality
of a patient’s recovery and restoration of optimal health. Research related to the presence,
severity, and consequences of hopelessness symptoms in speciﬁc illness populations is
paramount in that it is not known if hopelessness presents itself similarly among various
illnesses and it is unknown how hopelessness may affect a variety of health outcomes. It
will also be essential to evaluate the optimal points in time for measuring hopelessness in
physical illness as it is currently unknown at what point in time hopelessness symptoms
develop and at what time point interventions would be most effective in preventing,
diminishing or relieving hopelessness.

Biopsychosocial relationship between hopelessness and coronary heart disease.
The biopsychosocial relationship between hopelessness and CHD outcomes is currently
not understood. However, hopelessness may be similar to depression in its pathogenesis
of CHD and related outcomes. Research is needed to evaluate possible biomarkers for
hopelessness symptoms, including cholesterol levels, inﬂammatory risk markers,
glucocorticoids, and serotonin levels, all of which potentially have vasoconstrictive or

atherogenesis properties.

131

Intervention research. As described earlier, nursing research is needed to further
describe the frequency and severity of hopelessness symptoms post-MI, the relationship
between hopelessness and depression symptoms, predictors of hopelessness symptoms,
and consequences of hopelessness symptoms. Ultimately, this research may lead to the
design of effective nursing interventions that prevent, decrease, or resolve hopelessness
symptoms after a MI. Intervention research may include patient education and counseling
strategies by the staff nurse or cardiac rehabilitation nurse during the patient’s
hospitalization for an acute MI. Other interventions to be researched may include
outpatient teaching, counseling, or coaching by a staff nurse, cardiac rehabilitation nurse,
nurse case manager, or advanced practice nurse via telephone calls, telemonitoring, home
visits, or ofﬁce visits. Research related to cognitive therapy interventions for patients
with conﬁrmed hopelessness symptoms post-MI by trained nurses would be of interest.
Implications for Nursing Practice.

In addition to consequences for research, this study has essential implications for
nursing practice. Health care providers face a number of challenges in caring for post-MI
patients, including the need to educate, motivate, and counsel patients during treatment
and recovery. These challenges may be compounded when a patient is hopeless and/or
depressed. Previous research over the past two decades has demonstrated that depressed
CHD patients are less adherent to medical advice, are at greater risk of quitting cardiac
rehabilitation (Blumenthal et al., 1982; Ziegelstein et al., 2000), have decreased physical
functioning (Blumenthal et al., 1997), and decreased aerobic capacity (Glazer et al.,
2002) as compared to non-depressed CHD patients. Although no previous research was

found examining the effect of hopelessness on health outcomes after a MI, hopeless

132

individuals have negative and helplessness expectancies about the future and thus may be
unable to identify a purpose in adhering to a treatment regime and lifestyle changes if
they do not believe it will make a difference in their health outcomes. The results of this
study will contribute to practitioners’ understanding of hopelessness symptoms in the
early MI recovery period, assisting them in the assessment and treatment of patients with
hopelessness symptoms.

Frequency and severity of hopelessness symptoms. In this sample, hopelessness
symptoms were frequent and moderate to severe in a portion of patients at both baseline
and three months, and did not decrease signiﬁcantly over the three month period.
Practitioners must have an understanding of the symptoms of hopelessness (see Figure 1)
in order to assess and diagnose its presence in post-MI patients. Additionally, health care
providers must be able to assess the persistence of hopelessness symptoms in post-MI
patients over time, recognizing that hopelessness may represent a state in which the
patient is responding to the negative life event (i.e. M1) or may represent a chronic trait
for given patients.

Effective nursing interventions for hopelessness symptoms in response to physical
illness are unknown. The presence of trait hopelessness may be difﬁcult to modify and
would likely require long-term psychotherapy (Beck et al., 1990). However, state
hopelessness is generally modiﬁable (Beck et al.). Abramson et al. (1989) recommend
the use of situational cues, including education and counseling. Early research did show
that depressed individuals treated with cognitive therapy had a more rapid reduction in
hopelessness than individuals treated with antidepressant drugs (Rush et al., 1982).

Cognitive therapy, designed to decrease negative views of one’s self and future, could be

133

used by trained nurses. In addition, the use of positive psychology, learned optimism, and
hope have been identiﬁed as effective interventions for hopelessness (Seligrnan, 2000).
These strategies increase positive views of one’s self and future.

