Regular physical exercise is a part of a healthy lifestyle and is beneficial to physical and mental health. Many studies have shown that exercise can improve blood glucose, blood lipid and blood pressure, and reduce the impact of depression and stress on the human body, which leads to a healthy lifestyle and improved quality of life [1, 2, 3, 4, 5]. Moderate physical activity can also reduce the incidence of cardiovascular disease and adverse heart events [6, 7], and can lead to a substantial drop in all-cause mortality [8]. Exercise-based cardiac rehabilitation has been shown to improve outcomes in patients suffering from cardiovascular disorders such as coronary heart disease, atrial fibrillation, heart failure, and the need for cardiac resynchronization treatment [9, 10, 11, 12]. Aortic dissection (AD) is a pathological condition in which blood from an aortic intimal tear enters the aortic media and extends down the long axis of the aorta, resulting in the formation of true and false aortic lumens. Previous research has demonstrated that regular exercise is both safe and useful for AD patients [13, 14, 15, 16, 17]. Patients with AD are advised to perform light to moderate aerobic exercise (3-5METs) for at least 30 minutes for a total of 150 minutes/week to reduce resting blood pressure [18]. Competitive sports and isometric heavy weightlifting should be discouraged [18]. However, patients with AD may not exercise because of pain, fear of accidents during exercise, worries about disease recurrence, and other reasons [19]. Thus, it is very important to understand the attitudes and intentions of AD survivors before the formation of specific exercise programs and guidelines. Exercise attitude refers to the individual’s cognition, emotion and behavior tendency to exercise behavior, and the degree of positive or negative evaluation of behavior performance [20, 21]. Behavior intention is defined as an individual’s tendency to take exercise behavior. It is a cognitive activity that reflects an individual’s willingness and conscious plan to engage in the behavior [22, 23]. There is a link between attitude and behavior. Previous studies have shown that attitudes and beliefs are essential for individuals to accept and adhere to exercise [24, 25]. In order to promote positive health behavior and control health risk behavior, health psychologists have developed several relevant theoretical models of health behavior change, including the continuous theoretical model and the stage theoretical model. In 1992, Schwarzer proposed the Health Action Process Approach (HAPA) hypothesis [26]. This theory integrates the relevant concepts in the continuous theoretical model and the stage theoretical model. In HAPA, healthy behavior change is viewed as a continuous change process that includes the initiation, maintenance, and recovery of behavior. The theoretical model is built around behavior intention as an essential determinant of health behavior. The goal of the study is to create a questionnaire according to the HAPA theory to evaluate the attitudes and behavior intentions of AD patients about exercise, as well as to verify its reliability and validity, so as to provide a basis for personalized phased intervention programs in the future, boost patient rehabilitation, and increase post-operative quality of life.

There were two phases to the study between April 2021 and April 2022: (1) focusing on the development of Exercise Attitudes and Behavior Intentions Questionnaire (EABIQ) to create a pool of items (Phase I) and (2) testing the reliability and validity of the EABIQ (Phase II).

To our knowledge, this is the first survey to examine AD survivors’ views on exercise and behavior intentions. The theoretical framework of this study was based on the work of Schwarzer [26]. We developed the scale as a result of a thorough procedure including focus groups, interviews, expert advice, and quantitative psychometric testing. Eventually, 62 items were retained. According to the HAPA theory put forward by Schwarzer in 1992 [26], combined with the results of EFA, we divided the questionnaire into 11 dimensions, including possibility of risk, severity of risk, controllability of risk, positive outcome expectations, negative outcome expectations, behavior intentions, implementation intention, action self-efficacy, maintaining self-efficacy, recovery self-efficacy and social support. The results of EFA showed that action planning and coping planning were in the same dimension, so we combined the two into one dimension (implementation intention). In addition, in contrast from the HAPA theory, we found that social support was a very important factor for the persistence of exercise behavior in the interview process [19], so we added the dimension of social support to measure EABIQ. The modified questionnaire items were clear and easy to understand following a pilot study and formal investigation. With the help and guidance of researchers, the patients spent about 15–20 minutes to complete the questionnaire, which was acceptable to the researchers. This questionnaire enabled us to have a more comprehensive understanding of the attitudes, intentions and influencing factors of patients with AD towards exercise, to provide personalized exercise guidance and develop programs for patients with different psychological characteristics.

This study included a questionnaire survey involving 160 AD patients. Four methods were used for item analysis. Only item J6 did not meet the standard and was excluded after expert discussion. To guarantee the uniformity of the scale’s objectives. D7, D8, and E4 were eliminated by EFA, and the final 11 common factors’ total variance contribution rate was 75.216 percent. Each scale dimension’s correlation coefficient ranged from 0.405 to 0.785, suggesting adequate scale homogeneity. The Cronbach’s alpha for the entire scale was 0.929, and the alpha for each domain ranged from 0.835 to 0.965. The split-half reliability coefficient for the entire scale was 0.960, as well as the split-half reliability coefficient for each domain ranged from 0.844 to 0.962, indicating that the scale has good internal consistency and reliability. The questions were added to and adjusted following the Delphi survey’s two iterations; the I-CVI for the EABIQ varied from 0.813 to 1.000, and the S-CVI/Ave was 0.934. This showed that the content and distribution of each item were reasonable and highly recognized by experts [42]. By comparing two time points separated by two weeks, the Pearson’s correlation coefficient was used to determine the test-retest reliability [43]. However, because the patient’s condition was relatively stable at the time of the questionnaire survey, and most had been discharged when asked again two weeks later, retest reliability was not employed in this survey.

This new instrument demonstrated satisfactory psychometric properties for measuring exercise attitudes and behavior intentions for AD patients. This study has several limitations. The participants were all from Wuhan, China’s third-class Class A hospital. Patients with type B aortic dissection were significantly greater than those with type A aortic dissection. These findings may not be representative of all Chinese patients. Future studies will need to be conducted in multiple centers, with a larger and more diverse patient population to further evaluate the adaptability of the questionnaire. Furthermore, the questionnaire involves multiple dimensions of psychological measurements, but the relationship and interaction between various dimensions are not clear, which needs to be further verified in larger trials.

Promoting the rehabilitation of patients with AD and improving the quality of life after surgery are crucial in these patients. This study used a 62-item questionnaire based on the HAPA theory to understand the attitudes and behavior intentions of AD patients toward exercise, which was found to have good reliability and validity. The questionnaire is not only a judgment tool to measure the exercise behavior for AD patients, but also provides a basis for the medical staff to provide phased and individualized intervention programs, so as to better promote enhanced and sustained recovery for AD patients.

DNF, SFH and XRL designed the research study. DNF and SFH performed the research. XRL, YCL and KXZ provided help and advice on the research. DNF analyzed the data. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.

The Medical Ethics Committee of the Tongji Medical College, Huazhong University of Science & Technology, China, approved this study and it was carried out in compliance with the Declaration of Helsinki (approval number: TJ-IRB20191221).

The authors acknowledge the role of all support staff in the study and thanks to all the peer reviewers for their opinions and suggestions.

This research was funded by National Natural Science Foundation of China (Project 71874063) and the Fundamental Research Funds for the Central Universities (HUST: YCJJ202201055).

The authors declare no conflict of interest.