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Revista chilena de cardiología

versión On-line ISSN 0718-8560

Rev Chil Cardiol vol.34 no.3 Santiago  2015

http://dx.doi.org/10.4067/S0718-85602015000300001 

Facilitators and barriers to the adoption of healthy lifestyles after first myocardial infarction in Chile: A qualitative study.

 

Facilitadores y Barreras para la adopción de estilos de vida saludable después de un primer infarto del miocardio en Chile: estudio cualitativo

 

Claudia Bambs1 2, María Sgombich3, Loreto Leiva4, Fernando Baraona5, Paula Margozzini1, Claudia Pizarro6, Ana Rojas6.

1.    Department of Public Health, School of Medicine, Pontificia Universidad Católica de Chile, Marcoleta 434, Santiago, Chile, 8330073

2.    Advanced Center for Chronic Diseases (ACCDiS), Proyecto Fondap 15130011. Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 434, Santiago, Chile, 8330073

3.    Grupo Nous Ltda, Avenida Sucre 258, Ñuñoa, Chile, 7750000

4.    Department of Psychology, Faculty of Social Sciences, Universidad de Chile, Avenida Capitán Ignacio Carrera Pinto 1045, Santiago, Chile, 8320000

5.    Department of Cardiovascular Diseases, School of Medicine, Pontificia Universidad Católica de Chile, Marcoleta 367 fioor 8, Santiago, Chile, 8330024.

6.    Red de Salud UC CHRISTUS. Marcoleta 367, Santiago, Chile, 8330024

Correspondencia a:


Background: Factors associated with therapeutic lifestyle change (TLC) after myocardial infarction (MI) have not been fully investigated in Chile. This study aimed to provide a descriptive examination of facilitators and barriers to TLC after first MI.

Methods: Qualitative study based on in-depth interviews and focus groups with cardiologists and patients who had first MI one-year±2 months before the begin-ning of the study. Grounded theory research methods were used to guide sampling and coding of data. Results: Twenty-one patients who had first myocardial infarction and 14 cardiologists participated in in-depth interviews and focus groups until the point of theoretical saturation. Facilitators for TLC included optimism, self-efficacy, faith-based life purpose, positive attitudes by family and friends, social participation, good patient-physician relationship, and positive medical advice. Barriers were: individual (older age, female sex, lower educational level, limiting beliefs, ambi val ence, depressive mood, lack of knowledge on strategies to achieve TLC, financial constraints), family (family crisis, overprotection, im-posing attitudes, unhealthy habits at home), work (work overload and competition between work recovery and TLC), socio-environmental (neighborhood unsafety), and health provider-related (poor patient-physician re-lationship, limiting beliefs among physicians, medical advice centered on restrictions or imprecise, medical training focused on pharmacological therapies and in-terventional procedures over preventive care, and orga-nizational issues).

Conclusions: Reported facilitators and barriers enhance understanding of the process of lifestyle change after first myocardial infarction, and might be targets for optimization of secondary preventive strategies among Chilean patients.

Keywords: Lifestyle; myocardial infarction; prevention; qualitative research; health care


Antecedentes: Los factores asociados con el cambio terapéutico de estilos de vida (TLC) después de un infarto agudo al miocardio (IAM) no han sido suficientemente investigados en Chile. El objetivo de este estudio fue explorar y describir los facilitadores y barreras para la adopción de TLC en pacientes que han sufrido un primer IAM.

Métodos: Estudio cualitativo basado en entrevistas en profundidad y grupos focales con cardiólogos y pacientes que tuvieron un primer IAM un año ± 2 meses antes del inicio del estudio. Se usó metodología de Teoría Fundada para guiar el muestreo y la codificación de los datos.

Resultados: Veintiún pacientes con un primer IAM y 14 cardiólogos participaron en las entrevistas en profundidad y grupos focales, hasta el punto de saturación teórica. Facilitadores para TLC incluyeron optimismo, autoeficacia, propósito de vida basado en la fe, actitudes positivas por familiares y amigos, participación social, buena relación médico-paciente, y un consejo médico positivo. Las barreras fueron: individuales (edad avanzada, sexo femenino, bajo nivel educacional, creencias limitantes entre los pacientes, ambivalencia, estado de ánimo depresivo, falta de conocimiento sobre estrategias para lograr TLC, limitaciones financieras), a nivel familiar (crisis de la familia, sobreprotección, imposición de actitudes, hábitos no saludables en el hogar), a nivel laboral (sobrecarga de trabajo y competencia entre la recuperación del trabajo y la adopción de TLC), a nivel socio-ambiental (inseguridad del barrio), y a nivel del proveedor de salud (mala relación médico-paciente, creencias limitantes entre los médicos, consejo médico impreciso o basado en restricciones, formación médica centrada en aspectos farmacológicos e intervencionales por sobre lo preventivo, y problemas de organización). Conclusiones: Los facilitadores y barreras reportados mejoran la comprensión del proceso de cambio de estilos de vida después del primer infarto agudo al miocardio, y pueden contribuir a la optimización de estrategias de prevención cardiovascular secundaria en pacientes chilenos.


