{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,24]],"date-time":"2026-03-24T21:09:24Z","timestamp":1774386564643,"version":"3.50.1"},"reference-count":43,"publisher":"Public Library of Science (PLoS)","issue":"3","license":[{"start":{"date-parts":[[2026,3,24]],"date-time":"2026-03-24T00:00:00Z","timestamp":1774310400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000327","name":"Heart Research UK","doi-asserted-by":"crossref","award":["GR2686"],"award-info":[{"award-number":["GR2686"]}],"id":[{"id":"10.13039\/501100000327","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Coronary heart disease is the leading cause of global mortality, imposing significant health and economic burdens. Cardiac rehabilitation, including physical activity, can reduce coronary heart disease-related morbidity and mortality. We tested whether the addition of a behaviour change intervention to cardiac rehabilitation could promote and maintain physical activity achieved during cardiac rehabilitation, beyond standard care timeframes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A cluster randomised controlled trial was conducted across six community-based maintenance stage cardiac rehabilitation classes. A total of 96 participants (mean age 65.04\u2009\u00b1\u20098.38 years; 75% male) received either standard care or a behaviour change intervention, with physical activity, measured with an ActiGraph GT3X+ accelerometer as the primary outcome.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>No significant differences in daily minutes of moderate-to-vigorous physical activity and steps per day, or any secondary outcomes, including self-rated health, quality of life, and mental wellbeing, were observed between the intervention and control groups at six months follow-up. These findings suggests that the behaviour change intervention did not significantly impact physical activity or health outcomes during maintenance cardiac rehabilitation. This may be attributed to high baseline physical activity levels among participants, and the extended cardiac rehabilitation support provided to both groups, potentially masking any intervention effects.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>A behaviour change intervention added to standard maintenance stage cardiac rehabilitation did not improve physical activity or health outcomes. However, continued access to cardiac rehabilitation sustained high physical activity levels. Future research should disentangle the independent effects of behaviour interventions and ongoing cardiac rehabilitation support.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec005\">\n                    <jats:title>Trial registration<\/jats:title>\n                    <jats:p>\n                      ClinicalTrials.gov\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/clinicaltrials.gov\/ct2\/show\/NCT05705310\" xlink:type=\"simple\">NCT05705310<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0345293","type":"journal-article","created":{"date-parts":[[2026,3,24]],"date-time":"2026-03-24T17:41:58Z","timestamp":1774374118000},"page":"e0345293","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["The STRENGTH Study: A cluster randomised controlled trial of the effect of a behaviour change intervention added to cardiac rehabilitation on physical activity adherence"],"prefix":"10.1371","volume":"21","author":[{"given":"Clare T. 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Cardiovascular diseases (CVDs) Factsheet; 2025. Available from: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/cardiovascular-diseases-(cvds)"},{"key":"pone.0345293.ref003","unstructured":"British Heart Foundation (BHF). UK Factsheet 2025; 2025. Available from: https:\/\/www.bhf.org.uk\/-\/media\/files\/for-professionals\/research\/heart-statistics\/bhf-cvd-statistics-uk-factsheet.pdf"},{"key":"pone.0345293.ref004","unstructured":"British Heart Foundation (BHF). 2023 Statistics compendium; 2023. Available from: https:\/\/www.bhf.org.uk\/-\/media\/files\/for-professionals\/research\/heart-statistics\/bhf-statistics-compendium-2023.pdf"},{"issue":"8","key":"pone.0345293.ref005","doi-asserted-by":"crossref","DOI":"10.1016\/S2666-7568(24)00108-9","article-title":"The economic burden of cancer, coronary heart disease, dementia, and stroke in England in 2018, with projection to 2050: an evaluation of two cohort studies","volume":"5","author":"F Landeiro","year":"2024","journal-title":"Lancet Healthy Longev"},{"key":"pone.0345293.ref006","doi-asserted-by":"crossref","DOI":"10.1016\/j.lpm.2016.10.003","article-title":"Epidemiology of stroke in Europe and trends for the 21st century","volume":"45","author":"Y B\u00e9jot","year":"2016","journal-title":"Presse Med"},{"key":"pone.0345293.ref007","volume-title":"The BACPR standards and core components for cardiovascular disease prevention and rehabilitation 2023","author":"BACPR Standards and Core Components 2023 Edition Primary Writing Group","year":"2023"},{"key":"pone.0345293.ref008","unstructured":"Department of Health (DoH). UK physical activity guidelines; 2019. Available from: https:\/\/assets.publishing.service.gov.uk\/government\/uploads\/system\/uploads\/attachment_data\/file\/832868\/uk-chief-medical-officers-physical-activity-guidelines.pdf"},{"key":"pone.0345293.ref009","unstructured":"World Health Organization (WHO). WHO guidelines on physical activity and sedentary behaviour; 2020. Available from: https:\/\/iris.who.int\/bitstream\/handle\/10665\/336656\/9789240015128-eng.pdf"},{"key":"pone.0345293.ref010","article-title":"Cardiac rehabilitation","volume":"351","author":"HM Dalal","year":"2015","journal-title":"BMJ"},{"issue":"6","key":"pone.0345293.ref011","doi-asserted-by":"crossref","first-page":"659","DOI":"10.1007\/s11906-013-0386-8","article-title":"Physical activity and the