Responding to symptoms and signs of acute myocardial infarction--how do you educate the public?: a social-psychologic approach to intervention

Improving knowledge, attitudes and beliefs about acute coronary syndrome through an individualized educational intervention: a randomized controlled trial

OBJECTIVE

To test the effectiveness of an individualized educational intervention on knowledge, attitudes and beliefs about acute coronary syndrome (ACS).

METHODS

This multi-site, randomized controlled trial was conducted on 1947 patients with a diagnosis of ACS. Both groups received usual in-hospital education. Participants randomized to the intervention group received a 40-min one to one individualized education session, delivered using motivational interviewing techniques. The intervention was reinforced 1 month and 6 months later. Knowledge, attitudes and beliefs were measured using the ACS Response Index. A total of 1136 patients (control, n=551; intervention, n=585) completed the questionnaire at baseline, 3 and 12 months. Data were analyzed using repeated measures analysis of variance. Ethical approval was obtained.

RESULTS

There was a significant effect of the intervention on mean knowledge (p<0.001), attitude (p=0.003) and belief (p<0.001) scores at 3 and 12 months.

CONCLUSION

Ensuring patients retain information post education has always been difficult to attain. This study demonstrated that patient education using motivational interviewing techniques and an individualized approach has the potential to alter knowledge, attitudes and beliefs about ACS among a high risk population.

PRACTICE IMPLICATIONS

This relatively short, simple and effective educational intervention could be delivered by nurses in multiple settings.

The chain of survival for ST-segment elevation myocardial infarction: insights into the Middle East

Although coronary heart disease is the leading cause of morbidity and mortality in the Middle East (ME), not much is known about patients with ST-segment elevation myocardial infarction (STEMI) from this region. The STEMI Chain of Survival can be used to target regional improvements in patient care. We tried to adopt a modified chain of survival for STEMI to highlight the challenges and difficulties and the possible solutions to improve the STEMI care in the Middle East based on the few data available.

A review of interventions aimed at reducing pre-hospital delay time in acute coronary syndrome: what has worked and why?

BACKGROUND

Delay in seeking treatment for acute coronary syndrome (ACS) symptoms is a well recognised problem. While the factors that influence pre-hospital delay have been well researched, to date this information alone has been insufficient in altering delay behaviour.

AIM

This paper reports the results of a critical appraisal of previously tested interventions designed to reduce pre-hospital delay in seeking treatment for ACS symptoms.

METHODS

The search was confined to interventions published between 1986 and the present that were written in English and aimed at reducing pre-hospital delay time. The following databases were searched using keywords: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Pubmed, Academic Search Premier, Ovid, Cochrane, British Nursing Index, and Google Scholar. A total of eight intervention studies were identified as relevant. This review was developed following a systematic comparative analysis of those eight studies.

RESULTS

Seven of the eight interventions were based on mass media campaigns. One campaign was targeted at individuals. All were aimed at raising ACS symptom awareness and/or increasing prompt action in the presence of symptoms. Only two studies reported a statistically significant reduction in pre-hospital delay time.

CONCLUSION

In response to concerns about prolonged pre-hospital delay time in ACS, interventions targeting the problem have been developed. The literature indicates that responses to symptoms depend on a variety of factors. In light of this, interventions should include the scope of factors that can potentially influence pre-hospital delay time and ideally target those who are at greatest risk of an ACS event.

Spouses' experiences of a cardiac arrest at home: an interview study

INTRODUCTION

In case of out-of-hospital cardiac arrest (OHCA) influence of a bystander spouse is decisive for the chance of survival.

AIM

To describe spouses' experiences of witnessing their partners' cardiac arrest at home, focusing on the time before the event and when it happened.

METHODS

Interviews with fifteen spouses were recorded and transcribed verbatim. Qualitative content analysis was conducted.

RESULTS

In the domain entitled "Time before cardiac arrest", four themes emerged in the analysis process: "Lack of early warning signs", "Difficulty interpreting early warning signs", "Interpreting signs in the light of previous illness" and "Denial of serious illness". In the domain entitled "The cardiac arrest event", three themes emerged: "Perceiving the seriousness", "Being unable to influence" and "Doing what is in one's power". The emergency call services' (ECS) ability to instruct and help the spouses to do what they can becomes evident in these themes.

