Randomized controlled trial of an intervention to change cardiac misconceptions in myocardial infarction patients

There is converging evidence that changing beliefs about an illness leads to positive recovery outcomes. However, cardiac misconceptions interventions have been investigated mainly in Angina or Coronary Heart Disease patients, and less in patients following Myocardial Infarction (MI). In these patients, cardiac misconceptions may play a role in the adjustment or lifestyle changes. This article reports a randomized controlled trial of an intervention designed to reduce the strength of misconceptions in patients after a first MI. The primary outcome was the degree of change in misconceptions and the secondary outcomes were: exercise, smoking status, return to work and mood (anxiety and depression). Patients in the intervention condition (n = 60) were compared with a control group (n = 67) receiving usual care. Both groups were evaluated at baseline and 4, 8 and 12 months after hospital discharge. There was a significant time-by-group interaction for the total score of cardiac misconceptions. Patients in the intervention group significantly decreased their total score of cardiac misconceptions at 4 months compared with the control group and this difference was sustained over time. Patients in the intervention group were also more likely to exercise at the follow-up period after MI than the control group. This intervention was effective in reducing the strength of cardiac misconceptions in MI patients and had a positive impact on health behaviour outcomes. These results support the importance of misconceptions in health behaviours and the utility of belief change interventions in promoting health in patients with Myocardial Infarction.     

Effects of a post-hospitalization group health education programme for patients with coronary heart disease

Abstract

Effects of a post-hospitolization group health education programme for patients with coronary heart disease. A health education programme was offered to groups of coronary heart patients and their partners after discharge from hospital. A randomized pre-test post-test control group design was used to evaluate the effects of this experimental intervention. The health education programme was offered to 109 coronary heart patients in groups of between five and eight patients together with their partners in addition to standard medical care and physical training. A control group of 108 patients received only standard medical care and physical training.

The intervention consisted of eight weekly two-hour group health education sessions and one follow-up session. All sessions focused on the promotion of healthy habits and the reduction of adverse psychosocial consequences of the incident.

In the short term (about four months after the incident) the health education programme showed statistically significant intervention effects on knowledge about coronary heart diseases, smoking cessation, healthy eating habits and the number of consultations with the family physician, but no effects on emotional distress. In the long term (one year after the incident) there was only a significant intervention effect on smoking cessation.

These results suggest that the effects of the programme are modest, especially in terms of maintenance of behavioural change. As a consequence, it is suggested that the programme should not be offered to all coronary patients during cardiac rehabilitation, but only to those who can be expected to profit most from it.     

A randomized trial of a self-help smoking cessation intervention in a nonvolunteer female population: testing the limits of the public health model.

Reaching nonvolunteer female smokers with effective smoking cessation programs is a critical public health challenge. Smokers (N = 2,786) among 15,004 female members of a health maintenance organization who completed a routine needs assessment were invited into the "UCLA Preventive Health Behavior Study," consisting of five telephone interviews over 2 years assessing health practices. Participants (N = 1,396) were randomized into experimental or control conditions of an unsolicited, mailed, self-help smoking cessation program. Subjects were not alerted to the link between the program and the health study. Smoking status was assessed at 1, 6, 12, and 18 months. Across all subjects, point prevalence at 18 months was 18.62, and continuous abstinence was 2.71%. No difference was found between treatment and control groups regarding smoking status or readiness to stop smoking--raising questions about the value of mailing cessation materials to nonvolunteers. Quit rates increased over the 18-month follow-up; those still smoking at 18 months reported increased readiness to quit. Predictors at each follow-up point were examined multivariately.     

Personality predictors of smoking behavior in a sample of physicians

Abstract

The smoking status of 239 physicians was obtained from a mail survey in 1981. MMPI data, which had been obtained from these men 25 years earlier, was used to prospectively predict smoking status at follow-up. Those who never smoked had scores indicative of social conventionality (low scores on L, Pd, and Schubert scales; high scores on Ego-control). A similar pattern was found among smokers who quit after a relatively short smoking history. Compared to ex-smokers, those who continued to smoke at the time of follow-up were characterized by high scores on the Pd and Ma scales. These results were discussed in terms of a multi-stage conceptualization of the smoking cessation process.     

