Health Education Research Advance Access published online on May 30, 2008
Health Education Research, doi:10.1093/her/cyn028
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Expanding the value of qualitative theories of illness experience in clinical practice: a grounded theory of secondary heart disease prevention
1 Department of General Practice
2 Department of Psychology, National University of Ireland, Galway, Ireland
3 Department of General Practice, University College Cork, Cork, Ireland
Correspondence to: * Correspondence to: V. Ononeze. E-mail: v.ononeze{at}btinternet.com
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Abstract |
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 Top Abstract IntroductionMethodsFindingsDiscussionConclusionFundingConflict of interest statementAcknowledgementsReferences |
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Qualitative theories of illness experience are about the individual interpretations of the psychosocial and cultural aspects of living with illness. Thus, they contribute to a better understanding of health and health care provision. In this paper, we examine how a grounded theory (GT) of heart disease experience can inform secondary prevention. In-depth interviews of individual experience of heart disease were conducted with 26 patients, using GT iterative data collection and analysis framework. A GT was compiled from data and examined within a sociocultural framework to ascertain how experience influenced health behaviour. Despite individual contextual variations, the theory of ‘keeping it going’ describes the study sample’s common attitude to living with heart disease. The theory was adequate in explaining secondary cardiac behaviour, because it identified the aspects of patients’ beliefs and attitudes which are key to effective secondary prevention. The assessment of the impact of illness experience on health behaviour within a sociocultural framework helped to articulate the strong influence of social and contextual factors. The study offers an appropriate explanatory framework for encouraging health behaviour change. It emphasizes the importance of interventions being relevant to individual perceptions and interpretations. It provides a framework for designing and evaluating cardiac interventions and the theoretical principles which underpin them.
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Introduction |
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It is now widely recognized that establishing the evidence for the effectiveness of health care goes beyond numbers and includes the interpretations of patients and care provider experiences, actions and interactions. Exploring these issues allows health care to be assessed within a ‘natural’ context. Qualitative research provides the framework for examining the complexity of health, illness and care provision and evaluating the outcome of interventions. The importance of this approach is that it brings together the different aspects of illness experience, from the onset of symptoms to how illness is managed and its effects on daily life [1]. Such insights, sometimes represented as theories, help to improve the understanding of the meaning and significance that the individual attaches to illness and the effects on health behaviour [2, 3].
Grounded theory (GT) [4] is one of the qualitative methods used in health services research to generate theories of illness experience. GT has its origins in the interpretive tradition, one of many derived from the philosophy of symbolic interactionism [4, 5]. GTs provide information about how life is organized and lived; what has been referred to as practical knowledge based on individual interpretations [5]. Two main principles underpin GT studies. First, is that the study should emphasize the emergence of theory from data rather than theory being forced on the data [6]. Second, is that the study should focus on the daily life activities of the individuals studied as they undergo major life changes, and the internal and external influences on these activities [7]. Thus, good GT studies show the influence of the social environment and interactions on individual interpretations of experience. Distinctively, they highlight the factors and issues that exert important influences on the decisions and actions of patients and health professionals. These include impact of contextual and environmental influences [8], individual adaptations [9] and interventional and interactional processes [10]. For example, in the study of heart disease experience, Johnson [11] examined the process of individual adjustment following a heart attack. Rosenfeld and her colleagues [12] identified the meaning of illness for women with coronary heart disease. Elderly women in the study of Sutherland and Jensen [13] described their experiences of having a heart attack. While these and other studies have produced rich interpretations of experiences, they have not examined in detail how these influence the adoption of secondary preventive measures.
Secondary prevention involves the reduction of further risk of cardiac events and death in patients with established heart disease using drugs and lifestyle changes. The factors which determine the extent to which individuals adopt secondary preventive measures are multifaceted. The evidence is that these measures are effective and care processes can be improved to optimize implementation and uptake [14]. However, the extent to which these measures are adopted will depend on individual interpretations of heart condition. Studies have shown the effects of sociocultural factors on patients’ understandings of heart disease and the objectives of treatments [15, 16].
