521926

research-article2014

CNU0010.1177/1474515114521926European Journal of Cardiovascular NursingChen et al.

EUROPEAN
SOCIETY OF
CARDIOLOGY

Original Article

Physical self-concept and its link to

cardiopulmonary exercise tolerance
among adolescents with mild congenital
heart disease

European Journal of Cardiovascular Nursing

2015, Vol. 14(3) 206213
The European Society of Cardiology 2014
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1474515114521926
cnu.sagepub.com

Chi-Wen Chen1, Wen-Jen Su2, Jou-Kou Wang3, Hsiao-Ling Yang4,

Yueh-Tao Chiang5 and Philip Moons6

Abstract
Background: Due to medical advances, most children with congenital heart disease (CHD) are expected to survive into
adulthood. Establishing adequate physical self-concept and cardiopulmonary tolerance during the adolescent period can
primarily enhance overall well-being.
Aim: The purpose of this study was to undertake a gender-specific evaluation of the domain of physical self-concept
among adolescents with mild CHD, and to examine the relationships between physical self-concept and cardiopulmonary
exercise tolerance among adolescents with mild CHD.
Methods: Four hundred and thirteen adolescents 1220 years of age, whose cardiologists had not recommended any
limitation of exercise, completed Physical Self-Description Questionnaires and three-minute step tests in two outpatient
cardiology departments.
Results: The male participants had significantly greater scores in measures of overall physical self-concept, competence
in sports, physical appearance, body fat, physical activity, endurance, and strength than did the female participants. More
than 80% of the participants had at least an average cardiopulmonary exercise tolerance index. The perception of not
being too fat and being more physically active were significant correlates of better cardiopulmonary exercise tolerance
for adolescents with mild CHD.
Conclusions: The results provided evidence for gender-specific evaluation of domains of physical self-concept among
adolescents with mild CHD. The three-minute step test to measure cardiopulmonary exercise tolerance in adolescents
with mild CHD may be an appropriate objective measure for use in future research. Continued efforts are needed in
early intervention to promote cardiopulmonary exercise tolerance.
Keywords
Physical self-concept, cardiopulmonary tolerance, adolescents, congenital heart disease
Date received: 23 October 2013; revised: 6 January 2014; accepted: 9 January 2014

Introduction

1Department

The birth prevalence of congenital heart disease (CHD)

worldwide has been 9.1 per 1000 live births in the past 20
years.1 The highest reported total CHD birth prevalence is
found in Asia (9.3 per 1000 live births).1 Significant
advances in cardiac surgery and postoperative care have led
to an almost 90% rate of survival into adulthood for affected
individuals.2 Some adolescents have cardiac defects that
may result in significant challenges in developing a positive self-image because of activity restrictions and altered

of Nursing, Fu-Jen Catholic University, Taiwan

of Pediatric, Chang Gung Childrens Hospital, Taiwan
3Department of Pediatrics, National Taiwan University, Taiwan
4School of Nursing, National Taiwan University, Taiwan
5Graduate Institute of Clinical Medical Sciences, Chang Gung
University, Taiwan
6KU Leuven Department of Public Health and Primary Care, KU
Leuven-University of Leuven, Belgium
2Department

Corresponding author:
Chi-Wen Chen, Department of Nursing, Fu-Jen Catholic University,
510 Chung-Cheng Rd, Hsin-Chuan, New Taipei, 24205, Taiwan.
Email: 039761@mail.fju.edu.tw

Downloaded from cnu.sagepub.com at Airlangga University on September 4, 2015

207

Chen et al.
exercise capacity. However, little is known about their
views on physical self-concept and how that relates to levels of cardiopulmonary exercise tolerance.
Physical self-concept is considered to be a subdomain
of the overall self-concept. This latter entity also entails
family, school, and emotional self-concepts.3 The physical
self-concept in itself is also multidimensional, and incorporates different characteristics, such as appearance,
health, strength, body fat, and physical activity.4,5 This
self-perception plays an important role in participation in
physical activity 6,7 and physical fitness,8 especially during
adolescence. Several studies have demonstrated sex differences in physical self-concept among children and adolescents;812 boys generally have higher scores than do girls,
predominantly in subdomains, such as sport competence,
strength, and endurance.812 This means that genderspecific approaches are required in the study of physical
self-concept.
Physical self-concept is an insufficiently studied
aspect of CHD. To the best of our knowledge, few studies have explicitly investigated the patients physical
self-concept.3,13 Not surprisingly, the physical selfconcept of school-aged children with CHD is significantly worse than that of children from the general population;3 however, the physical self-concept of adolescent
boys with CHD is unexpectedly better than that of their
healthy counterparts.13 It is, however, not known to what
extent the physical self-concept stimulates or hampers
adolescents with CHD in engagement in physical activity, and thus in maintaining physical fitness. One prior
study concluded that of physical function was overestimated in adult patients when compared with actual exercise test results.14 If there is a relationship between the
physical self-concept and exercise tolerance in adolescents with CHD, this could be a target for interventions,
because the physical self-concept is a modifiable factor.
In that case, interventions focusing on the physical selfconcept of patients could have an impact on the physical
fitness throughout the patients life. This is particularly
important for individuals in whom there are no medical
reasons to restrict activity.
Therefore, the present study aimed (a) to undertake a
gender-specific evaluation of the physical self-concept
among adolescents with mild CHD and (b) to examine the
relationships between physical self-concept and cardiopulmonary exercise tolerance.

