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The Influence of Illness Severity on Health Satisfaction in Patients with Cardiovascular Disease: The Mediating Role of Illness Perception and Self-Efficacy Beliefs a

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Andrea Greco , Patrizia Steca , Roberta Pozzi , Dario Monzani , Gabriella Malfatto & Gianfranco Parati

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University of Milan–Bicocca

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University of Milan

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St. Luca Hospital, Istituto Auxologico Italiano

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St. Luca Hospital, Istituto Auxologico Italiano and University of Milan–Bicocca Accepted author version posted online: 28 Oct 2013.Published online: 03 Sep 2014.

To cite this article: Andrea Greco, Patrizia Steca, Roberta Pozzi, Dario Monzani, Gabriella Malfatto & Gianfranco Parati (2015) The Influence of Illness Severity on Health Satisfaction in Patients with Cardiovascular Disease: The Mediating Role of Illness Perception and Self-Efficacy Beliefs, Behavioral Medicine, 41:1, 9-17, DOI: 10.1080/08964289.2013.855159 To link to this article: http://dx.doi.org/10.1080/08964289.2013.855159

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BEHAVIORAL MEDICINE, 41: 9–17, 2015 C Taylor & Francis Group, LLC Copyright  ISSN: 0896-4289 print/1940-4026 online DOI: 10.1080/08964289.2013.855159

The Influence of Illness Severity on Health Satisfaction in Patients with Cardiovascular Disease: The Mediating Role of Illness Perception and Self-Efficacy Beliefs Andrea Greco and Patrizia Steca Downloaded by [University of Connecticut] at 10:11 13 April 2015

University of Milan–Bicocca

Roberta Pozzi University of Milan

Dario Monzani University of Milan–Bicocca

Gabriella Malfatto St. Luca Hospital, Istituto Auxologico Italiano

Gianfranco Parati St. Luca Hospital, Istituto Auxologico Italiano and University of Milan–Bicocca

The importance of psychological factors in improving conditions of cardiovascular disease (CVD) patients is stressed by the guidelines for their prevention and rehabilitation, but little is known about the impact of illness severity on patients’ well-being, and on the psychosocial variables that may mediate this association. The aim of this study was to investigate the role of illness perception and self-efficacy beliefs on the relationship between illness severity and health satisfaction in 75 CVD patients undergoing rehabilitation (80% men; mean age = 65.44) at the St. Luca Hospital, Istituto Auxologico Italiano, Milan, Italy. Illness severity was measured in terms of left ventricular ejection fraction; psychological factors were assessed at the beginning and end of rehabilitation. Results from path analyses showed that the relationships among CVD severity and health satisfaction were mediated by illness perception and selfefficacy beliefs. Findings underscored the importance of considering illness representations and self-efficacy beliefs to improve well-being in CVD patients. Keywords: cardiovascular disease, health satisfaction, illness perception, illness severity, self-efficacy beliefs

Cardiovascular disease (CVD) remains a major cause of mortality, morbidity and activity limitations in developed countries, despite the significant improvements in medical treatment.1 In the last decades, several studies have

Correspondence should be addressed to Andrea Greco, Ph.D., Department of Psychology, University of Milan “Bicocca,” Piazza dell’Ateneo Nuovo, 1 20126, Milan, Italy. E-mail: [email protected]

highlighted that the appearance and clinical progression of CVD are associated with a range of psychosocial factors, such as depression, anxiety, anger, hostility, and perceived stress.2–4 In addition to this line of research, a further area of study underlines the importance to consider psychological factors in the improvement of clinical condition of patients suffering from CVD; guidelines for cardiovascular rehabilitation from several countries emphasize the importance of considering psychosocial factors in the treatment of these

