Conceptions on treatment and lifestyle in patients with coronary heart disease--a phenomenographic analysis

Health literacy in persons at risk of and patients with coronary heart disease: A systematic review

BACKGROUND

Health literacy (HL) plays a crucial role in the maintenance and improvement of individual health. Empirical findings highlight the relation between a person's HL-level and clinical outcomes. However, the role of HL in persons at risk for coronary heart disease (CHD) and patients with CHD has not been researched conclusively.

OBJECTIVE

The aim of this study was to review systematically the current evidence on HL, its dimensions (access to, understanding, appraisal and apply of health-related information), and its important influencing factors, with regard to CHD risk.

METHOD

We used a mixed-methods approach. Eligible articles needed to employ a validated tool for HL or mention the concept and at least one of its dimensions. After the screening process, 14 quantitative and 27 qualitative studies were included and referred to one or more dimensions of HL. Six observational studies measured HL with a validated tool.

RESULTS

Findings suggest that patients with lower HL feel less capable to perform lifestyle changes, exhibit fewer proactive coping behaviors, are more likely to deny CHD, are generally older, are less often employed, have lower educational levels and lower socioeconomic status, experience faster physical decline, and use the healthcare system less, compared to patients with higher HL. Barriers to HL include inadequate provision of information by health providers, lack of awareness of the risk factors for CHD, perceived impairment of quality of life due to lifestyle changes, and negative experiences with the healthcare system. Facilitators include a good patient-physician relationship based on good communicative competences of health providers.

CONCLUSIONS

The concept of HL yields a promising potential to understand the process from obtaining information to actual health behavior change, and the results clearly indicate the need for more systematic research on HL in CHD patients and persons at risk.

Patient beliefs and attitudes to taking statins: systematic review of qualitative studies

BACKGROUND

Statins are effective in preventing cardiovascular disease (CVD) events and are recommended for at-risk individuals but estimated adherence rates are low.

AIM

To describe patients' perspectives, experiences, and attitudes towards taking statins.

DESIGN AND SETTING

Systematic review of qualitative studies reporting perspectives of patients on statins.

METHOD

PsycINFO, CINAHL, Embase, MEDLINE, and PhD dissertations from inception to 6 October 2016 were searched for qualitative studies on adult patients' perspectives on statins. All text and participant quotations were extracted from each article and analysed by thematic synthesis.

RESULTS

Thirty-two studies involving 888 participants aged 22-93 years across eight countries were included. Seven themes were identified: confidence in prevention (trust in efficacy, minimising long-term catastrophic CVD, taking control, easing anxiety about high cholesterol); routinising into daily life; questioning utility (imperceptible benefits, uncertainties about pharmacological mechanisms); medical distrust (scepticism about overprescribing, pressure to start therapy); threatening health (competing priorities and risks, debilitating side effects, toxicity to body); signifying sickness (fear of perpetual dependence, losing the battle); and financial strain.

CONCLUSION

An expectation that statins could prevent CVD and being able to integrate the statin regimen in daily life facilitated acceptance of statins among patients. However, avoiding the 'sick' identity and prolonged dependence on medications, uncertainties about the pharmacological mechanisms, risks to health, side effects, costs, and scepticism about clinicians' motives for prescribing statins were barriers to uptake. Shared decision making that addresses the risks, reasons for prescribing, patient priorities, and implementing strategies to minimise lifestyle intrusion and manage side effects may improve patient satisfaction and continuation of statins.

Evaluating the angina plan in patients admitted to hospital with angina: a randomized controlled trial

The aim of this trial was to evaluate the Angina Plan (AP), a cognitive-behavioral nurse-facilitated self-help intervention against standard care (SC). A randomized controlled trial of 218 patients hospitalized with angina assessed participants predischarge and 6 months later. Data were collected during a structured interview using validated questionnaires, self-report, and physiological measurement to assess between group changes in mood, knowledge and misconceptions, cardiovascular risk, symptoms, quality of life, and health service utilization. The intention-to-treat (ITT) analysis found no reliable effects on anxiety and depression at 6 months. AP participants reported increased knowledge, less misconceptions, reduced body mass index (BMI), an increase in self-reported exercise, less functional limitation, and improvements in general health perceptions and social and leisure activities compared to those receiving SC. Sensitivity analysis excluding participants with high baseline depression revealed a statistical significant reduction in depression levels in AP compared to the SC participants. Analysis excluding participants receiving cardiac surgery or angioplasty removed the ITT effects on physical limitation, self-reported exercise and general health perceptions and the improvements seen in social and leisure activities, while adaptive effects on knowledge, misconceptions and BMI remained and between-group changes in depression approached significance. Initiating the AP in a secondary care setting for patients with new and existing angina produces similar benefits to those reported in newly diagnosed primary care patients. Further evaluation is required to examine the extent of observed effects in the longer term.

