Hellenic Journal of Cardiology xxx (xxxx) xxx

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Hellenic Journal of Cardiology

journal homepage: http://www.journals.elsevier.com/
hellenic-journal-of-cardiology/

Original Article

Physical activity levels and self-efficacy of Greek children with

congenital heart disease compared to their healthy peers
Dimitra Moschovi a, *, Emmanouil I. Kapetanakis b, Panagiotis G. Sfyridis c,
Spyridon Rammos d, Evangelia Mavrikaki a
a
Department of Primary Education, School of Education, National & Kapodistrian University of Athens, 13A Navarinou str., Athens, 10680, Greece
b
Department of Cardiac Surgery, “Attikon” University Hospital, National & Kapodistrian University of Athens, 1 Rimini str., Athens, 12462, Greece
c
Department of Pediatric and Congenital Heart Surgery, “Mitera” Children's Hospital and “Hygeia” Hospital, 6 Erythrou Stavrou Str., Athens, 15123, Greece
d
Department of Pediatric Cardiology, “Onassis” Cardiac Surgery Center, 356 Sygrou Avenue, Athens, 17674, Greece

a r t i c l e i n f o a b s t r a c t

Article history: Objective: It remains a challenge for children with congenital heart disease (CHD) to develop healthy
Received 17 October 2018 lifestyle behaviors. This study investigates the interrelationship of physical activity and self-efficacy
Received in revised form levels in Greek children with corrected CHD and compares them with those of healthy controls.
21 December 2018
Methods: A prospective cross-sectional study of 76 patients with operated CHD and 78 healthy volun-
Accepted 3 January 2019
Available online xxx
teers (n ¼ 154) was conducted. The Self Efficacy Scale and Previous Day Physical Activity Recall self-
reporting questionnaires were used to assess self-efficacy and physical activity, respectively. Calculated
metabolic equivalent of task (MET) provided an indication of participation in moderate and vigorous
Keywords:
Congenital heart disease (CHD)
physical activities.
Physical self-efficacy Results: Mean physical self-efficacy in children with CHD was 29.01 ± 7.28, while that in healthy vol-
Physical activity unteers was 29.04 ± 6.60 (p ¼ 0.076). Average physical activity levels-METs in children with CHD
Education e all levels (2.38 ± 0.85) were significantly lower than those in controls (3.1 ± 0.95). Physical self-efficacy and
physical activity were positively correlated (r ¼ 0.515, p ¼ 0.001), thus indicating that children with
higher self-efficacy engaged in more vigorous physical activities. In children with CHD, self-efficacy was
quite important in predicting physical activity, thus explaining almost ¼ of the variability in observed
activities.
Conclusion: The low physical activity levels exhibited by Greek children with corrected CHD can lead to a
sedentary adult lifestyle. Improving physical self-efficacy may help encourage them and consequently
increase their physical activity levels. School-based education initiatives and athletic programs can play
an important role in improving this.
© 2019 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
In Greece, approximately 1,000 babies are born each year with
congenital heart disease (CHD), and 40,000-50,000 adolescents and
adults have various types of congenital heart lesions.1
Six decades ago, it was almost impossible to diagnose and
let alone treat these patients; however, advances in diagnosis and
surgical techniques over the years now means that the majority of
* Corresponding author. Department of Primary Education, School of Education,
National & Kapodistrian University of Athens, 13A Navarinou str., Athens, 10680,
Greece. Tel. 0030 6970375588.
E-mail address: dimoschovi@yahoo.gr (D. Moschovi).
Peer review under responsibility of Hellenic Society of Cardiology
cases are detected early, mainly in utero, and that prompt correction
is feasible.2 Given the high survival rate (85%) of children with CHD
following such surgical corrections, teachers and educators often
face the challenge of meeting the developmental, educational, and
psychosocial needs of these children.3,4
Research suggests that children with corrected CHD have low
self-efficacy and self-esteem levels, which impact their academic
performance, socialization in school, and quality of life.5e9 Negative
experience and feedback while attempting physical activity de-
creases their self-efficacy, thereby creating a vicious cycle and
causing long-term detriment in emotional, psychosocial, and
cognitive development. Considering the critical importance of
participating in physical activities and the risk of low self-efficacy in
this “vulnerable” group of children, it is imperative for schools to

https://doi.org/10.1016/j.hjc.2019.01.002
1109-9666/© 2019 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).

