The purpose of this study is to determine the effectiveness of a group cognitive-behavioral
treatment to modify coronary-prone behaviors in patients from a fairly low social and
educational level. Participants were 98 male coronary patients randomly allocated to one
experimental and two control groups. All groups received standard medical treatment.
The experimental group received an additional psychological treatment and one of the
two control groups received a health education treatment. Results showed that only the
psychological treatment group significantly reduced Pressured Drive and Speed-Impatience
after treatment, and at 1- and 2-year follow-ups. Depression was also significantly reduced
only in this group at 2-year follow-up. The results are considered a reliable first step in
the process of validating this program designed to improve coronary heart disease patients’
quality of life.
Keywords: coronary patients, coronary-prone behaviors, depression, low socio-economic
status, cognitive-behavioral treatment, Type A behavior
Este estudio pretende conocer la efectividad de un tratamiento cognitivo-conductual
aplicado a grupos de enfermos coronarios de un nivel educativo y status social
predominantemente bajo para modificar conductas prono-coronarias. Método: La
distribución de los 98 varones enfermos coronarios en un grupo experimental y dos de
control se realizó al azar. Los tres grupos recibieron el tratamiento médico estándar. El
grupo experimental recibió adicionalmente un tratamiento psicológico y uno de los dos
grupos de control recibió además un programa de educación para la salud. Los resultados
mostraron que sólo el grupo que recibió el tratamiento psicológico redujo significativamente
su Comportamiento Apresurado y su Prisa-Impaciencia después del tratamiento y durante
los dos años de seguimiento posteriores al tratamiento. La depresión también se redujo
sólo en este grupo tras los dos años de seguimiento. Los resultados se consideran un
primer paso fiable en el proceso de validar este programa diseñado para mejorar la
calidad de vida de los pacientes coronarios.
Palabras clave: pacientes coronarios, conductas prono-coronarias, depresión, estatus
socio-económico bajo, tratamiento cognitivo-conductual, conducta tipo A
Modification of Coronary-Prone Behaviors in Coronary Patients
of Low Socio-Economic Status
Antonio del Pino
1
, Mª Teresa Gaos
1
, Ruth Dorta
1
, and Martín García
2
1
La Laguna University
2
Cardiology Service of La Laguna University Hospital
The Spanish Journal of Psychology Copyright 2005 by The Spanish Journal of Psychology
2005, Vol. 8, No. 1, 68-78 1138-7416
This study was financed by the Autonomous Government of the Canary Islands. We gratefully acknowledge Margaret Gillon Dowens
and Dulce Mª Rodríguez for their revision of the English text and the anonymous reviewers for their suggestions. We are also indebted
to M. Friedman and the co-workers of the San Francisco Coronary/Cancer Prevention Project and acknowledge their influence, particularly
concerning procedure.
Correspondence concerning this article should be addressed to: Antonio del Pino, Department of Personality, Assessment, and
Psychological Treatments. La Laguna University. Campus de Guajara, 38205. La Laguna. Islas Canarias (Spain). E-mail: apino@ull.es
68
The results of the psychological interventions carried out
until fifteen years ago for the type A behavior pattern and for
coronary heart disease were reflected in the meta-analysis of
Nunes, Frank, and Kornfeld (1987). The effect sizes of the
Type-A behavior pattern (TABP) change ranged from 0.02 to
1.27, with a mean of 0.61. No single treatment modality could
be considered efficacious, although the change of the TABP
effect size did correlate positively and significantly with the
number of treatment modalities used, and the combination of
an educational component, a coping method, either relaxation
or cognitive therapy, and a behavioral rehearsal achieved the
most significant TABP changes. Fernández-Abascal, Martín,
and Domínguez (2003) reviewed this issue in detail.
Linden, Stossel, and Maurice (1996) found in their meta-
analysis that the addition of psychosocial treatment to
standard cardiac rehabilitation regimes reduced psychological
distress during the first 2 years and that the patients who did
not receive psychosocial treatment had greater mortality and
cardiac recurrence rates during the first 2 years of follow-
up. The meta-analysis of Dusseldorp, van Elderen, Maes,
Meulman, and Kraaij (1999) examined the effects of
psychoeducational programs for coronary heart disease (CHD)
patients. The results suggest positive distal effects (34%
reduction in cardiac mortality, and 29% reduction in
recurrence of myocardial infarction) and significant positive
effects on proximal targets such as blood pressure, cholesterol,
and smoking behavior, but not on anxiety or depression.
