An exploration of illness representations and treatment beliefs in heart failure

Exploring the Experience of Breathlessness with the Common-Sense Model of Self-Regulation (CSM)

Chronic breathlessness is a multidimensional, unpleasant symptom common to many health conditions. The Common-Sense Model of Self-Regulation (CSM) was developed to help understand how individuals make sense of their illness. This model has been underused in the study of breathlessness, especially in considering how information sources are integrated within an individual's cognitive and emotional representations of breathlessness. This descriptive qualitative study explored breathlessness beliefs, expectations, and language preferences of people experiencing chronic breathlessness using the CSM. Twenty-one community-dwelling individuals living with varying levels of breathlessness-related impairment were purposively recruited. Semi-structured interviews were conducted with questions reflecting components of the CSM. Interview transcripts were synthesized using deductive and inductive content analysis. Nineteen analytical categories emerged describing a range of cognitive and emotional breathlessness representations. Representations were developed through participants' personal experience and information from external sources including health professionals and the internet. Specific words and phrases about breathlessness with helpful or nonhelpful connotations were identified as contributors to breathlessness representations. The CSM aligns with current multidimensional models of breathlessness and provides health professionals with a robust theoretical framework for exploring breathlessness beliefs and expectations.

A Proposal of a Cost-Effectiveness Modeling Approach for Heart Failure Treatment Assessment: Considering the Short- and Long-Term Impact of Hospitalization on Event Rates

BACKGROUND

The rate of events such as recurrent heart failure (HF) hospitalization and death are known to dramatically increase directly after HF hospitalization. Furthermore, the number of HF hospitalizations is associated with irreversible long-term disease progression, which is in turn associated with increased event rates. However, cost-effectiveness models of HF treatments commonly fail to capture both the short- and long-term association between HF hospitalization and events.

OBJECTIVE

The aim of this study was to provide a decision-analytic model that reflects the short- and long-term association between HF hospitalization and event rates. Furthermore, we assess the impact of omitting these associations.

METHODS

We developed a life-time Markov cohort model to evaluate HF treatments, and modeled the short-term impact of HF hospitalization on event rates via a sequence of tunnel states, with transition probabilities following a parametric survival curve. The corresponding long-term impact was modeled via hazard ratios per HF hospitalization. We obtained baseline event rates and utilities from published literature. Subsequently, we assessed, for a hypothetical HF treatment, how omitting the modeled associations (through a simple two-state model) affects incremental quality-adjusted life-years (QALYs).

RESULTS

We developed a model that incorporates both short- and long-term impacts of HF hospitalizations. Based on an assumed treatment effect of a 20% risk reduction for HF hospitalization (and associated reductions in all-cause mortality of 15%), omitting the short-term, the long-term, or both associations resulted in a 5%, 1%, and 22% decrease in QALYs gained, respectively.

CONCLUSION

For both modeling components, i.e., the short- and long-term implications of HF hospitalization, the impact on incremental outcomes associated with treatment was substantial. Considering these aspects as proposed within this modeling approach better reflects the natural course of this progressive condition and will enhance the evaluation of future HF treatments.

Time to Revisit Heart Failure Self-Care: A Concept Analysis

Self-care is a central concept in heart failure management and nursing practice. Yet, the uptake of heart failure self-care has been uncritical and detached from broader contexts. Therefore, heart failure self-care was explored using Rodger's evolutionary concept analysis approach to identify antecedents, attributes, and consequences with attention to context, time, application, and meaning. The analysis suggests that heart failure self-care tends to focus on individual behaviors to the detriment of social and structural determinants of health. It also shifts responsibility away from the health care system and onto the individual. Moving forward, a more robust conceptualization of heart failure self-care is needed or possibly, the development of a new concept that focuses beyond the self .

An Integrative Review of the Symptom Perception Process in Heart Failure

BACKGROUND

Accurate symptom perception is a fundamentally essential component of self-care for patients with heart failure (HF) so they can make appropriate decisions about their symptoms.