 

Background: Coronary heart disease (CHD) is the leading cause of death and a major contributor to morbi-dity and premature disability among Chilean adults1-2-3. Myocardial infarction (MI) survivors are at an increased risk of recurrent coronary events and death, and have com-plex therapeutic requirements that account for high health-care costs 4.

Therapeutic lifestyle changes (TLC) -especially smoking cessation, improvement of dietary habits, regular physical activity and weight loss- have been associated with improved outcome following first MI, including higher survival rates, fewer recurrent MIs, less frequent hospitalizations, better control of metabolic risk factors (e.g. hyperten-sion, dyslipidemia, diabetes), improvement of psychosocial profile and quality of life, and considerable decrease in medical expenses among CHD patients5-6. However, fewer than 50% of Chilean patients who were hospitali-zed for cardiovascular events achieve healthy lifestyles at one-year7 and similarly poor results have been described in developed countries 8.

Several groups have questioned the futility of salvaging acutely ischemic myocardium without addressing the un-derlying causes of the disease, specifically those related to TLC8-9. An increasing number of studies have addressed this topic, including qualitative research on facilitators of and barriers to lifestyle change among people with cardiovascular risk factors as well as those with established CHD in USA and European countries10-11-12-13-14. A recent review of 22 qualitative observational studies from USA, England, Taiwan and Australia, found that factors such as social support, beliefs and psychological factors not only influence lifestyle change, but are important for maintai-ning healthy behaviours over time15. Qualitative work regarding lifestyle change among Hispanic populations is limited, and most of it has been conducted among groups of Latinos living in developed countries16-17. Moreover, heterogeneity of Hispanics according to their country of origin, and variety in their culture and identity make diffi-cult to apply findings to a different sociocultural context 18. This study presents the first descriptive qualitative exami-nation of factors that may enhance (facilitators) or hinder (barriers) adoption of TLC after a first MI among Chilean participants.

Methods

Setting

This study took place at two cardiac practices located in areas of low and middle socioeconomic levels in Santiago, Chile: Dr. Sótero del Río and San Joaquín, respectively.

Both cardiac practices serve as clinical campuses for the School of Medicine of the Pontificia Universidad Católica de Chile. Participants of this study had no access to a rehabilitation program after MI, mainly due to lack of coverage by the Chilean health system. Local ethics com-mittees approved the study and written informed consent was obtained.

Study design and Sample

Between April and October 2008, we conducted a qualita-tive study based on in-depth interviews and focus groups with cardiologists and patients who had first MI oneyear± 2 months before the beginning of the study. A qualitative approach was chosen due to the nature of the research questions being asked (dealing with why, how, beliefs, and experiences of post"MI patients and physicians regarding lifestyles)19-20.

Patients were purposively sampled from clinical CHD registries irrespective of knowledge of their achievement of TLC. Maximum variation method20-21 was used in or-der to cover a range of post"MI experiences (diversity of sex, age, educational level and type of revascularization therapy). Two groups of cardiologists were selected based on their experience on the topic under study (preventive cardiology experts) and on their work in the participating practices. Preventive cardiology experts were identified among their peers using a snowball sampling method22, starting with those who were known by the research team, whom then referred the researchers to other colleagues along the country. Patients and physicians were contacted by phone, project details and time commitment were exp-lained, and an interview was arranged.

Data collection

In-depth, open-ended interviews19-23 were conducted in person with 21 posbMI patients (13 patients from Dr. Sótero del Río and 8 patients from San Joaquín) and 8 preventive cardiology experts. Other 6 cardiologists from participating practices took part in focus group discussion. A total number of 35 respondents participated in the study. Interviews were each 60 to 90 minutes in length. Two interviewers with expertise in qualitative interviewing and the topic under study (LL and CB) were present at nearly all interviews and the focus group. Interviews and focus group were audio-taped and transcribed verbatim by an in-dependent transcriptionist. Interviewers also made written records of nonverbal communication and field notes. Individual interviews with patients were conducted using a standard semistructured guide that began with the general questions "please describe what a typical day in your life is like" and "what aspects of your life have changed as a result of the MI?" Specific probes concerning description of TLC followed and patients were asked to identify aspects that facilitated or hindered TLC after MI. Adequacy of interview guide (language and contents) was pre-tested on two post-MI patients from cardiac practices similar to study participating centres. A full version of patients" interview guide is available as supplement in Spanish and English (see Additional file 1).

