A conceptual care model for individualized care approach in cardiac rehabilitation - combining both illness representation and self-efficacy

Pain cognitions and impact of low back pain after participation in a self-management program: a qualitative study

Background

Benefits from low back pain (LBP) treatments seem to be related to patients changing their pain cognitions and developing an increased sense of control. Still, little is known about how these changes occur. The objective of this study was to gain insights into possible shifts in the understanding of LBP and the sense of being able to manage pain among patients participating in a LBP self-management intervention.

Methods

Using a qualitative study and a content analytic framework, we investigated the experiences of patients with LBP who participated in ‘GLA:D^® Back’, a group-based structured patient education and exercise program. Data were generated through qualitative semi-structured interviews conducted between January 2019 and October 2019. Interviews focused on experiences with pain and were analysed using a thematic analytical approach. The Common Sense Model and self-efficacy theory formed the theoretical framework for the interpretations. Participants were sampled to represent people who were either dissatisfied or satisfied with their participation in GLA:D^® Back. Fifteen participants aged 26–62, eight women and seven men, were interviewed from February to April 2020.

Results

Four main themes, corresponding to the characterisation of four patient groups, were identified: ‘Feeling miscast, ‘Maintaining reservations', ‘Struggling with habits’ and ‘Handling it’. The participants within each group differed in how they understood, managed, and communicated about their LBP. Some retained the perception of LBP as a threatening disease, some expressed a changed understanding that did not translate into new behaviors, while others had changed their understanding of pain and their reaction to pain.

Conclusions

The same intervention was experienced very differently by different people dependent on how messages and communication resonated with the individual patient's experiences and prior understanding of LBP. Awareness of the ways that individuals’ understanding of LBP interact with behaviour and physical activities appear central for providing adaptive professional support and meeting the needs of individual patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-022-00416-6.

Are Common Sense Model constructs and self-efficacy simultaneously correlated with self-management behaviors and health outcomes: A systematic review

This systematic review answered two questions among adults with chronic conditions: When included in the same statistical model, are Common Sense Model constructs and self-efficacy both associated with (1) self-management behaviors and (2) health outcomes? We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and included 29 articles. When included in the same statistical model, Common Sense Model constructs and self-efficacy were both correlated with outcomes. Self-efficacy was more consistently associated with self-management behaviors, and Common Sense Model constructs were more consistently associated with health outcomes. Findings support the continued inclusion and integration of both frameworks to understand and/or improve chronic illness self-management and outcomes.

Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis

Background

In 2012, a series of systematic reviews summarised the evidence regarding interventions to reduce preventable hospital admissions. Although intervention effects were dependent on context, the reviews revealed a consistent picture of reduction across different interventions targeting cardiovascular and respiratory conditions. The research reported here sought to provide an in-depth understanding of how interventions that have been shown to reduce admissions for these conditions may work, with a view to supporting their effective implementation in practice.

Objectives

To map the available evidence on interventions used in the UK NHS to reduce preventable admissions for cardiovascular and respiratory conditions and to conduct a realist synthesis of implementation evidence related to these interventions.

Methods

For the mapping review, six databases were searched for studies published between 2010 and October 2017. Studies were included if they were conducted in the UK, the USA, Canada, Australia or New Zealand; recruited adults with a cardiovascular or respiratory condition; and evaluated or described an intervention that could reduce preventable admissions or re-admissions. A descriptive summary of key characteristics of the included studies was produced. The studies included in the mapping review helped to inform the sampling frame for the subsequent realist synthesis. The wider evidence base was also engaged through supplementary searching. Data extraction forms were developed using appropriate frameworks (an implementation framework, an intervention template and a realist logic template). Following identification of initial programme theories (from the theoretical literature, empirical studies and insights from the patient and public involvement group), the review team extracted data into evidence tables. Programme theories were examined against the individual intervention types and collectively as a set. The resultant hypotheses functioned as synthesised statements around which an explanatory narrative referenced to the underpinning evidence base was developed. Additional searches for mid-range and overarching theories were carried out using Google Scholar (Google Inc., Mountain View, CA, USA).

