An exploratory mixed methods analysis of adherence predictors following acute coronary syndrome

Perspectives on barriers and facilitators to lifestyle change after cardiac events among patients in Saudi Arabia: a qualitative study

AIMS

Lifestyle interventions are an essential element in the prevention of cardiovascular disease. However, promoting a healthy lifestyle is challenging because a multitude of factors interact and influence people's decisions to adopt and maintain healthy lifestyles. The effects of these factors on Saudi cardiac patients are largely unknown. This study aimed to explore the barriers and facilitators to healthy lifestyle changes among Saudis after cardiac events.

METHODS AND RESULTS

The study followed an exploratory qualitative research design, using a social ecological approach. Semi-structured interviews were conducted with 21 participants (13 men and 8 women) who had a cardiac event. Participants were purposively recruited from cardiac clinics of two hospitals in Jeddah, Saudi Arabia. Data were analysed using the qualitative framework analysis, and factors were identified as salient based on their frequency and the potential strength of their impact. Six factors were identified as influencing lifestyle behaviours in cardiac patients, categorized as 'major' factors and 'mediating' factors. The 'major' factors were sociocultural norms, family values, and religious beliefs, and the mediating factors were insufficient healthcare services, physical environment, and policy regulations. Depending upon the behaviours reported and the context, the same factor could be classified as both a barrier and a facilitator.

CONCLUSION

The findings of this study can be used to inform the development of contextual-based interventions to promote the adoption of healthy lifestyles that meet the population needs and are relevant to Saudi society.

Predictors of adherence of enhanced external counterpulsation in patients with coronary heart disease after discharge: A mixed-methods study

Background

Although enhanced external counter pulsation (EECP) has been included in the cardiac rehabilitation prescription for coronary heart disease (CHD) in China, because the total treatment duration of a course of EECP is 36-36 h, the average hospital stay of CHD patients is short, and the adherence after discharge remains unclear. The purpose of this study is to investigate the adherence to EECP in CHD patients after discharge, and analyze the related influencing factors.

Methods

A retrospective mixed method study combining qualitative and quantitative methods. Quantitative component included CHD patients who had received EECP treatment between March 2020 and August 2021. The qualitative component included in-depth interviews with patients who did not adhere to EECP after discharge. Binary Logistic regression was used to analyze the predictors of EECP adherence after discharge. In-depth interviews with patients were conducted to explore the reasons for dropping out of the EECP after discharge.

Results

Among 1,304 patients, only 24.23% adhered to EECP treatment after discharge. Binary logistic regression results showed that patients with disease duration < 2 years (OR = 3.13, 95%CI: 2.31-4.24), high school or below (OR = 2.81, 95%CI: 1.98-4.01), distance between residence and hospital more than 20km (OR = 2.08, 95%CI: 1.47-2.96), age over 60 (OR = 2.00, 95%CI: 1.46-2.74), female (OR = 1.64, 95%CI: 1.78-2.29), and angina pectoris (OR = 1.65, 95%CI: 1.16-2.34) were more likely to not adhere to EECP treatment after discharge. However, patients with monthly family income over 8000¥ (OR = 0.46, 95%CI: 0.28-0.75) were more likely to adhere to EECP treatment after discharge than those with household monthly income below 4,000¥. In the qualitative results, the reasons why patients do not adhere to EECP after discharge mainly include insufficient understanding, restricted objective conditions and psychosocial factors.

Conclusions

The adherence of CHD patients to EECP treatment after discharge was poor. It is necessary to develop effective intervention measures, such as brochures or videos to improve patients' understanding of the importance of adherence to EECP treatment after discharge. In addition, offering EECP treatment during off-hours and weekends may also improve adherence in more young patients.

Understandings and experiences of adherence to secondary prevention for patients with cardiovascular disease and comorbid depression or anxiety

Over 20% of cardiovascular disease (CVD) patients have a comorbid mental health disorder, resulting in an increased risk of recurring major adverse cardiac events (MACE) and mortality. Despite the higher risk, patients with comorbid depression or anxiety disorders are twice as likely to be non-adherent to secondary prevention. Therefore, better understanding of the adherence experiences of this subgroup is needed to inform service delivery and enhance adherence for this higher risk group. This study aims to explore the perceptions, understandings, and experiences of adherence to secondary prevention amongst 33 cardiac patients with diagnosed depression and/or anxiety disorder. Participants were recruited as part of the Cardiovascular Health in Anxiety or Mood Problems Study. Semi-structured interviews were conducted and data were analysed via inductive thematic analysis. Patient understandings of adherence to secondary prevention were limited, with medication compliance considered the marker of adherence. Further, participants did not perceive unintentional non-adherence to constitute non-adherence, rather an intent to engage was viewed as defining adherence. Participants also reported that a lack of practitioner understanding and management around their mental health negatively impacted the practitioner-patient relationship and their engagement with secondary prevention. Results highlight that unique barriers, especially around management of comorbid mental health exist for this subgroup. Additionally, adherence to secondary prevention might be limited by patients' narrow understandings of adherence as the intent to engage and as medication compliance.

