Asian Nursing Research xxx (2016) 1e6

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Asian Nursing Research

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Research Article

Effects of Self-care Health Behaviors on Quality of Life Mediated by

Cardiovascular Risk Factors Among Individuals with Coronary Artery
Disease: A Structural Equation Modeling Approach
Sukhee Ahn, RN, PhD, Rhayun Song, RN, PhD, * Si Wan Choi, MD, PhD
College of Nursing, Chungnam National University, Daejeon, South Korea

a r t i c l e i n f o s u m m a r y

Article history: Purpose: The project was to test a structural equation model in which self-efficacy, self-care health
Received 21 August 2015 behaviors, and modifiable risk factors predict the quality of life (QOL) of individuals with coronary artery
Received in revised form disease.
26 January 2016
Methods: The data set from the intervention study with 130 patients with coronary artery disease before
Accepted 28 March 2016
the intervention was included in the secondary analysis for this study. The following parameters were
measured: self-efficacy, self-care health behaviors with the subscales of health responsibility, exercise,
Keywords:
consumption of a healthy diet, stress management, and smoking cessation; modifiable risk score; and
coronary artery disease
health behavior
QOL (assessed using the 36-item Short-Form Health Survey instrument).
quality of life Results: The mean age of the participants was 66.1 years. The following evaluation parameters indicated
risk that the proposed model provided a good fit to the data: comparative fit index at .87, goodness of fit
self efficacy index at .91, adjusted goodness of fit index at .84, standardized root mean square residual at .06, root
mean square error of estimation at .09, and confidence interval at 0.06e0.13. Self-efficacy, self-care
health behaviors, and modifiable risk factors had significant effects on QOL and explained 64.0% of the
variance, with modifiable risk factors mediating between self-care health behaviors and QOL.
Conclusions: The findings indicate that self-efficacy, self-care health behaviors, and modifiable risk fac-
tors play an important role in QOL in adults with coronary artery disease. Patients could be more
confident in performing self-care health behaviors, leading to a better QOL, by more effectively managing
their cardiovascular risk factors. Nursing strategies to improve QOL in this population should include
motivating them to perform self-care health behaviors.
Copyright © 2016, Korean Society of Nursing Science. Published by Elsevier. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction required to perform self-care health behaviors to manage modi-

Cardiovascular disease (CVD) is one of the leading causes of
premature mortality worldwide. Although the prevalence rate of
CVD has decreased over the past decade, cardio-cerebrovascular
diseases (e.g., hypertension, ischemic heart disease, and stroke),
which share common risk factors, remain the main cause of
mortality in Korea [1]. Patients diagnosed with CVD have at least
one modifiable risk factor, such as an inactive lifestyle, hyperten-
sion, obesity, or smoking [2], resulting in morbidity, decreased
quality of life (QOL), and even death. Individuals with a CVD are
* Correspondence to: Rhayun Song, RN, PhD, College of Nursing, Chungnam
National University, 266 Munwha-ro, Jung-Gu, Daejeon, South Korea.
E-mail address: songry@cnu.ac.kr
fiable risk factors. Self-care health behaviors refer to actions that
an individual can take to deal with a health problem or to promote
his or her health [3]. Performing self-care health behaviors is one
of the key elements in this population toward preventing or
reducing recurrent episodes of cardiac disease and the frequency
of hospitalizations, and consequently promoting positive health
outcomes [4].
Self-efficacy may influence the performing of self-care health
behaviors that can prevent or moderate the impact of risk factors on
the individual's QOL [5]. Self-efficacy, derived from Bandura's Social
Cognitive Theory, refers to self-confidence or the belief in one's
ability to achieve a desired result [6]. Self-efficacy plays a very
important role in management and control of health behaviors and
adoption of a healthy lifestyle in individuals with chronic disease
such as diabetes and cardiac patients [7,8]. Unfortunately, self-care