Results

A total of 569 publications were included in the mapping review. The largest group originated from the USA. The included studies from the UK showed a similar distribution to that of the map as a whole, but there was evidence of some country-specific features, such as the prominence of studies of telehealth. In the realist synthesis, it was found that interventions with strong evidence of effectiveness overall had not necessarily demonstrated effectiveness in UK settings. This could be a barrier to using these interventions in the NHS. Facilitation of the implementation of interventions was often not reported or inadequately reported. Many of the interventions were diverse in the ways in which they were delivered. There was also considerable overlap in the content of interventions. The role of specialist nurses was highlighted in several studies. The five programme theories identified were supported to varying degrees by empirical literature, but all provided valuable insights.

Limitations

The research was conducted by a small team; time and resources limited the team’s ability to consult with a full range of stakeholders.

Conclusions

Overall, implementation appears to be favoured by support for self-management by patients and their families/carers, support for services that signpost patients to consider alternatives to seeing their general practitioner when appropriate, recognition of possible reasons why patients seek admission, support for health-care professionals to diagnose and refer patients appropriately and support for workforce roles that promote continuity of care and co-ordination between services.

Future work

Research should focus on understanding discrepancies between national and international evidence and the transferability of findings between different contexts; the design and evaluation of implementation strategies informed by theories about how the intervention being implemented might work; and qualitative research on decision-making around hospital referrals and admissions.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Application of relational tool to support acute cardiac patients' emotional recovery: analysis of effects during acute and follow-up care

After an acute cardiac event, many patients experience emotional disturbance. This is a normal response to the event and to hospitalization, but, if not treated with emotive and social support, the symptoms can evolve, resulting in emotional and behavioural disorders. The aim of the study was to evaluate the outcome of the use of a new nursing relational tool, designed to support patients’ emotional recovery. The data are the result of semi-structured narrative interviews, conducted in the intensive cardio care unit of the Mauriziano hospital of Turin and by telephone, during March and August of 2017. The research sample involved 26 patients, divided into control and intervention groups. Exclusion criteria were: under age of 18, cognitive impairment or dementia, difficulty with comprehension and expression in Italian, and previous acute cardiac events. The interviews have shown that an emotional management tool improves the patient’s recovery, the quality of information received, and the quality of the patient’s everyday life after the event. The use of a relational tool by nursing staff improves the patient’s emotional management and increases the knowledge required to ensure a good quality of life. Continuous use also improves the confidence of health professionals in managing these emotional conditions.

A Network Analysis of the Links Between Chronic Pain Symptoms and Affective Disorder Symptoms

BACKGROUND

A range of psychological constructs, including perceived pain, self-efficacy, and pain avoidance, have been proposed to account for the comorbidity of chronic pain and affective disorder symptoms. Despite the likely inter-relation among these constructs, few studies have explored these predictors simultaneously. As such, the relative contributions of these psychological influences remain an open question.

PURPOSE

The present study uses a novel, network model approach to help to identify the key psychological contributors to the pain-affective disorder link.

METHOD

A cross-sectional design was implemented. The sample comprised 169 individuals with chronic pain (M_age 49.82; range 22-80 years; 58% female) admitted to a metropolitan chronic pain clinic in Victoria, Australia. Participants completed self-report measures of anxiety, depressive, and pain symptoms, pain self-efficacy, fear avoidance beliefs, perceived control, and pain-related disability.

RESULTS

Network analysis identified self-efficacy, fear avoidance, and perceived disability as key constructs in the relationship between pain and affective disorder symptoms, albeit in different ways. While self-efficacy appeared to have direct links to other constructs in the network model, fear avoidance and perceived disability seemed to function more as mediators, linking other constructs in the model. Perceived control and anxiety were found to be less influential in the model.