Please cite this article as: Moschovi D et al., Physical activity levels and self-efficacy of Greek children with congenital heart disease compared to
their healthy peers, Hellenic Journal of Cardiology, https://doi.org/10.1016/j.hjc.2019.01.002
2 D. Moschovi et al. / Hellenic Journal of Cardiology xxx (xxxx) xxx
support these children, through physical education and general
health education programs, so that they make healthy decisions
and establish proper long-term health habits by reinforcing their
physical self-efficacy.10, 11 Unfortunately, in Greece, there is
chronically a lack of such outreach programs, having been consid-
ered nonessential, and the recent fiscal crisis only made this situ-
ation worse.
The aim of this study therefore was to investigate physical ac-
tivity and self-efficacy levels in Greek children with CHD by
assessing their inter-relationship and comparing them with those
of their healthy peers.
2. Patients & methods
A prospective cross-sectional study was conducted from
September 2014 to October 2015, and data were obtained from
questionnaire interviews. Study approval was obtained from the
department's educational committee and from ethical committees
of each participating clinical center. Signed parental consent was
obtained during questionnaire completion at the follow-up visit.
School committees and each student's parent/guardian provided
authorization/consent for the control group participants.
2.1. Study participants
Greek children were recruited for the study. The recruited
children were aged 10-17 years, with a confirmed diagnosis of CHD
(cyanotic or acyanotic disease), who had undergone successful
surgical correction with no significant residual disease or recur-
rence and which were subsequently under routine long-term
follow-up in two pediatric cardiology clinics in Athens, at the
“Onassis” Cardiac Surgery Center and the “Mitera” Children's Hos-
pital. This specific age range was selected because children usually
start making their own lifestyle decisions during this age range.
Exclusion criteria included residual disease and organic reasons
that precluded participation in physical activity and mental or
developmental delays that prohibited questionnaire understanding
and completion. A comparable group of age-matched healthy
children volunteers was recruited as control.
2.1.1. Sample Size calculation
Study recruitment was based on a preceding sample size
calculation. Effect size was hypothesized, as no previously pub-
lished studies were available. Therefore, using the two-tailed
Pearson's correlation to detect a moderate difference r ¼ 0.3 be-
tween self-efficacy and physical activity scores at a 0.5 alpha level,
it was estimated that 76 sample measurements were needed to
provide a power of 0.80/80%. Therefore, children were recruited
until this sample size was achieved in each group.
2.1.2. Study group formation
The study samples consisted of two groups of children:
 A study group (SG) of 76 children with operated CHD, aged 10-
17 years, recruited during routine follow-up clinic appointments
in 2014 to complete two questionnaires (Self Efficacy Scale [SES]
and Previous Day Physical Activity Recall [PDPAR]) and an
investigator-developed demographic form.
 A control group (CG) of 78 healthy participants (students), aged
10-14 years, from two neighboring public schools in Athens.
They completed the two questionnaires in their classroom in the
presence of a researcher and their teacher at the beginning of
the school year 2014-2015.
Please cite this article as: Moschovi D et al., Physical activity levels and self-efficacy of Greek children with congenital heart disease compared to
their healthy peers, Hellenic Journal of Cardiology, https://doi.org/10.1016/j.hjc.2019.01.002
2.2. Research instruments used
Two questionnaires, with established validity and reliability,
and an accompanying demographic form were used. These ques-
tionnaires were translated/written in plain Greek language. It was
paramount for each child in either the SG or the CG group to
complete the questionnaires by themselves to equalize possible
recall bias; therefore, parental/teacher assistance was minimal. The
questionnaires were completed in less than 20 minutes.
a. Self-Efficacy Scale e (SES)
The SES measures the self-assessed level of a child's self-efficacy
relative to his/her physical condition. It consists of 8 items based on
a 5-point Likert scale, ranging from “totally disagree” to “totally
agree.” The scores range from 8 (the lowest level of self-efficacy) to
40 (the highest level).
b. Previous Day Physical Activity Recall e (PDPAR)
To measure the intensity, frequency, and duration of physical
activity of each child during their previous day after-school period,
Previous Day Physical Activity Recall (PDPAR), a self-reporting in-
strument, was used. Children recorded their previous day physical
activities from 3.00 pm to 11.00 pm in 30-min blocks. Thirty-five
common activities, including sedentary ones such as television
watching, were listed, and each child reported the main activity
engaged during each period in the form. The intensity of each ac-
tivity was rated as very light, light, moderate, or vigorous. PDPAR
was thoroughly explained by the researcher so that children could
properly assess the intensity of their activities. Moreover, to help
children select the correct intensity level, the instrument included
numerous cartoon illustrations depicting representative activities.
On the basis of the type and intensity of activity, each 30-min
block was subsequently assigned a metabolic equivalent task
(MET) value. To convert the self-reported physical activity to METs,
“The Compendium of Physical Activities” was used.12 Period blocks
with 3 and  6 METs relative energy expenditure were tabulated
to provide an index of participation in moderate and vigorous
physical activities, respectively.12
c. The Demographics recording form
Demographic information such as age, sex, cardiac diagnosis
(obtained from medical records), place of residence, height, weight,
father's and mother's profession, and educational level and
appropriate consent were obtained from the participants in a
separate demographics & consent form.
2.3. Data analysis
Continuous, normally distributed variables are presented as
mean ± standard deviation (SD), whereas categorical variables are
presented as absolute numbers and percentages (%). SG compari-
sons were performed using Student's t-test, Pearson's correlation
coefficient, and linear regression analysis. A p-value of 0.05 or less
was considered statistically significant. For the statistical analyses,
SPSS statistical software package for Windows (SPSS Inc., Chicago,
IL) was used.
3. Results
Cardiac disease diagnoses before surgical correction for the SG,
categorized according to complexity, are presented in Table 1.13 Of
the 76 children with CHD in the SG, 46 (60.5%) were male and 30
 D. Moschovi et al. / Hellenic Journal of Cardiology xxx (xxxx) xxx 3