Our aim in this paper is to describe the development of a GT of the individual experience of heart disease and to consider its usefulness in secondary prevention. The paper draws on a three-linked phased study (carried out as part of a 3-year full-time PhD in primary care at the Department of General Practice, National University of Ireland, Galway), which explored the individual experience of heart disease and the implications in heart disease prevention and management in the west of Ireland [17].
To enhance the usefulness of a qualitative theory of illness experience in practice, it is important to show how it is developed from empirical data. The theory should also be organized in such a way that practitioners understand it and it reflects their practical knowledge and experience [18–20]. Therefore, our aim is to show how a GT was compiled from data from individual experiences. The process employed to identify the theoretical components, responses and strategies that individuals employed to daily manage their heart condition, which provide the basis for developing outcome indicators [21, 22]. Such an understanding of the underpinning ideas in a qualitative theory is central to it being used to improve clinical care.
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Methods |
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Settings and participants
General practices
Patients were selected from a sampling frame consisting of 764 patients from 22 general practices (GPs) in the west of Ireland, who participated in a large quantitative study to determine uptake of secondary cardiac preventive measures in Irish GP [23]. Five GPs were recruited from the list of 22 using maximum variation sampling strategy. This means that we tried to ensure that the variations in GPs in the area were, to some extent, reflected in the sample (rural, urban and size of partnership). Another criterion was that these practices were in two catchment areas served by different hospitals (a regional centre and two district hospitals). This helped to further develop issues about cardiac care that emerged from the study. The sample consisted of one city (partnership, single: dropped out of study), two urban (single and partnership) and two rural (single and partnership).
Patients
A total of 26 patients with a primary diagnosis of angina or myocardial infarction were recruited and interviewed. Patients were contacted by letter to request participation. Initially, maximum variation sampling strategy [24] was used to recruit 13 patients from three practices. This strategy helped to recruit patients with the range of social characteristics (age, sex, educational level, length of time since diagnosis, etc.), which may affect individual experiences of heart disease. For example, the length of time a patient had lived with his/her heart problem is likely to influence his or her responses.
As the study progressed, theoretical sampling strategy was used to recruit a further 13 patients from two practices, including patients who attend outpatient heart clinics in two other hospitals. This was undertaken to help further develop issues about cardiac care that emerged from earlier interviews.
At about the 22nd interview, it was felt that the core issues in the data and the emerging theoretical framework were sufficiently developed and elaborated; data saturation had been reached. This meant that information obtained from subsequent interviews did not provide further insight in the analysis and interpretation of data. The remaining four interviews confirmed this decision.
Data collection and analysis
Interviews
The interview topic guide consisted of three open-ended questions which focused on three illness meanings, based on Kleinman’s [25] definitions of illness: ‘cardiac event or history’, ‘life world’ and ‘cultural significance of heart disease’. These illness definitions reflect the key principles underpinning the study, in terms of the influence of the social environment and interactions on individual interpretations. For example, the opening question was ‘Tell me what happened to you with your heart problem’. In keeping with the iterative nature of GT, significant issues arising from earlier interviews were used to direct the focus of subsequent ones. More focused questions were used to explore specific issues such as what patients thought caused their heart problems, self-care strategies employed and views about cardiac services. Patients were given the choice of place of interview: at their homes or GP surgeries.
Of the 26 patients, 12 were interviewed in GP surgeries and 14 in their homes. There was no indication (observable during interviews or from analysis of transcripts) that the place of interview affected patients’ responses in any important way. The interviews lasted between 45 min to 2 hours. Interviews lasted up to 2 hours with patients (19 out of 26) who described and interpreted their heart disease experiences in the context of their life circumstances. Interviews were of shorter duration with seven patients who were less willing to talk about their experiences in greater details.