http://dx.doi.org/10.1016/j.anr.2016.03.004
p1976-1317 e2093-7482/Copyright © 2016, Korean Society of Nursing Science. Published by Elsevier. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Ahn S, et al., Effects of Self-care Health Behaviors on Quality of Life Mediated by Cardiovascular Risk Factors
Among Individuals with Coronary Artery Disease: A Structural Equation Modeling Approach, Asian Nursing Research (2016), http://dx.doi.org/
10.1016/j.anr.2016.03.004
2 S. Ahn et al. / Asian Nursing Research xxx (2016) 1e6
among CVD patients is generally poor, and most of them have low
self-confidence in performing self-care [9]. Several reviews have
documented that low levels of self-efficacy are related to poor self-
care adherence, especially for exercise, while the self-care ability of
performing health behaviors improves when self-efficacy is
increased in cardiac patients [10,11].
Self-care is the cornerstone of therapy in cardiovascular risk
factor management, and consequently in improving QOL [12]. The
positive impact of self-care health behaviors on QOL in cardiac
patients has been confirmed in several randomized controlled trials
(RCTs) involving short-term (< 6 months) self-care interventions,
with 71.0% of findings from RCTs showing improved QOL in the
intervention group [13]. Previous research has also produced evi-
dence that self-care management plays a significant role in the
improvement of self-care and the reduction of modifiable risk
factors such as cholesterol and body mass index (BMI) [14].
Moreover, cardiovascular risk factors such as obesity are associated
with greater disease severity, increased number of hospitalizations,
subsequent prognosis, and poorer QOL among patients with heart
diseases than those without such risk factors [15,16]. It is therefore
necessary to pay more attention to factors that affect QOL in this
patient population, because it is clear that maintaining a good QOL
plays an important role in the rapid recovery of patients to a normal
life, reducing complications, and preventing recurrences of heart
diseases [17]. Little attention has been paid to the effect of modi-
fiable risk factors on the relationship between self-care health be-
haviors and QOL. If patients can achieve short-term outcomes such
as the reduction of risk factors through self-care health behaviors,
this will enhance their QOL.
A comprehensive model for the secondary prevention of coro-
nary artery disease (CAD) therefore seems necessary for improving
our understanding in this field. The findings of previous studies
suggest that self-efficacy is one of the most influential factors
explaining self-care activity, and that performing a greater number
of self-care activities plays an important role in reducing CAD risk
factors, which could consequently positively impact QOL (Figure 1).
The model proposed as explaining QOL in the present study could
provide useful information regarding the way motivation factors
(self-efficacy) and self-care health behaviors play a role in the pro-
motion of QOL in people with CAD through risk factor modification
as a mediator. Verification of the relationships among these vari-
ables can help health-care providers develop intervention strategies
to attain optimal health conditions and QOL in this population.
Purpose
The aims of this study were to identify the relationships among
self-efficacy, self-care health behaviors, modifiable risk factors, and
QOL, and to test a proposed model among people with CAD. In
Figure 1. Proposed model for quality of life in adults with coronary artery disease.
Please cite this article in press as: Ahn S, et al., Effects of Self-care Health Behaviors on Quality of Life Mediated by Cardiovascular Risk Factors
