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Development and validation of an English version of the Coronary Artery

Disease Education Questionnaire (CADE-Q)

Article in European Journal of Preventive Cardiology · January 2012

DOI: 10.1177/2047487312437061 · Source: PubMed

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EURO PEAN
SO CIETY O F
Original scientific paper CARDIOLOGY ®

European Journal of Preventive

Cardiology

Development and validation of an English 0(00) 1–10

! The European Society of
Cardiology 2012
version of the Coronary Artery Disease Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
Education Questionnaire (CADE-Q) DOI: 10.1177/2047487312437061
ejpc.sagepub.com

Gabriela Lima de Melo Ghisi1,2, Paul Oh2, Scott Thomas1 and

Magnus Benetti3

Abstract
Background: The Coronary Artery Disease Education Questionnaire (CADE-Q) is a validated specific tool used to
assess the knowledge and educate coronary patients in cardiac rehabilitation on aspects related to coronary artery
disease (CAD). The aim of this study is to translate, cross-culturally adapt and validate from Portuguese to English the
Coronary Artery Disease Education Questionnaire (CADE-Q).
Methods: Two independent translations were performed by qualified translators. After back-translation, both versions
were reviewed by a committee of experts. A final English version was tested in a pilot study. For the psychometric
validation, the tool was administered to 200 Canadian coronary patients enrolled in cardiac rehabilitation (CR). The
internal consistency was assessed using Cronbach’s alpha, the test–retest reliability using intraclass correlation coefficient
(ICC), and the construct validity through factor analysis. Criterion validity of CADE-Q was assessed with regard to
patients’ characteristics.
Results: Eleven of 19 questions were modified and culturally adapted in the English version. Cronbach’s alpha was 0.809
and ICC was 0.846. Factor analysis revealed five factors, all internally consistent and well defined by the items. Criterion
validity was supported by significant differences in mean scores by family income (p ¼ 0.02) and educational level
(p < 0.001).
Conclusion: The English version of the CADE-Q was demonstrated to have adequate reliability and validity, supporting
its use in further studies.

Keywords
Coronary artery disease, patient education, health knowledge, attitudes, practice, questionnaires, psychometric
validation
Received 26 September 2011; accepted 7 January 2012