The authors of these meta-analyses point out that these
programs should be adapted to the characteristics of different
groups of patients, especially groups of low socio-economic
status (Smith, Kendall, & Keefe, 2002), and the priority of
discovering the active components of the programs, so as to
reduce their duration and improve cost-benefit relationships.
The present study is an attempt to validate a treatment
program. While we acknowledge the influence, particularly
concerning procedure, of M. Friedman and co-workers from
the San Francisco Coronary/Cancer Prevention Project,
however, our theoretical perspective is closer to the
cognitive-behavioral orientation of Roskies (1987).
The aim of this study is to determine the effectiveness
of a cognitive-behavioral intervention trial to modify
coronary-prone behaviors, specifically the TABP components,
in people from a fairly low social and educational level who
have suffered from angina pectoris and/or myocardial
infarction. Using the treatment package strategy (Kazdin,
& Wilson, 1978), we began by elaborating a wide spectrum
cognitive-behavioral treatment package, so that in subsequent
research this treatment package could be dismantled.
Method
Sample and Selection Procedure
The sample was composed of males treated in the
University Hospital of the Canary Islands. The climate of
this region is mild and the life-style largely rural, the most
important economic activities involving service to the tourism
industry. The pace of life in the islands is, therefore, rather
slower than in more industrialized areas.
All the patients treated in the Cardiologist Service between
the years 1992-1995 were given information about secondary
prevention of CHD by a cardiologist and were invited to
participate in the project if they fulfilled the following three
conditions: (a) reliably documented evidence of CHD (in
most cases after catheterization), (b) no recommendation of
immediate surgical intervention, and (c) no medical or
psychological co-morbidity requiring individual intervention.
The project was developed in three stages or years. At
the beginning of each year, a meeting was organized with
the first 60 coronary patients who fulfilled the eligibility
requirements and had expressed interest in the project while
in hospital. At this meeting, the patients were given a short
explanation of the advantages of participating in a
Psychological Treatment (PsT) program or a Health
Education Treatment (HET) program to prevent reoccurrence
of coronary episodes. The need for participants in the control
group, who received only the University Hospital standard
medical treatment (SMT) program for coronary patients was
also explained, as was the calendar of the treatment programs
and the responsibilities acquired by the participants.
After this meeting, the research team allocated the
participants to the various groups. The first 40 volunteers
were allocated at random either to the PsT or the HET
groups, and the last 20 to volunteer, or those who would
have had difficulty in attending the treatment sessions at
that time, were assigned to the SMT control group. The
research design thus involved one experimental group, which
received the SMT and the PsT, and two control groups, one
that received both the SMT and the HET, and the other that
received only the SMT. This latter group was, in fact, a
waiting-list control group, as the members had the
opportunity to participate in the psychological or educational
treatment groups in subsequent years of the project.
At a second meeting, the patients who were still
interested in the program filled out a form with their personal
data and signed their free consent to participate and to
acknowledge their awareness of the commitment they
assumed as participants. In this session, the nurses and the
psychologists in charge of the treatments and a physician
acting for the University Hospital also signed the
responsibilities that each assumed. The participants also
filled in the psychological tests and questionnaires. After
this session, the psychologist in charge of the program had
an individual meeting with each participant to inform them
to which group they had been assigned.
In the first year of the project, both the PsT and HET
groups were randomly drawn and allocated, but the resulting
differences in education within the generally low educational
level of the groups made it difficult to carry out the treatment
programs and to achieve intragroup interaction.
MODIFICATION OF CORONARY-PRONE BEHAVIORS
69
DEL PINO, GAOS, DORTA, AND MARTÍN
70
Therefore, in the following years, we decided to employ
stratified allocation. Two groups were formed according to
educational level, they were assigned a treatment program
at random, and this was alternated the following year.
Each year, there was the same number of patients in
the SMT control group as in the PsT and HET groups. The
total size of the sample was exclusively determined by the
number of volunteers, as information about the program
was given to all the patients of the Cardiology Service during
the 3-year duration of the project.
Instruments
The dependent variables were assessed in group by the
first author of this paper, assisted by a minimum of three
collaborating psychologists. The Structured Interview was
necessarily carried out individually.
The Framingham Type-A Scale (FTAS; Haynes, Levine,
Scotch, Feinleib, & Kannel, 1978). This scale measures
Pressured Drive and Competitiveness/Impatience (Houston,
Smith, & Zuraswski, 1986; del Pino, Gaos, & Dorta, 1997).