Relationship between hopelessness and depression symptoms. This study found
hopelessness symptoms to be moderately to strongly correlated with depression
symptoms, yet distinct from depression in number of ways. Practitioners must be
educated to assess the distinct symptoms of hopelessness and depression (see Figure 1),
which can resemble each other in a number of ways. Uncertainty regarding the distinction
between hopelessness and depression may be reduced if the practitioner assesses
hopelessness as a future-oriented concept that is focused on expectations about the future,
while assessing depression as a condition that often occurs in response to a past event.

As illustrated in Figure 1, practitioners must also be educated that hopelessness
symptoms can potentially lead to symptoms of depression (Alloy et al., 1999; Joiner et
al., 2001; Johnson et al., 2001). In addition, hopelessness, beginning as a precursor, can
continue in conjunction with depression in some patients (Joiner, et al.). A portion of
subjects in this study were found to have symptoms of both hopelessness and depression.
Assessment and interventions must include the possibility of the presence of both
hopelessness and depression symptoms in some post-MI patients.

Predictors of hopelessness symptoms. In the current study, a non-married status
was a predictor of hopelessness symptoms at three months post-MI. Practitioners should
recognize that non-married post-MI patients may be at increased risk for hopelessness

symptoms in the early recovery period. Particular attention should be placed on the

134

assessment of hopelessness symptoms in non-married individuals with appropriate
interventions as needed.

Hopelessness as a predictor of exercise participation and physical functioning.

Practitioners working with post-MI patients must have an understanding of the
effect that hopelessness symptoms can have on post-MI outcomes. The current study
identiﬁed increased hopelessness symptoms as predictive of not starting hospital-based
cardiac rehabilitation exercise and of quitting a hospital-based exercise program early. It
is essential that practitioners identify post-MI patients with increased hopelessness
symptoms so that additional emphasis can be placed on encouraging hopeless individuals
to start a hospital-based cardiac rehabilitation exercise program. Additionally, health care
providers must recognize the importance of encouraging patients with increased
hopelessness symptoms to continue the hospital-based program until it is completed. The
current study also suggests that post-MI patients with increased hopelessness symptoms
may be less likely to either hear or receive a physician recommendation for home-based
exercise. A formal physician’s order is not required for home-based exercise; however,
encouragement from the physician and other health care providers may be especially
needed for post-MI patients who are hopeless.

Health care providers must also have an understanding that increased
hopelessness symptoms are predictive of decreased physical functioning in post-MI
patients. Practitioners must identify those post-MI patients with hopelessness symptoms
so that emphasis can be placed on encouraging these patients in their activities of daily
living and exercise. Additional follow-up may be needed with these patients after their

discharge home, including visits from a home health nurse or physical therapist.

135

Conclusion

This descriptive study is an important early step in the research of hopelessness
symptoms after an acute MI. A large sample size and the longitudinal analysis of both
hopelessness and depression symptoms in this post-MI sample contributed to the
strengths of the study ﬁndings. Similar to previous research in the cardiovascular
literature, depression symptoms in the current study were initially prevalent and severe
but signiﬁcantly decreased in the ﬁrst few months after a MI. Hopelessness symptoms
were also prevalent and severe in this study at the outset, but surprisingly did not
decrease in the three-month recovery period. Although hopelessness and depression
symptoms were fairly strongly correlated in this study, a number of distinctions between
the two variables were evident, including ﬁ'equency and severity over time, antecedents,
and effects on cardiac rehabilitation exercise participation.

Novel ﬁndings ﬁom the current study will help to increase the practitioner’s
knowledge of the ﬁ'equency, severity, and persistence of hopelessness symptoms post-
MI, including those post-MI patients at risk for hopelessness symptoms. This study will
also assist the practitioner in differentiating symptoms of hopelessness from depression.
Study ﬁndings support the need for practitioners to assess for hopelessness symptoms in
post-MI patients, to encourage those with symptoms of hopelessness in performing their
activities of daily living to their full potential, and to encourage participation in a cardiac
rehabilitation exercise program. Further research is needed to assist in the identiﬁcation
0f additional subgroups at risk for hopelessness symptoms, to ﬁrrther distinguish the
relationship between hopelessness and depression symptoms, and to identify the effects

of hopelessness on additional post-MI outcomes. Future research could ultimately lead to

136

nursing interventions focused on the prevention and treatment of hopelessness symptoms

and the prevention of adverse outcomes.