OBJECTIVE

The purpose of this integrative review was to describe the pathways of the symptom perception process and its contributing factors in patients with HF.

METHODS

A comprehensive literature search was conducted using PubMed, EMBASE, and PsycINFO databases to identify studies describing the symptom perception process (symptom detection, comprehension, and response) in adult patients with HF.

RESULTS

Two pathways of the symptom perception process were identified from 42 articles: ideal and undesirable pathways. Patients in the ideal symptom perception pathway had a comprehensive understanding of HF and a firm belief in the importance of self-care, were vigilant, and possessed good decision-making skills. They also were able to successfully use their experiences for future care. However, patients in the undesirable symptom perception pathway had a limited understanding of HF with poor symptom monitoring skills and inaccurate judgments about symptoms. Diverse factors contributing to the symptom perception process were identified (eg, levels of understandings of HF and social support).

CONCLUSION

Our review indicated that symptom perception was likely to diversify the pathway of HF management. A variety of contributing factors to the symptom perception process were found to be intertwined. The findings of our review can inform the development of best patient education practice, although further research needs to be conducted to understand why and how patients can follow the most appropriate path from their past experiences.

An evidence-based structured one-year programme to sustain physical activity in patients with heart failure in primary care: A non-randomized longitudinal feasibility study

Aim

The primary objective of this non-randomized feasibility study was to test a 1-year model programme for sustaining/increasing patients' motivation to perform daily physical activity.

Design

Non-randomized longitudinal feasibility study with a one-group repeated measures design.

Methods

The study took place at a primary care centre in mid-Sweden in 2017-2018. The model programme included individual and group-based support, individualized physical activity prescriptions, a wrist-worn activity tracker and an activity diary. The main outcomes were the participants' perceptions of programme feasibility and scores on the Exercise Self-Efficacy Scale.

Results

Seven patients were recruited. Six patients completed the programme that was perceived to imply learning, motivation and support. Compared with baseline, the median score of the Exercise Self-Efficacy Scale improved 3 months after participants completed the programme.

Effects of illness representation-focused patient education on illness representations and self-care in patients with heart failure: A randomised clinical trial

AIMS AND OBJECTIVES

To examine the effect of an illness representation-focused patient education intervention on illness representations and self-care behaviours in patients with heart failure 3 months after discharge from the hospital.

BACKGROUND

Few intervention studies have examined the effect of illness representation-focused interventions on illness representations and self-care in patients with heart failure.

DESIGN

A randomised clinical trial based on the Consolidated Standard of Reporting Trials-CONSORT 2010-guidelines was employed. The Clinical Trial Registry number is TCTR20190903002.

METHODS

One hundred and seven participants were randomly assigned to 2 groups, and 62 participants (n = 30 in the intervention group and n = 32 in the usual care group) completed the baseline and one- and three-month postdischarge follow-up assessments. The instruments included the Survey of Illness Beliefs in Heart Failure and the Self-care of Heart Failure Index. The intervention group received illness representation-focused patient education while hospitalised and telephone follow-ups after discharge. Data were analysed with linear mixed-effects model analysis.

RESULTS

The 107 participants had a mean age of 62.17 years and a mean left ventricular ejection of 53.03%. At baseline, the two groups tended to have accurate illness beliefs but insufficient self-care confidence and self-care maintenance. The analysis showed no significant differences between groups in the illness representation total scores, dimension scores or self-care maintenance scores but did show a significant difference in the self-care confidence scores (F = 3.42, p < .05) over the three months.

CONCLUSION

The study did not show an effect of the intervention on illness representations or self-care maintenance behaviours. However, the intervention did maintain participants' self-care confidence three months after discharge.

RELEVANCE TO CLINICAL PRACTICE

It is necessary to conduct long-term follow-ups of patients' illness representations, discuss the implementation of self-care behaviours with patients, enhance patients' self-care confidence, and involve family members or caregivers in self-care practices when needed.

Knowledge among patients with heart failure: A narrative synthesis of qualitative research

BACKGROUND

Patients' knowledge of heart failure (HF) is integral to improved outcomes. However, the HF literature has not adequately explored the nature of patients' knowledge of HF as part of their lived experience.