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patients. Among others, the American and European guidelines for cardiac rehabilitation,5,6 as the most recent guidelines on prevention of cardiovascular disease of the European Society of Cardiology,7 clearly stress that the rehabilitation programs should also be focused on psychological issues to achieve a better quality of life and to improve patients’ psychosocial well-being and quality of life. Relative to previous decades, it is now largely accepted that the promotion of patients’ physical health through the rehabilitation process is not sufficiently effective if their mental and social wellbeing is not adequately considered. The affirmation of this concept is based on empirical evidence showing that mental and social well-being largely benefit the physical health of people with CVD; in particular, a significant relationship between poor mental health, hopelessness, neuroticism, stress, adverse life events, and increased morbidity and mortality has been reported by several studies.3,8,9 In spite of this focused attention on negative dimensions, few studies have investigated the role of positive dimensions of patients’ psychological well-being and quality of life. Those focusing on subjective indicators showed the importance of life satisfaction, which can be considered an indicator of life quality reflecting a subjective judgment based on personal criteria for happiness and success,10 that can predict longevity, CVD events, and psychiatric morbidity in CVD population or in CVD risk population.11–14 In a similar way, health-related quality of life, that reflects a patient’s physical, mental and social beliefs and perceptions in relation to health, has been shown to have prognostic value in predicting adverse clinical events.15–18 At the same way, although fewer research have used the indicator of health satisfaction, also this variable has demonstrated to predict longevity and clinical events as well or better than objective medical reports, even controlling for these factors.19 Patients’ health satisfaction is considered a very important outcome of cardiovascular risk reduction programs20 and, as found by Erickson et al.,21 it is associated with fewer symptoms, better cardiac function scores, and lower perceived severity of the illness. As regards illness severity, other studies showed that it significantly affects satisfaction specifically related to health,22–24 leading to hypothesize a complex and reciprocal relationship. In spite of this increasing attention to psychological aspects, few studies have tried to identify the specific variables that may act as protective factors in buffering the effects of illness severity and progression on patients’ well-being. In the present study, we investigated the impact of illness severity on patients’ health satisfaction, and we tested the mediation of two key psychological factors that have demonstrated a crucial role in patients’ illness self-management:6 illness perceptions and self-efficacy beliefs. Previous studies showed their mediational role with respect to life satisfaction, measured at the same time of the personal control variables, and depression, both in case of cross-sectional design that in case of prospective design study.23–25

In particular, we tested a model, described in detail in the following sections, in which these factors mediate the impact of illness severity on patients’ health satisfaction. In the self-regulatory model of illness developed by Leventhal et al.,26 patients organize their previous experience of illness in a complex memory structure. This structure is useful in organizing specific cognitive representations, developing action plans, and appraising coping responses. Cognitive representations refer to different areas: identity, timeline, consequences, cause, cure/controllability, and coherence.27 A variety of studies have shown that the perceptions of less negative illness consequences are associated with better outcomes in the context of patients who have chronic CVD and who also attend cardiac rehabilitation, and maintain longterm behavioral changes.28–33 On the contrary, several studies have highlighted that negative illness perceptions are associated with more complications after CVD34 and with higher rates of re-hospitalization and mortality one year after the event.30,35–37 Self-efficacy is a key construct in Bandura’s socialcognitive theory,38,39 in which it corresponds to people’s perceived abilities to successfully perform specific tasks and activities. In the context of illness management, self-efficacy beliefs refer to patients’ confidence in their capability to successfully execute specific health behaviors, such as compliance to diet and exercise regimes.39–41 Several studies showed, in patients with CVD, that self-efficacy is a powerful predictor of behavioral changes in the initial decision to perform a different behavior such as smoking cessation or doing physical exercise.38,39,42,43 Furthermore, perceived self-efficacy predicted the attendance of cardiac rehabilitation, future hospitalizations, recovery of function following cardiac rehabilitation, better health status, better physical function, and low levels of anxiety and depression.30,44–50

AIMS OF THE STUDY The purpose of our study was to investigate the role of illness perception and self-efficacy beliefs in mediating the impact of illness severity on patients’ health satisfaction. Illness severity was evaluated at discharge from the cardiology department (time 0, t0) and was measured in terms of left ventricular ejection fraction (LVEF), an objective measure of the severity of left ventricular contractility in cardiac patients. This indicator corresponds to the fraction of blood pumped out of the left ventricle at each heartbeat; lower measures indicate reduced LV performance and thus poorer prognosis.51 Patients’ illness perception and self-efficacy beliefs were measured at the beginning of the rehabilitation program (wave 1, w1), after discharge from the cardiology department. Patients’ health satisfaction was measured at the beginning of the rehabilitation program, and two months later, at the end of the cardiovascular rehabilitation period (wave 2, w2).