CONCLUSIONS

Present findings identify self-efficacy, fear avoidance, and perceived disability as plausible candidate variables to target to disrupt the link between pain experience and affective disorder symptoms. However, further testing with longitudinal designs is needed to confirm this.

Personalised discharge care planning for postmyocardial infarction patients through the use of the Personalised Patient Education Protocol - implementing theory into practice

AIMS AND OBJECTIVES

This study aims to evaluate the service impact of the integration of an evidence-based instrument - the Personalised Patient Education Protocol - into an existing postmyocardial infarction care pathway.

BACKGROUND

Recent research indicates that while better patient health outcomes can be achieved when care planning is personalised, delivery staff feel less satisfied and less confident in its provision. To achieve a shift to personalised care, innovations are needed to enable an effective transition for staff.

DESIGN

A service evaluation using a patient survey and nurse interviews.

METHOD

A longitudinal patient survey measured changes in patient illness beliefs, cardiac diet and exercise self-efficacy, anxiety, depression and quality of life study of a patient cohort of 74. Paired t-tests analysed the effects before and after the implementation of the Personalised Patient Education Protocol. Cardiac rehabilitation nurses who implemented the Personalised Patient Education Protocol were interviewed and a patient survey identified perceptions of the usefulness of the service innovation.

RESULTS

Analysis of change from baseline to three months results showed statistically significant changes in Illness Belief component 'Understanding' and the Dartmouth Quality of Life 'General Health'. The integration of the Personalised Patient Education Protocol into the existing discharge process identified service improvements for cardiac nurse training and care pathway delivery, while patients identified the level and frequency of their use of the protocol following discharge.

CONCLUSION

The introduction of the Personalised Patient Education Protocol succeeded in increasing patient engagement, facilitated a more patient-centred service by enabling practitioners to systematically provide personalised patient education, and gave patients a postdischarge structure to better follow-up their illness concerns with health professionals in the community.

RELEVANCE TO CLINICAL PRACTICE

Integration of the Personalised Patient Education Protocol into an existing postmyocardial infarction care pathway enabled nurses to systematically respond to individual patients' illness beliefs and expectations.

Patients with alcohol-related liver disease--beliefs about their illness and factors that influence their self-management

AIM

To determine the association between illness belief and self-efficacy to provide the evidence-base to develop a personalized framework to support self-management in patients with alcohol-related liver disease.

BACKGROUND

Research in a variety of long-term illnesses suggests patients' illness beliefs are a more influential factor for patient recovery than the severity of the illness. However, research into illness belief and self-efficacy of patients with alcohol-related liver disease is sparse.

DESIGN

A cross-sectional survey.

METHODS

A cohort of 159 patients with alcohol-related liver disease who attended the Liver Outpatient Clinics at a London Hospital (October 2012-November 2013) completed a set of validated instruments measuring illness beliefs, self-efficacy, emotional states and quality of life.

FINDINGS

The mean age of enrolled patients was 52 years, 67% male, 26% live on their own, 61% had no previous history of other chronic illness and average Model for End-Stage Liver Disease and The AUDIT Alcohol Consumption Questions scores were 11·0 and 3·5 respectively. After adjusting for demographic and illness characteristic components, multiple regression analysis shows that the three illness belief components 'Symptoms', 'Understanding' and 'Concerns' made a significant contribution to their confidence to self-manage their liver condition and the 'Symptoms' component makes a signification contribution across to all outcome measures: Anxiety, Depression, Quality of Life and Self-Efficacy.

CONCLUSION

Interventions designed to improve these patients' understanding of their illness and strategies to manage their symptoms are likely to improve their self-management, quality of life and reduce anxiety and depression.

