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2004 15: 114J Transcult NursNahla Al-Ali and Linda G. Haddad

Infarction PatientsThe Effect of the Health Belief Model in Explaining Exercise Participation among Jordanian Myocardial

  

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10.1177/1043659603262484JOURNAL OF TRANSCULTURAL NURSING / April 2004Al-Ali, Haddad / THE EFFECT OF THE HEALTH BELIEF MODEL

The Effect of the Health Belief Model inExplaining Exercise Participation AmongJordanian Myocardial Infarction Patients

NAHLA AL-ALI, MSN, RNJordan University of Science and Technology

LINDA G. HADDAD, PhD, RNJordan University of Science and Technology

This study describes the effect of health belief model (HBM)in explaining exercise participation among Jordanian myo-cardial infarction (MI) patients. A convenient sample of 98MI patients was recruited from four governmental hospitalsin northern Jordan. A self-reported questionnaire and struc-tured interview were designed to obtain the needed informa-tion. Study results indicated that Jordanian MI patients had ahigh score in perceived severity and a low score in perceivedbarriers. Results also showed a significant correlationbetween exercise participation and health belief variablesand sociodemographics such as age, annual income, level ofeducation, and physician recommendation. These findingshave implications for designing intervention programs aimedat improving physical activity by all MI patients. These pro-grams should consider culture, socioeconomic status, per-sonal system, and demographics. Further research is neededto develop a culturally sensitive instrument that takes intoconsideration the cultural variation and the specific needs ofMI patients.

Keywords: health belief; exercise; myocardial infarction

Coronary artery disease (CAD) is the leading cause ofdeath in industrialized countries, and its emergence as a pub-lic health problem in developing countries has been recog-nized in the last decade (World Health Organization, 1993).In Jordan, CAD contributed to the overall mortality of menand women (34.5% and 43.1% respectively; Ministry ofHealth, 1998). In 1994, the American Heart Association

(AHA) named physical inactivity as an independent risk fac-tor for cardiovascular disease (CVD). This means thatregardless of smoking status, family history, and the presenceof other related diseases, if someone is inactive, his or her riskof developing CVD is higher than that of an active personwith similar characteristics (Berlin & Colditz, 1990). A largebody of evidence shows that all-cause mortality and deathand disability from CVD decreases with regular physicalactivity (Paffenbarger, Hyde, & Wing, 1993).

Health belief model (HBM), a cognitive-behavioralmodel, attempts to explain and predict individual participa-tion in programs for preventive and health-promoting behav-iors (Rosenstock, Strecher, & Becker, 1994). According tothe HBM, the likelihood that someone will take action to pre-vent illness depends on the individual’s perception that (a)they are personally vulnerable to the condition, (b) the conse-quences of the condition would be serious (c) the precaution-ary behavior effectively prevents the condition, and (d) thebenefits of reducing the threat of the condition exceed thecosts of taking action (Rosenstock, 1990). Individual percep-tions of severity and susceptibility to the disease are takenwith covariables, such as demographics, personal informa-tion from others, and experience with illness, as predictors oftaking action (Becker, 1977). In addition to the four originalconcepts, health motivation has also been used as part ofthe HBM in predicting health-related behavior (Champion,1984). Limited studies have, however, examined the relation-ship between the model and chronic health problems. Mostof these studies also have inconsistencies in the results thatare related to stimuli needed to promote a change in behavior(Kison, 1992; Redeker, 1988).

In Jordan, no single study has used the HBM as a frame-work to describe the myocardial infarction (MI) patient’s

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beliefs regarding exercise participation. One study by Al-Hassan and Wierenga (2000), however, has described the fac-tors predicting decisions to exercise following hospitalizationfor MI patients. Because there is little empirical evidence toidentify, describe, and explain the variables associated withthe individual’s participation in health-protective behaviorsuch as exercise, understanding the mechanism of how thesefactors influence the adoption of this behavior at the individ-ual level is needed.