Methods
Participant recruitment
All patients with mild CHD treated in the pediatric cardiology outpatient departments of two medical centers in
northern Taiwan in JulyAugust, 2010, who met the
inclusion and criteria, were approached to participate in

this study. Patients were eligible for inclusion if they

were 1220 years of age, and had been diagnosed with
mild CHD. Mild CHD in this study was defined as being
able to exercise with no limits, and being in class I of the
New York Heart Association classification, as scored by
cardiologists. The exclusion criteria were: chromosomal
aberrations, extracardiac malformations, pregnancy, regular medication on diuretics, cardiotonics, angiotensinconverting enzyme inhibitor or beta-blockers, a
pacemaker, an implantable cardioverter defibrillator
(ICD), and hospitalization or cardiac catheterization
within the last year.

Measures
Physical self-concept was measured by the Physical SelfDescription Questionnaire (PSDQ).15 The PSDQ consists
of a set of 54 items that assesses nine dimensions of sports
competence, appearance, body fat, health, flexibility,
physical activity, self-esteem, endurance, and strength. A
six-point Likert scale was used, with responses ranging
from false to true. On this scale, 17 negatively worded
items were scored inversely. Means were calculated for the
total score and subscale scores, all ranging from 16, with
a higher score representing a more positive self-concept.
The psychometric properties of the PSDQ have been tested
in diverse cultures.8,11,1520 Internal consistency has been
shown to be adequate with Cronbachs alpha coefficient of
internal consistency on the nine subscales ranging from
0.800.91.15 In the present study, Cronbachs alpha ranged
from 0.75 (health and strength) to 0.91 (sports competence
and body fat) for the subscales, and was 0.94 for the total
scale. The PSDQs validity has been established by its significant relationship to components of physical fitness8,19,21
and other self-concept instruments.5,11
In the present study, we measured cardiopulmonary
exercise tolerance using a three-minute step test, which is
also known as the Harvard Step Test. It is an easy and inexpensive method to screen for cardiopulmonary fitness and
an individuals ability to recover after strenuous exercise.
For its use in young Asian persons, we followed the standard procedure as described by the Sports Affairs Council in
Taiwan.22 A 35 cm (13.8 inch) step was used. A metronome
was set at a rate of 96 beats per min to control the frequencies of stepping up and down. Immediately after the
Harvard Step Test, the heart rate (HR) of each individual
was measured by a finger sensor between 11.5 min
(HR1), 22.5 min (HR2), and 33.5 min (HR3). The cardiopulmonary exercise tolerance index was calculated as
follows: duration of test (s)100/(HR1+HR2+HR3)2.22
The higher the score the better the cardiopulmonary exercise tolerance of the subjects because the score reflects the
speed of recovery from the physical activity. Prior research
has demonstrated that the three-minute step test has acceptable reliability, validity, and objectivity for predicting the

Downloaded from cnu.sagepub.com at Airlangga University on September 4, 2015

208

European Journal of Cardiovascular Nursing 14(3)

cardiopulmonary exercise tolerance of a large population.23,24 In addition, this step test seems to be more appropriate for female, youth, or vulnerable populations.25
In the present study, we compared the cardiopulmonary
exercise tolerance index of each subject with norm-based
cut-off scores from the Sports Affairs Council in Taiwan,
based on their gender and age. This allowed us to categorize our patients into five classes of cardiopulmonary exercise tolerance: very poor, poor, average, good, and very
good levels.