prevention of hypertension","volume":"15","author":"KM Diaz","year":"2013","journal-title":"Curr Hypertens Rep"},{"issue":"11","key":"pone.0345293.ref012","doi-asserted-by":"crossref","first-page":"983","DOI":"10.1007\/s00592-017-1037-3","article-title":"Physical activity and change in fasting glucose and HbA1c: a quantitative meta-analysis of randomized trials","volume":"54","author":"M Boniol","year":"2017","journal-title":"Acta Diabetol"},{"key":"pone.0345293.ref013","unstructured":"British Heart Foundation (BHF). Physical inactivity and sedentary behaviour report; 2017. Available from: https:\/\/www.bhf.org.uk\/-\/media\/files\/for-professionals\/research\/heart-statistics\/physical-inactivity-report---mymarathon-final.pdf"},{"issue":"21","key":"pone.0345293.ref014","doi-asserted-by":"crossref","first-page":"1414","DOI":"10.1136\/bjsports-2015-f5577rep","article-title":"Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study","volume":"49","author":"H Naci","year":"2015","journal-title":"Br J Sports Med"},{"issue":"17","key":"pone.0345293.ref015","doi-asserted-by":"crossref","first-page":"1394","DOI":"10.1136\/heartjnl-2017-312832","article-title":"Cardiac rehabilitation and physical activity: systematic review and meta-analysis","volume":"104","author":"GO Dibben","year":"2018","journal-title":"Heart"},{"issue":"11","key":"pone.0345293.ref016","article-title":"Exercise-based cardiac rehabilitation for coronary heart disease","volume":"11","author":"G Dibben","year":"2021","journal-title":"Cochrane 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Matthews","year":"2012","journal-title":"Med Sci Sports Exerc"},{"issue":"2","key":"pone.0345293.ref027","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1249\/MSS.0b013e3181ed61a3","article-title":"Validation of accelerometer wear and nonwear time classification algorithm","volume":"43","author":"L Choi","year":"2011","journal-title":"Med Sci Sports Exerc"},{"issue":"1","key":"pone.0345293.ref028","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1249\/mss.0b013e31815a51b3","article-title":"Physical activity in the United States measured by accelerometer","volume":"40","author":"RP Troiano","year":"2008","journal-title":"Med Sci Sports Exerc"},{"issue":"1","key":"pone.0345293.ref029","doi-asserted-by":"crossref","first-page":"60","DOI":"10.1080\/02701367.1992.10607557","article-title":"Self-efficacy and the stages of exercise behavior change","volume":"63","author":"BH Marcus","year":"1992","journal-title":"Res Q Exerc 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Policy"},{"issue":"8","key":"pone.0345293.ref033","doi-asserted-by":"crossref","first-page":"745","DOI":"10.1136\/jech-2011-200689","article-title":"An evaluation of the effectiveness and cost effectiveness of the National Exercise Referral Scheme in Wales, UK: a randomised controlled trial of a public health policy initiative","volume":"66","author":"SM Murphy","year":"2012","journal-title":"J Epidemiol Community Health"},{"key":"pone.0345293.ref034","doi-asserted-by":"crossref","first-page":"1021","DOI":"10.1186\/1471-2458-13-1021","article-title":"Cost-effectiveness of a national exercise referral programme for primary care patients in Wales: results of a randomised controlled trial","volume":"13","author":"RT Edwards","year":"2013","journal-title":"BMC Public Health"},{"issue":"10","key":"pone.0345293.ref035","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2018-022266","article-title":"Cost-effectiveness of exercise referral schemes enhanced by self-management strategies to battle sedentary behaviour in older adults: protocol for an economic evaluation alongside the SITLESS three-armed pragmatic randomised controlled trial","volume":"8","author":"M Deidda","year":"2018","journal-title":"BMJ Open"},{"issue":"4","key":"pone.0345293.ref036","doi-asserted-by":"crossref","DOI":"10.2196\/jmir.5191","article-title":"Cardiac patients\u2019 walking activity determined by a step counter in cardiac telerehabilitation: data from the intervention arm of a randomized controlled trial","volume":"18","author":"C Thorup","year":"2016","journal-title":"J Med Internet Res"},{"issue":"5","key":"pone.0345293.ref037","doi-asserted-by":"crossref","first-page":"351","DOI":"10.1097\/JCN.0b013e3182049f00","article-title":"Systematic review of physical activity intervention studies after cardiac rehabilitation","volume":"26","author":"J-AD Chase","year":"2011","journal-title":"J Cardiovasc Nurs"},{"issue":"1","key":"pone.0345293.ref038","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1186\/s12966-024-01642-2","article-title":"A cardiac-rehab behaviour intervention to reduce sedentary time in coronary artery disease patients: the SIT LESS randomized controlled trial","volume":"21","author":"SH Kroesen","year":"2024","journal-title":"Int J Behav Nutr Phys Act"},{"issue":"15","key":"pone.0345293.ref039","doi-asserted-by":"crossref","first-page":"1634","DOI":"10.1093\/eurjpc\/zwad145","article-title":"eHealth for maintenance cardiovascular rehabilitation: a systematic review and meta-analysis","volume":"30","author":"M Heimer","year":"2023","journal-title":"Eur J Prev Cardiol"},{"issue":"1","key":"pone.0345293.ref040","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1037\/a0021974","article-title":"Systematic review of maintenance of behavior change following physical activity and dietary interventions","volume":"30","author":"B 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Behaviour change: general approaches. NICE public health guidance 6; 2007. Available from: www.nice.org.uk\/guidance\/ph6"},{"key":"pone.0345293.ref042","unstructured":"National Institute for Health and Care Excellence. Behaviour change: individual approaches. NICE public health guidance 49; 2014. 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