The interviews involved listening to patients and being involved in the discussions of their reflections on life with a heart problem. This allowed patients to offer more than a response to the questions asked, but rather to explore contextual events and issues. In the shorter interviews, this did not happen in great depth. For example, one patient reported that her marriage breakdown contributed to her heart attack, but was uncomfortable about discussing this. Such personal issues were sensitively handled, but limited the extent to which the circumstances were further probed. However, all areas of study interest and emerging issues from previous interviews were sufficiently explored in these interviews. Four of these interviews took place in patients’ home and three in GP.
All interviews were taped and fully transcribed. The NUD*IST 5 qualitative data analysis software [26] was used to facilitate analysis.
Analytical framework
The analytical approach taken was to examine how patients made sense of living with their heart condition within the context of their lives. GT principles stipulate that the meaning an individual attaches to his or her experience will influence behaviour. Therefore, there were two analytical objectives. First, was to identify the theory of experience of heart disease, the meaning patients attributed to experience. Second, was to develop an explanatory framework to illustrate how the theory of experience influenced health behaviour. This entailed identifying components of the theory, which were used to interpret illness behaviour (Fig. 1).
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To help reduce the ‘researcher effect’, two researchers (C.B. and A.W.M.) independently reviewed the transcripts. A.M. also reviewed some transcripts and the interpretation of findings. All three reviewers have previous qualitative research experience and have peer reviewed publications in this area. C.B. has made significant contributions in the development of qualitative research in primary care. Themes were discussed and examined to achieve concordance about interpretation and meaning. In addition, Maxwell’s [27] framework was used to increase the reliability of data analysis process and the trustworthiness of findings. For example, the extent to which issues around key findings was true for the majority of patients. Data saturation was determined as the point when it was felt that the main ideas were sufficiently explored within the study time and financial constraints [28].
Data analysis
In keeping with GT, data analysis involved the complementary process of coding and categorization of data and developing analytical questions and a conceptual framework. Initial analysis involved familiarizing with data, examining data sentence by sentence and attaching codes to the issues. Subsequently, focused coding [29] was used to provide a more integrated way of linking and explaining the issues in the data. A conceptual framework was produced to examine how these issues relate to each other.
Theory of heart disease experience
The theory of experience was identified through a systematic process of coding and categorization of data, which comprised three stages. In the first stage, 55 codes were generated. A detailed examination of these codes in the second stage resulted in central categories. These categories contained issues which were frequently mentioned by all patients and they attached great importance to them. In the third stage of coding, the central categories were examined and integrated into three unifying categories to ascertain how they connect to each. This led to the identification of the theory of experience of heart disease. Further examination of the theory was carried out to identify the theoretical components. The extent to which theory reflected more general experience and the relevance of the theory to the clinical experience of health professionals was assessed in Phases II and III of the study [17].
Sociocultural framework of determinants of secondary cardiac behaviour
The second analytical objective of our study was to ascertain the relationship between the theory of experience (meaning) and secondary cardiac behaviour (Fig. 1). To help achieve this, the theory was examined within a sociocultural framework using Sword’s [30] socioecological model of determinants of health services utilization. Health professionals’ perspectives on the theory [17] were included in this analysis. The framework considers the impact of social networks, organizational and community factors and health policies and practice on health and illness behaviour. This analysis helped to draw out the important influences on secondary cardiac behaviour. To articulate these influences at the individual, social and policy level, three explanatory concepts of secondary cardiac behaviour were developed.
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Findings |
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Sample characteristics
Of the 26 patients interviewed, 16 were males and 10 females. The average age was 68 years (SD 10.9 years). Data on patients’ educational level, length of experience since diagnosis and ability to access health care in terms of costs are summarized in Table I. Of particular importance is the impact of Ireland’s public and private health care system mix on access and use of health care. The impact of health care costs on primary and secondary prevention is one of the manifestations of health inequalities in Ireland [31]. Fourteen patients in our study were general medical services eligible, nine had private health insurance and three described themselves as fee paying. People whose income is <
132 per week (in 2003) for a single person aged up to 66 years living alone in Ireland receive free primary care and medication. The rest of the population (about two-thirds) are responsible for their own primary care and costs through private health insurance and fee paying. We found that health care costs might be a barrier to the general practitioner prescribing appropriate medications and patients acquiring and adhering to these medications. They can also reduce timely access to appropriate interventions.