Procedure
This study was approved by the institutional review boards
of the two hospitals, and written informed consent was
obtained from the adolescents and their guardians. After
completing the demographic form and PSDQ, which
required about 15 min, the subjects underwent a step test in
a separate clinic room. In order to monitor the intensity of
exercise, each subject wore a pulse-oximetry monitor on
his/her wrist during the test. In accordance with the recommendations of the Health Promotion Administration,
Ministry of Health and Welfare in Taiwan, 6085% of
maximum predicted heart rate (220age) was defined as
the optimal exercise range. The subjects were instructed to
quit this test at any time if their heart rate exceeded 170
beat/min, and O2 saturation fell below 95%.26 Supplemental
oxygen and an Ambu bag were readily available in case of
emergency.

Data analysis
Data were analyzed using SPSS version 20.0 (SPSS Inc.,
Chicago, Illinois, USA). Descriptive statistics for all key
variables were calculated. The Mann-Whitney test was
used to compare the differences in age and body mass
index (BMI) between female and male participants. Chisquare tests were used to compare the differences in diagnosis, number of heart operations, and level of
participation in physical education between female and
male participants. To analyze the gender differences in
physical self-concept and cardiopulmonary exercise tolerance, we performed multiple regression analysis, with
adjustments for age, diagnosis, and number of heart operations. Furthermore, a hierarchical multivariable linear
regression analysis (enter method) was conducted to
investigate the relationship between the physical selfconcept and cardiopulmonary exercise tolerance index,
adjusted for gender, age, diagnosis, and number of heart
operations. In this analysis, gender, age, diagnosis, and
number of heart operations were entered in block 1, and
the subscale scores of self-concept were entered in block
2. The assumptions of normality and multicollinearity
were met. All tests were two-sided, and the level of significance was set at p<0.05.

Results
Participant characteristics
A total of 413 adolescents with mild CHD (48.4% boys
and 51.6% girls) participated in this study (Table 1). Both
male and female participants ranged in age from 1220
years, with the average age of 15.5 years (standard deviation (SD)=2.64). More than 80% of the participants had
acyanotic heart disease with left-to-right shunt. The most
common acyanotic heart defect was ventricular septal
defect (34.4%); and the most common cyanotic heart
defect was tetralogy of Fallot (11.6%). One hundred and
seventy-nine participants (43.3%) had never undergone
any open-heart surgery. The rest of the participants had
undergone open-heart surgery at preschool age. At least
90% of the participants often participated in physical education class, as a regular school activity for adolescents.
Significant gender differences were found for BMI category, diagnosis, and number of heart operations.

Physical self-concept and cardiopulmonary

exercise tolerance
Observed means for the overall and subscale scores of the
PSDQ are shown in Table 2. As for the specific dimensions of the PSDQ, the scores for self-esteem, health, and
body fat were the highest. The three lowest scores were
for endurance, physical activity, and strength. Adjusted
for age, diagnosis, and number of heart operations, the
male participants scored significantly higher than did the
female participants in measures of overall physical selfconcept, sports competence, physical appearance, body
fat, physical activity, endurance, and strength. However,
no significant differences between males and females
were observed for health, flexibility, and self-esteem.
Because BMI was highly correlated with body fat (r =
0.706; p<0.001), we did not include this variable as an
adjusting factor in the regression model above, in order to
avoid multicollinearity.
The duration of the step test had a range of 71180 seconds for our participants. Thirty-four subjects (8.2%) quit
stepping before three minutes. Twenty-six of these participants were female. None of the participants had a heart rate
higher than 170 beat/min or an O2 saturation <95%. All participants remained asymptomatic and did not complain of
chest pain or other adverse events. The mean cardiopulmonary exercise tolerance index was 60.11, with a range from
28.2102.2. This index score was significantly higher in
males than in females (Table 3). Patients could be categorized into levels of cardiopulmonary exercise tolerance,
based on norm-based cut-off scores. Overall, 41% (n=168)
of all participants could achieve up to very good levels of
cardiopulmonary exercise tolerance index (Figure 1).
Moreover, more than 80% of all participants had at least an
average level of cardiopulmonary exercise tolerance.