Focus group and individual interviews with cardiologists included questions about physicians’ own views on factors that might either facilitate or hinder TLC among post-MI patients. They were also asked to describe post-MI patients in terms of achievement of TLC. A full version of physicians" interview guide is available as supplement in Spanish and English (see Additional file 2).

Definition of lifestyle changes

Three self-reported TLC following MI were explored: Smoking cessation for >6 months, adoption of regular physical activity (at least brisk walking 30 minutes per day on most days), and weight lost >5% for overweight and obese patients. As an additional measure of smoking status, carbon monoxide (CO) concentration in expired air was measured to all patients. Using standard technique for monitor Smoke Check®, any value >6 parts per million was considered indicative of smoking24. Change in dietary patterns and other lifestyles spontaneously reported by patients were also registered and included in analysis.

Data Analysis

Grounded theory research methods were used to guide sampling and open coding of data19. Three researchers from different disciplines (medicine, psychology and phi-losophy) performed analysis in 4 steps: First, each resear-cher examined independently the transcripts deriving an initial coding frame; second, a total of 56 specific codes were refined and classified as facilitators for or barriers to TLC, using a group negotiated process; third, facilitators and barriers were grouped into five levels of factors accor-ding to the model of determinants of health25, even though the research team was open to the emergence of factors other than those included by the model of determinants of health; and fourth, distinctions between patients achieving greater TLC (2 or more) and those with lesser degree of TLC (less than 2) were explored. The cut-point of two TLC was arbitrarily chosen, being judged by the research team to be clinically relevant in order to contrast groups of greater and lesser TLC. Data collection and analysis on the first interviews influenced the collection of infor-mation on subsequent participants. Iteration between data collection and analysis continued until the point of data saturation19-26, e.i, until further interviews added no new concepts or insights to the research objectives. Deviant-case analysis27 was used in cases seeming to contradict the emerging facilitators and barriers for TLC.

Original quotations underwent a careful process of trans-lation from Spanish to English, with special attention to colloquial language and to maintain linguistic and cultural context of participants’ speech.

Results

Demographic and Clinicai Characteristics

Saturation point26 was reached after having interviewed 21 patients and 14 cardiologists and that defined the end of data collection. One patient from San Joaquín Medical Centre declined to participate, and an additional patient with similar sampling characteristics was invited. Table 1 presents demographic and clinical characteristics of postMI patients. Median age of the patients was 57 (range 41 to 73 years). Fifteen patients (71.4%) had at least 8 years of education, including 5 patients who had completed college (23.8%). Most patients (81%) reported living with a spouse or partner and 48% identified themselves as being heads of households with dependent children. Patients were treated with either percutaneous transluminal coronary angioplasty (76.2%) or coronary artery bypass graf-ting (CABG) (23.8%) when MI occurred.

Cardiologists from participant practices (n=6) reported a median of 12 years in cardiology (range 1 to 38). Preventive cardiology experts (n=8) had a median of 18 years of practice as cardiologists (range 9 to 29) and a median of 15 years of experience dedicated to CHD prevention (range 7 to 27). Cardiologists who participated as experts belonged to Universidad Católica de Chile, Universidad de Chile, Hospital DIPRECA, Universidad de Los Andes and Universidad de la Frontera.

Lifestyle changes among post-MI patients

All patients reported at least one unhealthy lifestyle (smoking, lack of regular physical activity or being overweight or obese) when they suffered the MI (Tabla 1), 57.1% had two or more, and 33.3% had all three unhealthy behaviors. Smoking cessation was the most frequently reported TLC. Eleven out of 14 smoker patients (78.6%) reported having quit smoking and maintained their non-smoking status at one-year post- MI. No cases of new smokers were found and concentration of CO in expired air coincided with patients’ self-report of smoking status in all cases. Overall, fourteen patients (67%) reported adoption of regular physical activity, while seven patients remained or became sedentary after MI. Seventeen patients (81%) were overweight or obese when MI occurred. Eleven patients (53%) reported having lost >5% weight, and the rest either maintained or increased weight after MI, including two previously normal weight patients who reported an increase >10% of body weight along with quitting smoking.

Table 1: Demographic and clinical characteristics of post myocardial

Facilitators of and barriers to lifestyle change

Facilitators and barriers were organized into five levels. Tabla 2 presents selected dimensions and quotations illustrating facilitators of and barriers to lifestyle change at individual, family, work and socio-environmental levels. Selected dimensions, contents and quotations illustrating facilitators of and barriers to lifestyle change at health-ca-reprovider level are presented in Tabla 3. Unless specifically noted, all results presented below correspond to con-sensus among post-MI patients and physicians.