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Beliefs, knowledge and attitudes
Patients’ knowledge, beliefs and attitudes to heart disease and health problems were influenced by individual and cultural factors. These influences reflected prior knowledge of heart disease, care experiences and interactions with care providers, individuals with heart disease and the wider social network. Heart disease was considered an illness; people can live with it because of the strong belief that it can be controlled with medication and lifestyle change. These beliefs and attitudes were interpreted within the context of the advances in heart health and sociocultural changes in heart disease prevention and treatment in Ireland. Patients reported a strong belief in the ability of the medical profession to treat their heart condition. They reported high levels of adherence to medication, perceived as being central to the effective management of condition. They also commented on the availability and relative access to surgical procedures, such as coronary artery bypass surgery. On the other hand, patients were sceptical about changes in lifestyle improving their condition. This is because interpretations of heart disease risk factors and perceived individual risks did not provide full explanations for heart condition.
‘Keeping it going’: the theory of living with heart disease
The analysis of patients’ responses to heart disease indicated that a common attitude, explained in different ways, was that they have to keep the heart going. This attitude to heart condition was considered to be the theoretical link in the data and was named ‘keeping it going: the theory of living with heart disease’ (Fig. 2). It describes and explains the meaning patients attached to heart disease experience. As expected, there were contextual variations between patients. However, the meaning did not differ with age, gender, social status of patients, number of years with heart disease or in patients with MI or angina. For example, although patients with ‘stable’ angina reported lesser disruptions to their lives, they were equally determined to keep the heart going because of the perceived risk of further cardiac problems:
"... well I suppose when you look at it, like I have damage done to my heart, they're (doctors) after telling me I have damage done to my heart, but you got a warning, you know, you got a kind of a warning with the angina. It's a blockage, and you didn't get a full-blown heart attack like. That's the only reason why I said only angina. I don't want to have angina. If I could do without it or give it back in the morning ...." ... As I say, I try to keep the ‘old ticker’ going (Male patient 9).
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Fig. 2. ‘Keeping it going’: the theory of heart disease experience.
Theoretical components
Three interrelated components of the theory of keeping it going were identified: making sense and coming to terms with illness, understanding and learning to live with illness and managing everyday life with illness. The first component, making sense and coming to terms with illness, relates to the process by which patients made sense of cardiac event and understood what had happened to them. Critical responses include managing symptoms, reflecting on the cause of condition and taking stock of their lives and the events preceding cardiac event. Increased understanding of heart problem facilitated ‘understanding and learning to live with illness’. A central feature of this second component is regaining control, which involved patients being aware of and monitoring the ‘new self’ with a heart condition. The third component, managing everyday life with illness, focused on the strategies employed to daily manage condition. Critical strategies include adhering to medicines and making lifestyle changes, reassessing life priorities and managing the uncertainty of cardiac illness.
These theoretical components indicate that patients have to go through critical stages (e.g. making sense, coming to terms and learning to live with illness) and deal with certain issues in order to manage their heart problems effectively and carry on with daily life. These stages and issues reflect changes in patients’ experiences over time. For example, patients reported that earlier in their experience, the concern was on managing chest discomforts, tiredness and weakness felt and dealing with emotional reactions. Later responses and self-care strategies were directed, for instance, on avoiding and anticipating situations that could precipitate symptoms. Earlier responses may also be re-employed if regained ‘normality’ was interrupted, for example, by unsuccessful treatment:
But then when the angioplasty, when that was collapsed at Christmas, that I feel I will always attribute to myself, to the fact that I was under stress and my work. I wasn't really living by the rules. If I had given up work perhaps or may be watch out, it might have been better after the heart attack, with hindsight. But I suppose I was trying to prove that I was going to try and lead a normal life so soon (Female patient 1).