Therefore, this study aims to (a) identify and describehealth beliefs of Jordanian myocardial infarction patients re-lated to exercise participation, (b) identify the associationamong health belief variables (health motivation, perceivedsusceptibility to disease, perceived severity, perceived benefitof exercise, and perceived barriers to exercise) and exerciseparticipation among Jordanian myocardial infarction pa-tients, and (c) examine the significant of health belief vari-ables in predicting exercise participation among Jordanianmyocardial infarction patients.

LITERATURE REVIEW

Theoretical Framework

The HBM indicated that a person’s health-related behav-ior depends on the person’s perception of four critical areas:the severity of a potential illness, the person’s susceptibility tothat illness, the benefits of taking a preventive action, and thebarriers to taking that action. The model also incorporatescues to action (e.g., leaving a written reminder to one to walk)as important elements in electing or maintaining patterns ofbehavior. Cues to action involve stimuli that motivate an indi-vidual to engage in the health behavior. The stimulus that trig-gers action may be internal or external (Becker & Maiman,1975). For example, when perceptions of susceptibility andseverity are high, a very minor stimulus may be all that isneeded to initiate action. More intense stimuli may be needed,however, to initiate action if perceived susceptibility and se-verity are low (Redding, Rossi, Rossi, Velicer, & Prochaska,2000). Health motivation has also been used as part of theHBM in predicting health-related behavior. More recent for-mulations of the HBM have included self-efficacy as a keyfactor. Self-efficacy refers to confidence in one’s ability totake action, and it is influenced by mediating variables and inturn by influences expectations (Weinstein, 1993).

Mediating factors (demographic, structural, and socialvariables) have also been explored in applying the HBM. Me-diating variables are believed to indirectly affect behavior byinfluencing an individual’s perceptions of susceptibility, se-verity, benefits, and barriers (Rosenstock, 1990). Rosenstock(1974) suggested that combined perceptions of susceptibilityand severity provide the force to act, and perception of bene-fits minus barriers provides the preferred action.

The four concepts of HBM, which are influenced by medi-ating variables, indirectly influence the probability of per-

forming protective health behaviors by influencing the per-ceived threat of the illness and expectations about outcome(Redding et al., 2000).

Factors Affecting Exercise Participation

Andrew (1999) reported that situational factors as well aspersonal factors were the main factors that affect exercise par-ticipation. These factors include time, money, energy, roleconflict, social support, exercising with others, facilities, cli-mate, and physical discomfort. Brezinka, Dusseldrop, andMaes (1998) reported that women have significantly lowerperceived exercise tolerance and significantly more func-tional and psychosomatic complaints and a lower level ofphysical functioning than men. This would explain the higherdropout and lower adherence rates for women in cardiacrehabilitation.

Moreover, Haddad, Al-Ma’aitah, and Umlauf (1998) re-ported similar findings regarding sex differences in health-related behavior. Their findings revealed that the score ofmoderate-to-intensive exercise subscales among the totalHealth Promotion Lifestyle Profile for the Jordanian popu-lation compared with the North American one was the low-est for the entire sample. The authors attributed this findingto the scarcity of public parks and to limited access to thegymnasium or any other sports facilities in Jordan. Accord-ingly, with regard to gender differences in health-promotinglifestyle behavior, mean scores of males were significantlyhigher than those for females.

Health Belief Model and Exercise

To clarify the beliefs that act as incentives and barriers tomore living, O’Brien (2000) conducted a study to describeolder women’s beliefs about exercise benefits and risks. Theauthor asked 143 women over 70 years of old to respond toopen-ended questions on their beliefs about benefits and risksfor six fitness activities: brisk walking, aquacize, riding a bikeor cycling, stretching slowly to touch the toes, modifies push-ups from a kneeling position, and supine curl-ups. Respon-dents generally recognized broad health benefits from fitnessactivities, but beliefs about risks were strong, anatomicallyspecific, and sometimes sensational in description. The find-ings suggested that older women may feel physically vulner-able and unsure about their actual risks and benefits in exer-cise settings.