Table 2: Selected dimensions and quotations illustrating facilitators and barriers to lifestyle change at individual, family, work and socio-environmental levels.

Table 3: Selected dimensions, contents and quotations Illustrating facilitators and barriers to lifestyle change at health-care-provlder level.

Individual factors

Five distinct dimensions of individual factors affecting TLC were identified: Demographics, psychological characteristics, knowledge and financial issues. Older age, female sex, lower educational level and financial constra-ints acted as barriers to TLC. Optimism, high-perceived self-efficacy, and faith-based life purpose acted as psy-chological facilitators for TLC. Psychological barriers to TLC included depressive mood and ambivalence between acceptance of CHD as a chronic condition versus wish to get back to normal life and forget MI. Additional barriers for TLC were patients’ belief that TLC are unachievable, belief that physical exercise may trigger a second heart at-tack, and beliefs about causal attribution of MI, all which acted as patients’ limiting beliefs about their ability to carry out the necessary TLC. For instance, patients who continued smoking believed that stress could have played a more significant role than cigarette smoking in causing their MI. In terms of knowledge, even less educated patients were informed about risk factors for CHD and all of them reported awareness of risks and fear of recurrence. However, patients’ lack of knowledge of TLC goals and of practical strategies to achieve them acted as barriers for TLC. See Tabla 2.

Family and friends factors

Emotional factors, practical care and attitudes of family members and close friends played a relevant role on patients’ TLC. Family, friends and especially children were described as main source of motivation for TLC after MI, while family crisis acted as an important barrier. Unheal-thy habits by family members, especially spouses, as well as lack of exercise partner were seen as practical barriers. Positive attitude by family members and engaging in heal-thy activities along with patients facilitated TLC, while imposing attitudes and overprotection by family members acted as barriers. See Tabla 2.

Work factors

Returning to work and resuming previous work routine were viewed as a source of personal enjoyment and moti-vation for TLC. However, competition between work re-covery and patients’ efforts toward TLC was identified as a barrier, especially among 9 young males who identified themselves as being heads of households. Work overload and extended work-hours were additional barriers to TLC, especially for physical activity. See Tabla 2.

Socio-community and environmental factors

Post-MI patients described participation in community groups as a source of enjoyment and emotional support after MI. Social groups also provided practical care in achieving TLC (e.g., having reminders about not smoking and checking for patients’ adherence to diet and medication). Physicians did not identify social participation among relevant factors that promoted patient's TLC.

Patients’ perceived insecurity in the streets emerged as an important environmental barrier, especially for physical activity post-MI. See Tabla 2.

Factors related to the health-care provider

Five dimensions of health-care-provider related factors were identified (Tabla 3).

First, most patients emphasized the importance of the patient-physician relationship, especially communication with their physicians, as a crucial element affecting their achievement of TLC. Few patients reported support from nurses, dietitians and other clinical staff as facilitators for TLC. Second, physicians’ beliefs regarding ineffectiveness of lifestyle versus pharmacological interventions, percei-ved lack of long-term success of TLC, and perception that lifestyle is something physicians also struggle with limi-ted their efforts toward promotion of TLC among their patients. Third, focus on restrictions, omission of relevant elements (e.g., missing checking smoking status at every visit), permissiveness (e.g., accepting cigarette smoking reduction instead of quitting smoking as a therapeutic goal), and lack of clear definition of TLC goals were iden-tified as elements of medical advice that hindered patients’ TLC. In contrast, precise and positive medical advice was seen as facilitator for TLC. Fourth, physicians reported that having been trained with focus on pharmacological therapies and interventional procedures over preventive care, being able to manage a limited variety of strategies to implement TLC, and having received deficient training on communication skills were factors that affected their performance when approaching TLC with patients. Finally, patients and physicians identified organizational barriers for TLC, including lack of access to healthcare, lack of coverage for cardiac rehabilitation programs, time constra-ints during visits, work overload for physicians, and poor collaboration between secondary and primary care teams. Financial constraints at organizational level played a signi-ficant barrier role at Dr. Sótero del Río’s cardiac practice.

Distinctions among post-MI patients

Two groups of post-MI patients were contrasted accor-ding to achievement of lifestyle goals. Twelve out of 20 patients reported having achieved two or more TLC, inclu-ding smoking cessation when applicable. The remaining 9 participants reported having achieved zero to one TLC. Patients who achieved greater TLC tend to be younger, predominantly males and with higher education; they had an optimistic view about future, a greater perception of self-efficacy and of their role as active agents in their own health. They reported higher interaction with health-care providers and their dependence on family support for TLC was lower than that of their counterparts who reported les-ser TLC. All CABG patients fell into this group. Six out of nine (67%) patients with lesser degree to TLC corresponded to the cardiac practice located in a low socioeconomic area (Dr. Sótero del Río).

