The illness perceptions of patients with percutaneous coronary intervention compared to patients with no percutaneous intervention, for acute myocardial infarction, in cardiac rehabilitation

PURPOSE

Patients who receive percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) have been found to have low attendance at cardiac rehabilitation (CR). It has been suggested that this is because PCI patients have a benign perception of their coronary disease; however, this has never been quantitatively investigated. The aim of this prospective study was to evaluate the illness perceptions (IP) of patients with AMI treated with PCI.

METHODS

The Heart Health Illness Perception Questionnaire (modified version of the Brief Illness Perception Questionnaire) and the Cardiac Beliefs Questionnaire were used to assess patients' IP and cardiac disease misconceptions, respectively. Patients in phase 2 of CR were recruited from the Royal Alexandria Hospital, Paisley, UK. One hundred two patients were identified from the cardiac unit database over a 16-week period and sent questionnaires.

RESULTS

Fifty-six patients returned questionnaires suitable for analysis (54.9% response rate). There was a significant difference in the IP scores of the 3 groups [primary-PCI (pPCI) = 0.18 ± 1.44, elective-PCI = 5.27 ± 15.65, non-PCI = 9.94 ± 11.19; P = 0.046]. PCI patients had a significantly lower IP score than non-PCI patients (PCI = 1.62 ± 12.76, non-PCI = 9.94 ± 11.19; P = 0.027). pPCI patients had a significantly lower IP score than non-pPCI patients (pPCI = 0.18 ± 11.44, non-pPCI = 8.04 ± 13.11; P = 0.021). Of the PCI patients 22.9% agreed they were 'fixed for life' and a lower IP score was found to predict this opinion (P = 0.032).

CONCLUSION

PCI patients, particularly pPCI patients, perceive their coronary disease to be relatively benign. Further research is required to investigate if this predicts poor attendance at CR.

Factors that influence adherence to treatment plans amongst people living with cardiovascular disease: A review of published qualitative research studies

BACKGROUND

Treatment plan adherence is recognized as a worldwide health issue, particularly important in the management of cardiovascular patients. Healthcare professionals are the primary sources of information and support for people diagnosed with CVD and those who have experienced a cardiac event, yet we know little about how healthcare professionals contribute to the process of adherence to treatment plans that aim to prevent and/or reduce disease and adverse events. Qualitative evidence that explores factors that influence adherence to treatment plans is limited.

OBJECTIVE

This systematic review identified and synthesised the best available evidence on factors that influence adherence to treatment plans amongst people living with cardiovascular disease.

DESIGN

Systematic review and qualitative synthesis.

METHODS

Data were collected from Medline, Web of Science, CINAHL, PsychINFO, Embase- Non-Medline, Scopus, Cochrane Library, ProQuest Central (Grey Literature). Pre-defined keywords and MeSH terms were used to identify qualitative methods English-language studies published between 2001 and 2018. Quality appraisal of each paper was completed using the JBI Critical Appraisal Checklist and two reviewers extracted the data independently.

RESULTS

Twenty-two articles were included. Eight key themes were identified that related to facilitators and barriers to adherence to treatment plans. Facilitators were identified as engaging in exercise, having support and mentorship, lifestyle modification, and the perceived value of taking medication. Barriers were identified as a perceived lack of support, concerns about taking medication, and lack of engagement in exercise and lifestyle changes.

CONCLUSIONS

The findings highlight the factors that support adherence and healthcare professionals can build on also the areas that can be targeted to support and improve adherence to treatment plans. Nurses can play an important role in enhancing the provision of information pre hospital discharge and support in the community on taking medication, the value of physical activity and dietary changes.

A qualitative study investigating patients' beliefs about cardiac rehabilitation

Background: The opportunity to attend a cardiac rehabilitation course is usually offered to patients who have suffered a myocardial infarction. However, despite referral, many patients fail to attend.

Objective: To elicit patients' beliefs about the role of the cardiac rehabilitation course following myocardial infarction.

Design: Qualitative study using in-depth semi-structured interviews.

Setting: London Teaching Hospital.

Subjects: Thirteen patients were interviewed after discharge from hospital following myocardial infarction, but prior to attendance at cardiac rehabilitation.

Main outcome measures: Patients' beliefs about cardiac rehabilitation that may act as barriers to attendance.

Results: Themes identified included: the content of cardiac rehabilitation, perceptions of exercise, benefits of cardiac rehabilitation, explicit barriers to attendance and cardiac knowledge. Whilst some patients viewed cardiac rehabilitation as an important and necessary part of recovery others expressed doubt that it was appropriate for them. Some patients were uncertain of the course content and misunderstood the role of exercise and its perceived effects. Misconceptions with regard to cardiac knowledge were also apparent. The combination of erroneous beliefs about cardiac rehabilitation and cardiac misconceptions seemed to result in doubts regarding attendance.

Conclusions: Prior to course attendance some patients hold erroneous beliefs about the course content, especially the exercise component. Co-existent cardiac misconceptions are also apparent. Further research is needed to clarify the extent to which these beliefs may contribute to the decision not to attend cardiac rehabilitation.