Among Individuals with Coronary Artery Disease: A Structural Equation Modeling Approach, Asian Nursing Research (2016), http://dx.doi.org/
10.1016/j.anr.2016.03.004
addition, the mediation effect of modifiable risk factors between
self-care health behaviors and QOL was examined.
The following hypotheses were tested in this study: (a) Self-
efficacy directly predicts self-care health behaviors. (b) Self-
efficacy indirectly predicts modifiable risk factors. (c) Self-efficacy
indirectly predicts QOL. (d) Self-care health behaviors directly
predict modifiable risk factors. (e) Self-care health behaviors indi-
rectly predict QOL. (f) Modifiable risk factors directly predict QOL.
(g) Modifiable risk factors mediate the relationship between self-
care health behaviors and QOL.
Methods
Study design
A cross-sectional, correlational study design was used. The data
from the previous intervention study [18] comprised two data sets
collected in 2010 and 2011. Both data collection applied the same in-
clusion criteria with a convenience sampling of outpatients with CAD
registered at the cardiovascular center of a university hospital in Korea.
The goal of the previous research was to evaluate the effects of
the outpatient cardiac rehabilitation program on cardiovascular
risks, recurrence risk in 10 years, and cardiac specific QOL in in-
dividuals with CAD [18]. The total sample of this study was 130
individuals diagnosed with CAD for the intervention study. We
used data from pretest measures for this secondary data analysis so
that the intervention did not influence the current data analysis.
Study sample
In total, 130 patients were included in this secondary analysis.
Potential participants were recruited from outpatients at the car-
diovascular center using the following inclusion criteria [18]: (a)
diagnosed with CAD at least 6 months previously, (b) were able to
communicate and understand the questionnaire, and (c) agreed to
participate in the survey with written consent. The sample size was
estimated based on the rule of thumb for structural equation
modeling (SEM), such that at least 10e15 cases per measured var-
iable or empirical indicator were required [19]. There were three
latent constructs with 10 empirical indicators, resulting in a
required sample size of 100e150 cases for this study.
Instrumentation
Self-efficacy
Self-efficacy was measured using a subscale of the Motivation
Scale for Health Behavior developed in a previous study involving
myocardial infarction patients [20]. The perceived self-efficacy
scale comprised six items that were scored on a 10-point numeri-
cal rating scale, from 1 (not confident at all) to 10 (very confident).
Higher scores in the perceived self-efficacy scale represent a more
confident state for performing health behaviors. Song and Lee [20]
reported psychometric tests of the scale, and reliability coefficients
of the perceived self-efficacy scale to be .86. Cronbach a for the
present study was .61.
Self-care health behaviors
The Cardiac Health Behavior Scale [21] was used to measure the
likelihood of engaging in the following five types of self-care health
behaviors: health responsibility (5 items), consumption of a healthy
diet (8 items), exercise (4 items), stress management (5 items), and
smoking cessation (3 items). This 25-item self-report scale employs
a 4-point response format from 1 (never) to 4 (routinely), and uses a
summated score, whereby a higher score indicates a higher fre-
quency of performing behaviors that are favorable for cardiac
 S. Ahn et al. / Asian Nursing Research xxx (2016) 1e6 3