We used the version translated and adapted by del Pino,
Borges, Díaz, Suárez, and Rodríguez (1990).
The Structured Interview (SI; Chesney, Eagleston, &
Rosenman, 1980). The SI was applied as indicated in del
Pino, Gaos, and Dorta (1999). The SI is made up of three
factors (Competitiveness/Hard Driving, Anger-Out, and
Speed/Impatience). All the interviews were carried out by
two trained collaborators and the recordings of the interviews
were evaluated by a person who was ignorant of the research
project and specially trained for this evaluation task.
The Multidimensional Anger Inventory (MAI; Siegel,
1986). A version translated and adapted by Sánchez-Elvira,
Pérez, and Bermúdez (1991) was employed. This
questionnaire evaluates four factors (Anger/Arousal, Hostile
Outlook, Anger-In, and Anger-Out) and a Total Anger Scale
calculated by adding the individual’s scores over the four
factors.
The Beck Depression Inventory (BDI; Beck, Ward,
Mendelson, Mock, & Erbaugh, 1961). We used the Spanish
adapted translation by Conde, Esteban, and Useros (1976).
Procedure
The total number of sessions and general training
procedure were the same in the PsT and the HET groups.
The PsT, summarized in del Pino (1998), consisted of
five parts:
1. Introduction to CHD and its contributing factors.
2. Tension control, including: (a) physical tension,
particularly relaxation practice; (b) behavioral tension
(time urgency); (c) modification of dysfunctional
thoughts, substituting them with productive thinking;
and (d) modification of negative emotions (anger-
hostility and frustration).
3. Stress management, working on recognition of
personal triggers and on how to cope with stressful
situations.
4. Planning and learning to enjoy events to reduce
tension and stress.
5. Lifestyle change as a lifetime aim.
The content and homework for each session and
suggestions for the participants were provided in the
Participant’s Guide, which was given to all the participants
in the PsT. All training sessions were directed and taught
by the first author of this article, with the collaboration of
the same three psychologists during the 3-year project. To
ensure the integrity and quality of the treatment, a Therapist’s
Guide was compiled.
The HET consisted of the following modules:
1. Heart anatomy and physiology.
2. CHD: a) clinical manifestations and treatment
modalities, b) signs and alarm symptoms, c) risk
factors.
3. Recommended lifestyle, including advice about
changing diet and certain patterns of coronary-prone
behaviors.
4. Medication: dosage conditions and effects.
The HET program was taught by a team of three nurses
who are teachers from the University of La Laguna School
of Nursing.
The 90-minute sessions involved an oral presentation
backed up by audiovisual material, followed by a question-
and-answer period. At the end of each session, the group
leaders gave out homework that was checked at the
beginning of the following session with the patients’ active
participation.
Both HET and the PsT were carried out in 24 group
sessions over a 9-month period, 12 meetings during the first
3 months, and 12 meetings during the following 6 months.
In the 10 months following the treatment programs, there
were 10 sessions (once a month) to maintain the effects of
the treatments.
Each group was comprised of a number of people that
ranged between a maximum of 12 and a minimum of 8.
Data Analysis
The effects of the treatment were analyzed by a repeated
measures general linear model. The results at 1 year were
analyzed by a 3 2 factorial design, with one between-
group factor with three levels (PsT, HET, and SMT) and
one within-group factor (the time of measure, with two
times: before and after treatment). The treatment effects,
including the 2 years of follow-up, were analyzed using a
2 4 design with one between-group factor with two levels
(PsT and HET) and one within-group factor with four levels
(times of measure: before treatment, after concluding
treatment, and at 1- and 2-year follow-up). All analyses were
carried out using the SPSS 10.0 computer program.
Results
The recruitment process and the results of this can be
seen in Diagram I.
Average attendance across the 24 sessions of the
program in the PsT group was 20.64 (86% of the sessions)
and 19.68 (82%) in the HET group, with a range of
attendance in each group of 12-24 individuals. Dropouts
in the treatment groups were those who did not attend
50% of meetings. In the control group, we included as
dropouts those who only filled in all the questionnaires
once.
MODIFICATION OF CORONARY-PRONE BEHAVIORS
71
Diagram 1. Selection Procedure and Distribution of the Sample.