OBJECTIVES

We aimed to characterize the nature of patients' knowledge of HF, in the context of living with the disease.

METHODS

We conducted a narrative synthesis of qualitative studies that addressed patients' knowledge of HF. Studies were systematically searched and retrieved from MEDLINE, CINAHL, PsycINFO and PsycARTICLES databases. Findings were synthesized using an iterative coding process carried out by multiple analysts and reported following Enhancing Transparency in the Reporting of Qualitative Health Research (ENTREQ) criteria.

RESULTS

Analysis of 73 eligible articles produced five themes: the content that comprises HF knowledge; development of HF knowledge over time; application of HF knowledge for decision making; communication of information between clinicians and patients; and patients' experience of knowledge.

CONCLUSION

The nature of patients' knowledge of HF is both explicit and implicit, dynamic, and personal. This multidimensional model of knowledge-in-context calls for equally multidimensional research and intervention design.

A qualitative meta-summary using Sandelowski and Barroso’s method for integrating qualitative research to explore barriers and facilitators to self-care in heart failure patients

Background:

Individual qualitative studies provide varied reasons for why heart failure patients do not engage in self-care, yet articles that aggregated primary studies on the subject have methodological weaknesses that justified the execution of a qualitative meta-summary.

Aim:

The aim of this study is to integrate the findings of qualitative studies pertaining to barriers and facilitators to self-care using meta-summary techniques.

Methods:

Qualitative meta-summary techniques by Sandelowski and Barroso were used to combine the findings of qualitative studies. Meta-summary techniques include: (1) extraction of relevant statements of findings from each report; (2) reduction of these statements into abstracted findings and (3) calculation of effect sizes. Databases were searched systematically for qualitative studies published between January 2010 and July 2015. Out of 2264 papers identified, 31 reports based on the accounts of 814 patients were included in the meta-summary.

Results:

A total of 37 statements of findings provided a comprehensive inventory of findings across all reports. Out of these statements of findings, 21 were classified as barriers, 13 as facilitators and three were classed as both barriers and facilitators. The main themes relating to barriers and facilitators to self-care were: beliefs, benefits of self-care, comorbidities, financial constraints, symptom recognition, ethnic background, inconsistent self-care, insufficient information, positive and negative emotions, organizational context, past experiences, physical environment, self-initiative, self-care adverse effects, social context and personal preferences.

Conclusion:

Based on the meta-findings identified in this study, future intervention development could address these barriers and facilitators in order to further enhance self-care abilities in heart failure patients.

Regional differences in health-related quality of life in elderly heart failure patients: results from the CIBIS-ELD trial

AIM

Patient-reported outcomes such as health-related quality of life (HRQoL) are main treatment goals for heart failure (HF) and therefore endpoints in multinational therapy trials. However, little is known about country-specific differences in HRQoL and in treatment-associated HRQoL improvement. The present work sought to examine those questions.

METHODS AND RESULTS

We analysed data from the Cardiac Insufficiency Bisoprolol Study in Elderly (CIBIS-ELD) trial, in which patients from central and south-eastern Europe completed the HRQoL questionnaire SF-36 at baseline and the end of a 12-week beta-blocker up-titration (follow-up). 416 patients from Serbia (mean age 72.21 years, 69% NYHA-class I-II, 27.4% women) and 114 from Germany (mean age 73.64 years, 78.9% NYHA-class I-II, 47.4% women) were included. Controlling for clinical variables, the change in mental HRQoL from baseline to follow-up was modulated by Country: Serbian patients, M _baseline = 37.85 vs. M _follow-up = 40.99, t(526) = 5.34, p < .001, reported a stronger increase than Germans, M _baseline = 37.66 vs. M _follow-up = 38.23, t(526) = 0.68, ns. For physical HRQoL, we observed a main effect of Country, M _Serbia = 39.28 vs. M _Germany = 35.29, t(526) = 4.24, p < .001.