ILLNESS PERCEPTION AND SELF-EFFICACY BELIEFS

We hypothesized that a subjective indicator of disease, such as the experience of illness and negative illness perception in particular, is negatively affected by LVEF, and that illness perception negatively affects health satisfaction. Furthermore, we hypothesized that LVEF has a positive effect on self-efficacy beliefs, which, in its turn, positively affect patients’ health satisfaction. No direct association between LVEF and health satisfaction was presumed because we hypothesized a full mediation by illness perception and selfefficacy beliefs. The effect of sociodemographic variables (age, sex, and marital status) and diagnosis having a significant relationship with outcome variables (health satisfaction at w1 and w2) was kept under control in the model.

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METHODS Participants and Study Design From July 2007 to August 2008, we recruited consecutive patients with heart disease who had been referred to the cardiovascular rehabilitation unit of the St. Luca Hospital, Istituto Auxologico Italiano, Milan, Italy. Eligible patients received written information about the study and an informed consent form to be signed. We included patients who were (1) diagnosed with a chronic (at least 5 years) heart disease (ie, heart failure, chronic ischemic, heart disease) or an acute illness (ie, acute myocardial infarction, or percutaneous coronary intervention, or coronary artery bypass surgery for reduced coronary reserve), (2) free from other serious diseases (such as cancer), (3) free from psychiatric problems, and (4) fluent in Italian. We collected data by self-report questionnaires; considering the frail state of health of the patients involved in the study, we administered brief questionnaires so as to engage the patient for the shortest time possible. The study was approved by the Medical Ethics Committee of the hospital. The study design was prospective. The clinical indicator (predictor variable) was measured at baseline only (t0), at discharge from the cardiology department. Illness perception and self-efficacy beliefs (mediator variables) were assessed at the beginning of the cardiovascular rehabilitation period (w1), one week after t0. Health satisfaction was measured (dependent variable) at the beginning (w1) and at the end of the rehabilitation cycle (w2), two months after t0. The time elapsed between measurements was based on standard recovery periods for patients in a cardiac day-hospital rehabilitation program. We asked 120 patients with CVD to participate in the study, 45 of whom did not respond or refused. Patients who did not participate did not differ significantly from the respondents with respect to age, sex, and illness severity. The study sample included 75 patients total (a response rate of 62.5%), out of which 60 (80%) were men and 15 (20%) were women, with a mean age of 65.44 years (SD = 10.20; range: 38–85 years). Of patients, 28 (37.3%) had a diagnosis of

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TABLE 1 Patients’ Characteristics Demographic

n

(%)

Sex Male 60 Female 15 Age, y; Mean (SD) = 65.4 (10.2); range 38–85 Marital status Unmarried 10 Married 59 Divorced 4 Widowed 4