No follow-up
Analysed after:
1-year follow-up: n = 23
2-year follow-up: n = 19
Analysed after:
1-year follow-up: n = 23
2-year follow-up: n = 18
Analysed after 1 year: n = 22
No 2-year follow-up
Allocated to intervention (n = 33)
Received intervention
for 1 year (n = 23)
Dropouts (n = 10)
1-year follow-up: n = 19
2-year follow-up: n = 19
Lost to follow-up: (n = 4)
Reasons: 1 died
1 moved away
2 dropouts
1-year follow-up: n = 18
2-year follow-up: n = 18
Lost to follow-up (n = 5)
Reasons: 2 died
2 moved away
1 dropout
Allocated to intervention (n = 33)
Received intervention
for 1 year (n = 23)
Dropouts (n = 10)
Allocated to assessment (n = 32)
Assessed dependent variables
after 1 year (n = 22)
Dropouts (n = 10)
Assessed for eligibility:
(n = 493)
Attended first informative meeting
(n = 111)
Eligible and willing to participate
when in hospital
(n = 219)
Psychological Treatment Health Education Treatment Waiting List Control
Participants at the second meeting
who filled in the tests and signed
free consent (n = 98)
Excluded (n = 274):
Did not meet inclusion criteria (n = 246)
Refused to participate (n = 19)
Other reasons (n = 9)
DEL PINO, GAOS, DORTA, AND MARTÍN
72
Analyses of the proportional distribution of the
demographic and clinical characteristics of the three groups
(68 participants) and of these 68 participants compared to
the 30 dropouts can be seen in Table 1.
As can be observed, the 68 participants of the three
groups were homogeneous in all variables except for age.
The participants of the PsT group were younger than those
of the control groups, which did not differ in this variable.
The age difference among groups was not associated with
statistically significant differences in the dependent variables
studied.
Comparisons of the 68 completers and the 30 dropouts
did not show significant differences in any of the descriptors
of the groups.
Table 1
Demographic and Clinical Background of Experimental Groups
Total
Receptors of intervention Completers Noncompleters
(n = 68) (n = 30)
Psychological Health Education Control Analysis Analysis
(n = 23) (n = 23) (n = 22)
Variable n % n % n % χ
2
(df) n% n% χ
2
(df)
Occupational status 11.20(6) 5.26(3)
Executives 3 13 7 30 1 4 11 16 10 33
Self-employed 8 35 6 26 3 14 17 25 8 27
Clerical 4 17 2 9 3 14 9 13 1 3
Manual Workers 8 35 8 35 15 68 31 46 11 37
Employment status 6.47(4) 1.40(2)
Retired 4 17 5 22 7 32 16 24 9 30
Sick Leave/Unemployed 11 48 16 69 9 41 36 52 12 40
Employed 8 35 2 9 6 27 16 24 9 30
Educational level 8.92(4) 0.01(2)
No studies 3 13 9 39 11 50 23 34 10 34
Eighth grade 12 52 8 35 9 41 29 42 13 43
High school /Graduate 8 35 6 26 2 9 16 24 7 23
Marital status 0.28(2) 0.19(1)
Married 20 87 21 91 20 91 61 90 26 87
Other 3 13 2 9 2 9 7 10 4 13
Smoking status 1.62(4) 0.06(2)
Current smoker 12 52 13 56 9 41 34 50 16 53
Previous smoker 10 44 8 35 11 50 29 43 12 40
Never smoker 1 4 2 9 2 9 5 7 2 7
Arteries with Significant
Stenosis
a
3.40(4) 0.51(2)
1 6 35 4 24 6 37.5 16 32 5 24
2 8 47 6 35 4 25.0 18 36 9 43
3 3 18 7 41 6 37.5 16 32 7 33
M SDM SDM SDF
(2,.65) M SD M SD t(96)
Age 49.65 8.22 6.70 7.19 58.09 5.45 9.31*** 54.76 7.90 52.90 6.27 1.14
FTAS 0.55 0.26 0.51 0.25 0.47 0.23 0.59 0.51 0.24 0.45 0.29 1.03
SI 90.00 9.01 90.42 9.21 90.04 7.12 0.02 90.15 8.36 90.43 15.98 –0.16
MAI 86.04 17.29 85.70 17.92 78.36 20.43 1.22 83.44 18.63 81.50 15.83 0.50
BDI 11.87 6.86 14.52 6.43 16.18 5.44 2.71 14.16 6.44 13.90 7.40 0.17
Note. FTAS: Framingham Type A Scale; SI: Structured Interview; MAI: Multidimensional Anger Inventory; BDI: Beck Depression Inventory.
a
Data not available for all of the patients in the study.
*** p < .001.