Consequently, patients described a dynamic and reflexive process of living with heart disease that consists of continuous self-monitoring and awareness. Individual progress may be affected by factors such as the severity of cardiac event, quality of family and social support and presence of other illnesses. Also, some patients who understood their cardiac illness to be an ‘acute’ event or had an understanding that they were cured after treatment may not go through the critical stages:
After the first bypass I was fine, could do anything, not a problem in the world. But since the second one I have angina. ... I was back in work in 3 months after the first one. But I have angina now and I have to take a spray if I rush or walk very fast (Male patient 5).
A better understanding of condition as a lifelong rather than an acute one from which ‘full’ recovery was possible helped these patients to respond appropriately to keeping the heart going. Thus, there was this apparent distinction between the acute and ‘chronic’ experience in some patients’ accounts. However, there was considerable tension between these two views of condition:
In actual fact I did (believe it was cured) and I'm sure and certain it's gone forever. But you have to remember that it isn't, if it started before it can start again. But there's no way possible that you go back to the things that you were doing, that you thought caused it, even though it mightn't have caused it. But there's no way you can go back, you know, rushing mad and doing this and doing that. You have to change your lifestyle (Male patient 2).
Sociocultural framework of determinants of secondary cardiac behaviour
The theory of keeping it going was examined within a sociocultural framework to identify how it influenced secondary cardiac behaviour (Fig. 3). The framework summarizes and links the various determinants of secondary cardiac behaviour, which operate within different and at multiple levels. It has three main features. First is that secondary cardiac behaviour is conceptualized as a product of ‘two interacting systems’: the individual understandings and cultural beliefs which shaped heart disease experience and meaning and the external factors that determine care provision and practice. Second is the ‘overlapping of circles’, which represents the extent to which effective secondary prevention is likely to occur. The data suggest that preventive activities are likely to be effective when care processes actively encourage preventive behaviour and activities are appropriate and responsive to needs. The overlapping of circles is therefore variable. And third, the ‘broken bi-directional arrow’ between patients and cardiac care practice, which was identified as a crucial relationship (Fig. 3). This relates to the nature and quality of interactions between patients and health professionals, which can reduce or enhance the uptake and effectiveness of preventive measures.
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The framework shows the importance of considering patients’ responses to heart disease and attitudes to secondary prevention as the consequences of wider social factors. In particular, it shows the influence of patients’ interactions with the health care system and community and social networks on secondary cardiac behaviour. It also highlights the influences of care issues such as the organization of care, professional disciplines of care providers, type of interventions and availability and manner in which they are provided and heart health policies. For example, care providers interpreted the lack of a more patient-centred approach to secondary prevention within the context of care organization and delivery.
Explanatory concepts of secondary cardiac behaviour
To articulate the sociocultural influences on secondary cardiac behaviour at the individual, social and policy level, three explanatory concepts were developed. These are concepts that can be translated into outcome indicators which can be observed and measured in clinical practice. The three explanatory concepts are knowledge, beliefs and attitude to heart disease; impact of health and social interactions and implications of general and cardiovascular health policies (Fig. 4). The broken arrow lines acknowledge the complex associations between these influences.
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Explanatory concept knowledge, beliefs and attitude to heart disease
This consists of factors that were considered as antecedents to health behaviour and provide the rationale for behaviour change. They include heart disease beliefs and direct and indirect illness experiences acquired through interactions with cardiac care providers, other cardiac patients and the wider social network (left half of the two interacting systems in Fig. 3). Data on these factors indicate that the majority of patients, previous to cardiac event, had clear ideas about heart disease based on the experiences of other people known to them and/or from information in the public.