13.0 76.6 5.2 5.2

Illness

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n

Diagnosis Acute 47 Chronic 28 LVEF (%) Mean (SD) = 49.9 (11.1); range 27–61

80.0 20.0

62.7 37.3

chronic (at least 5 years) heart disease (heart failure, chronic ischemic heart disease, hypertensive heart disease) whereas 47 patients (62.7%) had an acute illness (acute myocardial infarction, or percutaneous coronary intervention or coronary artery bypass surgery for reduced coronary reserve). A summary of participants’ characteristics is reported in Table 1. Variables and Instruments Illness Severity A clinical indicator of cardiovascular disease severity was obtained from patients’ cardiac testing records and hospital charts; LVEF was measured by echocardiography before the beginning of a rehabilitation program. LVEF is the single most used non-invasive measure of cardiac function in clinical practice; it indicates the severity of cardiac disease and the magnitude of the necrotic LV area after myocardial infarction, and it is considered a strong predictor of survival after an acute myocardial infarction, in stable coronary artery disease, and in heart failure.51–55 At the beginning of the rehabilitation program, a set of self-report questionnaires was administered to participants by a trained researcher. Sociodemographic Variables Participants were asked to report general demographic information including their sex, age, and marital status. Illness Perceptions The Italian version of the Brief Illness Perception Questionnaire, Brief-IPQ56,57 was used to measure the various components of the patients’ illness perception, as defined

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by the model developed by Leventhal and colleagues.26 Translation and back-translation were used by Pain et al.57 to develop the Italian version of the Brief Illness Perception Questionnaire. This study was conducted on 500 patients with different illnesses and included other measures such as the Illness Perception Questionnaire-Revised, IPQ-R.58 Results showed good test–retest reliability and concurrent validity of the scale, attested by significant associations between the Brief IPQ and the IPQ-R on all the equivalent dimensions. Furthermore, the Brief IPQ demonstrated good predictive validity in myocardial infarction patients; different representations were consistently related to mental and physical functioning at 3 months’ follow-up, cardiac rehabilitation class attendance, and speed of return to work.56,57 The Brief-IPQ has 8 items assessing the following illness perceptions: (1) consequences, referring to the patient’s perception of the impact of the illness on his/her life; timeline, reflecting (2) the individual’s sensation of the illness duration; (3) personal control, referring to the patient’s perception of his/her own degree of control over the illness; (4) treatment control, reflecting the perceived utility of the cure; (5) identity, corresponding to the perceived intensity of the illness symptoms; (6) concern, referring to the preoccupation related to the illness; (7) emotions, reflecting the extent to which the illness affects the patient’s emotions; and (8) comprehensibility, corresponding to the extent to which the patient thinks he/she understands his/her illness. All of the items were rated using a 10-point Likert scale; higher scores indicate stronger approval of the item. Following a procedure adopted by previous research, the overall score was calculated as the sum of the eight items’ scores.59–60 These scores reflect the overall positivity or negativity of patients’ illness perceptions; higher scores indicate a more negative illness representation. The Brief-IPQ contains nine open-response items, assessing patients’ causal attributions of the illness. The Brief-IPQ was not included in the present study because it does not add information to the overall score. The summary score, based on recommendations by Nunnally and Bernstein,61 had an adequate internal consistency (Cronbach’s alpha = .61). Adherence to Rehabilitation Therapy Self-Efficacy A four-item Adherence to Rehabilitation Therapy SelfEfficacy (ARTSE) scale was developed by the authors to assess patients’ beliefs regarding their ability to faithfully follow a set of important activities related to their rehabilitation therapy, as to make physical exercises and to take correctly medicine. For each item, participants rated the extent to which they were able to pursue their rehabilitation program on a five-point Likert scale (from 1, not at all confident; to 5, completely confident). A sample item from this scale is “How well can you remember to take correctly your medicines, even when there is nobody to remind you about