Downloaded from cnu.sagepub.com at Airlangga University on September 4, 2015

209

Chen et al.
Table 1. General characteristics of adolescents with mild congenital heart disease, shown by gender (n=413).
Variables

Males
(n=200; 48.4%)

Females
(n=213; 51.6%)

z-value/2

Age (years)

MeanSD
15.512.64
21.003.95
n (%)
43 (21.8)
95 (48.2)
59 (29.9)

MeanSD
15.492.39
20.113.18
n (%)
37 (17.5)
145 (68.7)
29 (13.7)

z= 0.186

154 (77.0)
46 (23.0)

191 (89.7)
22 (10.3)

73 (36.5)
111 (55.5)
6 ( 8.0)

106 (50.0)
84 (39.6)
22 (10.4)

6 ( 3.0)
6 ( 3.0)
44 (22.1)
143 (71.9)

6 ( 2.9)
15 ( 7.1)
59 (28.1)
130 (61.9)

Body mass index (BMI)

BMI category
Underweight
Normal
Overweightb
Diagnosis
Left to right shunt
Right to left shunt
Number of heart operations
None
1
25
PE participant level
Rarely participates
Sometimes participates
Often participates
Always participates

z= 1.939
2=20.638a

2=12.04c

2=10.429c

2=6.369

SD: standard deviation; PE: physical education.

ap<0.001.
bIncludes obesity: BMI>95th specific for age and gender.
cp<0.01.

Table 2. Physical Self-Description Questionnaire (PSDQ) and cardiopulmonary tolerance among adolescents with mild congenital
heart disease (n=413).
Variables

Overall physical self

Sports competence
Appearance
Body fat
Health
Flexibility
Physical activity
Esteem
Endurance
Strength
Cardiopulmonary
tolerance index

Overall

Males (n=200)

Females (n=213)

Adjusted differencea

MeanSD

MeanSD

MeanSD

p value

3.650.64
3.421.04
3.730.88
3.961.33
4.300.76
3.441.05
3.171.10
4.370.82
2.911.05
3.300.95
60.1111.95

3.770.62
3.590.97
3.820.87
4.161.31
4.360.73
3.391.05
3.451.06
4.420.80
3.071.02
3.430.99
63.2411.89

3.530.63
3.261.07
3.650.89
3.781.32
4.240.78
3.491.06
2.901.07
4.330.84
2.751.05
3.180.89
57.1711.26

0.268
0.371
0.213
0.427
0.131
0.061
0.519
0.141
0.360
0.265
6.241

<0.001
<0.001
0.015
0.001
0.081
0.561
<0.001
0.080
<0.001
0.005
<0.001

SD: standard deviation.

aAdjustment for age, diagnosis and number of heart operations.

Relationship with levels of cardiopulmonary

exercise tolerance index
The hierarchical multivariable linear regression analysis, adjusted for gender, age, diagnosis, and number of
heart operations, showed that cardiopulmonary exercise tolerance was determined by the dimensions of

body fat and physical activity (Table 3). More specifically, the perception of not being too fat and being
more physically active were significant correlates of
better cardiopulmonary exercise tolerance. This model
explained 18% of the variance for the levels of cardiopulmonary exercise tolerance among adolescents with
mild CHD.

Downloaded from cnu.sagepub.com at Airlangga University on September 4, 2015

210

European Journal of Cardiovascular Nursing 14(3)

Table 3. Hierarchical multivariable linear regression analysis

on the relationship of specific Physical Self-Description
Questionnaire (PSDQ) factors on cardiopulmonary tolerance
index among adolescents with mild congenital heart disease,
adjusted for gender, age, diagnosis, and number of heart
operations (n=413).
Variable

Estimate Standard Standardized p-value

error
estimate

Intercept
Gender
Age
Diagnosis
Number of heart
operations
Sports
competence
Appearance
Body fat
Health
Flexibility
Physical activity
Esteem
Endurance
Strength

53.79
4.11
0.30
2.63
0.40

6.10
1.17
0.23
1.69
0.87

0.17
0.06
0.08
0.02

<0.001
<0.001
0.191
0.120
0.648

1.39

0.95

0.12

0.144

0.93
2.02
0.81
0.66
1.90
1.03
0.05
0.13

0.88
0.48
0.80
0.66
0.72
0.90
0.79
0.88

0.07
0.22
0.05
0.06
0.18
0.07
0.004
0.01

0.289
<0.001
0.309
0.322
0.009
0.252
0.954
0.880

Adjusted R2=0.176.

n
90

Male

80

Female

70
60
50
40
30
20
10
0
Very poor
(n=41)

Poor
(n=33)

Average
(n=73)

Good
(n=98)

Very Good
(n=168)

Levels of Cardiopulmonary Tolerance Index

Figure 1. Levels of cardiopulmonary tolerance index among

adolescents with mild congenital heart disease, based on normbased cut-off scores (n=413).

Discussion
This present study showed that measures of self-esteem,
health, and body fat in PSDQ were the greatest among
measures of physical self-concept in adolescents with mild
CHD. The male participants had significantly higher
scores than did the female participants in measures of
overall physical self-concept, sports competence, appearance, body fat, physical activity, endurance, and strength.
More than 80% of the participants had at least ordinary
levels on the cardiopulmonary exercise tolerance index.