health. The psychometrics of the Cardiac Health Behavior Scale
have been reported previously, with a Cronbach a of .82 when used
with older populations [21] and .87 in the present study.
Modifiable cardiovascular risk factors
The summed scores for modifiable cardiovascular risk factors
were calculated based on the cardiac risk factor profile and the sum
of weighted scores for modifiable risk factors such as cholesterol,
glucose, systolic blood pressure, obesity (BMI and waist/hip ratio),
smoking habit, stress, and exercise. The profile was developed as an
assessment tool for cardiac rehabilitation participants in Korea [20],
and modified according to a gender-specific multivariable risk
factor algorithm [22]. Physiological variables including blood
pressure and anthropometric parameters were measured by an
exercise physiologist, and fasting blood for glucose and lipid profile
was sampled and processed at a research laboratory.
QOL
QOL was measured using version 2.0 of the Short Form Health
Survey [23]. The Korean version of the form, used with permission
from Quality Metric, consists of the weighted summed scores of
physical and mental components with norm-based scoring algo-
rithms of standard form (4-week recall) [23]. A higher score in-
dicates a better QOL in the corresponding dimension. The criterion
validity of the form has been confirmed with a CVD-specific QOL
scale (r ¼ .53e.62) in a Korean population [24]. Cronbach a co-
efficients for the present study were .75e.85.
Ethical considerations
The research team obtained approval from the institutional re-
view board at the university hospital where the data were
collected. The researchers explained the study purposes and
methods to potential study participants along with privacy, confi-
dentiality, and the right to withdraw at any time before obtaining
written consent to participate. All data were kept in a locked cab-
inet and on a computer.
Data analysis
male, and most (88.5%) were married and living with their partner.
The educational status of the sample varied, with about 8.0% being
illiterate, and the highest levels of education reached being
elementary school, middle school, high school, and university
(bachelor or higher) in 20.0%, 16.9%, 26.9%, and 27.4% of the cohort,
respectively. More of the participants perceived their economic
status as being moderate or high (74.6%).
Regarding the health-related characteristics of the participants,
about half (55.4%) had never smoked, and only 5.0% were still
smoking. In addition, 16.9% of the sample reported having diabetes
and 47.7% reported having hypertension. Their perceived health
status varied from very poor (16.9%), poor (28.5%), moderate
(32.3%), good (16.2%), to excellent (6.2%, Table 1).
Levels and relationships among main study variables
The means, standard deviations, and a correlation matrix with
zero-order correlations among the study variables are presented in
Table 2. On the 10-point Likert scale, participants reported a
moderate level of self-efficacy (7.06 ± 1.72), and among the self-
care health behaviors, scores on all of the 4-point subscales were
at the moderate level, with smoking cessation scoring the highest
(3.66 ± 0.57). The score for modifiable risk factors was 10.28 ± 3.17,
indicating a moderate level of risk for recurring CVD. Scores on the
dependent variable of QOL were also at a moderate level, at
44.90 ± 8.11 for physical component summary (PCS) and
42.09 ± 7.98 for mental component summary (MCS).
Except for modifiable risk factors, all other study variables were
significantly correlated with each other. Self-efficacy was positively
related to all subscales of self-care health behaviors and QOL. Each
self-care health behavior was partially associated with the QOL
component (Table 2).
Direct and indirect effects of study variables on QOL in cardiac
patients
Self-efficacy, self-care health behaviors indicated by the five
subscales, modifiable risk factors, and QOL indicated by PCS and
MCS were submitted to SEM analysis using AMOS. The resulting