CONCLUSION

Spouses who experienced OHCA demonstrated a lack of confidence in or ability to interpret early warning signs and symptoms. This lack of confidence also extended to the process of cardiopulmonary resuscitation (CPR). The support from the ECS and CPR training was acknowledged as helpful and important. Further research is required to determine which interventions can improve people's ability to intervene as early as possible.

Predictors of pre-hospital delay among patients with acute myocardial infarction

OBJECTIVE

To evaluate current literature on predictors of pre-hospital delay among patients with acute myocardial infarction (AMI).

METHODS

Medline, CINHAL, and Psych Info databases were searched using keywords: attitude to illness/health, health beliefs, help/health seeking behavior, health behavior, psychosocial factors, treatment delay, socioeconomic factors, time factors, pre-hospital delay, and symptoms. These keywords were combined with AMI to identify literature published during 1995-2008.

RESULTS

Twenty-six data-based research articles were identified. Delay varied across literature and median pre-hospital delay was often reported due to distribution skewness resulting from extremely prolonged values (1.5-15.2h). Six categories of predictors influenced pre-hospital delay; socio-demographic, symptom onset context, cognitive, affective/psychological, behavioral, and clinical factors. Pre-hospital delay was shortest when the decision to seek healthcare was facilitated by family members or coworkers and when symptoms suggestive of heart attack were continuous and severe.

CONCLUSION AND PRACTICE IMPLICATIONS

Developing interventions programs to reduce pre-hospital delay for high-risk patients is warranted. Because decision delay is the only modifiable part by intervention, it is recommended that future investigations and interventions attend to decision time as the primary variable of interest instead of combining it with transportation time. Moreover, content of patient education need to emphasize on symptom awareness and recognition, and prompt and proper patient actions for optimum results. Also, in order to eliminate sampling bias resulting from investigating surviving AMI patients, it is recommended that future studies incorporate data from both surviving and surrogates of non-surviving AMI patients.

Understanding prehospital delay behavior in acute myocardial infarction in women

Studies demonstrate that acute myocardial infarction (AMI) mortality can be reduced if reperfusion therapy is initiated within 1 hour of AMI symptom onset. However, a considerable number of men and women arrive at the emergency department outside of the time frame for thrombolytic and angioplasty effectiveness. This is especially true for women who have been shown to delay longer than men due to their prehospital decision-making process utilized. With a mean total delay time greater than 4 hours, the time interval from symptom onset to transport activation to the hospital consumes the majority of the prehospital phase of emergency cardiac care. The health belief model, self-regulation model, theory of reasoned action, and theory of planned behavior have all been used to describe the prehospital decision-making process of both men and women with an AMI and the variables that impact that process. These models have identified the importance of symptom attribution to cardiac-related causes as a target variable for research and interventions related to care-seeking behavior.

"I really should've gone to the doctor": older adults and family caregivers describe their experiences with community-acquired pneumonia

BACKGROUND

Responding to acute illness symptoms can often be challenging for older adults. The primary objective of this study was to describe how community-dwelling older adults and their family members responded to symptoms of community-acquired pneumonia (CAP).

METHODS

A qualitative study that used face-to-face semi-structured interviews to collect data from a purposeful sample of seniors aged 60+ and their family members living in a mid-sized Canadian city. Data analysis began with descriptive and interpretive coding, then advanced as the research team repeatedly compared emerging thematic categories to the raw data. Searches for disconfirming evidence and member checking through focus groups provided additional data and helped ensure rigour.

RESULTS

Community-acquired pneumonia symptoms varied greatly among older adults, making decisions to seek care difficult for them and their family members. Both groups took varying amounts of time as they attempted to sort out what was wrong and then determine how best to respond. Even after they concluded something was wrong, older adults with confirmed pneumonia continued to wait for days, to over a week, before seeking medical care. Participants provided diverse reasons for this delay, including fear, social obligations (work, family, leisure), and accessibility barriers (time, place, systemic). Several older adults and family members regretted their delays in seeking help.