Table 1 3.1. Physical activity

Cardiac disease diagnoses of the study group, with number of children per disease
categorized by complexity according to the 2018 AHA/ACC ACHD guidelines
When comparing the intensity of physical activity, the CG
Disease Diagnosis N ¼ 76 (%) demonstrated higher activity levels than the SG. Children in the SG
Class I (Simple Complexity) 22 (29%) were more likely to engage in low physical activities (<3 METs)
Atrial Septal Defect (ASD) 10 (13%) than healthy children (Fig. 1). Particularly, average MET activity in
Ventricular Septal Defect (VSD) 9 (12%) SG children was 2.37 ± 0.84 versus 3.1 ± 0.95 in the CG children
Pulmonary Artery Stenosis e Hypoplasia 3 (3.9%)
(p ¼ 0.002, Fig. 1). Conversely, healthy children also had more 30-
Class II (Moderate Complexity) 48 (63%)
Total Anomalous Pulmonary Vein Disparity* 1 (1.3%) minute blocks of moderate physical activity 3 МЕΤs
Anomalous Left Coronary Artery Origin from the 1 (1.3%) (4.85 ± 2.25) than children with operated CHD (3.65 ± 2.45) (t-
Pulmonary Artery statistic (t) ¼ 3.17, degrees of freedom (df) ¼ 152, p ¼ 0.002, Fig. 2).
Partial Atrioventricular Septal Defect (AVSD) 2 (2.6%)
Moreover, as the intensity of physical activity increased, the
Congenital Aortic Valve Stenosis (bicuspid) 2 (2.6%)
Congenital Aortic Valve Insufficiency 2 (2.6%)
differences between the two groups grew bigger. Healthy children
Congenital Mitral Valve Insufficiency 6 (7.9%) had on average 3.18 ± 2.06 30-minute blocks with a 6 МЕΤ,
Coarctation of the Aorta 3 (3.9%) whereas SG children had on average 1.80 ± 1.82 30-minute pe-
Еbstein Anomaly 4 (5.2%) riods of 6 МЕΤ, a statistically significant (t ¼ 4.390, df ¼ 152,
Sinus Venosus Defect 4 (5.3%)
p ¼ 0.001) difference (Fig. 3). In sub-analysis, there were no
Subaortic Stenosis 9 (12%)
Tetralogy of Fallot* 12 (16%) gender differences in physical activity levels for either groups
Vascular Ring 2 (2.6%) (p ¼ 0.12).
Class III (Great Complexity) 6 (8%)
Single Ventricle* 3 (3.9%)
3.2. Self-efficacy
Transposition of the Great Arteries* 2 (2.6%)
Truncus Arteriosus* 1 (1.3%)
*
Children with CHD did not demonstrate lower self-efficacy
Cyanotic diseases.
levels than healthy controls. No statistically significant difference
in physical self-efficacy levels between groups was found. Partic-
ularly, the SG reported a mean SES of 29.01 ± 7.28, whereas the CG
had a mean SES of 29.04 ± 6.60 (p ¼ 0.076). A high level of internal
(39.5%) female with a mean age of 12.68 ± 1.61 years. Similarly, of
consistency (Cronbach's a8 ¼ 0.82) of the SES measurements was
the 78 healthy children in the CG, 40 (51.3%) were male and 38
demonstrated.
(48.7%) female with an average age of 12.5 ± 0.95 years. Both
groups were comparable in terms of age (p ¼ 0.2) and sex (p ¼ 0.13)
distributions. Both groups were also comparable in terms of body 3.3. Correlation of self-efficacy to physical activity
mass index (BMI), with the SG having a slightly lower, but not quite
significant, average BMI (20.2 ± 2.1) than the CG (21.4 ± 1.8; Children's self-efficacy was positively correlated to their phys-
p ¼ 0.23). ical activity (healthy children: r ¼ 0.347, p ¼ 0.002, children with
CHD: r ¼ 0.515, p ¼ 0.001). In the scatter plot analysis of self-