The collected data were analyzed to describe the demographic

characteristics, the main study variables, and the relationships Table 1 Characteristics of Participants (N ¼ 130).
among the study variables. The following assumptions were
Characteristic Categories Frequency (%) Mean (SD) Range
examined before SEM: the absence of influential cases (comparing
the values of Mahalanobis d2 distance with a critical c2 value of Age (yr) 66.18 (4.81) 38e76
34.528, according to the nine indicators being used in the SEM), Gender Male 73 (56.2)
Female 57 (43.8)
multivariate normality, linearity, and homoscedasticity. None of the Marital status Married 115 (88.5)
assumptions were violated. SEM was conducted using AMOS 19.0 Other 15 (11.6)
software (IBM Corp.; Armonk, NY, USA) among the 130 participants Education Illiterate 10 (7.7)
to examine the direct and indirect effects of self-efficacy, self-care Primary 26 (20.0)
Middle school 22 (16.9)
health behaviors, and modifiable risk factors on the dependent
High school 35 (26.9)
variable (QOL). All p values were calculated using the bootstrapping College or higher 37 (28.4)
method in the AMOS software, which was also used to test the Economic status Moderate or higher 97 (74.6)
mediating effect of modifiable risk factors between self-care health Low 33 (25.4)
behaviors and QOL. The procedures outlined by Baron and Kenney Smoking Never smoked 72 (55.4)
Quit smoking 51 (39.3)
[25] were used to test these mediation hypotheses. Significance Currently smoking 7 (5.3)
testing of the mediation effect was achieved using the boot- Diabetes Yes 22 (16.9)
strapping method in AMOS to test indirect effects. No 108 (83.1)
Hypertension Yes 62 (47.7)
No 68 (52.3)
Results
Perceived Very poor 22 (16.9)
health
Sociodemographic characteristics of participants status
Poor 37 (28.5)
The participants were aged 66.18 years (± 4.81 years; range: Moderate 42 (32.3)
Good 21 (16.2)
38e76 years). Approximately half of the participants (56.2%) were