them?” The score for self-efficacy beliefs corresponds to the mean item scores. In line with recommendations by Nunnally and Bernstein,61 the scale showed an adequate internal consistency (Cronbach’s alpha = .76). Moreover, results of exploratory factor analysis (range of the four items’ factor loadings: from .83 to .53) and confirmatory factor analysis (χ 2 = 0.97, p = n.s.; SRMR = 0.04; RMSEA = 0.00) revealed an adequate fit of the data to a one-factor model. Health Satisfaction At the beginning and at the end of the cardiovascular rehabilitation period, health satisfaction was measured by the single item: “How satisfied are you with your health?” The participants rated their health satisfaction using a 10-point Likert scale, from 0, completely dissatisfied; to 10, completely satisfied. Many previous studies have used a single item to measure health satisfaction or other similar constructs, as self-rated health status, showing the good performance and good psychometric properties of these type of “tools.”21,62 Data Analyses Data analyses were conducted using SPSS Statistics 17.0 and Mplus program, version 6.11.63 In line with recommendations by West, Finch, and Curran,64 all the scales showed acceptable distributions. Skewness was: LVEF = −.82; IP = −.38; ARTSE = −.38; health satisfaction at w1 = −.14; health satisfaction at w2 = −.82; kurtosis was: LVEF = −.83; IP = −.44; ARTSE = −.64; health satisfaction at w1 = −1.04; health satisfaction at w2 = .74. As preliminary analyses, we calculated a multi-correlation matrix to examine the bivariate correlations among all of the measured variables; we used Pearson correlation coefficients for all the relationships, expect for the relations among all variables with sex, marital status, and diagnosis for which point-biserial correlation coefficients were used. Mediation analyses were performed conducting a path analysis to test the hypothesized model. To determine whether the expected model was plausible with the data, we used the chi-square test statistic. Considering the sensitivity of the chi-square statistic to the sample size, other goodness of fit indices were used based on Hu and Bentler’s recommendations65: the comparative fit index (CFI ≥ .95 indicate adequate fit), the standardized root-mean-square residual (SRMR ≤ .08 indicate adequate fit), and the root-mean square error of approximation (RMSEA ≤ .06 indicate adequate fit). According to Preacher and Hayes,66 mediation occurs when the predictor is significantly associated with both the dependent variable and the proposed mediator (or mediators) and when the mediator (or mediators) has a significant association with the outcome. The effect of the predictor on the dependent variable is significantly reduced when the mediator (or mediators) is added to the model. Full mediation

ILLNESS PERCEPTION AND SELF-EFFICACY BELIEFS TABLE 2 Correlation Coefficients among Dependent Variables, Mediator Variables, and the Independent Variable

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1. Age 2. Gender 3. Marital status 4. Diagnosis 5. LVEF 6. IP 7. ARTSE 8. Health satisfaction at w1 9. Health satisfaction at w2

5

6

7

−.27∗ −.11 .24∗ −.87∗∗∗ 1

.05 .22 .11 .34∗∗ −.24∗ 1

−.05 −.18 .01 −.25∗ .30∗∗ −.21 1

8

9

−.08 .07 −.24∗ −.20 .07 .22 −.43∗∗∗ −.31∗∗ .38∗∗ .29∗ −.43∗∗∗ −.52∗∗∗ .23∗ .29∗ 1 .63∗∗∗ 1

Note. LVEF, left ventricular ejection fraction; IP, illness perception; ARTSE, adherence to rehabilitation therapy self-efficacy beliefs. ∗ p < .05; ∗∗ p < .01: ∗∗∗ p < .001.

occurs if the direct effect is eliminated in the presence of the mediator (or mediators); partial mediation occurs if the direct effect is reduced but still present. In order to keep under control the effect of sociodemographic variables and diagnosis, we used the residual variance of health satisfaction at w1 and w2 adjusted for those variables with a significant relationship. A significance level of .05 was used for all statistical tests.

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reveal significant indirect effects between LVEF and health satisfaction for the mediators IP and ARTSE. IP was negatively affected by LVEF and negatively affected health satisfaction at w1 and w2. ARTSE was positively affected by LVEF and positively affected health satisfaction at w2, but health satisfaction at w1 didn’t receive significant influence from ARTSE. The results showed that IP and ARTSE completely mediated the relationship between the independent variable (LVEF) and the dependent variable (health satisfaction); in fact, the direct effect between LVEF and health satisfaction was not significant in the presence of the mediators. Fit indices indicated a good fit between the theoretical and the empirical model: χ 2(1) = .21, p = n.s.; CFI = 1.00; RMSEA = .00 [.00, .24]; SRMR = .01. The model explained 9.4% of the variance for health satisfaction at w1 and 43.4% of the variance for health satisfaction at w2. Furthermore, we tested the reverse model to ensure the role of mediators and dependent variables; in this model ARTSE and IP were the dependent variables, health satisfaction at w1 and w2 were the mediators, and LVEF was the independent variables. The results of this analysis revealed the bad fit between the theoretical and the empirical model: χ 2(1) = 28.74, p < .001; CFI = .26; RMSEA = .61 [.43, .81]; SRMR = .14. Moreover, the results showed that ARTSE was not influenced by health satisfaction and that IP was influenced only by health satisfaction at w2; moreover the explained variation for IP and ARTSE were low (1% for ARTSE and 23% for IP).

