Original research| Volume 101, ISSUE 3, P479-486, March 2020

Development and Validation of a Scale to Measure Fear of Activity in Patients With Coronary Artery Disease (Fact-CAD)

Published:September 25, 2019DOI:



      To develop and validate a scale to measure fear of activity in patients with coronary artery disease.


      Psychometric study.


      Outpatient cardiology clinics.


      The scale was applied to patients who had myocardial infarction, coronary artery bypass grafting, or percutaneous coronary intervention within the last 12 months (N=250).


      A scale for fear of activity in patients with coronary artery disease (Fact-CAD) was created through semistructured focus group interviews with patients. Face and content validity of Fact-CAD was verified.

      Main Outcome Measures

      Psychometric analysis included model fit, unidimensionality, reliability, local dependency, differential item functioning, and external construct validity. Analyses were performed using the Rasch Analysis Model.


      Fact-CAD scale was a reliable (high Person Separation Index of 0.89) and valid (unidimensional, no misfit, local independency supported, no residual correlations) measure of fear of activity. Three items showed differential item functioning according to employment status, marital status, and angina pectoris, which were not assigned as real item bias by experts and remained in the model.


      Fact-CAD was supported by Rasch analysis as a psychometrically valid scale to evaluate fear of activity in patients with coronary artery disease.

      List of abbreviations:

      BAI (Beck Anxiety Inventory), BDI (Beck Depression Inventory), CAD (coronary artery disease), CR (cardiac rehabilitation), DIF (differential item functioning), MI (myocardial infarction), NHP (Nottingham Health Profile), PA (physical activity), PSI (Person Separation Index), TSK (Tampa Scale for Kinesiophobia)