Introduction Knowledge of health and disease has been reported

Cardiac rehabilitation (CR), defined as ‘a combination
of the correct and practical use of guidelines, appropri-
ate consultation, supplies of drugs and ancillary ser-
vices, and education,1 helps heart patients not only to
improve their functional capacity, quality of life and
to reduce risk factors, but also to educate them and
to create a sense of wellbeing and optimism about
the future.1–3 Studies have shown that when all facets
of CR programs are applied in a comprehensive and
systematic fashion, including patient education, it has a
significant impact on recovery, reduction of admissions
to hospital, improvement of quality of life and the func-
tional state of these patients.4–6
as an important component relating to successful man-
agement of coronary artery disease.5–7 Studies have
1
Exercise Sciences, Faculty of Physical Education and Health, University of
Toronto, Toronto, Canada
2
Cardiac Rehabilitation and Prevention Program, Toronto Rehabilitation
Institute, Toronto, Canada
3
Health Sciences and Sports Center, Santa Catarina State University,
Florianopolis, Brazil
Corresponding author:
Gabriela Lima de Melo Ghisi, Toronto Rehabilitation Institute. 347
Rumsey Road, Toronto, Ontario – M4G 1R7, Canada
Email: meloghisi.gabriella@torontorehab.on.ca
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2 European Journal of Preventive Cardiology 0(00)
shown that patient education can influence cardiac
patients to make healthier choices in daily life, to
better manage their disease, to avoid adverse outcomes,
and educational programs have even been associated
with regression of coronary disease.8–16
Despite the well-established benefits of patient edu-
cation in the CR setting, there are few psychometrically
validated questionnaires published in the literature that
assess cardiac patients’ knowledge applicable to CR
programs or that could be integrated into the routine
management of this population. In addition, most of
the tools are structured in a ‘true/false/do not know’
way, which may not reflect the patient’s real under-
standing about the condition because this form of
structuring focuses more on ‘how much you know’
rather than ‘what you know’.9,17
Ghisi et al.18 recently developed the Coronary
Artery Disease Education Questionnaire (CADE-Q),
which assesses patients’ knowledge about their disease
and related factors in a CR setting. The questionnaire
was developed following an extensive review of the lit-
erature, with feedback from cardiologists and a CR
multidisciplinary team. The CADE-Q, originally devel-
oped and validated in Brazilian Portuguese, was dem-
onstrated to be a valid tool, with strong overall
characteristics in terms of content, development and
testing.
The objective of the present study was to translate
into English, cross-culturally adapt and psychometri-
cally-validate the CADE-Q in order to facilitate appli-
cation in a Canadian cardiac rehab setting.
Methods
The Coronary Artery Disease Questionnaire
(CADE-Q)
The CADE-Q was initially developed, validated and
applied in 155 coronary patients who were undergoing
CR in the South of Brazil. Its goal is to assess knowl-
edge about CAD in patients undergoing CR programs,
and through this assessment to develop strategies for
the education of coronary patients.18
The questionnaire is self-administered and has 19
items covering four areas of knowledge: A1 about path-
ophysiology and signs and symptoms of the disease; A2
about risk factors and lifestyle habits; A3 about diag-
nosis, treatment and medicines; and A4 about exercise.
The items are arranged randomly, and one item can be
part of more than one area of knowledge.
Each item has four alternatives or statements that
correspond to a knowledge level: a correct statement
showing ‘complete knowledge’; a correct statement
showing ‘incomplete knowledge’; an incorrect state-
ment showing ‘wrong knowledge’; and, a ‘don’t
[1–10]
know’ statement showing a ‘lack of knowledge’. A
numerical weight was also applied to each response:
complete knowledge ¼ 3; incomplete knowledge ¼ 1;
wrong knowledge ¼ 0; and lack of knowledge ¼ 0.
Addition of the scores establishes a level of knowl-
edge, classified as ‘excellent’, ‘good’, ‘acceptable’, ‘poor’
or ‘insufficient’.
The participants are characterized through demo-
graphic information questions, attached to the tool.
Participants
For the testing and validation of the English CADE-Q,
we recruited CR patients from the Toronto
Rehabilitation Institute, Toronto, Canada. The inclu-
sion criteria at baseline were the following: confirmed
coronary artery disease diagnosis or multiple cardiovas-
cular risk factors (such as hypertension and diabetes).
The exclusion criteria were the following: younger than
18 years old; any significant visual, cognitive or psychi-
atric condition that would preclude the participant
from answering the questionnaire.
Data were collected between June and August of
2009.
Participants were characterized according to gender,
age, comorbidities, cardiac surgical procedures, dura-
tion of participation in CR programs, occupation, edu-
cational level and family income.
This study was reviewed and approved by the
Toronto Rehabilitation Research Ethics Board accord-
ing to the standards required by the Declaration of
Helsinki, according to Resolution CNS 196/96.
Participants were informed about the objectives of
this study and signed the Free and Informed Consent
Form prior to study enrolment.
Process of translation of the CADE-Q
The process of translation and adaptation of the
CADE-Q followed strict norms aimed at making the
tool available to the Canadian population taking into
account cultural differences.19 The entire process of