Discussion

This qualitative study explored the process of lifestyle change from the perspective of post-MI patients and car-diologists in Chile. Variables that acted as facilitators of and barriers to lifestyle change were identified.

Findings in relation to other studies

Our study adds to previous research by providing a comprehensive examination of facilitators of and barriers to TLC among Chilean post-MI patients. In consistency with previous studies, we identified individual factors such as older age, low education, depressive mood, ambivalence, causal attribution and beliefs regarding physical exercise as barriers for TLC among post-MI patients11-28-29. Lack of knowledge regarding TLC goals and the means to adopt them emerged as an important barrier post-MI, which may be explained in part by the lack of clear definition of TLC goals and poor medical training on strategies to implement TLC reported by physicians. Previous studies have also shown that CHD patients find difficult to identify their lifestyle goals 29.

Increasing evidence supports our findings regarding optimism, perceived self-efficacy, positive attitudes by family and friends, faith-based life purpose and our observation that medical advice facilitated TLC when focused on positive messages, but hindered them when focused on restric-tions such as strict eating plans30-31-32-33. Indeed, facilitating healthy lifestyles is one of the proposed mechanisms through which these positive psychological traits and positive care environment might impact cardiovascular out-comes30-34.

In terms of work and social factors, our findings coincide with previous studies11-35 in that resuming a normal working and social routine was an important goal for post-MI patients. However, our participants reported that this goal was in direct competition with efforts toward TLC. Ad-ditionally, the high relevance assigned by patients to participation in socio-community groups as a facilitator for TLC contrasts with physicians’ accounts, in which social participation was scarcely mentioned. Explanation of this observation is likely multifactorial, and may include focus on biomedical aspects over social and psychological as-pects of health during clinical encounters.

Meaning of the study

To the best of our knowledge, this is the first Chilean study in examining patients and cardiologists’ perspectives about potential facilitators of and barriers to TLC after a first MI, thus contributing to generate local evidence that might be useful for the design of improved secondary preventive strategies in our country. Our study also contributes to highlight the unique contribution of qualitative research to the understanding of lifestyle change after MI in a population of Hispanics living in their country of origin, among which this kind of research is scarce. Through providing insight into social, emotional and experiential aspects of TLC after first MI, our findings enhance understanding of why TLC can be hard to achieve or maintain by cardiac patients, and what factors play a role as facilitators of or barriers to TLC. In addition, our study identified differences between subgroups of patients with greater and lesser achievement of TLC, which seem to differ in their distri-bution of facilitators of and barriers to TLC. This constitutes a preliminary finding that needs to be confirmed and further explored in future studies.

In particular, our study offers an itemized description of health-care-provider factors that affected patients’ TLC. Patient-physician relationship, focus on pharmacological over lifestyle interventions, physicians’ perceptions of in-effectiveness of TLC and a variety of organizational issues have also been previously shown to influence patients’ attitudes and health behaviors, as well as professionals efforts toward promotion of TLC during clinical encounters9-36-37. Our study is the first to report that physicians associate themselves with patients in terms of being struggling with lifestyles, and that this acted as an important barrier to promotion of TLC among their patients. Our study also identified aspects of medical training that negatively affected physicians’ effectiveness in promoting TLC among their patients. This observation offers valuable information for curriculum design, especially due to findings represent the unique perspective of Chilean practicing cardiologists with a wide range of experience.

The fact that most of the barriers to TLC reported here correspond to modifiable factors is encouraging for clini-cians and policymakers as well. Evidence is clear that TLC are achievable and that even modest improvements in li-festyles are associated with significant benefits in health9-38. Furthermore, an array of behavioral strategies has been used for decades in the field of lifestyle modification, including the stages of change model39, motivational inter-viewing (MI)40, and goal setting41. Our findings support the concept that components of motivational interviewing (specially expressing empathy and supporting patients’ self-efficacy) and goal setting are particularly well-suited for addressing TLC among post-MI patients in Chile.