Fig. 1. Comparison of average metabolic equivalent of task (MET) activity levels in children diagnosed with congenital heart disease (CHD) and in healthy children.

Please cite this article as: Moschovi D et al., Physical activity levels and self-efficacy of Greek children with congenital heart disease compared to
their healthy peers, Hellenic Journal of Cardiology, https://doi.org/10.1016/j.hjc.2019.01.002
4 D. Moschovi et al. / Hellenic Journal of Cardiology xxx (xxxx) xxx

Fig. 2. Distribution of moderate activity levels (MET3) in children diagnosed with CHD and in healthy ones.

efficacy (SES) vs. physical activity (mean METs) in the SG showing
the best-fit regression line, the overall fit was significant
(p < 0.001), and thus, self-efficacy was highly associated with
physical activity in this group (Fig. 4). Consequently, self-efficacy
explained 26.6% of variability in physical activity in children with
corrected CHD.
The scatter plot analysis of self-efficacy (SES) vs. physical activity
(mean METs) in the CG also produced a significant best-fit
regression line (p < 0.01), thus demonstrating that self-efficacy was
also moderately associated with physical activity in healthy chil-
dren; however, their self-efficacy explained only 12% of the vari-
ability in their physical activity (Fig. 5).
A positive relationship between physical self-efficacy and
participation in intense physical activities was also found in the
SG. A statistically significant correlation was demonstrated be-
tween self-efficacy levels and the number of 30-minute blocks of

Fig. 3. Distribution of vigorous activity levels (MET6) in children diagnosed with CHD and in healthy ones.

Please cite this article as: Moschovi D et al., Physical activity levels and self-efficacy of Greek children with congenital heart disease compared to
their healthy peers, Hellenic Journal of Cardiology, https://doi.org/10.1016/j.hjc.2019.01.002
 D. Moschovi et al. / Hellenic Journal of Cardiology xxx (xxxx) xxx 5

Fig. 4. Scatterplot analysis of self-efficacy (SES) vs. physical activity (mean METs) in children with CHD.

moderate (r ¼ 0.35, p ¼ 0.001, Fig. 6) and vigorous physical
activities (r ¼ 0.35, p ¼ 0.002, Fig. 7) children with CHD
engaged in.
4. Discussion
The low participation in physical activity rate reported for
children with corrected CHD is mainly due to activity restrictions,
decreased exercise capacity, and, most importantly, low physical
self-efficacy.14, 15 This prospective cross-sectional study sought to
investigate the relationship between physical activity and self-
efficacy levels in Greek children with operated CHD by comparing
them with equivalent healthy peers. All patients had undergone
successful surgical correction at an early age, with no significant
residual disease or lesion recurrence, and therefore were
physiologically able to participate in a wide range of physical ac-
tivities unhindered.
According to our results, Greek children with CHD demonstrated
significantly lower levels of physical activity than healthy ones, thus
confirming similar findings from the United States and Australia.16,
17
As the degree of difficulty and intensity of physical activity
increased (30-minute periods of 3 and  6 METs), these differ-
ences also increased.
Two previously published studies by Bar-Mor et al. and by
Ray and Henry have reported that the sense of self-efficacy of
children with CHD has a direct and positive correlation with
their level of physical activity.18, 19 The findings of this study also
support this, demonstrating that low physical self-efficacy was
associated with lower participation in physical activities and
exercise.

