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

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Abstract

Twenty-three patients with an acute event of coronary heart disease (CHD) received routine care including information about medication and lifestyle changes. They were interviewed after 1 year about their conceptions concerning drug treatment and lifestyle changes. The interviews were taped, transcribed and analysed using the phenomenographic approach. Conceptions were hierarchically categorised with regard to level of understanding. The results showed that the patients’ understanding of the effects and health benefits of their treatment was superficial as judged on an informed layman level. The knowledge was fragmentary and mechanistic. Several misconceptions were revealed. Few answers related to prognostic benefits. However, a conception about effects of stopping drug intake was risk of relapse. Some patients considered fate and heredity as the main causes of CHD. Thus, our patients had not achieved an adequate understanding of CHD treatment. The level of knowledge was lower than anticipated.

Introduction

There is increasing evidence that both prognosis and quality of life can be improved for patients with coronary heart disease (CHD) by lifestyle changes and drug therapy. Guidelines for secondary prevention have been launched in the USA [1] and Europe [2]. Despite these efforts, the implementation of secondary prevention has been incomplete in most European countries [3] and enrolment to cardiac rehabilitation programmes is low [4], [5]. Part of the problem seems to be on the patients’ side. Adherence to recommendations and medication varies from patient to patient. Studies carried out since the 1960s show that up to 80% of patients with chronic diseases do not follow the drug prescriptions to attain therapeutic benefits [6], [7], [8], [9], [10]. Furthermore, adherence to dietary regimens for diabetes and CHD ranged from 50 to 86% and 13 to 76%, [10]. Factors related to poor adherence to diet regimens among patients with CHD were, e.g. smoking, poor knowledge of CHD risk factors and lack of close relatives or friends afflicted with CHD [11].

One essential aspect of patient education is to contribute to adherence to specific health-related goals. Such goals can be achieved by a change in behaviour and accomplished in several ways, e.g. by a decision and/or action taken because of newly acquired knowledge; recently practised skills; reshaped attitudes, or any combination of these [12]. Positive relationships have been found between patient education and understanding of the aims and effects of the advice/treatment and adherence [13], [14], [15]. Spouse support is another strategy that has proved successful in improving adherence to drug therapy [16].

The positive effects of multifactorial rehabilitation programmes for CHD patients are well recognised [17], [18], [19]. A recent meta-analysis of studies on psycho-educational programmes indicates a reduction in cardiac mortality and new myocardial infarction of 34% and 29%, respectively [20]. Several studies report significant positive changes in behaviour as a result of patient teaching as exemplified by a healthier diet post-MI [21], [22], adherence to drug therapy and exercise as reviewed by Burke et al. [5]. In a meta-analysis, counselling by nurses was found to significantly increase the rate of smoking cessation [23]. Taken together, the data presented favour the view that patients should have a knowledge base in order to make rational decisions in relation to their disease and health promoting factors.

This project was undertaken to increase the understanding of patients’ conceptions of their disease and treatment as a means of adjusting communication with patients and developing a new education programme. In a previous part of the present study, CHD patients showed a weak and fragmentary basic knowledge and understanding of their disease about 1 year after an event. The aim of the present part was to investigate these patients’ conceptions with a focus on cognitive aspects of their drug treatment and lifestyle changes. The present form of patient education is described even if the design does not allow an evaluation of the rehabilitation programme that the patients took part in.

Section snippets

Patients

Twenty-three patients were studied in Norrköping (south-east Sweden, 125,000 inhabitants) about 1 year after an event of CHD. All patients had experienced a myocardial infarction (MI) and some in addition had also undergone coronary artery by-pass grafting and/or percutaneous transluminal coronary angioplasty. The selection of patients was strategic to be heterogeneous regarding age (<60 years at time of event), sex, profession and residential area (Table 1). The mean age was 51 for women (n=9)

Conceptions concerning drug treatment

The initial question for all medication: how does it work?

The following four different conceptions (A–D) were found for aspirin.

(A) Prevents thrombosis, lifelong treatment: Among patients who regarded aspirin as preventive treatment to avoid thrombus formation, some also mentioned that the treatment was lifelong, which may be of importance for adherence. One man said, “… it has been established that acetylsalicylic acid in small quantities statistically has a clot-preventing effect …, but it

Discussion and conclusion

As reviewed in the introduction of this paper, if patients have a knowledge and understanding of their disease and its treatment, this seems to favour adherence to different regimens. In this perspective, the results of our study are unfavourable. One year after an event of CHD most patients made statements without deeper reflection and understanding of what benefits their treatment might have. The patients’ understanding was mostly incomplete, i.e. fragmentary and on a superficial level

Acknowledgements

Grants from the Committee for Medical Research and Development, the County of Östergötland no. 97/004, Vardal Foundation (v98 424) and the Swedish Heart and Lung Association are gratefully acknowledged.

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