The influence of illness severity on health satisfaction in patients with cardiovascular disease: the mediating role of illness perception and self-efficacy beliefs

The importance of psychological factors in improving conditions of cardiovascular disease (CVD) patients is stressed by the guidelines for their prevention and rehabilitation, but little is known about the impact of illness severity on patients' well-being, and on the psychosocial variables that may mediate this association. The aim of this study was to investigate the role of illness perception and self-efficacy beliefs on the relationship between illness severity and health satisfaction in 75 CVD patients undergoing rehabilitation (80% men; mean age = 65.44) at the St. Luca Hospital, Istituto Auxologico Italiano, Milan, Italy. Illness severity was measured in terms of left ventricular ejection fraction; psychological factors were assessed at the beginning and end of rehabilitation. Results from path analyses showed that the relationships among CVD severity and health satisfaction were mediated by illness perception and self-efficacy beliefs. Findings underscored the importance of considering illness representations and self-efficacy beliefs to improve well-being in CVD patients.

Evaluation of an intervention to increase self-efficacy for independent exercise in cardiac rehabilitation

Adherence to independent exercise is an essential outcome of cardiac rehabilitation (CR), yet limited theory-based interventions to improve adherence exist. This study tested the effects of an intervention based on Bandura's conceptualization of self-efficacy. The self-efficacy coaching intervention (SCI), a supplement to standard care, was designed to increase self-efficacy for independent exercise and independent exercise behavior in CR. We examined whether the SCI vs. attention control (AC) resulted in improved exercise self-efficacy (ESE), barriers self-efficacy (BARSE), and minutes of independent exercise for CR participants (n = 65). While between-group differences did not reach significance (p > .10) for any of the outcome measures, significant within-group changes were noted in BARSE scores and independent exercise (p < .001) for the SCI group. Change in independent exercise for the AC group was also significant (p =. 006). Further study is needed to explore whether short-term changes translate into maintenance of independent exercise participation after program completion.

Living with chronic low back pain: a metasynthesis of qualitative research

OBJECTIVES The purpose of this qualitative metasynthesis is to articulate the knowledge gained from a review of qualitative studies of patients' experiences of chronic low back pain. METHODS Meta-ethnographic methodology guided the review of 33 articles representing 28 studies published in English in peer-reviewed journals between 2000 and 2012. A systematic comparison of the main themes from each study was conducted and 'synthesised' to create superordinate themes. RESULTS Three overarching interrelated themes were identified: the impact of chronic low back pain on self; relationships with significant others that incorporated two streams - health professionals and the organisation of care and relationships with family and friends; coping with chronic low back pain. Coping strategies were predominantly physical therapies, medication and avoidance behaviours with very few successful strategies reported. Professional and family support, self-efficacy, motivation, work conditions and exercise opportunities influenced pain experiences. Review authors' recommendations included psychological therapies, education, the facilitation of self-management strategies and support groups. DISCUSSION The review substantiates chronic low back pain as complex, dynamic and multidimensional, underpinned by experiences of persistent distressing pain, loss, and lowered self-worth, stigma, depression, premature aging, fear of the future. Future research should address the paucity of longitudinal studies, loss and issues of ethnicity, gender, ageing.

Examining the Matthew effect on the motivation and ability to stay at work after heart disease

AIMS

Cardiac rehabilitation should safeguard that socioeconomic factors or other differences that affect people's cardiovascular health are not further aggravated after healthcare treatment. The study examines whether socioeconomic status, emotional problems, or the severity of disease affect people's ability to continue to work after heart disease. We also examined if these effects can be explained by differences in motivational factors.

METHODS

217 patients (41 women) from the Krokeide Rehabilitation Centre in Bergen participated. Multiple linear regression analysis was used to examine motivational differences, and logistic regression analysis was used to examine whether socioeconomic factors or other differences affected people's ability to continue to work after heart disease.

RESULTS

Self-efficacy for future work strongly impacted the likelihood of being incapacitated for work during the 2-year follow-up. The household's total income and emotional problems were statistically significant related to patients dropping out from work in the course of the observation. The association between emotional problems and future work was mediated by motivational problems. The relation between income and future incapacity for work could not be explained by motivational factors.