Explanatory concept implications of general and cardiovascular health policies
This represents health service-related factors (right half of the two interacting systems in Fig. 3). Data on these factors show multifaceted links between patients’ expectations of care, experiences and views about the delivery and value of secondary prevention. These policy and practice influences operate at three levels. At the micro-level is the availability and accessibility of cardiac services including support groups and the knowledge, skills and attitudes of these providers. Mid-level influences include local heart health strategies and service priorities that determine the allocation of resources and professional education. The factors at the micro- and mid-levels are directed at the macro-level by national and international cardiovascular health policies.
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Discussion |
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Adequacy of theory of keeping it going in explaining secondary cardiac behaviour
Glaser and Strauss [4] state that for GT to be useful, there must be evidence that it fits the problem where it will be applied, is readily understandable to practitioners working in the area and is general enough to be applied to similar problems and adaptable to allow the practitioner some control over everyday practice.
The theory of keeping it going demonstrates a ‘fit’ for explaining secondary cardiac behaviour because it identifies patients’ attitudes to heart problems and heart disease as key to effective secondary prevention. Specifically, the theory provides a framework for improving care outcomes by indicating the necessary patient, practice and policy issues, which need exploring with patients. Furthermore, it was developed from multiple perspectives—from patients from a range of backgrounds and personal experiences. Therefore, it is likely to be relevant to patients with a similar level of cardiac illness and experience.
The theory is also ‘understandable’ because it is developed from patients’ perspectives on heart disease and experiences of cardiac care. These ideas were also reflected in the clinical experiences of health professionals [16]. The theory is ‘general’ because of its potential in helping to understand illness behaviour in social context. This is because it contains sufficient number of general ideas related to health behaviour and credible relationships between these ideas to explain attitudes to behaviour change.
Comparison with other studies
The theory of keeping it going was compared with similar theories of heart disease and chronic illness experience. Individual accounts of illness experiences from other studies were compared with those from the theory of keeping it going. The cyclic and reflexive process of experience identified accords with previous findings [11–13]. However, while we identified a progressive experience, some studies have shown evidence of regressive experience [11]. Regressive experiences are said to manifest as non-acceptance of illness with characteristic feelings of powerlessness and despair. One interpretation of the difference in experiences is that these studies examined experience during the acute phase of cardiac illness or surgery, usually up to 1 year. The length of experience in our study varied from 1.5 to 22 years. It was clear that the capacity to carry on with ‘normal life’ for all patients increased with time and health and social interactions. The length of experience may also help to explain the similar experiences in men and women in our study. Greater emotional distress and anxiety in women than men have been reported [13, 32].
The absence of or relatively low symptoms experienced by patients may also partly explain the reported positive heart disease experiences. Many regarded this as an indication that their illness was under control. Similar findings have been reported in studies on patients with diabetes [33] and rheumatoid arthritis [34]. There were some references to heart problem as being ‘cured’ or ‘episodic’. The reported transition from acute illness back to ‘normal’ health was, however, over simplified. The tension between trying to act healthy and normal against the background of discomforts and uncertainty surrounding their illness was evident in some patients’ accounts. Radley [35] explains such responses in terms of the individual’s need to resolve the dual demands of symptoms and society—‘living with illness in an apparent healthy society’.
Implications for secondary prevention
The overall aim in secondary heart disease prevention is to reduce the impact of the disease on individuals. To facilitate this, health services and care providers are constantly developing new and better ways of caring for these patients. However, our study shows the need for interventions and care processes to be underpinned by appropriate theories or models which take into account the individual illness experience and meaning attached to it. The theory of keeping it going offers an appropriate explanatory framework for encouraging health behaviour change. It emphasizes the importance of secondary preventive measures being relevant to individual perspectives on illness. The analysis of the determinants of secondary cardiac behaviour within a sociocultural framework has drawn more attention to the wider social factors in secondary heart disease prevention.