137

APPENDICES

138

Antecedent Patient Factors

Baseline Self-Report Telephone Tool

Are you of Hispanic or Latino origin?

(1) Yes

(2) No

(3) Missing

(4) Don’t know

(5) Refused

What is your race?__

(1) White

(2) Black/African American

(3) American Indian or Alaska Native
(4) Native Hawaiian or other Paciﬁc Islander
(5) Asian

(6) Other

(7) Missing

(8) Don’t know

(9) Reﬁrsed

What is your marital status?—

(1) Married

(2) Separated

(3) Divorced

(4) Widowed

(5) Never been married

(6) Missing

(7) Don’t know

(8) Refused

Is there someone who helps you with care after being in the hospital?—
(1) Yes

(2) No

(3) Missing

(4) Don’t know

(5) Refused

Have you personally ever been diagnosed or treated for depression?—
(1) Yes

(2) No

(3) Missing

(4) Don’t know

(5) Refused

 

139

Prior to this hospitalization, have you ever been diagnosed or treated for a heart
attack?

(1) Yes

(2) No

(3) Missing

(4) Don’t know
(5) Reﬁlsed

140

Antecedent Patient Factors
Chart Abstraction Form
Control or experimental group assignment
Date of birth: _/_/_

Sex: Male (1) / Female (2)

Ejection fraction percentage via cardiac catheterization or echocardiogram:

141

Five-item Cognitive Expectations Factor of the Beck Hopelessness Scale® (BHS®)

(Sample Items)
1. (Item #4)
I can’t visualize my future.
(1) True
(2) False
(7) Don’t know
(9) Refused
2. (Item #7)
My future is dismal.
(1) True
(2) False
(7) Don’t know
(9) Refused
3. (Item #8)
I have good luck and positive things happen to me.
(1) True ‘
(2) False
(7) Don’t know
(9) Refused
4. (Item #14)
Things don’t go my way.
(1) True
(2) False
(7) Don’t know
(9) Refused

5. (Item #18)
The future is unclear.

(1) True

(2) False

(7) Don’t know
(9) Refused

Beck Hopelessness Scale. Copyright© 1988, 1993 by Harcourt Assessment, Inc.
Reproduced with permission. All rights reserved.

142

Center for Epidemiologic Studies- Depression Scale

For each statement, tell me which best describes how oﬁen you felt or behaved this way
within the past week.

 

WITHIN THE Rarely or Some or a Occasionally Most or all Missing/
PAST WEEK none of the little of the or moderate of the time Don’t know/
time (less time (1-2 amount of (5-7 days) Refused
than 1 day) days) time (3-4
days)

0 1 2 3 9

 

1. I was
bothered by
things that
usually don’t
bother me.

 

2. I did not
feel like
eating; my
appetite was
poon

 

3. I felt that I
could not
shake off the
blues even
with help from
my family or
friends.

 

4. I felt that I
was just as
good as other

people.

 

5. I had
trouble
keeping my
mind on what
I was doing.

 

6. I felt
depressed.

 

 

 

 

 

 

 

 

 

143

 

7. I felt that

everything I
did was an
effort.

 

8. I felt
hopeful about
the future.

 

9. I thought
my life had
been a failure.

 

10. I felt
fearful.

 

11. My sleep
was restless.

 

12. I was
happy.

 

13. It seemed
that I talked

less than
usual.

 

14. I felt
lonely.

 

1 5. People
were
unﬁiendly.

 

16. I enjoyed
life.

 

17. I had
crying spells.

 

18. I felt sad.

 

19. I felt that
people
disliked me.

 

 

20. I could not

' ’9

et “ om

 

 

 

 

144

 

 

 

Cardiac Rehabilitation Exercise Participation Tool

Did your physician recommend a hospital or clinic-based cardiac rehab exercise program
for you?

(1) Yes
(2) No (go to Q8)
(9) Missing/don’t know/refused

On a scale of 1 to 5, with 1 being mild and 5 being strong, how would you rate the
physician’s recommendation for the exercise program?

(1) 1 (Mild)

(2) 2

(3) 3

(4) 4

(5) 5 (Strong)

(9) Missing/don’t know/refused

Did you begin participation in the exercise program?