Participating in cardiac rehabilitation: a systematic review and meta-synthesis of qualitative data

BACKGROUND

Participation in cardiac rehabilitation (CR) benefits patients with coronary heart disease (CHD), yet worldwide only some 15–30% of those eligible attend. To improve understanding of the reasons for poor participation we undertook a systematic review and meta-synthesis of the qualitative literature.

METHODS

Qualitative studies identifying patient barriers and enablers to attendance at CR were identified by searching multiple electronic databases, reference lists, relevant conference lists, grey literature, and keyword searching of the Internet (1990–2010). Studies were selected if they included patients with CHD and reviewed experience or understanding about CR. Meta-synthesis was used to review the papers and to synthesize the data.

RESULTS

From 1165 papers, 34 unique studies were included after screening. These included 1213 patients from eight countries. Study methodology included interviews (n = 25), focus groups (n = 5), and mixed-methods (n = 4). Key reasons for not attending CR were physical barriers, such as lack of transport, or financial cost, and personal barriers, such as embarrassment about participation, or misunderstanding the reasons for onset of CHD or the purpose of CR.

CONCLUSIONS

There is a vast amount of qualitative research which investigates patients’ reasons for non-attendance at CR. Key issues include system-level and patient-level barriers, which are potentially modifiable. Future research would best be directed at investigating strategies to overcome these barriers.

What sustains long-term adherence to structured physical activity after a cardiac event?

PURPOSE

Research addressing methods to sustain long-term adherence to physical activity among older adults is needed. This study investigated the motivations and supports deemed necessary to adhere to a community-based cardiac rehabilitation (CBCR) program by individuals with established coronary heart disease.

METHODS

Twenty-four long-term adherers (15 men, 9 women; age 67.7 ± 16.7 yr) took part in focus-group discussions.

RESULTS

Constant comparative analysis supported previous research in terms of the importance of referral procedures, social support, and knowledge of health benefits in influencing uptake and adherence to CBCR. Results also highlighted the routine of a structured class and task-, barrier-, and recovery-specific self-efficacy as necessary to sustain long-term adherence for this specific clinical group.

DISCUSSION

Older adults themselves provide rich information on how to successfully support their long-term adherence to structured exercise sessions. Further research into how to build these components into any exercise program is necessary.

Perceptions of exercise among people who have not attended cardiac rehabilitation following myocardial infarction

Perceptions of exercise among nonattenders of cardiac rehabilitation (CR) were explored using semi-structured interviews. Analysis indicated that participants did not recognize the cardiovascular benefits of exercise, and perceived keeping active through daily activities as sufficient for health. Health professionals were perceived to downplay the importance of exercise and CR, and medication was viewed as being more important than exercise for promoting health. The content of CR programmes and the benefits of exercise need to be further explained to patients post-MI, and in a manner that communicates to patients that these programmes are valued by significant others, particularly health professionals.

`I'm Cured But….'

The current qualitative research studied representations of illness posttreatment from a heart transplant group, a panic disorder group, and a tic disorder group. All three groups were preoccupied with perceptions about the impact of the illness, perception of self and the perception of how others view the ill person. The heart transplant group seem to adopt an active style of coping compared to the panic disorder group who presented a more passive, anticipatory mode of coping, and the tic group who were preoccupied with control over the perceptions of others. This qualitative information could help optimize adaptation strategies.

Reframing the dilemma of poor attendance at cardiac rehabilitation: an exploration of ambivalence and the decisional balance

AIM

To discuss the problem of poor attendance at cardiac rehabilitation from the alternative perspective of patient ambivalence.

BACKGROUND

Evidence supports the benefits of cardiac rehabilitation as a means for secondary prevention of coronary heart disease, yet current literature continues to document poor attendance at these programmes. Whilst extrinsic factors, such as transportation and lack of physician support have been identified as barriers, patients who choose not to attend these programmes are often described as lacking motivation or being non-compliant. However, it is possible that non-attendance is the result of ambivalence - the experience of simultaneously wanting to and yet not wanting to, or the 'I want to, but I don't want to' dilemma.

DESIGN

Discussion paper.

METHOD

This discussion paper draws on the literature of ambivalence and decision-making theory to reframe the issue of poor attendance at cardiac rehabilitation.

CONCLUSIONS

This paper has demonstrated that the problem of poor attendance may be explained from the perspective of patient ambivalence and that using strategies such as the decisional balance may assist these individuals in exploring their ambivalence to engage in secondary prevention programmes.

RELEVANCE TO CLINICAL PRACTICE

Understanding the dynamics of ambivalence provides an alternative to thinking of patients as lacking motivation, being non-compliant, or even resistant. Helping patients to explore and resolve their ambivalence may be all that is needed to help them make a decision and move forward.

“Maybe It Could Be a Heart Attack . . . But I'm Only 31”: Young Men's Lived Experience of Myocardial Infarction—An Exploratory Study

This study examines the lived experience of myocardial infarction (MI) in younger men. Seven men, aged between 32 and 58, all of whom had suffered MI within the previous 12 months, were interviewed. Thematic analysis of the interview transcripts revealed four main themes. The themes were “disillusionment with life,” “tension and stress,” “keeping up appearances,” and “invincibility.” Collectively the four themes reflected the complexities, subtleties, and consensus of the experiences of these younger men who have survived MI. This study reveals that the individuals within the authors' sample appear to allude to the ideal or hegemonic form of masculine identity. Utilization of a qualitative approach with this younger male sample has enabled the authors to elicit the defining features of their experience as identified by themselves. Implications for these findings are discussed.