Mirotznik, Feldman, and Stein (1995) found that two di-mensions of the HBM—general motivation (special healthpractice) and perceived severity of CHD—were associatedwith exercise adherence in theoretically predicted direction,whereas perceived susceptibility to CHD or perceived barri-ers in terms of cost, health problems, or interference with nor-mal activities were associated in the directions opposite thatpredicted by the model. In addition, Robertson and Keller(1992) measured frequency and duration of CHD patient’shome-based exercise behavior. Findings revealed that per-

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ceived barriers significantly and negatively predicted adher-ence to exercise. Perceived benefits were, however, found tobe unrelated to an individual’s decisions to exercise. Thesame results were found related to diabetes patients (Polly,1992; Woodridge, Wallston, Graber, Brown, & Davidson,1992).

The effects of components of HBM and optimism on pre-ventive intention were examined in 144 Hong Kong Chinese.Two variables related to HBM, susceptibility and severity,were examined related to flu outbreak and hypothetical vac-cine. Analysis suggested that both higher susceptibility andhigher severity were associated with stronger behavioral in-tention to take the vaccine. Higher optimism scores were sig-nificantly associated with lower intention to take preventiveaction. The effect of optimism was higher when severity waslow than when it was high (Lai, Hamid, & Cheng, 2000).

In addition, perceived severity and susceptibility were alsosignificant contributors to behavior in many studies. Also, itwas expected that severity of the MI would motivate individu-als to think seriously about exercising (Courneya, 1995),although perceived benefits and costs are related to the deci-sion to initiate exercise behavior. Perceived barriers appar-ently differ among populations and between exercisers andnonexercisers within the same population. In one study(Godin et al., 1994), CHD patients perceived their age andhealth status as barriers to exercise, whereas pregnant womenwere concerned about their baby’s health and lactation con-straints. Difficulty finding time and access to sporting facili-ties were still rated, however, as the top perceived barriers.Several barriers restrict physical activity with increasing age:lower perceived control over exercise, poor health, lack ofaccess to home programs and appropriate facilities, fear ofinjury, lack of knowledge of health benefits, and low inten-tion to initiate an exercise program.

Seze-Eesoh (1999) examined the health beliefs and self-efficacy beliefs of women with osteoarthritis (OA) who par-ticipated regularly in an exercise program. The results in-dicated that perceived barriers to exercise and belief in thebenefits of exercise were strongly associated with exerciseadherence, and this association was not accounted for in dif-ferences in age and perceived health status.

Swift, Armstrong, Beerman, Campbell, and Pond-Smith(1995) and Mirotznik et al. (1995) reported a significant rela-tionship between perceived benefits and exercise but in thedirection opposite to that predicted by the HBM; persons whoattended a greater number of exercise sessions perceivedfewer benefits of exercise than those who did not.

A combined qualitative and quantitative design was usedby Resnick and Spellbring (2000) to explore the factors thatinfluenced adherence to an exercise program for adults andcompare differences in motivation, efficacy expectations,health status, age, functional performance, and falls betweenadherers and nonadhereres. The findings supported that be-lief about exercise, benefits of exercise, past experiences with

exercise, goals, personality, and unpleasant sensations asso-ciated with exercise affect the exercise adherence. So it wasrecommended that intervention that focuses on teachingolder adults about the benefits of exercise, establishing ap-propriate goals, and decreasing unpleasant and increasingpleasant sensations associated with exercise might be usefulto improve adherence to a regular exercise program.

The HBM has been used for explaining preventive, protec-tive, and sick-role behaviors. It has not, however, been testedin relation to exercise programs for CHD. Also, most HBM-based research to date has incorporated only selected compo-nents of the HBM, thereby not testing the usefulness of themodel as a whole relating to exercise behaviors. Literaturealso has demonstrated that attitudes and beliefs have beenassociated with the decision to join CHD exercise programs,and several studies have indicated that they are not correlatedwith maintenance over time. Unfortunately, in Jordan fewstudies have been conducted to describe individual beliefs re-garding preventive health behavior using HBM as a concep-tual framework.