The dimensions of body fat and physical activity in PSDQ

were significant factors in explaining improved levels of
cardiopulmonary exercise tolerance, over and above the
impact of gender.
Adolescents with mild CHD in this study reported the
highest mean score on self-esteem, which was overall positive feelings about oneself. This finding is similar to findings in studies of resilience, quality of life, and sense of
coherence. Adolescents with CHD reported even greater
resilience, better quality of life, and greater sense of coherence than did healthy controls.14,2729 The positive perceptions could be reinforced through dealing with stress in
their daily lives, such as stress that result from physical
limitations of the disease and medical treatment.
In one of our previous studies, adolescents with mild
CHD experienced progressive ability to engage in physical exercise. To this end, a positive physical self-concept
was crucial in the mastery of physical challenges with the
ultimate goal of living a normal life.30 Nonetheless, one
previous study reported that there was marked overestimation of physical functioning measured by self-reported
health-related quality of life (Short Form health Survey
36 (SF-36)) in most adolescents and adults with CHD
when compared with actual exercise test results.14 In the
present study, we attempted to explicate physical selfconcept multidimensionally, to understand the relationship between each subdomain and cardiopulmonary
exercise tolerance, and to provide a target for future
interventions.
In addition, the participants in the present study reported
health as the top second dimension of PSDQ. The participants usually received a check-up once yearly, and did not
have exercise limitations recommended by cardiologists.
Most participants perceived that they were not often ill,
and that they generally recovered quickly from illness. As
expected, perception of better physical health could be a
factor promoting better quality of life in adolescents with
CHD.29 Body fat was the third greatest dimension of PSDQ
reported by the participants. The higher the score on body
fat, the less self-perception being overweight or too fat.
Little attention has been paid to the self-perception regarding body fat among adolescents with CHD in past studies;
attention was paid to BMI instead.3133
The male participants achieved significantly greater
scores in measures of overall physical self-concept, sports
competence, appearance, body fat, physical activity,
endurance, and strength dimensions of PSDQ than did the
female participants. No significant differences were
observed between male and female adolescents with mild
CHD in terms of health, flexibility, and self-esteem. These
findings are consistent with findings in adolescents without CHD despite the fact that (a) we controlled for personal attributive variables; (b) over 80% of the adolescent
girls and boys with CHD had acyanotic heart disease; and
(c) adolescent boys with CHD had significantly more

Downloaded from cnu.sagepub.com at Airlangga University on September 4, 2015

211

Chen et al.
cyanotic heart disease than did adolescent girls with CHD
(p<0.01).
There are many well-known genetic, cultural, or behavioral factors that could explain these results, in which boys
performed better on tasks demanding explosive strength
and cardiorespiratory endurance, whereas girls had greater
flexibility.812 Although measures of physical self-concept
are generally greater in adolescent boys than in girls, boys
may have vulnerabilities of their own. Societys stereotypical gender expectations may lead boys to feel that they
should be strong, tough, and fearless at all times;13,34 however, based on the subjective experience of adolescents
with mild CHD,30 they are able to perform weight-bearing
exercises such as climbing stairs with heavy loads, swimming and jumping rope, but report feeling exhausted afterward the exercise, and taking a long time to recover. This
observation may be reflected in the present results of the
three lowest dimensions of PSDQ, which were endurance,
physical activity, and strength.
In contrast to the treadmill testing or cycle ergometer
most commonly used to assess exercise capacity objectively in children and adolescents with CHD,14,3538 the
step test is a measurement requiring only simple equipment to predict peak oxygen uptake for teenagers.25 The
present study showed that over 90% of participants could
continue stepping for up to three minutes. Of all participants who quit stepping before three minutes, 76.5%
(n=26) were female. The study also demonstrated that
male adolescents with mild CHD had a significantly higher
mean score on the cardiopulmonary exercise tolerance
index than did females participants (p<0.001). Thus, it is
noteworthy that while we measure cardiopulmonary exercise tolerance and physical self-concept in adolescents
with CHD, it may be not suitable to pool data from male
and female participants, rather, a gender-specific approach
may be preferable.
As compared with the norm-based cut-off scores, the
means of the cardiopulmonary exercise tolerance index in
male and female adolescents with mild CHD could be
achieved at least at a good level. More than 80% of all
participants had at least average levels on the cardiopulmonary exercise tolerance index. These findings are in
accordance with one previous study that has reported at
least a moderate level of aerobic fitness in the majority of
children with CHD.37 There was no previous study on the
step test for adolescents with CHD, but other related studies reported that patients with CHD had a significantly
reduced peak oxygen uptake, including those with minor
lesions.14,36,38,39
Only the relationship between the dimensions of body
fat and physical activity was significantly associated with
the cardiopulmonary exercise tolerance. There was a similar finding in the relationship between obesity measured
by BMI and cardiovascular endurance assessed by the
three-minute step test among adolescents who did not have