Illness perceptions predict attendance at cardiac rehabilitation following acute myocardial infarction: a systematic review with meta-analysis

OBJECTIVE

Early reports indicated that the illness perceptions of patients following acute myocardial infarction (AMI) predict attendance at cardiac rehabilitation. However, null findings have subsequently been reported, and there is variation between studies in terms of which illness perception constructs predict attendance. The aim of this meta-analysis was to examine whether illness perceptions really predict attendance at cardiac rehabilitation and to examine factors that moderate this relationship.

METHODS

The strategy and procedures recommended by Hunter and Schmidt [Hunter JE, Schmidt FL. Methods of meta-analysis: correcting error and bias in research findings. Thousand Oaks (CA): Sage, 2004] were followed. Based on a systematic literature search, eight studies (N=906 patients) that examined the relationship between illness perceptions and attendance at cardiac rehabilitation were included.

RESULTS

Four illness perception constructs significantly predicted attendance at cardiac rehabilitation: patients with more positive identity (r=.123), cure/control (r=.111), consequences (r=.081), and coherence (r=-.160) beliefs were more likely to attend cardiac rehabilitation. For all relationships, except that between cure/control beliefs and rehabilitation attendance, there was significant heterogeneity, which was attributable to two studies: one that assessed illness perceptions after leaving the hospital yielded higher effect size estimates, whereas another that involved an intervention yielded effect size estimates in the direction opposite to those of most other studies. The exclusion of these studies resulted in largely unchanged, but homogeneous, effect size estimates.

CONCLUSION

Illness perceptions of AMI patients predict attendance at cardiac rehabilitation, although the effect sizes are small and often heterogeneous. AMI patients who view their condition as controllable, as symptomatic, and with severe consequences, and who feel that they understand their condition are more likely to attend.

Patient-Provider Communication Regarding Referral to Cardiac Rehabilitation

This study investigated the dynamics of patient-provider communication in the cardiac rehabilitation (CR) referral process, to identify which aspects lead to CR participation. Semi-structured individual interviews were conducted with 31 patients eligible for CR. Questions probed the content and perception of the discussion that patients had with healthcare providers (HCP) regarding CR attendance. The interviews were audiotaped, transcribed, and imported into N6 software for grounded analyses. Key emerging themes were identified: illness perceptions; HCP encouragement; timing of discussion; and ease of referral. CR attenders were apt to self-advocate to ensure their enrollment in CR, whereas nonattenders were more likely to minimize the seriousness of their disease, and less likely to persevere to overcome obstacles in enrolling in a CR program. Surprisingly, the strength of the HCP referral did not influence the decision to attend CR as strongly when compared to the HCP's ability to facilitate enrollment in a CR program.

Trying to do my best as a mother: decision-making in families of children undergoing elective surgical treatment for short stature

OBJECTIVES

To explore how families make decisions about elective leg-lengthening surgical treatment.

DESIGN

Interviews were conducted and analysed using Interpretative Phenomeno logical Analysis (Smith, 1995).

METHODS

Data were gathered using semi-structured interviews with nine mothers of children who had recently decided to undergo treatment.

RESULTS

Overall, the decision process was guided by the mothers' central concern to act responsibly as a parent. Thematic analysis indicated that the decision was taken in a social context where short stature could lead to discrimination and disability. The decision-making process evolved gradually over several years as mothers and children gathered information about treatment. While mothers emphasized that ultimately it was their child's decision, they monitored the decision process and filtered the information available in an attempt to ensure that the child made a well-informed and wise choice.

CONCLUSIONS

The decision was presented as an ongoing process by the mothers, their concerns representing their desire to do their best as parents for their children. Theoretically, the mothers' description of the process can be understood in terms of their attempts to resolve an ethical dilemma. Clinical implications include recognition of the role of the psychologist in supporting mothers in their decision making and thus indirectly helping children.

Patients’ interpretation of the symptoms of myocardial infarction: implications for cardiac rehabilitation

Research has shown that patients' models of illness are likely to be different from those of health professionals and that these beliefs may be more important than medical factors in directing the recovery process. Beliefs about myocardial infarction may influence coping with the illness, expectations for recovery, patients' reactions to subsequent cardiac events, morbidity and compliance rates and attendance at rehabilitation courses. This qualitative study explores patients' interpretation of the symptoms of myocardial infarction and their personal theories about the illness. Data collection was undertaken in a coronary care unit, using semi-structured interviews with 50 patients. Ethnographic content analysis was used to develop an insightful description of commonalties in the data. Major categories from the data included: providing a historical context, the metaphor of a heart attack, labelling of symptoms and making sense of the illness experience. Interventions to increase participation in rehabilitation programmes need to take into consideration patients' theories about their illness.