We acknowledge that overcoming the multiple barriers presented here, especially socio-cultural, environmental and organizational barriers will require initiatives that go beyond the factors examined in this work, including improvement of social conditions, health policies that favour healthy lifestyles and discourage unhealthy options, better insurance coverage for preventive interventions and better organization of health services. Low coverage for cardiac rehabilitation programs and scarcity of formally trained cardiac preventive professionals in Chile42 makes imperative that healthy lifestyles be promoted and pursued as therapeutic goals in all settings where post-MI patients encounter the health system. Effective collaboration between cardiologists and primary care physicians, as well as nurses, other healthcare professionals and non-professional community members will be also needed if secondary prevention of CHD is to be improved. Initiatives such as EUROACTION43 and Coaching patients On Achieving Cardiovascular Health (COACH)44 are good examples of family-based, nurse-coordinated programs that have demonstrated significant improvements of TLC among CHD patients.

Strengths and limitations of the study

This study shares the strengths and limitations of quali-tative research. Several qualitative techniques were used in order to ensure comprehensive analysis of data27 including triangulation at methodological (two methods of data collection), disciplinary (clinical, psychological and phi-losophical perspective) and informant (post-MI patients and cardiologists) levels. The use of maximum variation sampling and deviant case analysis also contributed to refine analysis and maximize credibility and transferability of our findings27. Among the limitations of this study is the inability to exclude the influence of prior assumptions and experience of researchers over data collection and interpretation of findings. Furthermore, this study was carried out in two medical practices which are university clinical campuses and we did not have access to patients lost to follow-up after MI. Therefore, these data are likely to correspond to a "best-case-scenario" and the reality of TLC in post-MI Chilean patients might be worse. Finally, our results reflect patients and physicians’ perspectives and experiences regarding TLC and we have no data on what actually took place in the medical encounters that are re-ferred to. However, perceptions and beliefs represent a valuable source of knowledge and they may be as important as reality on influencing health behaviours45-46.

Future research

Our findings might be useful for the design of future secondary CHD prevention strategies in Chile, targeting the barriers found in this work. Further research that assesses aspects such as design, applicability, effectiveness and cost of such strategies is warranted. Additionally, the contrast that we found between a group with greater and lesser TLC needs to be considered as a preliminary finding, which needs to be confirmed and better characterized by future studies. Indeed, statistical differences could not be tested based on the qualitative design of this study. In addition, the views expressed in this study are those of postMI patients and cardiologists. Future research may include family members, members of community groups, co-wor-kers, and other health professionals such as nursing staff and primary care physicians, whom might provide different and valuable insight on the topic of interest.

In conclusion, reported facilitators and barriers enhance understanding of the process of lifestyle change after first myocardial infarction, and might be targets for optimi-zation of secondary preventive strategies among Chilean patients.

Abbreviations

TLC: Therapeutic lifestyle change MI: Myocardial infarction CHD: Coronary heart disease CABG: Coronary artery bypass grafting

Competing interests

The authors declare that they have no competing interests.

Funding

This work was funded by FONIS (Fondo Nacional de Investigación y Desarrollo en Salud), grant number SA07I20034. Additional funding was provided by FON-DAP through the Advanced Center for Chronic Diseases (ACCDiS), grant number 15130011.

Authors’ contributions

All authors were responsible for the study concept and design, and participated in the analysis and interpretation of data. CB had full access to all the data in the study and is the study guarantor. MXS was involved in supervising the study, discussing data collection and analysis and wri-ting the paper. LL participated in data collection, analysis and writing the manuscript. FB gave on-going support to the study in recruiting patients and cardiologists, provided clinical advice and contributed to interpretation of results. PM and CP contributed to interpretation of results and de-velopment of manuscript. AMR contributed to the study preparation and conduct, and interpretation of results. All authors critically revised and approved the manuscript and can take responsibility for the integrity of the data and the accuracy of the data analysis.

Acknowledgements

The authors thank the practices that took part in the study and the patients and physicians who gave their time and shared their experiences and thoughts. Thank you to Dr Osvaldo Pérez, Dr Pablo Sepúlveda and Dr Andrés Schus-ter for their help during the pilot phase of the study; Cheryl Rodgers for translating the interviews from Spanish to English; Dr. Steven E. Reis (Cardiovascular Institute at University of Pittsburgh, PA), Dr. Patricia Documet (Behavioural Sciences Department at University of Pittsburgh, PA), Dr. Catterina Ferreccio (Department of Public Health at Pontificia Universidad Católica de Chile) and Dr. Paula Bedregal (Department of Public Health at Pontificia Universidad Católica de Chile) for their valuable comments on previous versions of this manuscript.