METHODOLOGY

Sample and Sampling Criteria

A convenient sample of 98 Jordanian MI patients was re-cruited from four governmental hospitals in the northern partof Jordan—Princes Basma Hospital (292 beds), Prince RaiahHospital (60 beds), Al-Ramtha Hospital (56 beds), and Abu-Obediah Hospital (32 beds)—during a period of two months.Inclusion criteria include (a) experienced first attack of MI,(b) alert and oriented, and (c) able to ambulate. Participantswere excluded from the study if they had one or more of thefollowing conditions: unstable dysrhythmias, neuromusculardisorder, psychiatric problems, and chronic renal failure.

Instrument

The Health Belief Questionnaire (HBQ) originally devel-oped by Mirotznik et al. (1995) was used for the purpose ofthis study. The HBQ consists of six sections:

• Section 1 consisted of a demographic data collection formand a self-report for exercise behavior. The exercise self-report includes reporting the type, frequency, and duration ofexercise performed by the patients one month prior to the datacollection according to the definition of regular exercise. Pa-tients also were asked to report if they received recommenda-tion from their physicians to exercise regularly.

• Section 2 (general health motivation) consisted of 12 factualquestions about patients’general concern with health mattersand whether patients engage in specific health behavior. Ituses a Likert-type 5-point scale, with the total score rangedfrom 12 to 60 points. Question 13 asks patients to report theirbehavior regarding contacting their physician after experi-encing some signs and symptoms, using a 2-response scalewith a total score ranging from 0 to 7 points.

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• Section 3 (perceived susceptibility) consisted of 11 questionsabout patients’ perceived susceptibility to get a disease ingeneral and heart disease in particular, using a 5-point scale.The total score ranges from 11 to 55 points.

• Section 4 (perceived severity) consisted of 15 questions aboutpatients’ perceived severity of heart disease using a 5-pointscale. The total score ranges from 15 to 75. Question 11 askspatients to rank a group of diseases in order of seriousnessfrom most serious to least serious.

• Section 5 (perceived benefits) consisted of 14 questions aboutpatients’ perceived benefits of exercise, using a 5-point scalewith total scores from 14 to 70. One question asks patients torank seven health behaviors in terms of their importance topreventing heart disease from the most important to leastimportant.

• Section 6 (perceived barriers to exercise) consisted of sevenitems about patients’ perceived barriers to exercise in termsof time, pain, efforts, and interference with normal activi-ties. It uses a 5-point scale with a total score from 7 to 35points.

Validity and Reliability of the HBQ

The internal consistency reliability of this instrument wasassessed using Cronbach’s alpha, which ranged from 0.44 to0.73 for the study by Mirtoznik et al. (1995) and from 0.82 to0.32 for this study, as seen in Table 1.

Content validity of HBQ was assessed by four experts inthe area of cardiovascular nursing, who were employed asfaculty members in both a public health department and a fac-ulty of nursing at Jordan University of Science and Technol-ogy. Experts rated the content relevance of each item using a4-point rating scale: 1 = not relevant, 2 = somewhat relevant,3 = quite relevant but need alteration, and 4 = very relevant.The content validity index (CVI) for the items ranged from 3to 4. Minor changes were suggested and focused on the modi-fication of types of exercise that apply to Arab culture by add-ing a self-report question about exercise behavior accordingto the definition of regular exercise and focusing on walkingas a most popular type of exercise and the most safe for MIpatients. Another question was added about physician adviceto exercise regularly.

Procedure of Data Collection

A self-reported questionnaire was used for data collec-tion. A structured interview was designed to require the data.Permission for data collection was obtained from the targethospitals to recruit participants from the cardiology clinicsaffiliated with the hospitals. The investigator reviewed the pa-tients’ files before carrying out interviews to exclude patientswho did not met the inclusion criteria. Interviews by the re-searchers were carried out in the clinic’s waiting rooms. Inter-viewers needed 20-25 minutes for the completion of the ques-tionnaire. Each questionnaire had a cover letter explaining thepurpose and significance of the study, the information collec-tion technique, and the time needed to complete the interview.Patients that agreed to be interviewed were asked to sign a let-ter giving their permission to participate. Only two patientswere unable to complete the questionnaire because of timeconstraints. These patients were excluded from the analyses.