Knowledge and beliefs regarding the consequences of cigarette smoking and their relationships to smoking status in a biracial sample

The purpose of this investigation was to evaluate carefully smoking-related knowledge and beliefs and their relationships to smoking status in a large, heterogeneous sample of smokers and nonsmokers in two settings: (a) a large, biracial southern city and (b) a small midwestern community. Participants were 611 (198 male, 413 female) adult respondents to a random-dialing telephone survey in Fargo, North Dakota (n = 200), and Memphis, Tennessee (n = 411). Each participant was given the Smoking Attitudes Survey, which assesses generalized health beliefs as well as health-related problems associated with smoking. Participants' knowledge of smoking-associated diseases (e.g., lung cancer) and of diseases not associated with smoking (e.g., kidney stones) was assessed. Stepwise regression analysis of composite knowledge scores revealed four independent predictors of the health consequences of smoking: education, race, smoking status, and income. Smokers, compared to nonsmokers, reported less knowledge related to the health consequences of smoking, were more likely to be male, were less concerned with the health consequences of smoking, and were more concerned about the health consequences of cholesterol. The best predictor of smokers who had never attempted cessation was their greater concern over weight control when compared to smokers with a history of smoking cessation attempts. The results are discussed in terms of smoking prevention and intervention efforts.     

Marital Status and Outcome in Patients with Coronary Heart Disease

The purpose of this study was to examine the relationship of marital status to health outcomes in 818 post-MI, coronary artery bypass surgery, and angioplasty patients (651 males, 157 females) from seven Northern California hospitals who completed 12 months of a nurse-managed, home-based multifactorial risk reduction program. Compared to married patients, nonmarried patients were significantly less likely to complete the program than married patients, more likely to smoke at baseline, and drank significantly less alcohol at baseline. At 12 months there were no significant differences between married and nonmarried groups on smoking cessation rates, HDL, LDL, triglycerides, or exercise treadmill test results. When patients were categorized as married, divorced, separated, widowed, or single, similar results were found for the analyses using two groups (married versus nonmarried), with the following exceptions. Separated patients were significantly less likely to quit smoking. In addition, separated patients showed significantly higher rates of starting (and continuing) to smoke during the time following their MI. Mortality was not significantly different between married and unmarried patients. Implications for intervention with separated patients and the importance of assessing both marital status and marital quality are discussed.     

Quality of life after quitting smoking and initiating aerobic exercise

Quitting smoking and aerobic exercise each improve health. Although smokers may be concerned that quitting smoking will reduce their quality of life (QOL), recent research has shown that cessation is associated with QOL benefits. Elements of smoking cessation interventions, such as exercise, may contribute to changes in QOL. However, it is unknown whether initiating exercise in the context of smoking cessation is associated with greater or different effects on QOL than smoking cessation alone. The current study is a secondary analysis of data from a randomized trial (n = 61) of an exercise intervention for smoking cessation. We hypothesized that smoking abstinence and engagement in exercise would have positive, additive effects on QOL at end-of-treatment, 6- and, 12-month follow-ups. Sedentary adult smokers were randomized to the exercise intervention or a health education control (HEC) group. Additionally, all participants received smoking cessation counseling and nicotine patches. Data were analyzed using actual engagement in exercise, rather than group assignment as a proxy for exercise engagement, because some HEC participants also began exercising. Abstinence was positively associated with higher total and physical health QOL at follow-up. Exercise was not associated with total QOL and only marginally associated with physical health QOL, but was positively related to overall sense of well-being. Emphasizing that smoking cessation is associated with higher QOL may help motivate smokers to initiate quit attempts.     

The effect of low social support on short-term prognosis in patients following a first myocardial infarction

The objectives of the current study were (1) to assess adjustment in patients following a first myocardial infarction (MI) at 9 months compared with 4-6 weeks post-MI, (2) to examine the availability of and satisfaction with social support over time, and (3) to determine separate baseline psychosocial predictors of recurrent cardiac events. A questionnaire assessing post-traumatic stress disorder, anxiety, depression, health complaints, and social support, was distributed to consecutive patients 4-6 weeks and 9 months post-MI. Prior to assessment at follow-up, 8 (7%) of 112 patients had dropped out, and two had died due to cardiac causes. Objective clinical measures were obtained from medical records. There was an improvement in somatic and cognitive symptoms at follow-up, but no change in symptoms of arousal, depression, and anxiety. Half of the patients were afraid of a recurrent MI. There was a significant decrease in social support between baseline and follow-up, and lower social support at baseline was associated with a 10% increased risk of recurrent cardiac events at follow-up (OR: 0.90; 95% CI: 0.84 to 0.97) adjusting for all other variables. Some patients still experienced difficulties with psychosocial adjustment 9 months post-MI despite a reduction in somatic and cognitive symptoms. Social support decreased over time, which may have serious prognostic implications; lower social support at baseline was an independent predictor of recurrent events at 9 months. An important step for future research will be to investigate how social support can be enhanced in patients at risk.     