Fig. 5. Scatterplot analysis of self-efficacy (SES) vs. physical activity (mean METs) in healthy children.

Please cite this article as: Moschovi D et al., Physical activity levels and self-efficacy of Greek children with congenital heart disease compared to
their healthy peers, Hellenic Journal of Cardiology, https://doi.org/10.1016/j.hjc.2019.01.002
6 D. Moschovi et al. / Hellenic Journal of Cardiology xxx (xxxx) xxx

Fig. 6. Correlation between self-efficacy levels and the number of 30-minute blocks of moderate physical activity in children with CHD.

However, in this study, both SG and CG children did not have
statistically significantly difference in self-efficacy scores; there-
fore, the disparity in their physical activity levels cannot be solely
explained by the differences in their self-efficacy levels. This finding
has also been previously reported by Lunt and colleagues.16 This
finding is likely because these children had corrective surgery for
CHD at an early age, and having remained asymptomatic, their self-
efficacy was not significantly affected while growing up.
Teachers and educators should be well informed by healthcare
professionals regarding their pupils’ health status, and close

Fig. 7. Correlation between self-efficacy levels and the number of 30-minute blocks of vigorous physical activity in children with CHD.

Please cite this article as: Moschovi D et al., Physical activity levels and self-efficacy of Greek children with congenital heart disease compared to
their healthy peers, Hellenic Journal of Cardiology, https://doi.org/10.1016/j.hjc.2019.01.002
 D. Moschovi et al. / Hellenic Journal of Cardiology xxx (xxxx) xxx
cooperation by all relevant parties (teachers, parents, and health
care professionals) is needed to meet the challenges of integrating
students with corrected CHD within an active classroom and thus
ensure their best possible physical, educational, and psychosocial
development.20, 21 All those involved and interested in the well-
being of these students must be aware exactly what they cannot
but in particular what they can do to have appropriate and real-
istic expectations.7, 20 Historically, recommendations for physical
activity among patients with CHD have focused on restriction,
rather than promotion, of activity.13 However, since 2015, the
“Eligibility and Disqualification Recommendations for Competitive
Athletes with Cardiovascular Abnormalities: Task Force 4:
Congenital Heart Disease” has been encouraging participation and
shared decision-making with patients with corrected CHD
regarding sports participation.13 Currently, the prevailing advice is
that most patients with corrected CHD can engage safely in reg-
ular, moderate physical activity, with only a few conditions war-
ranting a more restrictive stance.13 Moreover, most patients with
corrected CHD can live normal lives and pursue a full range of
physical and personal activities successfully including
childbearing.22
Recognizing the benefit of engaging in physical activity to both
the physical and the mental health of these children, our advice was
always supportive, and no medically imposed restrictions to that
effect were placed on them by their cardiology team. The findings
of this study therefore are suggestive that other, nonmedically
imposed, reasons are responsible for the reduced physical activity
levels of Greek children with CHD.
Consequently, considering the significant impact school in-
teractions have on a child's development, Greek teachers and ed-
ucators need to develop a more positive and supporting attitude
toward promoting physical activity in children with CHD and try to
increase their self-efficacy through their engagement in meaning-
ful and attainable physical activities.
5. Conclusion
Children with CHD are less physically active than their healthy
peers or they engage in less intense physical activities, which may
lead to a sedentary lifestyle in adulthood with all the associated
health-related risks. Physical self-efficacy is positively correlated
with physical activity in both groups of children, with higher levels
of self-efficacy producing higher levels of activity. Therefore, it is
important that children with CHD have positive experiences with
physical activity, thus increasing their self-efficacy, something that
could be achieved with the help of well-prepared teachers and
educators.
6. Study limitations e suggestions for further research
Self-reporting questionnaires have limitations including over-
estimation of activities and forgetfulness. In addition, other
contributing factors affecting physical activity, such as medications
or parental perception of safe activity levels, are not adjusted for.
However, there is no other nonintrusive, reliable way to record a
child's physical activity. Developing such an instrument could be a
future research objective.
Another potential limitation is that the SES and PDPAR have not
been fully validated in a Greek population, although preliminary
studies showed no significant deviations from the U.S.
population.23
Please cite this article as: Moschovi D et al., Physical activity levels and self-efficacy of Greek children with congenital heart disease compared to
their healthy peers, Hellenic Journal of Cardiology, https://doi.org/10.1016/j.hjc.2019.01.002
7
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