CHD.40 In the present study, BMI was highly correlated to

the dimension of body fat ( = 0.706; p<0.001). This is
similar to the findings of Dishman etal.41 in North
American adolescent girls and of Carraro etal.8 in a study
of Italian adolescents. However, Gurin etal.19 did not find
a correlation as high as was expected between perceived
body fat and BMI in French high school students. Since
the dimension of body fat has consistently been assessed
as a reliable construct, results involving BMI should be
interpreted cautiously. BMI is not only related to adiposity,
but also to muscularity and other critical determinants,
such as tissue and bone density, body frame size and shape,
and other variables.42 It is still worthy to note that the prevalence of overweight and obese adolescents with mild
CHD in the present study was up to 21.3%, and even
29.9% in the boys. It is consistent with the prevalence of
overweight and obese adolescents without CHD in Taiwan,
where boys were more likely to become overweight and
obese (25.4%) than were their female counterparts
(17.5%).43 The present study showed that not being overweight or obese was a significant correlate of a better cardiopulmonary exercise tolerance in adolescents with mild
CHD. This study also supported self-perceptions of body
fat as a realistic evaluation of the patients own adiposity.
Future research may employ multiple indices of adiposity,
such as skinfolds and circumferences, along with body-fat
self-perception.
As in the present study, the previous study confirmed
that the perception of being regularly physically active
seems to be positively linked to cardiopulmonary exercise tolerance among adolescents with mild CHD.
Published research has reported that physical activity or
exercise is associated with physical benefits in children
and adolescents without CHD,44,45 as well as in children
and adolescents with CHD.37,46 Exercise capacity may be
a barrier to participation in physical activity in patients
with CHD. The present findings would emphasize that
being more physically active was one of the significant
correlates of a better cardiopulmonary exercise tolerance
for adolescents with CHD who have the ability to exercise. Children and adolescents with a stable CHD may
have activity behaviors that are similar to those in individuals without CHD.47,48 However, less than one-fifth
of children and adolescents in either group performed
sufficient physical activity to meet current physical
activity recommendations for children and adolescents.48
Thus, habitual physical activity in adolescents with mild
CHD should be encouraged early in life in order to promote cardiopulmonary fitness and to protect them from
further co-morbidities.
The conclusions of this study may apply only to adolescents with mild CHD who do not have exercise limitations. We suggest that future studies involve more severe
cardiac function classifications of adolescents with CHD,
and thereby provide a better understanding of physical

Downloaded from cnu.sagepub.com at Airlangga University on September 4, 2015

212

European Journal of Cardiovascular Nursing 14(3)

self-concept and its link to cardiopulmonary exercise tolerance in all adolescent patients with CHD.

Conclusion
In summary, the present study provided evidence for a
gender-specific evaluation of the domain of physical selfconcept among adolescents with mild CHD. The threeminute step test to measure cardiopulmonary exercise
tolerance for adolescents with mild CHD may further provide an objective reference measure in future research. In
addition, the relationship between physical self-concept
and cardiopulmonary exercise tolerance among adolescents with mild CHD was examined. Continuing efforts in
early intervention to promote cardiopulmonary fitness are
needed.

Implications for practice

A gender-specific approach is preferred in measuring cardiopulmonary exercise tolerance and
physical self-concept in adolescents with congenital heart disease.
Education about their illness and encouragement
to maintain physical fitness can help adolescents
with congenital heart disease to develop a positive self-perception of body fat and physical
activity.
Early effective interventions should be developed to promote cardiopulmonary fitness and to
protect patients with congenital heart disease
from developing co-morbid conditions.

Acknowledgements
The authors wish to thank all the study subjects for their
participation.

Conflicts of interest
The authors declare that there are no conflicts of interest.

Funding
This research was supported in part by National Science Council
grant (NSC 97-2314-B-030-004-MY3).