Positive psychological constructs and health behavior adherence in heart failure: A qualitative research study

Psychological well-being may play an important role in health behavior adherence and cardiovascular health, but there has been limited study of well-being in patients with heart failure. In this descriptive qualitative research study, we interviewed 30 patients with heart failure to explore their psychological experiences with heart failure and the perceived associations between positive psychological constructs and adherence to physical activity, diet, and medication recommendations. Interviews were transcribed, then coded in NVivo using directed and conventional content analysis, and the Consolidated Criteria for Reporting Qualitative Research checklist was applied to report our findings. Participants spontaneously reported positive psychological constructs both during an acute phase of illness and 3 months later. Participants most commonly experienced gratitude, acceptance, connectedness, and faith in the setting of heart failure. In contrast, pride, determination, and hope were identified most frequently as playing a role in health behavior adherence. Finally, participants reported a reinforcing relationship between positive constructs and health behavior engagement. These findings suggest that interventions to boost positive constructs have the potential to improve well-being and health behavior adherence in patients with heart failure.

Developing a Psychological-Behavioral Intervention in Cardiac Patients Using the Multiphase Optimization Strategy: Lessons Learned From the Field

BACKGROUND

The Multiphase Optimization Strategy (MOST) is an approach to systematically and efficiently developing a behavioral intervention using a sequence of experiments to prepare and optimize the intervention.

PURPOSE

Using a 6 year MOST-based behavioral intervention development project as an example, we outline the results-and resulting decision-making process-related to experiments at each step to display the practical challenges present at each stage.

METHODS

To develop a positive psychology (PP) based intervention to promote physical activity after an acute coronary syndrome (N = 255 across four phases), we utilized qualitative, proof-of-concept, factorial design, and randomized pilot experiments, with iterative modification of intervention content and delivery.

RESULTS

Through this multiphase approach, we ultimately developed a 12 week, phone-delivered, combined PP-motivational interviewing intervention to promote physical activity. Across stages, we learned several important lessons: (a) participant and interventionist feedback is important, even in later optimization stages; (b) a thoughtful and systematic approach using all information sources is required when conflicting results in experiments make next steps unclear; and (3) new approaches in the field over a multiyear project should be integrated into the development process.

CONCLUSIONS

A MOST-based behavioral intervention development program can be efficient and effective in developing optimized new interventions, and it may require complex and nuanced decision-making at each phase.

Positive psychological experiences in allogeneic hematopoietic stem cell transplantation

OBJECTIVE

Positive psychological constructs (e.g., optimism and hope) have been associated with superior health outcomes in the recovery from hematopoietic stem cell transplantation (HSCT) in prior work. However, such studies have not examined a broad range of positive psychological constructs, their sources or evolution over time, or their connections with key health behaviors. We used semistructured qualitative interviews in 25 HSCT patients to explore the nature and sources of positive psychological experiences during the first 100 days after transplantation.

METHODS

Participants completed interviews during their HSCT hospitalization and approximately 100 days after transplantation. Transcribed interviews were organized and analyzed using NVivo 12 software by two coders (κ = 0.92). Interviews focused on the breadth of positive psychological experiences, their sources and evolution during the 100 days, and participants' perceived impact of positive constructs on health behaviors.

RESULTS

Several positive psychological constructs especially gratitude, determination, and optimism were frequently expressed. Family support and deliberate participation in pleasant and meaningful activities were the two primary sources of positive psychological experiences after HSCT. At baseline, participants consistently reported gratitude for their donors while follow-up was consistently characterized by hope for cure and return to baseline level of functioning. Additionally, participants related bidirectional relationships between positive psychological well-being experiences and completion of health behaviors over time.

CONCLUSIONS

As one of the first qualitative studies characterizing the breadth, sources, and evolution of positive psychological experiences in HSCT patients, these findings add to the literature aimed at understanding psychological well-being in this complex and growing patient population.

Relationships among medication adherence, lifestyle modification, and health-related quality of life in patients with acute myocardial infarction: a cross-sectional study

Background

The healthy adherer effect is a phenomenon in which patients who adhere to medical therapies tend to pursue health-seeking behaviors. Although the healthy adherer effect is supposed to affect health outcomes in patients with coronary artery disease, evaluation of its presence and extent is not easy. This study aimed to assess the relationship between medication adherence and lifestyle modifications and health-related quality of life among post-acute myocardial infarction (AMI) patients.