CONCLUSION

Treatment-seeking delay is a variable, multi-phased decision-making process that incorporates symptom assessment plus psychosocial and situational factors. Public health and health care professionals need to educate older adults about the potential causes and consequences of unnecessary waits. Such efforts may reduce the severity of community-acquired pneumonia upon presentation at clinics and hospitals, and that, in turn, could potentially improve health outcomes.

Factors influencing Hong Kong Chinese patients' decision-making in seeking early treatment for acute myocardial infarction

The purpose of this study was to identify, through in-depth interview, factors that influenced 27 Hong Kong Chinese patients' decision-making in seeking early treatment for acute myocardial infarction (AMI). The median delay time from the onset of symptoms to arrival at the hospital was 15.6 hours for men and 53.7 hours for women. Three major categories emerged from the data: (a) becoming aware of the threat, (b) maintaining a sense of normality, and (c) struggling to mobilize resources. A variety of decisions were made by patients from the onset of chest pain to seeking help. These decisions were heavily influenced by healthcare factors (access to emergency medical service (EMS) and treatment), personal factors (cognitive interpretations of symptoms), sociocultural factors (family situation, cultural beliefs, and practices), and coping strategies.

"It's like an explosion in your life...": lay perspectives on stress and myocardial infarction

Psychological difficulties are common after myocardial infarction (MI). These difficulties are most often represented to patients through cardiac rehabilitation services and the literature offered to patients after MI as being related to "stress" and its management. However, no research has examined what MI patients understand by the term "stress" or how congruent lay views of stress are with those evident in the professional literature. The aim of the study reported here was to examine post-MI patients' views of stress, its functioning and relationship to their MI. As patients' views of stress were sought, qualitative interviews were used. A philosophical approach was taken (critical realism) that recognizes the legitimacy of both professional and lay perspectives. Data were generated in 44 semistructured interviews with 14 MI patients who were interviewed 48 hours, 1 week, 1 month and 3 months after hospital admission. While participants described their experiences after MI as being difficult, to convey this they used everyday terms such as fear, fright and worry. Rather than viewing stress as being a consequence of their MI, they perceived it to be a common cause of heart problems. Many considered stress as having a more influential role than other risk factors, such as smoking and diet. They expressed a wide variety of sophisticated and diverse views of stress and its functioning. Each of these views placed different weighting on the roles of social, personal and situational factors in contributing to the stressful reaction. Parallels were apparent between these lay accounts and theories of stress developed in the professional literature.

Perceptions of symptoms of myocardial infarction related to health care seeking behaviors in the elderly

Research on acute myocardial infarction (AMI) suggests that older persons may delay significantly longer than younger persons between the first appearance of symptoms of AMI and seeking treatment and that this delay is associated with increased morbidity and mortality. The factors that potentially influence delay in older persons can be grouped into 4 categories: (a) symptom attribution to aging, (b) symptom severity and duration, (c) symptom attribution to comorbid and chronic conditions, and (d) previous experience with cardiac problems. This article explores the link between symptom interpretation and health care seeking behaviors in elderly patients with AMI as it relates to delay in seeking treatment for AMI. Potential nursing interventions are presented.

Mass media interventions to reduce help-seeking delay in people with symptoms of acute myocardial infarction: time for a new approach?

Minimizing patient delay in seeking care for acute myocardial infarction (AMI) is important in the reduction of morbidity and mortality. However, mass media interventions to reduce these delays have had limited success. This paper critiques delay reducing intervention studies and draws on other public health campaigns to identify new directions. A Medline search for the years 1985 through 2000 yielded eight intervention studies meeting inclusion criteria. Three of eight studies reported successful interventions although two of three were only marginally successful. Most studies used similar messages. Campaign lengths, type of media, and sample sizes varied. High risk populations and those with confirmed MI responded more quickly. To reduce patient delay, media messages need to do more than create awareness. Future interventions should target high risk audiences, promote dialogue between previous AMI patients and high risk patients, address problems of denial, provide gender specific education, and emphasize symptom evaluation, problem solving, and decision-making skills.