Referencias:

1.    SOLIMANO G, MAZZEI M. Which are the causes of death among Chileans today? Long term perspectives. Rev Méd Chile 2007;135:932-38.         [ Links ]

2.    SZOT J. Mortality caused by acute myocardial infarction in Chile in the period 1990- 2001. Rev Méd Chile 2004;132:1227-33.         [ Links ]

3.    MINISTRY OF HEALTH CHILE. Estudio de carga de enfermedad y carga atribuible, Chile 2007, 2008. http://epi.minsal.cl/epi/html/invest/cargaenf2008/Informe%20final%20carga_ Enf_2007.pdf (November 11, 2014)        [ Links ]

4.    SMITH SCJ, BLAIR SN, BONOW RO, BRASS LM, CER-QUEIRA MD, DRACUP K, et al. AHA/ACC Scientific Statement: AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update: A statement for healthcare professionals from the American Heart Association and the American College of Car-diology. Circulation 2001;104: 1577-9.         [ Links ]

5.    CHOW CK, JOLLY S, RAO-MELACINI P, FOX KA, ANAND SS, YUSUF S. Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation 2010;121: 750-8.         [ Links ]

6.    IESTRA JA, KROMHOUT D, VAN DER SCHOUW YT, Grobbee DE, Boshuizen HC, van 16 Staveren WA. Effect size estimates of lifestyle and dietary changes on all-cause mortality in coronary artery disease patients: a systematic review. Circulation 2005;112: 924-34.         [ Links ]

7.    GUARDA E, ACEVEDO M, LIRA MT, CHAMORRO G, CORBALAN R. Prevalence of cardiovascular risk factors among patients suffering vascular events on admission and one year later. Rev Méd Chile 2005;133: 1147-52.         [ Links ]

8.    KOTSEVA K, WOOD D, DE BACKER G, DE BACQUER D, PYORALA K, KEIL U. Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries. Lancet 2009;373: 929-40.         [ Links ]

9.    MOZAFFARIAN D, WILSON PW, KANNEL WB. Beyond established and novel risk factors: lifestyle risk factors for cardiovascular disease. Circulation 2008;117: 3031-8.         [ Links ]

10.    TOD AM, READ C, LACEY A, ABBOTT J. Barriers to uptake of services for coronary heart disease: qualitative study. BMJ 2001;323: 214.         [ Links ]

11.    CONDON C, MCCARTHY G. Lifestyle changes following acute myocardial infarction: patients perspectives. European journal of cardiovascular nursing 2006;5: 37-44.         [ Links ]

12.    GREGORY S, BOSTOCK Y, Backett-Milburn K. Recovering from a heart attack: a qualitative study into lay experiences and the struggle to make lifestyle changes. Family Practice 2006;23: 220-225.         [ Links ]

13.    COLE JA, SMITH SM, HART N, Cupples ME. Do practitio-ners and friends support patients with coronary heart disease in lifestyle change? a qualitative study. BMC Family Practice 2013,    14:126-136        [ Links ]

14.    ASTIN F HORROCKS J, CLOSS SJ. Managing lifestyle change to reduce coronary risk: a synthesis of qualitative research on peoples’experiences. BMC Cardiovascular Disorders 2014,    14:96-112

15.    MURRAY J, FENTON G, HONEY S, BARA AC, HILL KM, House A. A qualitative synthesis of factors influencing maintenance of lifestyle behaviour change in individuals with high cardiovascular risk. BMC Cardiovascular Disorders 2013, 13:48-59        [ Links ]

16.    ALBARRAN CR, HEILEMANN MV, KONIAK-GRIFFIN D. Promotoras 17 as facilitators of change: Latinas’ perspectives after participating in a lifestyle behaviour intervention pro-gram. Journal of Advanced Nursing 2014, 70: 2303-2313

17.    GERCHOW L, TAGLIAFERRO B, SQUIRES A, NICHOL-SON J, SAVARIMUTHU SM, GUTNICK D, et al. Latina food patterns in the United States: a qualitative metasynthesis. Nurs Res. 2014, 63:182-93        [ Links ]

18.    SCHNEIDERMANA N, CHIRINOSA DA, AVILÉS-SANTAB ML, HEISSC G. Challenges in Preventing Heart Disease in Hispanics:Early Lessons Learned from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Progress in Cardiovascular Diseases 2014, 57: 253 - 261        [ Links ]

19.    GLASER BG, STRAUSS AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago, Ill: Al-dine, 1967.         [ Links ]

20.    CRABTREE BF, MILLER WL. Doing Qualitative Research. Calif: Sage Publications, 1999.         [ Links ]

21.    POPE C, MAYS N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ 1995;311: 42-5.         [ Links ]

22.    BIERNACKI P, WALDORF D. Snowball sampling: problems and techniques of chain referral sampling. Sociological Methods and Research 1981;10: 141-63.         [ Links ]

23.    MCCRACKEN G. The Long Interview. Newbury Park, Calif: Sage Publications, 1988.         [ Links ]

24.    WALD NJ, IDLE M, BOREHAM J, BAILEY A. Carbon monoxide in breath in relation to smoking and carboxyhaemoglo-bin levels. Thorax 1981;36: 366-9.         [ Links ]