References
1. Van der Linde D, Konings EEM, Slager MA, etal. Birth
prevalence of congenital heart disease worldwide: A systematic review and meta-analysis. J Am Coll Cardiol 2011;
58: 22412247.
2. Moons P, Bovijn L, Buds W, etal. Temporal trends in survival to adulthood among patients born with congenital
heart disease from 1970 to 1992 in Belgium. Circulation
2010; 122: 22642272.

3. Chen CW, Li CY and Wang JK. Self-concept: Comparison

between school-age children with congenital heart disease
and normal school-age children. J Clin Nurs 2005; 14:
394402.
4. Shavelson RJ, Hubner JJ and Stanton GC. Self-concept:
Validation of construct interpretations. Rev Educ Res 1976;
46: 407441.
5. Marsh HW, Richards GE, Johnson S, etal. Physical selfdescription questionnaire: Psychometric properties and
a multitrait-multimethod analysis of relations to existing
instruments. J Sport Exerc Psychol 1994; 16: 270305.
6. Fox KR. The physical self: From motivation to well-being.
Champaign, Illinois: Human Kinetics, 1997.
7. Eklund RC and Bianco T. Social physique anxiety and
physical activity among adolescents. Reclaim Child Youth
2000; 9: 139142.
8. Carraro A, Scarpa S and Ventura L. Relationships between
physical self-concept and physical fitness in Italian adolescents. Percept Mot Skills 2010; 110: 522530.
9. Maano C, Ninot G and Bilard J. Age and gender effects on
global self-esteem and physical self-perception in adolescents. Eur Phys Educ Review 2004; 10: 5369.
10. Smolak L. Body image in children and adolescents: where
do we go from here? Body Image 2004; 1: 1528.
11. Lau PWC, Lee A , Ransdell L, etal. The association between
global self-esteem, physical self-concept and actual vs ideal
body size rating in Chinese primary school children. Int J
Obes Relat Metab Disord 2004; 28: 314319.
12. Calar E. Similarities and differences in physical self
concept of males and females during late adolescence and
early adulthood. Adolescence 2009; 44: 407419.
13. Chen CW, Chen YC, Beckstead JW, etal. Self-concept
in Taiwanese adolescents with congenital heart disease.
Pediatr Int 2011; 53: 168174.
14. Gratz A, Hess J and Hager A. self-estimated physical functioning poorly predicts actual exercise capacity in adolescents and adults with congenital heart disease. Eur Heart J
2009; 30: 497504.
15. Yeh SR and Huang MC. Relationship between physical
self-concept, degree of exercise participation and physical
fitness for college student. J Tzu Chi College Technol 2006;
9: 135144.
16. Marsh HW and Redmayne R. A multidimensional physical self-concept and its relations to multiple components of
physical fitness. J Sport Exerc Psychol 1994; 16: 4355.
17. Marsh HW, Marco IT and Ab FH. Cross-cultural validity
of the physical self-description questionnaire: comparison
of factor structures in Australia, Spain, and Turkey. Res Q
Exerc Sport 2002; 73: 257270.
18. Marsh HW, Martin AJ and Jackson S. Introducing a short
version of the physical self description questionnaire: new
strategies, short-form evaluative criteria, and applications of factor analyses. J Sport Exerc Psychol 2010; 32:
438482.
19. Gurin F, Marsh HW and Famose JP. Generalizability of the
PSDQ and its relationship to physical fitness: the European
French connection. J Sport Exerc Psychol 2004; 26: 1938.
20. Nigg CR, Norman GJ, Rossi JS, etal. Examining the structure of physical self-description using an American university sample. Res Q Exerc Sport 2001; 72: 7883.