A meta-ethnographic synthesis on phenomenographic studies of patients' experiences of chronic illness

Phenomenography is a qualitative research approach developed within an educational framework, focusing on the qualitative experience of learning. It is also being used, to a lesser degree, in healthcare research. In the present study, we conducted a meta-ethnographic synthesis of phenomenographic studies on chronic illness, in order to give a broader perspective of how chronic illness can be experienced. Our aim was not to describe patients’ various individual experiences of illness, but instead to identify the different ways chronic illness can be experienced by patients. Our synthesis and phenomenographic interpretation of 12 selected articles found that patients’ experiences of chronic illness can be described in terms of a different lived body, a struggle with threat to identity and self-esteem, a diminished lifeworld, and a challenging reality. These experiences relate to each other in a process of recurring loops, where the different ways of experiencing continue to influence each other over time. According to these findings, the use of phenomenography as a research approach has the potential to add to the understanding of how chronic illness can be experienced. Patients may benefit from seeing that their illness can be experienced in many different ways and that it has many aspects, which then can lead to a better understanding and coping with their illness. We suggest that it may be worthwhile to expand the scope of phenomenography outside pedagogics. This presupposes a revision of the application to include a wider and more comprehensive description, for instance, of the different ways illness and healthcare phenomena can be experienced, and how these different ways are related to each other, with less focus on hierarchical relations.

Medication taking in coronary artery disease: a systematic review and qualitative synthesis

PURPOSE

Despite the compelling evidence supporting cardiovascular medications in the secondary prevention of coronary artery disease, many patients discontinue treatment. In this synthesis, we sought to understand from a patient perspective the factors that promote medication persistence.

METHODS

We systematically searched 7 databases (MEDLINE, Embase, PsycINFO, SCOPUS, CINAHL, ASSIA, and SSCI) for published qualitative research about the medication-taking experiences of patients with coronary artery disease and their partners. Articles were assessed for quality using a modified CASP (Critical Appraisal Skills Programme) checklist. Synthesis was undertaken using well-established meta-ethnographic approaches.

RESULTS

We included 17 articles in the final synthesis from the United Kingdom (6), Europe (5), United States (4), China (1), and Australia (1), with a total sample size of 391 patients. Analyses suggested that some patients hold fatalistic beliefs about their disease, whereas others believe they have been cured by interventions; both can lead to failure to take medication. Patients who adapt to being a "heart patient" are positive about medication taking. Some individuals dislike taking tablets generally and are wary of long-term effects. Relationships with prescribing clinicians are of critical importance for patients, with inaccessibility and insensitive terminology negatively affecting patients' perceptions about treatments.

CONCLUSIONS

Strategies to promote higher persistence of secondary prevention medications in patients with coronary artery disease need to recognize the key role of the prescribing clinician. Providing medication-specific information at the time of initiating therapy, improving the transition between secondary and primary care, and explaining the risk of disease recurrence may all help to modify patient attitudes toward drugs to prevent further cardiovascular disease.

Patients' Perspectives on Cardiac Rehabilitation, Lifestyle Change and Taking Medicines: Implications for Service Development

Objectives

Cardiac rehabilitation programmes offer eligible coronary heart disease patients information on lifestyle modification and medicines. Our aim was to understand patients' perspectives on these topics.

Methods

In-depth qualitative interviews were conducted and audiotaped with 15 patients approximately three months after hospital discharge, after they had completed a hospital-based cardiac rehabilitation programme. Repeat interviews with ten patients explored whether their perspectives had changed when interviewed again approximately nine months later.

Results

Patients tended to talk about the exercise component of cardiac rehabilitation and only talk about the information provision component when prompted, which suggested they viewed the programme as being primarily about exercise. They seemed to have little subsequent contact with health services, except routine six-monthly check-ups for their coronary heart disease. Unmet information needs were common, especially about medicines. Nevertheless, all patients reported continuing to take cardiac medicines, but tended to only maintain changes to aspects of lifestyle perceived as causes of coronary heart disease, rather than viewing lifestyle recommendations as standards to achieve.