translation of this tool – from Brazilian Portuguese to
Canadian English – was carried using a multi-stage
questionnaire validation process described as follow:
translation, back-translation, review by a committee
of experts and pre-testing (Pilot Study).19,20
The translation of the original instrument was per-
formed by two independent qualified translators.
Conceptual translation, rather than strictly literal, was
emphasized. Both translators were aware of the objec-
tives and concepts of the study and sought to resolve
the ambiguities and the unexpected meanings in the
original item.
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Ghisi et al.
Both translations were back-translated by two
others qualified translators who were not aware of the
goals of the instrument.
The two translations were reviewed and compared to
the original to check whether there was any change
in the context of the questions. It was concluded that
there were no discrepancies. A version was generated
and was further reviewed by a Canadian Committee of
Experts in CR that verified the instrument was appro-
priate for administration in a Canadian population.
The next step was the Pilot Study, which was a pre-
test performed on 50 coronary patients who had
finished their CR programs. The aims of this phase
were to verify the applicability of the CADE-Q instru-
ment in the English language and to evaluate the under-
standing of the questions (clarity) and resolve any
doubts on the structure of the questions. To assess clar-
ity, patients were asked to rate each question level on a
scale from 1 (not clear or understood) to 10 (completely
clear and easily understood).21
A final version was then generated and this was used
for the psychometric validation tests.
Measures to assess the psychometric properties
of the CADE-Q
To investigate the psychometric properties of the
English CADE-Q, the internal consistency, test–retest
reliability, construct and criterion validities were
assessed.
The internal consistency was assessed by Cronbach’s
Alpha. In this analysis, Alpha values higher than 0.60
were considered acceptable, reflecting the internal cor-
relation between items and factors.22
The test–retest reliability was assessed through the
intraclass correlation coefficient (ICC).22 In this case,
the questionnaire was re-administered two weeks after
the first application in 25 randomly selected subjects. In
this analysis, ICC values range between 0 and 1, and
the higher the value, the greater the reproducibility.22
The construct validity was analyzed through explor-
atory factorial analysis. The main component method
for factor extraction was used, considering only those
that presented eigenvalues >1.0. After the selection of
the factors, a correlation matrix was generated in which
the associations between items and factors were
observed through factorial loads greater than 0.30 on
only one factor. The equamax method was used to
interpret the matrix.22,23
To assess the criterion validity of the CADE-Q,
t-tests, one-way analysis of variance and chi-square
tests were used to assess differences in mean total
scores regarding patients’ characteristics (age, gender,
comorbidities, cardiac surgical procedures, duration of
3
participation in CR programs, occupation, educational
level and family income).
SPSS Version 17.0 was used for entering, cleaning
and analyzing the data and the level of significance was
set at 0.05 for all tests. If more than 10% of the items
were missing, the data were excluded from further
analysis.
The sample size followed the criterion of ten subjects
per item of the instrument.24
Results
Participants characteristics
For the psychometric validation, 200 coronary patients
(50 female; mean age 63.6 years) who had participated
in CR programs for at least one month completed the
CADE-Q. The majority had risk factors including
hypertension (49%) and dyslipidemia (29%).
Moreover, 45% of the participants reported previous
acute myocardial infarction and 66% of the individuals
had a cardiac procedure. Of these, 24% had an associ-
ated surgical procedure (coronary artery bypass graft
surgery).The prevalence of smokers and patients with
chronic obstructive pulmonary disease was very low
(5% and 3% respectively).
The socioeconomic level was characterized by occu-
pation, education level and family income. The partic-
ipants tended to be retired or have professional level
occupation, to have an education level greater than
high school and to earn more than C$51,000 per year.
The characteristics of the study population are pre-
sented in Table 1.
Translation, cross-cultural adaptation and pilot study
The final English version of CADE-Q also had 19
items. Eleven of the items were adapted to Canadian
culture (for example, terminology, adjustments of
common terms) but no scores were modified. Many
of these changes, both in questions and possible
answers, related to what patients typically learn
during Canadian educational cardiac programs and
also the way in which the CAD is managed in Canada.
The pilot study carried out in 50 coronary patients
showed a mean clarity index of 8.5 (scale 1–10), indi-
cating that the questionnaire was easily understood by
the target population. It was observed that all patients
from the pilot study had ‘excellent’ to ‘good’ knowl-
edge, which could be justified because this sample had
already finished their CR programs, including educa-
tional sessions and lectures.
The instrument took 11  5 minutes to fill out, which
was similar to the time taken with the original question-
naire in Brazil (13  4 minutes).18
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Table 1. Characteristics of the coronary patients enrolled in the study (n ¼ 200)