Methods

A cross-sectional study was conducted in 417 post-AMI patients who underwent percutaneous coronary intervention (PCI). Patients were recruited from 11 university hospitals from December 2015 to March 2016 in South Korea. Details regarding socio-demographic factors, six health behaviors (low-salt intake, low-fat diet and/or weight-loss diet, regular exercise, stress reduction in daily life, drinking in moderation, and smoking cessation), medication adherence using the Modified Morisky Scale (MMS), and HRQoL using the Coronary Revascularization Outcome Questionnaire (CROQ) were surveyed in a one-on-one interview.

Results

In the univariate logistic analysis, sex (female), age (≥70 years), MMS score (≥5), and CROQ score were associated with adherence to lifestyle modification. In the multiple logistic analysis, a high MMS score (≥5) was associated with adherence to lifestyle modification after adjusting for sex, age, marital status, education, and family income (adjusted odds ratio [OR] = 11.7, 95% confidence interval [CI] = 1.5–91.3). After further adjusting for the CROQ score, the association between high MMS score and adherence to lifestyle modification was significant (adjusted OR = 11.5, 95% CI = 1.4–93.3).

Conclusions

Adherence to medication was associated with adherence to lifestyle modification, suggesting the possible presence of the healthy adherer effect in post-AMI patients. After further adjusting for HRQoL, the association remained. To improve health outcome in post-AMI patients, early detection of patients with poor adherence to medication and lifestyle modification and motivational education programs to improve adherence are important. In addition, the healthy adherer effect should be considered in clinical research, in particular, in studies evaluating the effects of therapies on health outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-0921-z) contains supplementary material, which is available to authorized users.

A Positive Psychology Intervention for Patients with an Acute Coronary Syndrome: Treatment Development and Proof-of-Concept Trial

Positive psychological constructs are associated with superior outcomes in cardiac patients, but there has been minimal study of positive psychology (PP) interventions in this population. Our objective was to describe the intervention development and pilot testing of an 8-week phone-based PP intervention for patients following an acute coronary syndrome (ACS). Initial intervention development and single-arm proof-of-concept trial, plus comparison of the PP intervention to a subsequently-recruited treatment as usual (TAU) cohort. PP development utilized existing literature, expert input, and qualitative interview data in ACS patients. In the proof-of-concept trial, the primary outcomes were feasibility and acceptability, measured by rates of exercise completion and participant ratings of exercise ease/utility. Secondary outcomes were pre-post changes in psychological outcomes and TAU comparisons, measured using effect sizes (Cohen's d). The PP intervention and treatment manual were successfully created. In the proof-of-concept trial, 17/23 PP participants (74 %) completed at least 5 of 8 exercises. Participants rated the ease (M = 7.4/10; SD = 2.1) and utility (M = 8.1/10, SD = 1.6) of PP exercises highly. There were moderate pre-post improvements (ds = .46-.69) in positive affect, anxiety, and depression, but minimal effects on dispositional optimism (d = .08). Compared to TAU participants (n = 22), PP participants demonstrated greater improvements in positive affect, anxiety, and depression (ds = . 47-.71), but not optimism. A PP intervention was feasible, well-accepted, and associated with improvements in most psychological measures among cardiac patients. These results provide support for a larger trial focusing on behavioral outcomes.

Psychometric Testing of the Self-Care of Coronary Heart Disease Inventory (SC-CHDI)

Although coronary heart disease (CHD) requires a significant amount of self-care, there are no instruments available to measure self-care in this population. The purpose of this study was to test the psychometric properties of the Self-Care of Coronary Heart Disease Inventory (SC-CHDI). Using the Self-Care of Chronic Illness theory, we developed a 22-item measure of maintenance, management, and confidence appropriate for persons with stable CHD and tested it in a convenience sample of 392 adults (62% male, mean age 61.4 ± 9.6 years). Factorial validity was tested with confirmatory factor analysis. Convergent validity was tested with the Medical Outcomes Study MOS-SAS Specific Adherence Scale and the Decision Making Competency Inventory (DMCI). Cronbach alpha and factor determinacy scores (FDS) were calculated to assess reliability. Two multidimensional self-care scales were confirmed: self-care maintenance included "consultative behaviors" (e.g., taking medicines as prescribed) and "autonomous behaviors" (e.g., exercising 30 minute/day; FDS = .87). The multidimensional self-care management scale included "early recognition and response" (e.g., recognizing symptoms) and "delayed response" (e.g., taking an aspirin; FDS = .76). A unidimensional confidence factor captured confidence in each self-care process (α = .84). All the self-care dimensions were associated with treatment adherence as measured by the MOS-SAS. Only self-care maintenance and confidence were associated with decision-making (DCMI). These findings support the conceptual basis of self-care in patients with CHD as a process of maintenance that includes both consultative and autonomous behaviors, and management with symptom awareness and response. The SC-CHDI confidence scale is promising as a measure of self-efficacy, an important factor influencing self-care. © 2016 Wiley Periodicals, Inc.