Conclusion

Ensuring that individual patients' information needs about medicines and lifestyle are adequately met remains a key focus for cardiac rehabilitation development. Key aspects include individualizing information and actively seeking and responding to patients' needs during and after cardiac rehabilitation.

Living with heart disease after angioplasty: A qualitative study of patients who have been successful or unsuccessful in multiple behavior change

OBJECTIVE

To document values, attitudes, and beliefs that influence behavior change among a diverse group of patients post-angioplasty.

METHODS

Purposive and maximum-variation sampling were used to assemble a demographically diverse patient cohort (N=61) who had been successful or unsuccessful at post-angioplasty multibehavior change. Semistructured interviews and grounded theory methods were used to collect and analyze qualitative data.

RESULTS

Themes showed the following: a) Patients reported surviving a life-threatening event and feared disease recurrence and death; b) the perception of a turning point and self-determination facilitated behavior change; c) social support and spiritual beliefs promoted coping with the uncertainty of living with heart disease; and d) unsuccessful behavior change was related to physical limitations, a sense that "nothing helps," and the belief that angioplasty "cures" heart disease.

CONCLUSION

Lifestyle interventions should be culturally relevant and adapted to physical abilities. Fostering self-determination and social support may promote successful behavior change.

‘It Got Right to the Spot’ The Patient Experience of Primary Angioplasty: A Qualitative Study

Background: Primary angioplasty is becoming an established treatment for myocardial infarction. Yet we have a limited understanding of patients' attitudes toward this treatment and their experiences of receiving it in practice.

Aims: Exploration of patients' experiences and perceptions of primary angioplasty as treatment for their heart attack.

Methods: Qualitative study of a purposive sample of patients admitted to a tertiary cardiology unit in east London, UK. Participants were interviewed either in their own homes or in hospital. Recruitment continued until no new substantial themes emerged. Eleven men and four women aged 35 to 74 years who had sustained a myocardial infarction were interviewed 13 to 90 days after primary angioplasty. We used the framework method of analysis to identify and explore emerging themes.

Results: Informants were expecting open-heart surgery as treatment for their heart attack. They were impressed by the service they actually received. They were generally not engaged in decisions about their treatment in the acute setting and this passivity sometimes persisted after discharge. Expectations of follow up in primary care were not often met.

Conclusions: Patients are satisfied with the primary angioplasty as treatment for acute myocardial infarction but have poor understanding of the management of this condition.

Concept analysis of adherence in the context of cardiovascular risk reduction

TOPIC

Cardiovascular disease is the number one cause of death in the United States. Examination of the concept of adherence is essential to provide informed patient-centered care to prevent the development and progression of this largely preventable disease.

OBJECTIVE

The purpose of this concept analysis is to explore and clarify the concept of adherence. This analysis will provide a framework for those seeking a better understanding of patient decision-making, reduction of relapse to unhealthy behaviors, and increased long-term adherence to cardiovascular health recommendations. Reviews of major theories related to health behavior are reviewed in the second part of the article and are linked to the concept of adherence.

METHOD

Following a review of the literature, Morse's guidelines were utilized to present a concept analysis of adherence and the related terms concordance and compliance from the disciplines of nursing, health psychology, ethics, pharmacy, and medicine.

RESULTS

Adherence is dependent on the collaborative relationship between patient and healthcare provider. Adherence is influenced by the meaning of health, heart disease, and sense of personal risk as well as socioeconomic status, decision support, motivation, and desire for change, self-efficacy, and sources of credible health information. Attributes of successful adherence include alignment of patient behavior and health recommendations, mastery of new health knowledge and behavior, continued collaborative relationships between the patient and healthcare provider, and ability to meet outcome targets.

CONCLUSION

Adherence is defined as persistence in the practice and maintenance of desired health behaviors and is the result of active participation and agreement. Adherence is dependent on the development of a concordant relationship and its measurement should be specific utilizing the correct tools. Special attention should be paid to shared decision-making between patient and healthcare provider.

Participants' willingness to consume soy foods for lowering cholesterol and receive counselling on cardiovascular disease by nutrition professionals

Objectives

To determine if participants would be interested in consuming soy foods to lower cholesterol in primary and secondary prevention of heart disease, and to identify the role physicians and registered dietitians have in providing dietary advice, about soy foods or other foods, for participants with elevated cholesterol.