CONCLUSION

We observed significant differences in HF patients from Germany and Serbia and country-specific differences between Serbian and German patients in mean physical HRQoL. Changes in mental HRQoL were modulated by country. Those results may reflect psychological, sociocultural, aetiological differences or regional differences in phenotype prevalence. More importantly, they suggest that future multinational trials should consider such aspects when designing a trial in order to avoid uncertainties aligned to data interpretation and to improve subsequent treatment optimisation.

The association of catastrophizing with quality-of-life outcomes in patients with irritable bowel syndrome

Background

Catastrophizing is a cognitive process characterized by a propensity to concentrate on and magnify the value of an actual or anticipated painful stimulus and negatively assesses one’s ability to cope. Catastrophizing is an important predictor of pain-related outcomes. A cornerstone symptom of irritable bowel syndrome (IBS) is abdominal pain or discomfort. Also individuals with IBS have been reported to have a tendency to catastrophize. In a sample of individuals who suffer from IBS, we hypothesized that those individuals who catastrophize (catastrophizers) would have worse outcomes as compared to those who do not catastrophize (non-catastrophizers).

Methods

One hundred and one adults with IBS (79% female, mean age 42 years, 97% Caucasian) were recruited from outpatient clinics and data were collected through self-report measures. Catastrophizing was measured with the catastrophizing subscale of the Coping Strategies Questionnaire, illness representations were measured with The Revised Illness Perception Questionnaire (IPQ-R), psychological distress was measured with the Brief Symptom Inventory 18 (BSI-18), and health-related quality of life was measured using the Irritable Bowel Syndrome-Quality of Life (IBS-QOL) measure. Descriptive statistics, correlations, and multiple linear regression analyses were completed to describe participants, the associations of the variables of interest, and the unique relationship between psychosocial variables and HRQOL.

Results

Overall, participants reported poor HRQOL (M = 63.32, range 0–100). Catastrophizers differed significantly on IBS-QOL from non-catastrophizers (M = 48.98 vs. non-catastrophizers M = 78.53; p < 0.001), BSI-18 (M = 21.35 vs. non-catastrophizers M = 6.76; p < 0.001), and IPQ-R, specifically the consequences (M = 21.75 vs. non-catastrophizers M = 17.20; p < 0.001) and emotional representations (M = 20.90 vs. non-catastrophizers M = 15.43; p < 0.001). Catastrophizing was positively correlated with the consequences (r = .54; p < 0.01) and emotional representations (r = .65; p < 0.01) and negatively correlated with total HRQOL (r = −0.76; p < 0.01).

Conclusion

The findings indicated that participants who catastrophized reported worse psychosocial and functional outcomes. Thus, catastrophizing, in addition to psychological distress variables, may be an important factor to address in optimizing health outcomes in individuals with IBS. In addition, illness perceptions were strongly related to catastrophizing and HRQOL; assessment and integration of illness perceptions as well as catastrophizing into the management of individuals who suffer with IBS may maximize the health outcomes.

The heart is a representation of life: an exploration of illness beliefs in couples living with atrial fibrillation

AIMS AND OBJECTIVES

To explore illness beliefs in couples where one spouse has atrial fibrillation.

BACKGROUND

Beliefs are the lenses through which we view the world, guiding our behaviour and constructing our lives. Couples evolve an ecology of beliefs from their interaction whereby their actions and choices arise from their beliefs. Atrial fibrillation is a common cardiac arrhythmia that has implications for both patients and partners. A couple's illness beliefs play an important role in convalescence and illness management, and no previous studies have explored illness beliefs in couples living with atrial fibrillation.

DESIGN

A qualitative hermeneutic design.

METHODS

Data collection constituted in-depth interviews with nine couples (patient and partner together). Hermeneutic philosophy as described by Gadamer was used to interpret and to understand illness beliefs in couples living with atrial fibrillation.