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        • Chomistek A.K.
        • Manson J.E.
        • Stefanick M.L.
        • et al.
        Relationship of sedentary behavior and physical activity to incident cardiovascular disease: results from the Women's Health Initiative.
        J Am Coll Cardiol. 2013; 61: 2346-2354
        • Sattelmair J.
        • Pertman J.
        • Ding E.L.
        • Kohl 3rd, H.W.
        • Haskell W.
        • Lee I.M.
        Dose response between physical activity and risk of coronary heart disease: a meta-analysis.
        Circulation. 2011; 124: 789-795
        • Apullan F.J.
        • Bourassa M.G.
        • Tardif J.C.
        • Fortier A.
        • Gayda M.
        • Nigam A.
        Usefulness of self-reported leisure-time physical activity to predict long-term survival in patients with coronary heart disease.
        Am J Cardiol. 2008; 102: 375-379
        • Balady G.J.
        • Williams M.A.
        • Ades P.A.
        • Bittner V.
        • Comoss P.
        • Foody J.M.
        • et al.
        Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation.
        Circulation. 2007; 115: 2675-2682
        • Anderson L.
        • Thompson D.R.
        • Oldridge N.
        • et al.
        Exercise-based cardiac rehabilitation for coronary heart disease.
        Cochrane Database Syst Rev. 2016; 1: CD001800
        • Gallagher R.
        • Neubeck L.
        • Du H.
        • et al.
        Facilitating or getting in the way? The effect of clinicians' knowledge, values and beliefs on referral and participation.
        Eur J Prev Cardiol. 2016; 23: 1141-1150
        • Stewart R.
        • Held C.
        • Brown R.
        • et al.
        Physical activity in patients with stable coronary heart disease: an international perspective.
        Eur Heart J. 2013; 34: 3286-3293
        • Tokgözoğlu L.
        • Kaya E.B.
        • Erol Ç.
        • Ergene O.
        EUROASPIRE III: a comparison between Turkey and Europe.
        Arch Turk Soc Cardiol. 2010; 38: 164-172
        • Karapolat H.U.
        • Kurtais Y.
        • Tur B.S.
        • et al.
        What do patients really know about cardiopulmonary rehabilitation: a cross-sectional survey study.
        Eur J Phys Rehabil Med. 2012; 48: 223-230
        • Dunlay S.M.
        • Witt B.J.
        • Allison T.G.
        • et al.
        Barriers to participation in cardiac rehabilitation.
        Am Heart J. 2009; 158: 852-859
        • Rogerson M.C.
        • Murphy B.M.
        • Bird S.
        • Morris T.
        "I don't have the heart": a qualitative study of barriers to and facilitators of physical activity for people with coronary heart disease and depressive symptoms.
        Int J Behav Nutr Phys Act. 2012; 9: 140
        • Fernandez R.S.
        • Salamonson Y.
        • Juergens C.
        • Griffiths R.
        • Davidson P.
        Development and preliminary testing of the Cardiac Rehabilitation Enrolment Obstacles (CREO) scale: implications for service development.
        Eur J Cardiovasc Nurs. 2008; 7: 96-102
        • Grace S.L.
        • Gravely-Witte S.
        • Brual J.
        • et al.
        Contribution of patient and physician factors to cardiac rehabilitation enrollment: a prospective multilevel study.
        Eur J Cardiovasc Prev Rehabil. 2008; 15: 548-556
        • Koho P.
        • Borodulin K.
        • Kautiainen H.
        • Kujala U.
        • Pohjolainen T.
        • Hurri H.
        Finnish version of the Tampa Scale of Kinesiophobia: reference values in the Finnish general population and associations with leisure-time physical activity.
        J Rehabil Med. 2015; 47: 249-255
        • Blanchard C.M.
        • Reid R.D.
        • Morrin L.I.
        • et al.
        Correlates of physical activity change in patients not attending cardiac rehabilitation.
        J Cardiopulm Rehabil. 2006; 26: 377-383
        • Back M.
        • Cider A.
        • Herlitz J.
        • Lundberg M.
        • Jansson B.
        The impact on kinesiophobia (fear of movement) by clinical variables for patients with coronary artery disease.
        Int J Cardiol. 2013; 167: 391-397
        • Lapier T.K.
        • Cleary K.
        • Kidd J.
        Exercise self-efficacy, habitual physical activity, and fear of falling in patients with coronary heart disease.
        Cardiopulm Phys Ther J. 2009; 20: 5-11
        • Aldcroft S.A.
        • Taylor N.F.
        • Blackstock F.C.
        • O'Halloran P.D.
        Psychoeducational rehabilitation for health behavior change in coronary artery disease: a systematic review of controlled trials.
        J Cardiopulm Rehabil Prev. 2011; 31: 273-281
        • Marcus B.H.
        • Dubbert P.M.
        • Forrsyth L.A.
        • et al.
        Physical activity behavior change: issues in adoption and maintenance.
        Health Psychol. 2000; 19: 32-41
        • Kaminsky L.A.
        • Brubaker P.H.
        • Guazzi M.