Methodology

Qualitative data from 12 focus groups were gathered from a convenience sample of 74 adults, aged 18–91 years, with and without high cholesterol (total cholesterol >200 mg dl−1). Participants were recruited from Minneapolis/St. Paul mainstream and natural foods grocery stores. Focus group interviews were taped and transcribed verbatim. Common themes were identified, coded and compared using NVivo computer software.

Results

Participants believed diet, lifestyle and genetics were the cause of high cholesterol and cardiovascular disease (CVD). Few participants were aware of the Food and Drug Administration health claim for soy protein, yet many were willing to consume soy as part of lifestyle modification to prevent CVD. They reported preferring food and exercise over medication to treat high cholesterol. Few participants had ever received dietary advice from physicians on treating high cholesterol or CVD, and most doubted the accuracy of such advice. They believed registered dietitians were the most credible source of nutrition counselling and expressed an interest in physician referrals to dietitians.

Conclusions

A collaboration and referral system between physicians and registered dietitians could increase CVD patients' consumption of soy foods as a means potentially leading to a reduced risk of heart disease in participants.

Disease knowledge and adherence to treatment in patients with familial hypercholesterolemia

BACKGROUND

Familial hypercholesterolemia (FH) is one of the most common genetic metabolic disorders and is associated with a high risk of premature coronary heart disease. Primary prevention directed at lifestyle changes, combined with preventive medical treatment, is the most important way to reduce the risk of coronary heart disease in individuals with FH. Knowledge about the condition and adherence to drug treatment may facilitate reaching treatment goals.

OBJECTIVE

The purpose of this study was to describe disease knowledge and adherence to treatment in patients with FH.

SUBJECTS AND METHODS

Seventy-four patients, more than 18 years of age, with FH were asked to participate. A questionnaire on disease knowledge about FH and adherence to drug treatment was sent to the patients. Response rate was 92% (n = 68). Drug treatment, laboratory results, blood pressure, and smoking were also documented.

RESULTS

Most patients knew about cholesterol, prevention, and the reason for drug treatment but were less informed about the risk of genetic transmission and family history. No significant correlation was found between knowledge and low-density lipoprotein cholesterol level. A significant, negative correlation between adherence and low-density lipoprotein cholesterol level was found (r = -.354, P < .01).

CONCLUSIONS

Patients with FH had scant understanding about the risk of genetic transmission and family history. High adherence to drug prescription has significant correlation to low-density lipoprotein cholesterol level.

Women, men and coronary heart disease: a review of the qualitative literature

AIM

This paper presents a review of the qualitative literature which examines the experiences of patients with coronary heart disease. The paper also assesses whether the experiences of both female and male patients are reflected in the literature and summarizes key themes.

BACKGROUND

Understanding patients' experiences of their illness is important for coronary heart disease prevention and education. Qualitative methods are particularly suited to eliciting patients' detailed understandings and perceptions of illness. As much previous research has been 'gender neutral', this review pays particular attention to gender.

METHODS

Published papers from 60 qualitative studies were identified for the review through searches in MEDLINE, EMBASE, CINAHL, PREMEDLINE, PsychINFO, Social Sciences Citation Index and Web of Science using keywords related to coronary heart disease.

FINDINGS

Early qualitative studies of patients with coronary heart disease were conducted almost exclusively with men, and tended to generalize from 'male' experience to 'human' experience. By the late 1990s this pattern had changed, with the majority of studies including women and many being conducted with solely female samples. However, many studies that include both male and female coronary heart disease patients still do not have a specific gender focus. Key themes in the literature include interpreting symptoms and seeking help, belief about coronary 'candidates' and relationships with health professionals. The influence of social roles is important: many female patients have difficulties reconciling family responsibilities and medical advice, while male patients worry about being absent from work.

CONCLUSIONS

There is a need for studies that compare the experiences of men and women. There is also an urgent need for work that takes masculinity and gender roles into account when exploring the experiences of men with coronary heart disease.