RESULTS Correlations Among Variables As shown in Table 2, LVEF was negatively and significantly related to the age, diagnosis, and IP; it was also positively and significantly associated with marital status and ARTSE. Health satisfaction at w1 was negatively and significantly related to sex, diagnosis, and IP; it was also positively associated with ARTSE. Health satisfaction at w2 was negatively and significantly related to diagnosis and IP, and it was positively associated with ARTSE. Health satisfaction at w1 and w2 were strongly and positively associated. LVEF and health satisfaction at w1 and w2 were positively associated. IIP and ARTSE were uncorrelated. Furthermore, ARTSE was negatively and significantly related to diagnosis, whereas IP was positively associated with diagnosis. Mediation Analyses Based on results from correlational analyses, the hypothesized model was tested using as outcomes the residual variance of health satisfaction at w1 and w2 adjusted for sex and diagnosis. Figure 1 shows the results of the mediation analyses that partially confirmed the proposed model. These analyses

DISCUSSION The aim of this study was to examine the mediational role of illness perception and self-efficacy beliefs in the impact of illness severity on patients’ health satisfaction. The results partially confirmed our hypotheses. Illness severity, measured in terms of LVEF, was related to patients’ self-reported health satisfaction; this result is similar to previous findings that demonstrated a relationship between the severity of cardiac disease and satisfaction with health status in CVD patients.21–24 Nevertheless, this relationship between a clinical indicator of cardiovascular disease severity and health satisfaction was fully mediated by personal control variables: illness perception and adherence to rehabilitation therapy self-efficacy completely mediated the relationship between LVEF and patients’ health satisfaction, both in case of satisfaction measured at the same time of the personal control variables and in case of satisfaction detected two months later. Moreover, the inconsistency of the results of the reverse model, strengthen the hypothesis that these variables were mediators of the relationships between illness severity and health satisfaction. Illness perception was negatively related to LVEF and negatively affected health satisfaction; this influence could

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GRECO ET AL.

IP

-.32** - .24*

-.30** HEALTH SATISFACTION

-.09 n.s. LVEF

HEALTH SATISFACTION

-.10 n.s. .26*

.45***

.11 n.s.

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.19* ARTSE

t0

w1

w2

FIGURE 1 Summary of mediation analyses. LVEF, left ventricular ejection fraction; IP, illness perception; ARTSE, adherence to rehabilitation therapy self-efficacy beliefs. Health satisfaction at w1 R2 = .09; Health satisfaction at w2 R2 = .43. ∗ p < .05; ∗∗ p < .01; ∗∗∗ p < .001; n.s., not significant (dashed lines indicate non-significant paths).

be read in agreement with previous findings that identified a significant relationship between negative illness perceptions and dissatisfaction in patients with CVD.25,34,67,68 Moreover, previous research on illness perception have suggested that illness representations effect former leisure pursuits, social activities and return to work more than the severity of the illness.32,69 Adherence to rehabilitation therapy self-efficacy was positively associated with LVEF; furthermore, adherence to rehabilitation therapy self-efficacy positively affected health satisfaction measured two months later. These findings are consistent with previous research that found low levels of self-efficacy associated with worse baseline cardiac function in patients with CHD49; moreover, previous research found that self-efficacy beliefs predict better health status and better physical function in patients with CVD.44,48,50 Contrary to our expectations, no significant relationship between selfefficacy beliefs and health satisfaction measured at the same time was found. This lack of association was probably due to the effect of illness perceptions that were strongly related to health satisfaction and received a significant influence from LVEF. Furthermore, these results suggest that self-efficacy beliefs could help patients over time, while positive illness perceptions play a protective role also in the period immediately following the onset of the disease. The present findings provide important implications for implementing interventions aiming to improve patients’ quality of life. Guidelines for cardiac rehabilitation highlighted that rehabilitation programs must focus on psychological issues to help patients achieve a positive mental regarding