The framework contrasts with psychological models such as the health belief model [36], theory of planned behaviour [37] and Leventhal’s self-regulatory model [38]. These models rely heavily on rational processing of information as a predictor of behaviour, ignoring potential predictors such as the social and environmental factors. The inadequacy of such models in explaining illness behaviour was found in participants in this study. Byrne et al. [23] examined the content and structure of illness perceptions and treatment beliefs in a sample of 1084 from which 26 patients who took part in our study were recruited. Their aim was to assess the extent to which secondary preventive behaviour such as smoking, exercise, diet, alcohol consumption and medication adherence in these patients could be explained by illness and treatment beliefs within Leventhal’s self-regulatory model [38] framework. The authors found that illness perceptions were associated with increased levels of self-care, but were found not to be appropriate predictors of secondary preventive cardiac behaviour.
The authors gave two reasons for the weak associations. First, patients reported low symptoms which may mean low motivation to change behaviour. Second is that the behaviours examined (e.g. smoking, healthy eating and exercise) are long term. The relationship between the behaviours and managing illness in everyday life was, therefore, less evident to these patients. It was also suggested that it was likely that patients’ views about their heart problems will differ between the acute and chronic phases of cardiac illness. This was evident in our study with some patients reporting restoration to normal heath from an acute cardiac event.
Limitations of study
This study is limited in some ways. The theory of keeping it going is a representation of the study sample’s way of articulating what it means to them to live with angina or MI and the issues that they feel impact on the process. Caution needs to be exercised regarding the generalizability of the theory to patients with more severe cardiac condition such as heart failure, associated with more impaired physical functioning and diminished quality of life [39]. Furthermore, the sample was dependent on lead general practitioners, which made the recruitment of patients with a wider range of characteristics more difficult. For example, we were unable to recruit patients who may be finding it difficult coping with living with angina or MI.
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Conclusion |
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TopAbstractIntroductionMethodsFindingsDiscussionConclusionFundingConflict of interest statementAcknowledgementsReferences |
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The main features of this study are cardiac illness experience and meaning and secondary preventive cardiac behaviour. The relationships between these features have been illustrated, described and interpreted within a theoretical and sociocultural framework. The interpretation of the relationships was contextualized within broad interactional, practice and policy issues relating to cardiovascular health. The discussion of the findings suggests ways of improving care processes and effectiveness to maximize secondary heart disease prevention. In particular, the findings show the adequacy of the theory of keeping it going, the theory of individual perspectives on cardiac illness, in explaining secondary preventive cardiac behaviour. Further work is needed to determine how these perspectives can provide the appropriate focus, timing and processes for effective interventions. The efficacy of such theoretically grounded interventions could then be assessed using quantitative methods. Such a study will provide a way of evaluating interventions and the theoretical principles which underpin them [15].
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Funding |
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TopAbstractIntroductionMethodsFindingsDiscussionConclusionFundingConflict of interest statementAcknowledgementsReferences |
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Irish Health Research Board; Western Health Board.
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Conflict of interest statement |
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TopAbstractIntroductionMethodsFindingsDiscussionConclusionFundingConflict of interest statementAcknowledgementsReferences |
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None declared.
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Acknowledgements |
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TopAbstractIntroductionMethodsFindingsDiscussionConclusionFundingConflict of interest statementAcknowledgementsReferences |
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We thank the participating GPs, patients and service providers. Contributors: V.O. had the original idea of and carried out the study, wrote the first draft of the paper and will act as guarantor of the paper. A.W.M. was involved in supervising the study, in discussing data collection and analysis and writing the paper. A.M. assisted in reviewing data collection and interpretation and the write-up of the study and paper. M.B. gave ongoing support to the study in recruiting GPs and patients and contributed in writing paper. C.B. contributed by refining the original idea of the study, data analysis and interpretation and in writing the paper.
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References |
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Received on January 3, 2007; accepted on April 29, 2008
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