“Sneaky disease”: the body and health knowledge for people at risk for coronary heart disease in Ontario, Canada

The contribution of modifiable risk factors to the prevalence of coronary heart disease (CHD) has been well documented in the literature. A focus group component of a cardiovascular risk reduction project, The Community Outreach in Heart Health and Risk Reduction Trial was designed to explore issues that facilitate or constrain individual efforts to implement changes to health behaviours. Eight focus groups were conducted in urban, northern and rural sites in Ontario, Canada. In this article, we elaborate on the difficulties all group members experienced as they attempted to interpret their personal candidacy for CHD. For many participants, CHD was an undetectable or "sneaky disease" in its earlier stages, thus coronary risk was to them an abstract concept that could not ordinarily be detected through sensory perception. Participants drew on three possible strategies to determine their candidacy for CHD: they cognitively engaged in weighing risks, they relied on the interpretive powers of medical hermeneutics, or they waited for "the big event". The findings suggest that lay understandings of the body and health differ from those of health professionals and educators, and that lay understandings differ according to SES and gender. This has implications for health literacy and must be considered in devising strategies for health education.

Coronary heart disease: causes and drug treatment - spouses' conceptions

BACKGROUND

Spouses are important in the rehabilitation process of their partner after coronary heart disease event. Their knowledge and attitudes have an impact on their support to the partner concerning lifestyle changes and drug treatment after an event.

AIMS AND OBJECTIVES

To explore spouses' conceptions concerning causes of coronary heart disease and drug treatment 1 year after the partner's cardiac event.

DESIGN

Qualitative with an empirical and inductive approach.

METHODS

Semi-structured interviews with strategically selected spouses (17 women and eight men) were taped. The transcripts were analysed within the phenomenographic framework.

RESULTS

Spouses' conceptions about causes of coronary heart disease and its treatment consisted of correct facts, as judged on a lay level, less elaborated conceptions and misconceptions. Among causes of coronary heart disease, the spouses were most knowledgeable about fat intake. They knew less about contributions from inactivity, stress and smoking. Ambivalent feelings were expressed about benefits vs. side effects of drugs. The treatment was conceived as necessary for the heart, but harmful for other organs. Men and women were evenly distributed in most of the derived categories. More women than men considered stress as a cause of coronary heart disease and also misconceived physical exercise to cause the disease.

CONCLUSION

A variation of spouses' conceptions was revealed about causes of coronary heart disease and drug treatment. There was a lack of understanding concerning important parts of cardiac rehabilitation activities. These misconceptions may have implications by influencing their partner's co-operative behaviour.

RELEVANCE TO CLINICAL PRACTICE

Spouses' pre-existing conceptions of coronary heart disease and its treatment should be considered in the rehabilitation process of their partner. Couples with misconceptions should be given the opportunity to increase qualitatively their knowledge starting from their point of view rather than from that of the professional perspective.

The illness experiences of patients after a first time myocardial infarction

The purpose of this study was to investigate illness experiences of patients after a first myocardial infarction (MI), focusing on life situation and the recovery process over time. Thirty patients were interviewed within the first 3 days of hospitalisation, and again 17 weeks after discharge. The interviews were tape-recorded verbatim and the transcriptions were analysed and categorised using qualitative content analysis. The main category was Uncertainty of the life situation that was combined with and articulated the superior theme in both interviews. Analyses revealed uncertainty focused on problems related to: treatment-seeking behaviour; existential threat; preventing another coronary and need for knowledge and support, which the patients considered important for their case and future life. The findings are fundamental for the health care when education and counselling are planned and challenge health care personnel to listen to MI-patients' own experiences.

Patients' conceptions of coronary heart disease--a phenomenographic analysis

Readjustment after an event of coronary heart disease (CHD) is defined to comprise cognitive, instrumental and affective components. The cognitive dimension refers to understanding of the disease. Twenty-three patients (<60 years) with CHD were interviewed about the nature of their disease and encouraged to use their own words. The study was conducted 1 year after the event of myocardial infarction (MI) and some patients had also been revascularized. The interviews were transcribed in extenso and analysed according to the phenomenographic approach. The main finding was the great variation of conceptions revealed. Six different conceptions were found concerning CHD. Some patients comprehended MI by involving (A) blood and vessels, (B) either blood or vessel or referred to (C) risk factors/symptoms. Angina pectoris was expressed as (A) insufficient heart capacity, (B) atherosclerosis/contracted vessel or as (C) symptoms. Several patients found it difficult to expand their answers and some expressed misconceptions about the course of events. Patients' pre-existing knowledge and their way of reasoning about central phenomena related to their disease should be taken into consideration in patient education and is also applicable in individual encounters with patients.