Personality correlates of smoking behaviour in men with heart disease

In two populations of male patients attending a cardiac clinic who underwent invasive procedures [coronary angiography (n = 67)] and coronary artery bypass graft surgery (n = 78) there was an association between smoking behaviour and the personality dimension of psychoticism. Follow-up assessment 12 months after both procedures revealed that the resumption of smoking was also highly correlated with psychoticism, and to a lesser extent with extraversion. There was an inverse association between duration of anginal symptoms and a smoking history, and among smokers, those with the heaviest consumption had shorter histories of chest pain both non-smokers and light smokers. Poor compliance among high P scorers has implications for the management of patients with coronary heart disease (CHD). Because cessation of smoking is the most important single measure in reducing mortality from CHD, more effort should be directed towards patients with these personality characteristics before cardiac surgery is undertaken.     

Specifying the determinants of the initiation and maintenance of behavior change: an examination of self-efficacy, satisfaction, and smoking cessation.

Using data from smokers (N = 591) who enrolled in an 8-week smoking cessation program and were then followed for 15 months, the authors tested the thesis that self-efficacy guides the decision to initiate smoking cessation but that satisfaction with the outcomes afforded by quitting guides the decision to maintain cessation. Measures of self-efficacy and satisfaction assessed at the end of the program, 2 months, and 9 months were used to predict quit status at 2, 9, and 15 months, respectively. At each point, participants were categorized as either initiators or maintainers on the basis of their pattern of cessation behavior. Across time, self-efficacy predicted future quit status for initiators, whereas satisfaction generally predicted future quit status for maintainers. Implications for models of behavior change and behavioral interventions are discussed.     

Psychosocial Predictors of Change in Cigarette Smoking

Over a period of 6 months, factors related to change in cigarette smoking were investigated in a group of 250 adult outpatients, all of whom smoked at the time of enrollment in the study. Among the variables tested were demographic, social, and situational factors, beliefs about the health effects of smoking and difficulty of quitting, and intentions regarding future smoking. Information was gathered at baseline and the first and sixth months by means of telephone interviews. Relative to smoking at 6 months, intention, education, and professional advice made independent contributions to cessation. The processes of quitting were examined in more detail. Attempting to quit was related to intention, professional advice, level of smoking, and social cues to smoke. Among those who tried to stop, difficulty with urges to smoke, and education affected success versus failure. Earlier success related to less anxiety and tension, and to less difficulty in not smoking when in negative situations. The findings suggest that a complex set of social and cognitive factors affect change in smoking behavior, and that somewhat different factors are operative at different stages.     

Relapse and risk perception among members of a smoking cessation clinic

Assessed perceptions of the health risks associated with smoking in comparison with not smoking among members of smoking cessation clinics. We measured these perceptions at three different time periods during the clinic, and then again at a 6-month follow-up. Results indicated that members who were abstinent at the follow-up had lowered their perceptions of the likelihood of contracting smoking-related illnesses (e.g., emphysema) if they were not smoking. In contrast, those who had relapsed lowered their perceptions of the health risks associated with smoking, but not their perceptions of nonsmoking disease vulnerability. The implications of these changes in risk perception for therapy involvement are discussed.     

Psychological factors associated with maintenance of improved health behaviors in postcoronary patients

Multiple regression analyses of interview data determined whether certain behavioral, personality, and social support variables were associated with maintenance of changes in exercise, weight loss, and smoking cessation for a group of postcoronary patients. The results indicate that the psychological reactions to success or failure at one health behavior change, especially smoking, may affect the ability to maintain changes in other health behaviors. Also, the affective psychological sequelae to heart attacks may disrupt attempts to change health habits or may themselves be alleviated once successful health changes are achieved.     

A meta-analysis of psychoeduational programs for coronary heart disease patients.

In a meta-analysis of 37 studies, the effects of psychoeducational (health education and stress management) programs for coronary heart disease patients were examined. The results suggest that these programs yielded a 34% reduction in cardiac mortality; a 29% reduction in recurrence of myocardial infarction (MI); and significant (p < .025) positive effects on blood pressure, cholesterol, body weight, smoking behavior, physical exercise, and eating habits. No effects of psychoeducational programs were found in regard to coronary bypass surgery, anxiety, or depression. The results also suggest that cardiac rehabilitation programs that were successful on proximal targets (systolic blood pressure, smoking behavior, physical exercise, emotional distress) were more effective on distal targets (cardiac mortality and MI recurrences) than programs without success on proximal targets.     

Do similar patient and spouse perceptions of myocardial infarction predict recovery?

The present study examines whether the degree of congruence between the patient's and the partner's perceptions of myocardial infarction (MI) has an influence on a range of recovery outcomes in the patient. The MI perceptions of 70 Portuguese couples in which the male had suffered a first heart attack were assessed at 3 months after discharge from hospital, using the Illness Perception Questionnaire (IPQ). Several dimensions of patient recovery were assessed at 3, 6 and 12 months post-MI, using standardised measures of psychological well-being, return to work, disability, social functioning, sexual functioning, and indices of lifestyle changes. The degree of congruence in each couple's illness perceptions was assessed and related to each outcome measure. The results suggest that the degree of congruence between patients and partners in their illness perceptions was related to different dimensions of recovery at 3, 6 and 12 months. The results revealed that in couples who had similar positive perceptions of the identity and consequences of the MI, patients showed (a) better physical and psychological functioning, (b) better sexual functioning, and (c) less impact of MI on social and recreational activities. Also, similar positive perceptions of timeline were associated with lower levels of disability, and similar positive cure/control beliefs were linked with greater dietary changes. Separate analyses showed that these effects were not confounded with marital functioning. This study provides clear evidence that the degree of match/mismatch between the patient's and partner's perceptions of the MI is associated with a range of recovery outcomes.     