CONCLUSIONS

The study shows a clear Matthew effect on people's ability to continue to work after heart disease as low-income groups and people with emotional problems are more at risk of dropping out of work. This Matthew effect was, however, only explained by the motivational difficulties for the association between emotional distress and dropping out of work and not for the impact of household income on the likelihood of leaving work.

Adoption of community-based cardiac rehabilitation programs and physical activity following phase III cardiac rehabilitation in Scotland: a prospective and predictive study

Little is known about levels of physical activity and attendance at phase IV community-based Cardiac Rehabilitation (CR) programs following completion of exercise-focussed, hospital-based phase III CR. This study aims to test, compare and combine the predictive utility of the Common-Sense Self-Regulation Model (CS-SRM) and the extended Theory of Planned Behaviour (TPB) with action planning for two rehabilitation behaviours: physical activity and phase IV CR attendance. Individuals diagnosed with coronary heart disease (n = 103) completed baseline measures of illness perceptions, intentions, perceived behavioural control (PBC), action planning and past physical activity in the last week of a phase III CR program, and 95 participants completed follow-up measures of physical activity and attended phase IV CR (objectively confirmed) 2 months later. Only one predictor (PBC/cyclical timeline) significantly predicted levels and change of physical activity. While illness perceptions were not predictive of phase IV CR attendance, the extended TPB model showed good predictive power with action planning and intention as the most powerful predictors. Amongst participants who planned when and where to attend phase IV CR at the end of phase III rehabilitation, 65.9% subsequently attended a phase IV CR program compared to only 18.5% of those who had not made a plan. This study adds to our understanding of cardiac rehabilitation behaviour after completion of health service delivered programs. Comparing theoretical models and rehabilitation behaviours contributes to the development of behaviour theory.

Randomized controlled trials of interventions to change maladaptive illness beliefs in people with coronary heart disease: systematic review

AIM

This paper is a report of a systematic review of randomized controlled trials of interventions to change maladaptive illness beliefs in people with coronary heart disease, and was conducted to determine whether such interventions were effective in changing maladaptive beliefs, and to assess any consequent change in coping and outcome.

BACKGROUND

An increasing body of evidence suggests that faulty beliefs can lead to maladaptive behaviours and, in turn, to poor outcomes. However, the effectiveness of interventions to change such faulty illness beliefs in people with coronary heart disease is unknown.

DATA SOURCES

Multiple data bases were searched using a systematic search strategy. In addition, reference lists of included papers were checked and key authors in the field contacted.

REVIEW METHODS

The systematic review included randomized controlled trials with adults of any age with a diagnosis of coronary heart disease and an intervention aimed at changing cardiac beliefs. The primary outcome measured was change in beliefs about coronary heart disease.

RESULTS

Thirteen trials met the inclusion criteria. Owing to the heterogeneity of these studies, quantitative synthesis was not practicable. Descriptive synthesis of the results suggested that cognitive behavioural and counselling/education interventions can be effective in changing beliefs. The effects of changing beliefs on behavioural, functional and psychological outcomes remain unclear.

CONCLUSION

While some interventions may be effective in changing beliefs in people with coronary heart disease, the effect of these changes on outcome is not clear. Further high quality research is required before firmer guidance can be given to clinicians on the most effective method to dispel cardiac misconceptions.

Cardiac rehabilitation: Adding years to life and life to years

Abstract

Cardiac rehabilitation is an integral component of comprehensive cardiac care and is effective in reducing morbidity and mortality and improving quality of life. However, despite a 50-year-history and extensive evidence base attesting to its clinical and cost-effectiveness, including adding years to life and life to years, and exhortations that its implementation should be a key priority, the majority of cardiac patients do not receive rehabilitation. There is a comparative dearth of funding and wide variation in service provision, with a health care system that often fails to address issues such as sub-optimal referral, enrolment and completion, particularly amongst certain potential user groups that could benefit. This paper reviews these issues and suggests ways of overcoming the obstacles identified. It also highlights some of the knowledge gaps and areas that warrant further research.