RESULTS

The total sample size was 98 MI patients. They were middle-aged (M = 50 years, SD = 12.15), Moslems (90%), and male(58%), and almost all of the patients were married (92%). Asthe national income is US$1,500 per capita (World Bank,2000), more than 50% of the sample had annual householdincomes of less than US$5,000, and 57% had a high schooleducation or greater. Forty percent of the total samplereported receiving no recommendation to exercise from theirphysicians. The frequency of exercise reported by thepatients was ranged from 0 to 30 times in one month prior todata collection.

General Descriptionof the MI Patients’ Health Beliefs

The means (SDs) and ranges of the health belief variablesfor the sample are presented in Table 2. Data indicated thatperceived severity was ranked the highest mean among allhealth belief variables followed by perceived susceptibility,health motivation, and perceived benefits respectively,whereas perceived barriers ranked the lowest mean. More-over, 80% of patients ranked heart disease as number 2 in theseverity after cancer.

More than 80% of the patients reported that they contacttheir physician immediately when they experience chest pain,and 61% of the total sample ranked heart disease as number 2in severity after cancer. Only 3% of patients ranked exerciseas the most important factor in preventing or treating MI.

Identification of the Relationship BetweenHealth Belief Variables and Exercise Participation

Spearman’s correlation coefficient was used to describethe relationship between the health beliefs of MI patients andexercise participation. Table 3 shows a significant positivecorrelation between health motivation and exercise participa-

Al-Ali, Haddad / THE EFFECT OF THE HEALTH BELIEF MODEL 117

TABLE 1Internal Consistency Reliability of the

Scales for HBM and Exercise

Previous Studya Current StudyVariable Alpha Values Alpha Values

General health motivation 0.82General health concern 0.58Special health practices 0.44

Perceived susceptibility to CHD 0.51 0.71Perceived severity of CHD 0.71 0.44Perceived benefit of exercise 0.73 0.32Perceived costs (barriers) to exercise — 0.41

a. Mirtoznik et al. (1995).

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tion (r = .326, p < .01). This indicated that patients who wereconcerned about their health and who engage in specialhealth practices were more likely to participate in regularexercise. In addition, there was a negative correlation (r =–.210, p < .05) between perceived barriers to exercise andexercise participation. This indicated that patients who faceseveral barriers to change a specific behavior would morelikely to hold this behavior. Furthermore, a negative signifi-cant relationship was found between exercise participationand the patient’s age: the younger the individuals, the morelikely to engage in regular exercise. Other health belief vari-ables like perceived severity of MI, susceptibility and benefitof exercise, and exercise were not significantly correlatedwith exercise participation.

A negative relationship (r = –.206, p < .05) was foundbetween the perceived severity of disease and the perceivedbenefit of exercise. This indicated that although patients per-ceived MI as severe, they perceived exercise as not beneficialin treating or preventing MI.

Further analysis was conducted to examine the effect ofdemographic variables on exercise participation. Resultsrevealed that there were significant differences between gen-

der, income, and level of education and exercise participation(Table 4). Male patients engaged in regular exercise morethan females. Patients with an annual income of JD3000 orgreater were more likely to participate in regular exercise.Also, patients who had a high level of education were en-gaged in regular exercise more than those who did not. Physi-cians’ recommendations to exercise, however, demonstratedno significant differences between patients who receive rec-ommendations and who did not.

Furthermore, a t test was carried out to examine the effectof sociodemographic variables on health belief variables.Data showed a significant difference between gender, annualincome, and perceived susceptibility to MI. Female patientshad high mean scores in the variables of susceptibility, indi-cating that female patients perceived themselves more sus-ceptible to MI than male (t = –2.219, df = 96, p < .05). No sig-nificant difference between males and females in other healthbelief variables was found.