Please cite this article in press as: Ahn S, et al., Effects of Self-care Health Behaviors on Quality of Life Mediated by Cardiovascular Risk Factors
Among Individuals with Coronary Artery Disease: A Structural Equation Modeling Approach, Asian Nursing Research (2016), http://dx.doi.org/
10.1016/j.anr.2016.03.004
4 S. Ahn et al. / Asian Nursing Research xxx (2016) 1e6

Table 2 Levels and Interrelationships among Study Variables (N ¼ 130).

r(p)

No. Variables Mean (SD) 1 2 3 4 5 6 7 8 9

1 Self-efficacy 7.06 ± 1.72 1

2 Health responsibility 2.95 ± 0.70 .54 1
(<.001)
3 Exercise 2.91 ± 0.80 .66 .40 1
(<.001) (<.001)
4 Healthy diet 3.34 ± 0.54 .51 .54 .44 1
(<.001) (<.001) (<.001)
5 Stress management 2.69 ± 0.59 .37 .39 .26 .43 1
(<.001) (<.001) (.003) (<.001)
6 Smoking cessation 3.66 ± 0.57 .27 .14 .07 .29 .19 1
.002) (.114) (.451) (.001) (.032)
7 Modifiable risk factors 10.28 ± 3.17 .14 .09 .17 .07 .04 .08 1
(.108) (.294) (.056) (.462) (.649) (p ¼ .388)
8 QOL PCS 44.90 ± 8.11 .24 .02 .29 .15 .05 .05 .17 1
(.006) (.861) (.001) (.086) (.553) (.557) (.056)
9 QOL MCS 42.09 ± 7.98 .21 .10 .15 .17 .28 .03 .18 .13 1
(.018) (.253) (.093) (.057) (.001) (.697) (.046) (.145)

Note. QOL MCS ¼ quality of life mental component summary; QOL PCS ¼ quality of life physical component summary.

model (Figure 2) yielded a significant c2 value of 56.08 (df ¼ 25,
p < .001), suggesting an inadequate fit between the sample and the
implied covariance matrices. However, c2 statistics are very sensi-
tive to large sample sizes and data distribution, and relative c2 (the
c2 index divided by the degree of freedom) was also used to eval-
uate model fit because this index might be less sensitive to sample
size. In this study, the relative c2 was 2.24, suggesting this model is
regarded as acceptable since the criterion for acceptance was less
than 3. Other goodness of the model fit was tested with the
following indices [26]: the goodness of fit index (GFI) and
comparative fit index (CFI) (desired value  .90). Standardized root
mean square residual (SRMR; desired value  .08) and the root
mean square error of approximation (RMSEA; desired value  .05)
were used as additional indices for precision.
These indices indicated an acceptable fit between the hypoth-
esized model and the sample data: GFI at .91, CFI at .87, adjusted GFI
at .84, SRMR at .06, and RMSEA at .09. A narrow confidence interval
around the RMSEA (0.06e0.13) reflected a good degree of precision
in estimating the true RMSEA values in the population [27]. Self-
efficacy accounted for 70.0% of the variance associated with self-
care health behaviors, while self-care health behaviors and modi-
fiable risk factors together accounted for 64.0% of the variance in
QOL. Standardized regression coefficients (both direct and indirect)
for the structural model analysis are listed in Table 3 and presented
in Figure 2. Self-efficacy had a significantly positive direct effect on
self-care health behaviors, with a standardized regression coeffi-
cient of .84 (p ¼ .006), a negative indirect effect on risk factors, with
a standardized regression coefficient of .10 (p ¼ .006), and a
Figure 2. Effect of health behavior on quality of life without risk factor.
positive indirect effect on QOL, with a standardized regression co-
efficient of .58 (p ¼ .007). Self-care health behaviors had a signifi-
cantly positive direct effect on QOL, with a standardized regression
coefficient of .64 (p ¼ .009); there was also an indirect effect of .05
(p ¼ .004). The direct effect of risk factors on QOL was significant,
with a standardized regression coefficient of .41 (p ¼ .015,
Table 3).
Effects of modifiable risk factors mediating between self-care health
behaviors and QOL
One of the study hypotheses required testing of the effects of
risk factors in mediating self-care health behaviors and QOL. This
was achieved using the procedures outlined by Baron and Kenney
[25], according to whom the following three conditions must be
met for a variable to be considered as a mediator: (a) the predictor
variable must be significantly associated with the hypothesized
mediator, (b) the mediator must be significantly associated with the
dependent variable after controlling for the predictor, and (c) the
impact of the predictor variable on the dependent variable be-
comes nonsignificant (supporting the presence of a complete
mediating effect) or significantly reduced (supporting the presence
of a partial mediating effect) when the mediator is controlled.
The results regarding the effects of risk factors in mediating
self-care health behaviors and QOL are depicted in Figures 2 and 3.
The first condition was satisfied, as depicted in Figure 2, the var-
iable of self-care health behaviors was significantly associated
with the mediator (modifiable risk factors; b ¼ 0.12, p ¼ .006).
The second condition of mediation required that the mediator
(risk factors) be significantly associated with the dependent var-
iable of QOL after controlling for self-care health behaviors. The
second condition was also satisfied, as shown in Figure 2. The
variable of modifiable risk factors was significantly associated
with QOL after controlling for self-care health behaviors
(b ¼ 0.41, p ¼ .015). The third condition of mediation required
that the impact of the predictor variable (self-care health behav-
iors) on the dependent variable (QOL) was nonsignificant or
reduced significantly after controlling for the mediator of risk
factors; this condition was also satisfied (Figure 3). The direct ef-
fect of self-care health behaviors on QOL was 0.69 (p ¼ .006),
which has been reduced to 0.64 (p ¼ .009). The reduced effect of
0.05 was significant (p ¼ .004), confirming the mediating role of
modified risk factors. These results indicated that all three