(1) No
(2) Yes (go to Q 5)
(9) Missing/don’t know/refused

What were the reasons you did not begin the exercise program?(circle all that apply)

(1) Lack of energy

(2) Lack of motivation

(3) Financial cost or lack of insurance

(4) Distance to cardiac rehabilitation site

(5) Transportation problems

(6) Heart condition prevented participation

(7) Other health condition prevented participation

(8) Physician did not encourage

(9) No cardiac rehabilitation program was available outside of the home
(10) Cardiac rehabilitation program offered at an inconvenient time

(11) Conﬂicts with work or other activities

(12) Other (specify):
(99) Missing/don’t know/refused

 

Are you still participating in the exercise program?

(1) Yes: Still attending the program at this time (go to Q 7)
(2) No: Completed the program

(3) No: Quit before the program was completed

(9) Missing/don’t brow/refused

145

What were the reasons you did not complete the exercise program? (circle all that apply)

( 1) Lack of energy

(2) Lack of motivation

(3) Financial cost or lack of insurance

(4) Distance to cardiac rehabilitation site

(5) Transportation problems

(6) Heart condition prevented participation

(7) Other health condition prevented participation

(8) Physician did not encourage

(9) No cardiac rehabilitation program was available outside of the home
(10) Cardiac rehabilitation program offered at an inconvenient time

(11) Conﬂicts with work or other activities

(12) Other (specify):
(99) Missing/don’t know/refused

 

On an average, how many days a week have you participated in the exercise program?

(1) One day

(2) Two days

(3) Three days

(4) Four days

(5) Five days

(6) Six days

(7) Seven days

(9) Missing/don’t know/refused

Did your physician recommend any other type of exercise program, such as walking or
biking at home?

(1) No (go toQ 10)
(2) Yes
(9) Missing/don’t know/refused

On a scale of 1 to 5, with 1 being mild and 5 being strong, how would you rate the
recommendation of the exercise program?

(1) 1 (Mild)

(2) 2

(3) 3

(4) 4

(5) 5 (Strong)

(9) Missing/don’t know/refused

146

10.

ll.

12.

Did you begin participation in the exercise program?

(1)
(2)
(9)

No
Yes (Go to Q 12)
Missing/don’t lmow/refused

What were the reasons you did not begin the exercise program? (circle all that apply)

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(99)

Lack of energy

Lack of motivation

Financial cost or lack of insurance

Distance to cardiac rehabilitation site

Transportation problems

Heart condition prevented participation

Other health condition prevented participation

Physician did not encourage

No cardiac rehabilitation program was available outside of the home
Cardiac rehabilitation program offered at an inconvenient time
Conﬂicts with work or other activities

Other (specify):
Missing/don’t know/refused

 

On an average, how many days a week have you participated in the exercise program?

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(9)

One day

Two days

Three days

Four days

Five days

Six days

Seven days

Missing/don’t know/refused

147

Activity Status Index

These questions are about any physical limitations that you might have. For each
question, please rate whether, in the previous month. you could do one or more of the
activities. Some questions mention more than one activity. Answer according to the one
activity you could do @. Please choose the one answer that best describes you. If you
have never done an activity or don’t usually do it, answer “I don’t do this for other

 

reasons.”
IN THE PREVIOUS No, I Yes, but Yes, Don’t do Missing/
MONTH COULD YOU... can’t do with with no this for Don’t
this some difﬁculty other know/
difﬁculty reasons Refused
1 2 3 4 9

 

. ...take care of yourself,
that is eating, dressing,
bathing or using the
toilet?

 

. ...walk indoors, such as
around your house?

 

. ...walk a block or two on
level ground?

 

. ...climb a ﬂight of stairs
or walk up a hill?

 

. ...run a short distance?

 

. .do light work around
the house like dusting or
washing dishes?

 

. ...do moderate work
around the house like
vacuuming, sweeping
ﬂoors, or carrying in
gpceﬁes?

 

 

. . . .do heavy work around
the house like scrubbing
ﬂoors, or lifting or

moving heavy furniture?

 

 

 

 

 

 

148

 

 

9. ...do yardwork like
raking leaves, weeding or
pushing a power mower?

 

10. ...have sexual relations?

 

11. participate in moderate
recreational activities like
golf, bowling, dancing,
doubles tennis, or
throwing a baseball or
football?

 

 

12. ...participate in
strenuous sports like
swimming, singles tennis,
football, basketball or
skiing?

 

 

 

149

 

 

 

 

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