In addition, patients from low income (i.e., annual incomeJD3000) perceived themselves as more susceptible to MI (t =2.015, df = 96, p < .05). In addition, physicians’recommenda-tions have a high mean score in the variable of health motiva-tion (t = 2.071, df = 96, p < .05), indicating that patients whoreceived physicians’ recommendation were more concernedwith health and engaged in special health practices.

Significance of Health Belief Variablesin Predicting Exercise Participation

A stepwise regression analysis was used to examine therelative importance of health belief variables and some demo-graphic variables in predicting exercise participation. Onlytwo variables (health motivation and income) were able tosignificantly predict variance in exercise participation (F =11.2, p = .000) and significantly explained 0.173 of the vari-

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TABLE 2Descriptive Statistics of Subscale Variables (n = 98)

Mean Actual PossibleVariable (SD) Range Range

General health motivation 34.7 (7.2) 19-52 12-60Perceived severity 52.7 (3.9) 41-60 15-75Perceived susceptibility 37.6 (6.2) 12-50 11-55Perceived benefit 33.2 (4.3) 22-43 14-70Perceived barriers 19.6 (3.1) 12-28 7-35

TABLE 3Spearman’s Correlation Coefficient of the

Study Variables (n = 98)

Variable 2 3 4 5 6 7

1. Age –.231* –.050 –.092 .087 –.019 .1722. Exercise

participation .326** .110 –.126 –.139 –.210*3. Health

motivation .160 .001 –.169 –.1964. Perceive

severity .180 –.206* –.1855. Perceive

susceptibility .107 –.0426. Perceive

benefit .1337. Perceive

barriers

*correlation is significant at the .05 level (2-tailed). ** correlation is sig-nificant at the .01 level (2-tailed).

TABLE 4The Effect of Demographic Variables on

Exercise Participation

MeanVariable (SD) t df p

GenderMale 11.0 (7.8) 2.373* 96 .02Female 7.4 (6.3)

Level of educationLess than high school 7.5 (6.3) –2.349* 96 .021High school or greater 11 (7.8)

Annual incomeLess than 3000 JD 7.2 (6.4) –3.69* 96 .0003000 JD or greater 12.4 (7.6)

Physician’s recommendationYes 8.7 (7) –1.186 96 .239No 10.5 (8)

*p < .05.

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ance in exercise participation. Annual income of patients (β =.311) is more important than health motivation (β = .279) inpredicting exercise participation (Table 5).

DISCUSSION

That severity was ranked the highest among all HBM vari-ables could be explained by the fact that sudden death byheart attack is increasing, and CVD’s mortality rate is thehighest in Jordan. On the other hand, the majority of patientsperceived themselves as susceptible to MI. These beliefsmight be related to many factors such as the economic statusof the study sample, or patients had many risk factors thatmight put them in risk for developing heart disease. Further-more, going through the experience of having a first attackmay resulted in continuous perception of susceptibility.

The perception of exercise as not beneficial in preventingor treating heart disease might be explained by two reasons:First, patients who exercised on a routine basis before infarc-tion and then developed infarction might come to the conclu-sion that they cannot prevent or control heart disease. It wouldtherefore appear that lack of knowledge about the benefitsof exercise in preventing or treating heart disease among pa-tients may be one of the reasons. To be more specific, theabsence of mass media health education messages about thebenefits of exercise plays a major role in having the low per-ception. Second, reliance on God’s will, an important beliefin Arab Jordanian culture, is the absolute dependence on thebeneficence of higher power. As a result, many Jordanianmay accept MI with resignation and fatalism without think-ing of the importance of preventing and reducing certain riskfactors.