Importance of illness beliefs and self-efficacy for patients with coronary heart disease

AIM

This paper is a report of a study to assess the association between coronary heart disease patients' illness beliefs and their self-efficacy 3 years after hospital discharge.

BACKGROUND

Cardiac rehabilitation guidelines recommend that both the illness representation model and the concept of self-efficacy are relevant frameworks for developing effective psychological support, although little is known about what aspects of patients' illness beliefs influence their self-efficacy.

METHOD

In a longitudinal prospective survey, consecutive patients with coronary heart disease were asked to complete questionnaires measuring illness perceptions; self-efficacy and demographic, illness characteristics; and attendance at a cardiac rehabilitation programme. The questionnaire was completed three times between 2001 and 2005. The response rates were 84% at time 1, 77% at time 2 and 72% at time 3. Multiple regression analysis was used to assess the association between illness beliefs and self-efficacy. The data were collected between 2001 and 2005.

FINDINGS

The average age of the participants was 65 years, 79% were male, 50% had acute myocardial infarction, 50% had angina and 61% had no previous history of cardiac illness; 55% had been admitted as an emergency and 57% subsequently attended cardiac rehabilitation. At baseline 30% of the variance in the exercise self-efficacy at 3 years after index admission was accounted for by patients' view of their illness being long-term. Data collected 9 months after discharge showed similar findings.

CONCLUSION

Early interventions designed to address individuals' sense of control, beliefs about the length of illness and the management of perceived symptoms before hospital discharge could increase rehabilitation programmes effectiveness in sustaining patients' long-term lifestyle changes.

Behavioral Medicine Review: The Dialectic of Tradition and Progress in Osteoarthritis Management

In his state of the art review, Katz provided an evidence-based perspective on nonpharmacologic approaches to osteoarthritis. His overview prompts discussion of the tradition-progress dialectic that has punctuated this area as exemplified, on one hand, by continuing tendencies to privilege biomedical over biopsychosocial conceptualizations and persisting barriers to the widespread implementation of nonpharmacologic, best-evidence treatments in primary care. On the other hand, the field has been sparked by considerable innovation, including the bursting of traditional treatment boundaries, an expanding range of intervention strategies, and the emergence of promising trends that may unleash further advances in patient care.

Predicting self-efficacy using illness perception components: a patient survey

OBJECTIVES

To assess the measures of illness representation components in predicting measures of self-efficacy in patients with coronary heart disease.

DESIGN

A longitudinal design was adopted with predictor variables and dependent variables (general self-efficacy, diet self-efficacy and exercise self-efficacy) measured twice while participants were in hospital and 9 months following discharge. Change scores of the predictor variables can be calculated and dependent variables at baseline can be controlled.

METHOD

A cohort sample of 300 patients admitted to hospital with coronary heart disease were given the questionnaire measuring their illness perception (illness representation components: identity, consequences, timeline and control/cure and outcome expectation for diet and exercise); self-efficacy (general, diet and exercise self-efficacy measures), demographic and illness characteristics and attendance on a cardiac rehabilitation programme. The patients were asked to complete the questionnaire in hospital before discharge following their cardiac diagnosis, and again, 9 months later, when participants were expected to be functioning independently of any rehabilitation programme.

RESULTS

Demographic and illness characteristics were found to have a more significant relationship with illness representation components than with specific self-efficacy. The relationship between illness representation components and specific self-efficacy changes overtime, consequence and timeline were significantly related to self-efficacy measures initially; however, symptom and control/cure were the variables that were significantly related to self-efficacy measures 9 months later. After statistically controlling individuals' baseline self-efficacy measures, demographic and illness characteristic effects, symptom and control/cure were found to make significant contributions to exercise and diet self-efficacy, respectively, 9 months later.

CONCLUSION

A significant relationship exists between illness representation and self-efficacy. There is potential to integrate both approaches to the assessment of psychosocial factors to provide effective individualized care in cardiac rehabilitation.