their condition and recovery. The findings of this study suggest that psychological interventions should be designed in two different ways: promoting patients’ management of their perceived illness and fostering their sense to faithfully follow the activities of the rehabilitation therapy. Illness perception and self-efficacy beliefs are modifiable and can be improved through health behavior interventions, especially during cardiac rehabilitation.30,39,70–75 As largely demonstrated by the literature, changing a patient’s negative perception of his or her illness into a more positive one may contribute to a decrease in morbidity and mortality after CVD.74,75 Moreover, promoting self-efficacy beliefs in the management of risk factors may increase healthier behaviors.71,72 The relevance of working on both illness perception and self-efficacy beliefs is well showed by the Interactive Care Model proposed by Lau-Walker.30 This model emphasizes the importance of incorporating both illness perception and self-efficacy into a single conceptual care mode in order to create a more holistic regime to help patients to manage initial conceptualizations of their condition and to develop their perceived ability to cope with their condition and treatment over time.

LIMITATIONS OF THE STUDY Despite its strengths, our study also has some limitations. First of all, the number of participants was not sufficiently large to allow the generalization of the results. Furthermore, the small cohort of patients has limited both the statistical analysis approach and the method to control potential

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ILLNESS PERCEPTION AND SELF-EFFICACY BELIEFS

confounding variables. Data from larger samples of patients with various cardiovascular diseases are needed. Although in this study the role of acute and chronic illness on health satisfaction has been kept under control, the two groups are composed by patients with various types of heart disease (ie, AMI, percutaneous coronary intervention, coronary artery bypass surgery for reduced coronary reserve, heart failure, and chronic ischemic heart disease) that may be better classified distinguishing among all these diseases. Specifically, for example, levels of health satisfaction are probably different for acute patients who have undergone surgery from levels in acute patients who have not undergone surgery; the same could be true for illness perception and self-efficacy. Moreover, it would be useful to investigate whether a change in LVEF is reflected by a change in health satisfaction, illness perception, and self-efficacy beliefs; research with more time-points assessing independent and mediator variables are needed. Furthermore, extended examinations of patients’ histories of CVDs and different illness indicators, such as the number of main vessels and branches occluded, are warranted; likewise, additional outcomes, such as rehospitalization and mortality, are also worth investigating. Moreover, further studies should differentiate subjects by other sociodemographic factors, as educational level, income to have a sample that is less heterogeneous and more specified. Moreover, a further limit is represented by the type of measurements: the use of a single item to measure health satisfaction and the use of the scale developed by the authors to measure self-efficacy beliefs, though in course of validation, may partially limit the generalization of the results. Finally, further studies could consider other variables that may play a role in the associations between illness severity and health satisfaction during a rehabilitation period, like patients’ attendance, performance, and benefits. CONCLUSIONS The present study adds to the literature on health psychology and psychology of well-being by investigating the relationships among illness severity and health satisfaction, and on how the factors of illness perceptions and self-efficacy beliefs may affect these relationships in patients with CVD involved in a rehabilitation program. The disease severity was unrelated to patients’ health satisfaction in the presence of illness perceptions and self-efficacy beliefs. Overall, current findings suggest the importance of implementing psychological interventions aimed at bettering patients’ quality of life through the management of their illness representations, and strengthening their sense of personal control in following the activities of rehabilitation therapy. FUNDING The support of Fondazione Umberto Veronesi is gratefully acknowledged.

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