General health motivation correlated positively with exer-cise participation. This finding was in a way predicted by theHBM conceptual framework, which assumed that personswith high scores on health motivation were more likely to beengaged in health-promoting behavior (i.e., exercise). Previ-ously, other investigators who have used the HBM, such asMirotznik et al. (1995), reported that special health practicesexhibited statistically significant association with attendancein community center–based, supervised CHD exercise pro-grams. Also, perceived severity of MI was negatively corre-

lated with perceived benefits of exercise. This finding indi-cated that patients perceived MI as a severe disease and do notbelieve that exercise is beneficial in preventing or treatingheart disease. This finding could be contributed to the factthat high level of seriousness may function to inhibit re-sponse. In fact, the precise reasons for this finding are vague,but a possible explanation could be that patients who exerciseon a routine basis preinfarction might come to the conclusionthat they cannot prevent or control heart disease.

Sociodemographic variables such as age, gender, income,and level of education for the participants demonstrate a var-ied effect on exercise participation. Age was correlated nega-tively with exercise participation, indicating that older per-sons may experience other chronic illness that interfere withexercise, such as arthritis. In fact, normal progress in age wasassociated with many physiological changes and functionaldeterioration that influence the patients to be physically ac-tive. The findings of this study could be attributed to the factthat the majority of our sample was middle-aged (M = 50.2years).

This finding was consistent with several previous studies(Booth, 1997; Conn, Taylor, & Abele, 1991; Godin et al.,1994), which revealed that there were several barriers thatrestrict physical activity with increasing age. As a practiceimplication, it is important to consider a patient’s age wheneducating him or her about the importance of safe exercise inpreventing and treating CHD.

On the other hand, gender differed significantly in pa-tients’ participation in exercise. Female patients less fre-quently participated in regular exercise than males. This find-ing was attributed to several explanations: (a) Women mightperceive lower exercise tolerance; (b) Arab custom discour-ages women from participating in outdoors physical activi-ties and sports; thus, there are very few means for women toexercise; and (c) women were concerned about family andhousehold responsibilities that make it difficult to find timefor exercise and access to sporting facilities. This findingwas congruent with Al-Hassan and Wierenga (2000); Al-Ma’aitah, Haddad, and Umlauf (1999); Mirotznik et al.(1995); and Brezinka et al. (1998), who reported that fe-male patients less frequently participate in regular exercise.Lindgren and Fridlund (2000) found that several factors in-fluence physically nonactive women to exercise adherence,the influence coming either from the exercise or from the en-vironment connected to the exercise. The obvious conclusionof this discussion should be that women need further atten-tion to raise their motivation to exercise.

In addition, data indicated that patients with high incomeswere more likely to engage in regular exercise. Indeed, in-come is a modifying variable as proposed by the study con-ceptual framework, and it indirectly affects the likelihood thatpatients will take preventive health action (i.e., exercise).High income was related to many factors that enhance exer-cise participation, such as accessibility to exercise programs

Al-Ali, Haddad / THE EFFECT OF THE HEALTH BELIEF MODEL 119

TABLE 5A Stepwise Linear Regression Analysis Result

Using the Health Belief Variables andSociodemographic as Predictors (n = 98)

AdjustedModel Variable b β t p R2 R2

(Constant) 0.369 .173Income 0.311 .311 3.35 .001 .191Health motivation 1.938E-02 .279 3.005 .0003

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or having devices for training at home. Also, patients withhigh incomes could easily change their residence from ruralto urban areas for easier access to such programs.

This finding is consistent with other clinical and popu-lation-based studies (Andrew, Oldridge, & Parker, 1981;Kison, 1992; Sallis, Simons-Morton, & Stone, 1992), whichreported that lower socioeconomic status may impede or enda previously continuous exercise program.

Furthermore, patients with high level of education (highschool or greater) were more likely to participate in regularexercise than the non–high school education. It may be thatpatients who have a high level of education may access infor-mation about disease and appropriate regimens through manymeans such as magazines, newspaper, and medical textbooks.The result also may attribute to the fact that educated peoplemay understand the nature of the disease and the rationale ofcomplying with an exercise regimen. This result is consis-tent to that cited by Kison (1992), who found that college-educated individuals were more compliant with the activityvariable than were non-college-educated individuals.