Please cite this article in press as: Ahn S, et al., Effects of Self-care Health Behaviors on Quality of Life Mediated by Cardiovascular Risk Factors
Among Individuals with Coronary Artery Disease: A Structural Equation Modeling Approach, Asian Nursing Research (2016), http://dx.doi.org/
10.1016/j.anr.2016.03.004
 S. Ahn et al. / Asian Nursing Research xxx (2016) 1e6
Table 3 Direct and Indirect Effects of Independent Variables on Dependent Variables (N ¼ 130).
Independent variables
Self-care health behaviors
Direct effect
Self-efficacy 0.84 (.006)
Self-care health behaviors
Modifiable risk factors
a
Data are standardized regression weights with p values as calculated using bootstrap methods.
conditions for mediation were satisfied, indicating that modifiable
risk factors mediate the relationship between self-care health
behaviors and QOL. Since the impact of self-care health behaviors
on QOL was reduced significantly, it can be concluded that risk
factors partially mediate the effect of self-care health behaviors on
QOL.
Discussion
Self-efficacy has been recognized as an important factor for
improving self-care activity in people with chronic diseases [8,9].
The model proposed in the present study was that performing self-
care health behaviors with higher self-efficacy would lead to a
better QOL through modification of the cardiovascular risk factors
among people with CAD in Korea. The proposed model provided a
good fit to the data based on the values of various model fit indices.
A total of 70.0% of the variance in self-care health behaviors was
explained by self-efficacy, supporting the hypothesis that self-
efficacy plays a significant role in performing self-care health be-
haviors in cardiac patients, which is consistent with the results of
previous studies [7,8,28,29]. Self-efficacy also had an indirect effect
on QOL through self-care health behaviors and modifiable risk
factors. This finding is consistent with a previous study showing
that psychological protective factors including general self-efficacy
conferred a positive impact, and psychological risk factors such as
perceived stress conferred a negative impact on QOL in patients
with CAD [30].
All of the variables in the present study, including modifiable
risk factors, significantly predicted a higher QOL, explaining 64.0%
of the total variance. The self-care health behaviors had a positive
impact on QOL, whereas modifiable risk factors had a negative
impact. Previous studies support these findings, given that per-
forming the health behaviors and higher self-efficacy have consis-
tently been linked to increases in event-free survival and QOL in
people with cardiac disease [12,13]. There have been similar results
indicating that optimal self-care can enhance QOL in heart failure
patients, whereby early benefits to performing self-care activities
helped to reduce symptoms and improve QOL, while later benefits
have greater effects on promoting health, and determinants of
Figure 3. Mediation effect of risk factor between health behavior and quality of life.
Please cite this article in press as: Ahn S, et al., Effects of Self-care Health Behaviors on Quality of Life Mediated by Cardiovascular Risk Factors
Among Individuals with Coronary Artery Disease: A Structural Equation Modeling Approach, Asian Nursing Research (2016), http://dx.doi.org/
10.1016/j.anr.2016.03.004
5
Dependent variablesa
Modifiable risk factors Quality of life
Direct effect Indirect effect Direct effect Indirect effect
0.10 (.006) 0.58 (.007)
0.12 (.006) 0.64 (.009) 0.047 (.004)
0.41 (.015)
better QOL were better functional capacity and higher self-care
confidence [13,14].
Cardiovascular risk factors including obesity, smoking, and low
physical activity are responsible for a poor health condition and
health-related QOL in people who are diagnosed with cardiac dis-
eases; QOL may be improved if those cardiovascular risk factors are
reduced through self-care activities [26]. We hypothesized a
mediation effect of modifiable risk factors between self-care health
behaviors and QOL because performing health behaviors should
lead to reductions in cardiovascular risk factors as a short-term
health outcome, and consequently contribute to the long-term
health outcome by improving QOL. The data supported the medi-
ating effect of modifiable risk factors, indicating that performing
self-care health behaviors by patients had a positive impact on
reducing modifiable risk factors and an indirect effect on improving
QOL. This is consistent with studies showing that better self-care
performance through cardiac rehabilitation eventually led to re-
ductions in cholesterol and BMI, and a tendency to cease smoking
and increase exercise activity as primary outcomes [14]. These
observations indicate that motivating individuals to perform self-
care health behaviors will effectively lead to successful manage-
ment of modifiable risk factors over time, consequently leading to a
better QOL in this population. Future research that includes in-
vestigations of motivation-related variables such as perceived
barriers and benefits, and social support is warranted to determine
the direct and indirect effects of self-care health behaviors on
modifiable risk factors and QOL in individuals with CVD.
Limitations
The data for this secondary analysis were obtained from an
intervention study, and therefore the participants were homoge-
neous with respect to their medical diagnosis and management of
their cardiovascular risk factors. The study findings can thus only be
generalized to those with moderate risks for CAD and with enough
motivation to participate in the cardiac rehabilitation program.
Second, the instrument used to measure self-efficacy exhibited a
low level of reliability, with a Cronbach a of .61, even though it did
have an acceptable level of reliability in other studies.
Implications
The study findings indicate that cardiovascular risk factors can
be more effectively managed in individuals with CAD by the in-
dividuals performing the self-care health behaviors. Health pro-
fessionals should focus on motivation strategies to encourage
individuals to perform self-care health behaviors in order to ach-
ieve better outcomes in risk factor management.
Conclusion
The findings of this study indicate that self-efficacy, self-care
health behaviors, and modifiable risk factors play an important role
in QOL in adults with cardiac disease. Nursing strategies to increase
6 S. Ahn et al. / Asian Nursing Research xxx (2016) 1e6
QOL in this population should include motivating them to perform
the self-care health behaviors associated with the improved QOL
directly, as well as indirectly through the mediating effect of
modifiable cardiovascular risk factors.
Conflicts of interest
The authors have no conflicts of interest to declare.
Acknowledgment
This research was supported by Research Fund of Chungnam
National University in 2013.
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