Variable Category n % Total

Age (mean ¼ 63.58 years) Younger than 65 years 46 23

65 years or older 154 77
Gender Male 150 75
Female 50 25
Associated comorbidities Arterial hypertension (AH) 98 49
Congestive heart failure (CHF) 59 29
Diabetes mellitus type I (DI) 4 5
Diabetes mellitus type II (DII) 33 16
Peripheral arterial disease (PAD) 22 11
Dyslipidemia 59 29
Chronic obstructive pulmonary disease 6 3
Smokers 11 5
Acute event Acute myocardial infarction (AMI) 83 41
Cardiac procedures Coronary artery bypass graft (CABG) surgery 36 18
Percutaneous coronary intervention (PCI) 87 43
CABG þ PCI 12 6
Other 17 8,5
None 48 24
Occupation Retired 76 38
Secondary level 20 10
University level 65 32
Home 5 2
Health 6 3
No answer 28 14
Educational level Elementary school 1 0.5
High school 43 21.5
College 51 25.5
University 61 30.5
Postgraduate 31 15.5
No answer 13 6.5
Family income Less than C$10.000 per year 2 1
Between C$11.000 and C$50.000 per year 31 15.5
Between C$51.000 and C$100.000 per year 78 39
Between C$101.000 and C$150.000 per year 41 20.5
More than C$150.000 per year. 24 12
No answer 24 12

The questions of the English CADE-Q are shown in
Table 2.
Psychometric validation
The internal consistency was assessed by Cronbach’s
Alpha, and the English CADE-Q was considered inter-
nally consistent (Alpha ¼ 0.809). The test–retest reli-
ability was evaluated through the intraclass
correlation coefficient (ICC), in a two-week interval
application in 25 patients. The ICC was quite high at
0.846. These values were greater than those found in the
validation of the original tool: Alpha of 0.68 and ICC
of 0.783.18
The construct validity was evaluated through explor-
atory factorial analysis. The results from the Kaiser-
Meyer-Olkin index (KMO ¼ 0.797) and Bartlett
Sphericity tests (X2 ¼ 839.67, p < 0.001) indicated that
the data were suitable for factor analysis. Five factors
were extracted (representing 62.23% of the total vari-
ance). All factors were internally consistent and well-
defined by the items and knowledge areas of the
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Table 2. Questions in the English version of CADE-Q

Questions

Q1 Coronary artery disease (CAD) is:

a) A disease of the arteries of the heart that occurs in older age in people with high cholesterol and who smoke.
b) A disease of the arteries of the heart that starts silently at a young age, is influenced by poor life style habits, has a
genetic component, and involves inflammation in the arteries.
c) A disease of the heart’s arteries related to older age and that leads to memory Impairment.
d) I don’t know.
Q2 Which factors have the most influence on the risk of myocardial infarction?
a) Drinking small amounts of alcoholic beverages.
b) Environment factors (such as weather) and socioeconomic factors (such as monthly family income).
c) Smoking, high levels of blood cholesterol (dyslipidemia), and hypertension.
d) I don’t know.
Q3 Which description below is a typical symptom of CAD?
a) Headache after meals.
b) Chest pain or discomfort during physical activity.
c) Chest pain or discomfort, at rest or during physical activity, which can also be felt in the arm and/or back and/or
neck.
d) I don’t know.
Q4 Which of the following statements is most accurate regarding our understanding of CAD?
a) The CAD is related to blockage of the arteries that supply blood to the heart caused by the formation of
atherosclerotic plaques (fat deposit on the artery walls), that can cause angina (chest pain).
b) Acute myocardial infarction (MI) is the only manifestation of CAD.
c) The presence of chest pain is suggestive of a diagnosis of CAD.
d) I don’t know.
Q5 The best time of the day for people with coronary disease to carry out their prescribed exercise is:
a) In the afternoon or evening, because the early morning is the time of day with the highest risk of a heart attack.
b) Never, because exercise is considered too risky for people with CAD.
c) Any time, because the benefits of exercise outweigh the risks at any time of day.
d) I don’t know.
Q6 Of the investigations listed below, which ones provide the most precise information about the diagnosis and
prognosis of CAD?
a) X-ray and magnetic resonance imaging of the chest.
b) Exercise treadmill test (stress test) and cardiac catheterization (angiogram).
c) Electrocardiogram (EKG) at rest and a clinical history.
d) I don’t know.
Q7 Which of the following statements about the management of blood cholesterol levels is most accurate?
a) Physical exercise and diet are enough to lower cholesterol to target levels after a heart attack.
b) Physical exercise and diet should be followed regularly and when necessary, a medication such as a ‘‘statin’’ may be
required
c) There is no treatment because high cholesterol levels are genetically inherited and can’t be changed.
d) I don’t know.
Q8 Which of the following statements about the use of ‘nitroglycerin’ is most accurate?
a) They are a class of medications that can be administered to improve coronary blood flow and can be given either
continuously (such as in a tablet or patch) or used sublingually (under the tongue as a spray or small tablet) in
situations of acute chest pain.
b) They are medications given only by the sublingual route in emergency situations to relieve chest pain.
c) They are medicines used to decrease blood pressure and bad cholesterol (LDL) in patients with cardiac problems.
d) I don’t know.
Q9 Which of the following dietary components is usually recommended to persons with CAD?
a) A diet with reduced salt, low fat and rich in fiber.
b) A diet based on whole grains, vegetables, fish, extra virgin olive oil and nuts.
c) An unrestricted diet, because diet is not a relevant factor.
d) I don’t know.
(continued)
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Table 2. Continued

Questions

Q10 Which values for LDL cholesterol and HDL cholesterol are the optimal targets persons with established CAD
(values in mmol/l)?
a) LDL less than 2.0 and HDL greater than 1.2.
b) LDL 2.0 to 2.5 and HDL greater than 1.0.
c) LDL greater than 3.0 and HDL less than 1.0.
d) I don’t know.
Q11 Under which of the following conditions would you avoid carrying out your usual physical exercise?
a) If you had a recent heart attack (for example 8 weeks ago).
b) If you have a bad infection today (for example a really bad ‘flu’).
c) If your blood pressure is moderately elevated (for example 150/90).
d) I don’t know.
Q12 While walking, if you experience a new episode of severe chest discomfort that you think that is angina, you should:
a) Drive your car directly to the hospital to seek medical care.
b) Try to relax, wait for the pain to improve, and then seek medical attention.
c) Stop your walk and sit, take a sublingual nitroglycerin, and seek medical care if the pain does not subside. Call your
doctor to let him or her know what has happened.
d) I don’t know.
Q13 Based on your knowledge about physical exercise and CAD, choose the most appropriate statement below:
a) Physical exercise should never be practiced by patients with coronary artery disease because of high risk of death.
b) Physical exercise is a fundamental part of the treatment plan, because it helps to control risk factors, prolongs
survival and enhances quality of life.
c) Physical activity should be included in the treatment plan only when patients are fully recovered from their heart
event.
d) I don’t know.
Q14 Guidelines for physical activity for people with coronary disease should be based upon which of the following:
a) The exercise prescription should be individually devised based on an exercise stress test and respect the person’s
abilities and disabilities.
b) Start at a low level to moderate level and build up gradually.
c) Be the same for all persons of the same gender and age, because these groups have the same physical ability and
risk.
d) I don’t know.
Q15 Which of the following favorable physiological and bodily changes resulting from regular physical exercise are most
important to long-term cardiac health?
a) Blood vessel function improvement, growth of new blood vessels, and even a possible regression (shrinking) of
atherosclerotic plaque.
b) Resting heart rate decrease, more forceful heart beat, and lipid profile improvement.
c) Blood pressure increase, higher heart rates, and higher triglyceride levels.
d) I don’t know.
Q16 Which of the following statements best describes the pattern for exercise activity in persons recovering from a
heart event:
a) At any place, daily duration of about 30 minutes, which can be cumulative (10 minutes in the morning, 10 minutes
at noon and 10 minutes at night).
b) In an appropriate setting, with periodic monitoring by qualified professionals, with the goal of achievement of self-
sufficiency.
c) In a hospital environment only.
d) I don’t know.
Q17 Which of the following statements is the most appropriate guidance around levels of blood pressure levels in
persons with CAD:
a) It doesn’t matter whether blood pressure is normal or high because it does not have any long-term health effects.
b) A value of less than 140/90 mmHg is considered normal.
c) An optimal blood pressure is 120/80 mmHg.
d) I don’t know.
Q18 Which of the statements below regarding psychological stress is most correct?
a) It is one of the important risk factors for AMI (acute myocardial infarction).
b) Stress is related to the presence of anxiety and depression.
(continued)
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Table 2. Continued