        • et al.
        Assessing physical activity as a core component in cardiac rehabilitation: a position statement of the American Association of Cardiovascular and Pulmonary Rehabilitation.
        J Cardiopulm Rehabil Prev. 2016; 36: 217-229
        • Lundberg M.
        • Grimby-Ekman A.
        • Verbunt J.
        • Simmonds M.J.
        Pain-related fear: a critical review of the related measures.
        Pain Res Treat. 2011; 2011: 494196
        • Back M.
        • Jansson B.
        • Cider A.
        • Herlitz J.
        • Lundberg M.
        Validation of a questionnaire to detect kinesiophobia (fear of movement) in patients with coronary artery disease.
        J Rehabil Med. 2012; 44: 363-369
        • Acar S.
        • Savci S.
        • Keskinoglu P.
        • et al.
        Tampa Scale of Kinesiophobia for Heart Turkish Version Study: cross-cultural adaptation, exploratory factor analysis, and reliability.
        J Pain Res. 2016; 9: 445-451
        • Karmali K.N.
        • Davies P.
        • Taylor F.
        • Beswick A.
        • Martin N.
        • Ebrahim S.
        Promoting patient uptake and adherence in cardiac rehabilitation.
        Cochrane Database Syst Rev. 2014; 6: CD007131
        • Brubaker P.H.
        Steps for improving physical activity orientation among health-care providers of older cardiovascular patients.
        Curr Geriatr Rep. 2014; 3: 291-298
        • Linacre J.M.
        Sample size and item calibration stability.
        Rasch Meas Trans. 1994; 7: 328
        • Kucukdeveci A.A.
        • McKenna S.P.
        • Kutlay S.
        • Gursel Y.
        • Whalley D.
        • Arasil T.
        The development and psychometric assessment of the Turkish version of the Nottingham Health Profile.
        Int J Rehabil Res. 2000; 23: 31-38
        • Ulusoy M.
        • Sahin N.H.
        • Erkmen H.
        Turkish Version of the Beck Anxiety Inventory: Psychometric Properties.
        J Cogn Psychother. 1998; 12: 163-172
        • Hisli N.
        Beck depresyon envanterinin geçerliği üzerine bir çalışma [Validity Study of the Beck Depression Inventory] [Turkish].
        Turk J Psychol. 1988; 6: 118-122
        • Rasch G.
        Probabilistic models for some intelligence and attainment tests.
        University of Chicago Press, Chicago1960 (reprinted 1980)
        • Andrich D.
        Rasch models for measurement.
        SAGE Publications, London1988
        • Elhan A.H.
        • Oztuna D.
        • Kutlay S.
        • Kucukdeveci A.A.
        • Tennant A.
        An initial application of computerized adaptive testing (CAT) for measuring disability in patients with low back pain.
        BMC Musculoskelet Disord. 2008; 9: 166
        • Tennant A.
        • Penta M.
        • Tesio L.
        • et al.
        Assessing and adjusting for cross-cultural validity of impairment and activity limitation scales through differential item functioning within the framework of the Rasch model: the PRO-ESOR project.
        Med Care. 2004; 42: I37-48
        • Cronbach L.
        Coefficient alpha and the internal structure of tests.
        Psychometrika. 1951; 16: 297-334
        • Andrich D.L.
        • Sheridan B.
        • Luo G.
        RUMM2020: Rasch unidimensional measurement models software.
        RUMM Laboratory, Perth2003
        • Evans J.D.
        Straightforward statistics for the behavioral sciences.
        Brooks/Cole Publishing Company, Pacific Grove1996
        • Frei A.
        • Williams K.
        • Vetsch A.
        • et al.
        A comprehensive systematic review of the development process of 104 patient-reported outcomes (PROs) for physical activity in chronically ill and elderly people.
        Health Qual Life Outcomes. 2011; 9: 116
        • Senol-Durak E.
        • Belgin Ayvasik H.
        Factors associated with posttraumatic growth among the spouses of myocardial infarction patients.
        J Health Psychol. 2010; 15: 85-95
        • Kim H.S.
        • Sherman D.K.
        • Taylor S.E.
        Culture and social support.
        Am Psychol. 2008; 63: 518-526
        • Post M.W.
        What to do with "moderate" reliability and validity coefficients?.
        Arch Phys Med Rehabil. 2016; 97: 1051-1052
        • Condon C.
        • McCarthy G.
        Lifestyle changes following acute myocardial infarction: patients perspectives.
        Eur J Cardiovasc Nurs. 2006; 5: 37-44
        • Tulloch H.
        • Reida R.
        • D'Angeloa M.S.
        • et al.
        Predicting short and long-term exercise intentions and behaviour in patients with coronary artery disease: a test of protection motivation theory.
        Psychol Health. 2009; 24: 255-269
        • Grace S.L.
        • Gravely-Witte S.
        • Brual J.
        • et al.
        Contribution of patient and physician factors to cardiac rehabilitation referral: a prospective multilevel study.
        Nat Clin Pract Cardiovasc Med. 2008; 5: 653-662