Knowledge of stroke risk factors, warning symptoms, and treatment among an Australian urban population

BACKGROUND AND PURPOSE

Reduction in the risk of stroke and increase in the speed of hospital presentation after the onset of stroke both depend on the level of knowledge of stroke in the general population. The aim of the present study was to assess baseline knowledge regarding stroke risk factors, symptoms, treatment, and information resources.

METHODS

A community-based telephone interview survey was conducted in the Newcastle urban area in Australia. A total of 1278 potential participants between the ages of 18 to 80 were selected at random from an electronic telephone directory. A trained telephone interviewer conducted a telephone survey using the Computer-Assisted Telephone Interviewing (CATI) program.

RESULTS

A total of 822 participants completed the telephone interview. Six hundred three participants (73.4%) correctly identified the brain as the affected organ in stroke. The most common risk factors for stroke identified by respondents were smoking (identified by 324 [39.4%]) and stress (identified by 277 [33.7%]). The most common warning sign of stroke described by respondents was "blurred and double vision or loss of vision in an eye," listed by 198 (24.1%). A total of 626 (76.2%) respondents correctly listed >/=1 established stroke risk factor, but only 409 (49.8%) respondents correctly listed >/=1 warning sign.

CONCLUSIONS

The level of knowledge in the community of established stroke risk factors, warning signs, and treatment as indicated by this survey suggests that a community-based education program to increase public knowledge of stroke may contribute to reducing the risk of stroke and to increasing the speed of hospital presentation after the onset of stroke.

The experience of chronic illness and post-traumatic stress disorder: the consequences of cumulative adversity

In this paper the experiences of the chronically ill are examined to explore the impact of post-traumatic stress disorder (PTSD), accumulated burden of adversity and trauma spectrum disorder on subsequent illness and coping behaviors. Individuals experiencing chronic diseases have been studied with regard to depression, anxiety and a variety of coping maladaptions, but negligible attention has been given to the PTSD potential of chronic disease over the life course. Yet, growing evidence suggests that the traumatogenic potential of chronic diseases, some sudden and unexpected onsets, and the traumatogenic changes in life circumstance, may produce maladaptive illness coping over the life course. More importantly, attention needs to focus on the additive effect of co-morbid life events and the traumatic potential of invasive medical therapies. Consideration of PTSD and a continuum of cumulative adversity provide a more complex and fully drawn understanding of the circumstances surrounding chronic illness coping and reasons for maladaptive coping following invasive therapies and changes in the disease trajectory. The pathophysiology that produces a chronic diseases does not begin at symptom onset, and the psychosocial strategies to cope with a chronic illness, whether efficacious or maladaptive, also do not begin at symptom onset, but develops over the life course.

Acute myocardial infarction and posttraumatic stress disorder: the consequences of cumulative adversity

This article examines the experiences of acute myocardial infarction (AMI) patients who are at high risk for reinfarction or sudden death to determine the impact of posttraumatic stress disorder (PTSD), accumulated burden of adversity, and trauma spectrum disorder on subsequent AMI care-seeking. Individuals experiencing an AMI have been studied with regard to depression and anxiety disorders, but negligible attention has been given to the PTSD potential of the total cardiovascular disease experience. Yet, growing evidence suggests the traumatogenic potential of AMI, with its sudden and unexpected onset, dramatic changes in life circumstance, and the additive effect of comorbid life events, is significant in producing impaired and extended coping during subsequent ischemic events. Consideration of PTSD and a continuum of cumulative adversity provides a more complex and fully drawn understanding of the circumstances surrounding AMI coping and reasons for delayed access to thrombolysis.

Patient delay in seeking treatment for acute myocardial infarction symptoms

Patient delay before seeking treatment for the symptoms of acute myocardial infarction has a significantly negative effect on morbidity and mortality. Most patients delay 2 or more hours before accessing the emergency medical system, which limits the ability to use reperfusion strategies. This article reviews variables that have been implicated in delay and explores possible explanations for why certain characteristics may be associated with longer delays. The outcomes of educational campaigns that have targeted delay behavior will be examined and directions for future research are identified.