Downloaded from cnu.sagepub.com at Airlangga University on September 4, 2015

213

Chen et al.
21. Marsh HW and Redmayne R. A multidimensional physical self-concept and its relations to multiple components of
physical fitness. J Sport Exerc Psychol 1994; 16: 4355.
22. Wang SC. Step test. Exerc Physiol Weekly News 2001; 95:
13.
23. Chang SC and Lin JC. The validity generalization of step
test as a measure of the maximal oxygen intake. Phys Edu J
1995; 20: 351362.
24. Sun ML. The intensity relationships among different cardiopulmonary fitness tests. J Physi Edu Higher Edu 2006; 8:
229238.
25. Hong SJ, Goh EY, Chua SY, etal. Reliability and validity
of step test scores in subjects with chronic stroke. Arch Phys
Med Rehabil 2012; 93: 10651071.
26. Chen MH. A literature review on the relationships of physical activity, self-concept and self-esteem. Bull Sport Exerc
Psychol Taiwan 2007; 11: 1739.
27. Nio K. Resilience of junior and senior high school students
with congenital heart disease: Differences in resilience due
to attributive factors. J Child Health 2008; 67: 826833.
28. Nio K. Sense of coherence in adolescents with congenital
cardiac disease. Cardiol Young 2010; 20: 538546.
29. Apers S, Moons P, Goossens E, etal. Sense of coherence
and perceived physical health explain the better quality
of life in adolescents with congenital heart disease. Eur J
Cardiovasc Nurs 2013; 12: 475483.
30. Chiang YT, Chen C and Chen YC. From limitation to mastery: Exercise experience for adolescents with mild congenital heart disease. J Clin Nurs 2011; 20: 22662276.
31. Stefan MA, Hopman WM and Smythe JF. Effect of activity
restriction owing to heart disease on obesity. Arch Pediatr
Adolesc Med 2005; 159: 477481.
32. Pinto NM, Marino BS, Wernovsky G, etal. Obesity is
a common comorbidity in children with congenital and
acquired heart disease. Pediatrics 2007; 120: e1157
1164.
33. Ray TD, Green A and Henry K. Physical activity and obesity in children with congenital cardiac disease. Cardiol
Young 2011; 21: 603607.
34. Radzik M, Sherer S and Neinstein LS. Psychosocial development in normal adolescents. In: Neinstein LS, Gordon
CM, Katzman DK, et al. (eds) Adolescent health care: A
practical guide. Philadelphia: Lippincott Williams and
Wilkins, 2008, pp.2731.
35. Hovels-Gurich HH, Konrad K, Skorzenski D, etal. Longterm neurodevelopmental outcome and exercise capacity
after corrective surgery for tetralogy of Fallot or ventricular septal defect in infancy. Ann Thorac Surg 2006; 81:
958966.

36. Moalla W, Dupont G, Temfemo A, etal. Assessment of

exercise capacity and respiratory muscle oxygenation in
healthy children and children with congenital heart diseases.
Appl Physiol Nutr Metab 2008; 33: 434440.
37. Arvidsson D, Slinde F, Hulthn L, etal. Physical activity, sports participation and aerobic fitness in children who
have undergone surgery for congenital heart defects. Acta
Paediatr 2009; 98: 14751482.
38. Mller J, Bhm B, Semsch S, etal. Currently, children with
congenital heart disease are not limited in their submaximal
exercise performance. Eur J Cardiothorac Surg 2013; 43:
10961100.
39. Diller GP, Dimopoulos K, Okonko D, etal. Exercise intolerance in adult congenital heart disease: Comparative severity, correlates, and prognostic implication. Circulation
2005; 112: 828835.
40. Chen LJ, Fox KR, Haase A, etal. Obesity, fitness and health
in Taiwanese children and adolescents. Eur J Clin Nutr
2006; 60: 13671375.
41. Dishman RK, Hales DP, Almeida MJ, etal. Factorial

validity and invariance of the Physical Self-Description
Questionnaire among black and white adolescent girls. Ethn
Dis 2006; 16: 551558.
42. Eston RG. Use of the body mass index (BMI) for individual
counseling: The new section editor for Kinanthropometry
is grade 1 obese, overweight (BMI 27.3), but dense and
distinctly muscular (FFMI 23.1). J Sports Sci 2002; 20:
515518.
43. Liou TH, Huang YC and Chou P. Prevalence and secular
trends in overweight and obese Taiwanese children and adolescents in 19912003. Ann Hum Biol 2009; 36: 176185.
44. Dencker M, Thorsson O, Karlsson MK, etal. Daily physical
activity and its relation to aerobic fitness in children aged
811 years. Eur J Appl Physiol 2006; 96: 587592.
45. Dunton GF, Schneider M, Graham DJ, etal. Physical activity, fitness, and physical self-concept in adolescent females.
Pediatr Exerc Sci 2006; 18: 240251.
46. Duppen N, Takken T, Hopman MT, etal. Systematic review
of the effects of physical exercise training programmes in
children and young adults with congenital heart disease. Int
J Cardiol 2013; 168: 17791787.
47. Lunt D, Briffa T, Briffa NK, etal. Physical activity levels of
adolescents with congenital heart disease. Aust J Physiother
2003; 49: 4350.
48. Ewalt LA, Danduran MJ, Strath SJ, etal. Objectively

assessed physical activity and sedentary behaviour does not
differ between children and adolescents with and without a
congenital heart defect: A pilot examination. Cardiol Young
2012; 22: 3441.

Downloaded from cnu.sagepub.com at Airlangga University on September 4, 2015