RESULTS

The findings revealed both core illness beliefs and secondary illness beliefs. From the core illness belief 'The heart is a representation of life', two secondary illness beliefs were derived: atrial fibrillation is a threat to life and atrial fibrillation can and must be explained. From the core illness belief 'Change is an integral part of life', two secondary illness beliefs were derived: atrial fibrillation is a disruption in our lives and atrial fibrillation will not interfere with our lives. Finally, from the core illness belief 'Adaptation is fundamental in life', two secondary illness beliefs were derived: atrial fibrillation entails adjustment in daily life and atrial fibrillation entails confidence in and adherence to professional care.

CONCLUSION

Couples' interaction has developed mutual illness beliefs regarding atrial fibrillation that guide them in their daily lives and influence their decisions. The adoption of a family-centred perspective in cardiovascular care settings is warranted.

Symptom perceptions and self-care behaviors in patients who self-manage heart failure

BACKGROUND

Patients with heart failure (HF) are at heightened risk for acute exacerbation requiring hospitalization. Although timely reporting of symptoms can expedite outpatient treatment and avoid the need for hospitalization, few patients recognize and respond to symptoms until acutely ill.

OBJECTIVE

The purpose of this study was to explore patients' perceptions of symptoms and self-care behaviors for symptom relief, leading up to a HF hospitalization.

METHODS

To examine prehospitalization symptom scenarios, semistructured interviews were conducted with 60 patients hospitalized for acute decompensated HF.

RESULTS

Thirty-seven patients (61.7%) said that they had a sense that "something just wasn't quite right" before their symptoms began but were unable to specify further. Signs and symptoms most often recognized by the patients were related to dyspnea (85%), fatigue (53.3%), and edema (41.7%). Few patients interpreted their symptoms as being related to worsening HF and most often attributed symptoms to changes in diet (18.3%) and medications (13.3%). Twenty-six patients (43.3%) used self-care strategies to relieve symptoms before hospital admission. More than 40% of the patients had symptoms at least 2 weeks before hospitalization.

CONCLUSIONS

Despite the wide dissemination of HF evidence-based guidelines, important components of symptom self-management remain suboptimal. Because most of HF self-management occurs in the postdischarge environment, research is needed that identifies how patients interpret symptoms of HF in the specific contexts in which patients self-manage their HF. These findings suggest the need for interventions that will help patients expeditiously recognize, accurately interpret, and use appropriate and safe self-care strategies for symptoms.

The effect of heart failure nurse consultations on heart failure patients' illness beliefs, mood and quality of life over a six-month period

AIMS AND OBJECTIVES

To explore the effect contact with a heart failure nurse can have on patients' illness beliefs, mood and quality of life.

BACKGROUND

There is growing interest in patients' illness beliefs and the part they play in a patients understanding of chronic disease.

DESIGN

Secondary analysis on two independent datasets. Patients were recruited from five UK hospitals, four in London and one in Sussex. Patients were recruited from an inpatient and outpatient setting. The first dataset recruited 174 patients with newly diagnosed heart failure, whilst the second dataset recruited 88 patients with an existing diagnosis of heart failure.

METHODS

Patients completed the Minnesota Living with Heart Failure Questionnaire, Hospital Anxiety and Depression Scale, Illness Perception Questionnaire and the Treatment Representations Inventory at baseline and six months. We used a linear regression model to assess the association that contact with a heart failure nurse had on mood, illness beliefs and quality of life over a six-month period.

RESULTS

Patients who had contact with a heart failure nurse were more satisfied with their treatment and more likely to believe that their heart failure was treatable. Contact with a heart failure nurse did not make a statistically significant difference to mood or quality of life.

CONCLUSIONS

This study has shown that contact with a heart failure nurse can improve patient satisfaction with treatment decisions but has less influence on a patient's beliefs about their personal control, treatment control and treatment concerns. With appropriate support, skills and training, heart failure nurses could play an important role in addressing individual patient's beliefs. There is a need to further investigate this.

RELEVANCE TO CLINICAL PRACTICE

Exploring patients' illness beliefs and mood could help to enhance person-centred care. Heart failure nurses would need additional training in the techniques used.