Questions

c) It has no impact on heart disease, since atherosclerosis is a completely physical process and is not related to
psychological factors.
d) I don’t know.
Q19 Which interventions can extend and improve a patient’s quality of life for persons recovering from a cardiac event?
a) Lifestyle changes þ medical treatments þ in some cases surgical intervention.
b) Medication þ in some cases surgical intervention.
c) Prolonged bed rest.
d) I don’t know.

Table 3. Empirical structure of CADE-Q in English

Components

Factor 3 Factor 4
Diagnosis, Pathophysiology,
Factor 1 Factor 2 treatment, signals, Factor 5 Risk
Items Exercise Risk factors medicines symptoms factor prevention

5 .791
11 .814
13 .738
14 .771
16 .387
2 .557
10 .394
17 .724
18 .432
6 .368
8 .505
12 .612
19 .308
1 .539
3 .521
4 .576
15 .391
7 .728
9 .505

questionnaire. Factor 1 reflected exercise; Factor 2 risk
factors; Factor 3 diagnosis, treatment and medicines;
Factor 4 pathophysiology, signals and symptoms;
Factor 5 prevention of risk factors.
Table 3 shows the factorial loads of each question in
the five factors extracted, based on loadings greater
than 0.30 on only one factor.22
To assess the criterion validity of the English
CADE-Q, t-tests, one-way analysis of variance and
chi-square tests were used to evaluate differences in
mean total scores regarding patients’ characteristics
that have previously been shown to discriminate
knowledge across populations. Mean total scores were
significantly greater among those with higher family
income (p ¼ 0.02) and higher educational level
(p < 0.001), which demonstrates the influence of socio-
economic level in patient knowledge. This is consistent
with prior studies.5,9,11,13,14,16,25–28 In addition, the
mean total score was 41.85, which is classified as
‘good’ and it is positively related to the fact that the
participants received information from the CR
program.
The frequency of each question in the four alterna-
tives is reported in detail in Table 4. The results showed
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Table 4. Frequencies and marked alternatives per question

Marked alternatives n(%)

Questions Complete Incomplete Wrong Don’t know

Q1 123(61.5) 26(13) 9(4.5) 42(21)