Female patients perceived themselves more susceptible toMI than male patients. The perception of susceptibility herewas more related to the cultural influences apart from thehealth beliefs. A lack of studies that examined the associa-tion between sociodemographic and health belief variablesmakes it difficult to explained this result. Brezinka et al.(1998) found, however, that women reported significantlymore functional and psychosomatic complaints and a lowerlevel of physical functioning than men, and therefore per-ceived themselves as more susceptible to disease. In addition,patients from low socioeconomic backgrounds perceivedthemselves as more susceptible to disease. It is possible thatthese patients might not have insurance and thus not haveaccess to health care facilities. Similar findings were reportedby Kison (1992).

In addition, patients who receive a recommendation fromtheir physicians to exercise were more concerned with healthand engaged in special health practices to improve theirhealth. This finding supports the important role of health careprofessionals in motivating patients to adopt health-relatedbehavior such as exercise, and patients tended to comply withthis behavior. Furthermore, in Jordan a physician is still con-sidered an authority, so patients would engage in regular ex-ercise programs as prescribed because that was what the phy-sician had ordered. This finding was congruent with thoseof Stromberg, Brostromg, Dahlstrom, and Frindlund (1999);Britten (1994); and Halbert, Silagy, Finucane, Withers, andHamdrof (2000).

The health-motivation variable and patients’ annual in-come were found to be the most significant predictors of exer-cise participation among Jordanian MI patients, and they ex-plained 17.3% of the variance in exercise behavior. Incomewas a more important predictor of exercise participation,indicating that patients with high incomes can easily access

exercise programs (either home programs by buying appro-priate devices and equipment, or center-based programs).Also, high income was correlated with high level of educa-tion, indicating that patients might understand the rationale ofcomplying with exercise programs and the extent to whichthis behavior can treat or prevent coronary heart disease.Thus, patients’ income enhances or impedes the exercise be-havior. This finding was in agreement with Kimiecik (2000),who found that lower socioeconomic groups face far moreexternal barriers to exercise than those with higher income.Desmond, Conard, Montgomery, and Simon (1993) foundthat income was a predictor for physical activity among maleworkers.

Finally, reasons why perceptions of benefit, barriers,severity, and susceptibility were not significant predictorsof exercise participation are unclear in the present study:whether it is related to the fact that the HBM was not sensitiveenough to measure exercise behavior within the JordanianArabic culture, or whether uncontrolled confounding vari-ables interfere with the prediction such as sociodemographicvariables.

The findings of this study should be interpreted carefullyin the light of the following limitations. First, the operationaldefinition of exercise participation did not include intensityof exercise, so it is possible that patients may have been exer-cising the same amount but in quite different patterns; also, itprovided no indication of whether an exercise behavior wascarried out with the frequency and duration necessary toachieve the benefit of exercise. Second, self-reports of exer-cise behavior for 1 month prior to data collection may bebiased by recalled memory, especially for elderly patients.Finally, a convenient nonprobability sample made it difficultto test the significance of HBM variables in predicting exer-cise participation among MI patients.

The results of this study can be used to design interventionprograms aimed at improving physical activity by all MIpatients. Educational programs should include both benefitsand barriers to exercise. Nurses can help patients express theirconcerns and make strategies to exercise in spite of these bar-riers. Information about exercise as well as strategies to con-trol barriers may motivate patients to exercise regularly.

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Nahla Al-Ali, MSN, RN, is a lecturer in the Department of Com-munity Health Nursing at Jordan University of Science and Technol-ogy. She received her master’s degree in nursing from JordanUniversity of Science and Technology at Irbid, Jordan. Her researchand teaching interests include smoking, health promotion, and com-munity health.

Linda G. Haddad, PhD, RN, is the dean of the Faculty of Nursingin the Department of Community Health Nursing at Jordan Univer-sity of Science and Technology. She received her doctorate in 1993from the University of Maryland at Baltimore. Her research andteaching interests include smoking and health promotion.

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