Dimensions of verbal denial in myocardial infarction: Correlates to 3 denial scales

The concept of denial in medical patients was reviewed, and problems in the past research on denial was noted. A questionnaire developed to assess different aspects of denial in myocardial infarction was tested in a group of 367 patients. A factor analysis of the questionnaire gave 3 independent factors, termed Denial of Illness, Denial of Impact, and Suppression. This finding gave support to the model that guided the construction of the questionnaire, and also casted some doubt on the validity of using either single specific or global criteria in assessing denial. Multiple regression analyses, including a series of medical, psychological and social variables, showed that social desirablity and external health locus of control contributed to the prediction of high scores on all 3 scales. Denial of Illness was furthermore associatd with less previous cardiac disease and a less severe index MI, whereas Denial of Impact was related to indicators of more optimistic attitudes. Suppression was related to indicators of lower socio-economic status and less cardiac health knowledge. The 3 scales should be further examined in relation to outcome after a myocardial infarction.     

Concurrent brief versus intensive smoking intervention during alcohol dependence treatment.

Alcohol dependent smokers (N=118) enrolled in an intensive outpatient substance abuse treatment program were randomized to a concurrent brief or intensive smoking cessation intervention. Brief treatment consisted of a 15-min counseling session with 5 min of follow-up. Intensive intervention consisted of three 1-hr counseling sessions plus 8 weeks of nicotine patch therapy. The cigarette abstinence rate, verified by breath carbon monoxide, was significantly higher for the intensive treatment group (27.5%) versus the rate for the brief treatment group (6.6%) at 1 month after the quit date but not at 6 months, when abstinence rates fell to 9.1% for the intensive treatment group and 2.1% for the brief treatment group. Smoking treatment assignment did not significantly impact alcohol outcomes. Although intensive smoking treatment was associated with higher rates of short-term tobacco abstinence, other, perhaps more intensive, smoking interventions are needed to produce lasting smoking cessation in alcohol dependent smokers.     

Aversive smoking therapies: A conditioning analysis of therapeutic effectiveness

Rapid smoking (RS) and a less aversive rapid-puffing (RP) treatment were compared on ability to enhance the impact of a behavioral-counseling (BC) procedure on psychophysiological, attitudinal and behavioral response to cigarettes. Data reveal that both aversive smoking treatments resulted in less smoking once treatment began, reduced smoking in post-treatment taste tests, and superior follow-up performance at 6 months and 1 yr. At 1 yr, RS S s achieved the highest number of days abstinent of any group. Regression analyses showed that Ss' confidence ratings of remaining abstinent were highly predictive of follow-up status, and that these ratings were related to number of cigarettes smoked during treatment and amount of smoking during post-treatment taste tests.     

Knowledge and expectations: Perceived illness in myocardial infarction patients

In a study of 367 patients with myocardial infarction (MI), questionnaires were developed to assess two central aspects of perceived illness: factual and consensual illness knowledge and subjective expectations for the personal consequences of the MI. In a factor analysis, these two aspects of perceived illness were found to load on separate factors, and the patients views of the personal consequences of the MI were only moderately associated with their general cardiac health knowledge. Among a series of sociodemographic, medical, and psychological variables, including a standardized in-hospital patient education programme, the two aspects of perceived illness also proved to have different determinants. Differences in factual and consensual illness knowledge were mainly related to differences in formal education, and this aspect of perceived illness was influenced by the standardized education programme. In contrast, differences in subjective expectations were associated with levels of hopelessness. The implications for psychosocial interventions in the rehabilitation of MI patients are discussed.     

Smoking cessation: social comparison level predicts success for adult smokers.

The affiliation preferences of 151 adult heavy smokers who joined smoking cessation groups were assessed at the 1st group session and were then used to predict their smoking status 6 and 12 months later. Those who preferred to be in groups with other smokers who were having relatively little trouble quitting were more likely to be successful than were those who preferred others who were having more difficulty quitting. This prospective effect was mediated by psychological distancing from the image of the typical smoker: Preference for others who were doing well was associated with a decrease in perceived similarity to the typical smoker, which, in turn, was associated with successful cessation. Implications of these findings for cessation groups and social comparison theory are discussed.