Q2 173(86.5) 4(2) 4(2) 19(9.5)
Q3 157(78.5) 26(13) 2(1) 15(7.5)
Q4 161(80.5) 12(6) 6(3) 21(10.5)
Q5 166(83) 23(11.5) – 11(5.5)
Q6 125(62.5) 27(13.5) 23(11.5) 25(12.5)
Q7 167(83.5) 17(8.5) 2(1) 1(7)
Q8 105(52.5) 41(20.5) 3(1.5) 51(25.5)
Q9 57(28.5) 129(64.5) 1(0.5) 13(6.5)
Q10 85(42.5) 34(17) 8(4) 73(36.5)
Q11 89(44.5) 19(9.5) 51(25.5) 41(20.5)
Q12 162(81) 19(9.5) 8(4) 11(5.5)
Q13 173(86.5) 17(8.5) – 10(5)
Q14 153(76.5) 34(17) – 13(6.5)
Q15 114(57) 46(23) 2(1) 38(19)
Q16 141(70.5) 35(17.5) 10(5) 14(7)
Q17 140(70) 33(16.5) 1(0.5) 26(13)
Q18 96(48) 82(41) 2(1) 20(10)
Q19 194(97) 3(1.5) – 3(1.5)
Mean 12.89(SD ¼ 3.6) 3.14(SD ¼ 2) 0.66(SD ¼ 0.8) 2.31(SD ¼ 2.9)
Critical items are in bold.

three items as considered critical (higher scores not
related to the complete knowledge).
Discussion
This study sought to develop and validate the English
version of the CADE-Q and we achieved this through a
rigorous process. The key steps included translation
and back-translation, review by a committee of experts,
adaption of questions to Canadian culture, assessment
of clarity, pilot testing) and psychometric validation.
Factor analysis revealed five factors, namely exer-
cise, risk factors, diagnosis/treatment/ medicines, path-
ophysiology/signals/symptoms, and prevention of risk
factors. All factors were internally consistent and well
defined by the items and knowledge areas of the ques-
tionnaire. English CADE-Q scores were significantly
related to socioeconomic levels and cardiac rehabilita-
tion participation, such that the criterion validity was
established. Finally, internally consistency was demon-
strated and test–retest reliability was valid.
When compared to the original version,18 the
English CADE-Q presented powerful psychometric
properties, which can be explained by the adjustments
made to the instrument and the greater understanding
and involvement of researchers in this area.
Although only the characteristics associated with the
socioeconomic level presented significant differences in
total scores, other factors, such as age, gender associ-
ated comorbidities, participation in CR and cardiac
surgical interventions, must be analyzed with the use
of this questionnaire, as they can also have an impact
on the attainment of knowledge by coronary patients.23
The critical items (questions 9, 10 and 11) reflect
misconceptions in practical information about diet,
cholesterol and physical exercise. This result supports
and emphasizes the use of this tool in the routine care
of coronary patients.
In conclusion, the English CADE-Q proved to be a
reliable and valid tool that evaluates patient knowledge
about CAD and related factors. It can be used not only
in clinical practice, but also will be a particularly impor-
tant measure to use in forthcoming research studies,
including those focused on the uptake and translation
of educational programs.
There are few valid and reliable instruments in the
patient education and CR context. The availability of
an English version of CADE-Q was a necessary and
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K:/CPR/CPR 437061.3d (CPR) [PREPRINTER stage]
Ghisi et al.
timely development, especially given the emphasis on
managing CVD morbidity and mortality in English-
speaking nations. Tools tailored to specific comorbid-
ities groups (for example people with diabetes or hyper-
tension) are still needed.
Implications
Before implementing patient education programs, it is
prudent to show their efficacy. The availability of a
relevant valid knowledge questionnaire is essential to
evaluate a novel educational intervention and to tailor
the educational component of CR programs. In addi-
tion, this questionnaire would also be useful in clinical
practice to identify both patients who do not have ade-
quate knowledge about CAD in general as well as to
specific areas or to provide educational opportunities to
meet a patient’s specific need within this world of
knowledge.
Studies of patient knowledge can be quite useful in
the creation of strategies to increase patient satisfaction
and stimulate patient adherence to CR programs,
which can also interfere in the success of this interven-
tion.10,29,30 Additionally, the association between CAD
and knowledge can collaborate to optimize treatment,
with a change in beliefs, lifestyle and risk factors.14 In
this context, CADE-Q can be a useful tool.
Funding
This research received no specific grant from any
funding agency in the public, commercial or not-for-profit
sectors.
Conflict of interest
There are no conflicts of interest.
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