25.    MARMOT M, WILKINSON R. Social determinants of health. Oxford (UK): Oxford University Press, 2006.         [ Links ]

26.    MORSE J. Determining sample size. Qualitative Health Research 2000;10: 3-5.         [ Links ]

27.    MAYS N, POPE C. Qualitative research in health care. Assessing quality in qualitative research. BMJ 2000;320: 50-2.         [ Links ]

28.    DARR A, ASTIN F, ATKIN K. Causal attributions, lifestyle change, and coronary heart disease: illness beliefs of patients of South Asian and European origin living in the United King-dom. Heart & lung : the journal of critical care 2008;37: 91 104-18        [ Links ]

29.    CORRRIGAN M, CUPPLES ME, SMITH SM, BYRNE M, LEATHEM CS, CLERKIN P, MURPHY AW. The contribution of qualitative research in designing a complex intervention for secondary prevention of coronary heart disease in two different healthcare systems. BMC health services research 2006;6:90.         [ Links ]

30.    BOEHM JK, KUBZANSKY LD. The heart’s content: the asso-ciation between positive psychological well-being and cardiovascular health. Psychological bulletin 2012;138: 655-91.

31.    SOL BG, VAN DER GRAAF Y, VAN PETERSEN R, VISSE-REN FL. The effect of selfefficacy on cardiovascular lifestyle. European journal of cardiovascular nursing: journal of the Wor-king Group on Cardiovascular Nursing of the European Society of Cardiology 2011;10: 180-6.         [ Links ]

32.    RICHARDS H, REID M, WATT G. Victim-blaming revisited: a qualitative study of beliefs about illness causation, and responses to chest pain. Family practice 2003;20: 711-6.         [ Links ]

33.    PETERSON JC, ALLEGRANTE JP, PIRRAGLIA PA, ROB-BINS L, LANE KP BOSCHERT KA, CHARLSON ME. Living with heart disease after angioplasty: A qualitative study of patients who have been successful or unsuccessful in multiple behavior change. Heart & lung : the journal of critical care 2010;39: 105-15.         [ Links ]

34.    DUBOIS CM, BEACH SR, KASHDAN TB, NYER MB, PARK ER, CELANO CM, HUFFMAN JC. Positive psychological attributes and cardiac outcomes: associations, mechanisms, and interventions. Psychosomatics 2012;53: 303-18.         [ Links ]

35.    THOMPSON DR, ERSSER SJ, WEBSTER RA. The experiences of patients and their partners 1 month after a heart attack. Journal of advanced nursing 1995;22: 707-14.         [ Links ]

36.    SUMMERSKILL WS, POPE C. ‘I saw the panic rise in her eyes, and evidence-based medicine went out of the door.’ An exploratory qualitative study of the barriers to secondary pre-vention in the management of coronary heart disease. Family practice 2002;19: 605-10.

37.    GASCON JJ, SANCHEZ-ORTUNO M, LLOR B, SKIDMORE D, SATURNO PJ. Why hypertensive patients do not comply with the treatment: results from a qualitative study. Family 19 practice 2004;21: 125-30.         [ Links ]

38.    FRANKLIN BA, CUSHMAN M. Recent advances in preventive cardiology and lifestyle medicine: a themed series. Circula-tion 2011;123: 2274-83.         [ Links ]

39.    PROCHASKA JO, DICLEMENTE CC. The Transtheoretical Approach: Towards a Systematic Eclectic Framework Homewood, IL, USA: Dow Jones Irwin 1984.         [ Links ]

40.    MILLER WR, ROLLNICK S. Motivational Interviewing: Pre-paring People for Change. 2nd Edition ed. New York: Guilford Press, 2002.         [ Links ]

41.    STRECHER VJ, SEIJTS GH, KOK GJ, LATHAM GP GLASGOW R, DE VELLIS B, MEERTENS RM, BULGER DW. Goal setting as a strategy for health behavior change. Health education quarterly 1995;22: 190-200.         [ Links ]

42.    ROMERO T. Cardiac rehabilitation as a first step in the secondary prevention of coronary heart disease. Rev Méd Chile 2000;128: 923-34.         [ Links ]

43.    WOOD DA, KOTSEVA K, CONNOLLY S, JENNINGS C, MEAD A, JONES J, HOLDEN A, DE BACQUER D, COLLIER T, DE BACKER G, FAERGEMAN O. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coro-nary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial. Lancet 2008;371: 1999-2012.         [ Links ]

44.    VALE MJ, JELINEK MV, BEST JD, DART AM, GRIGG LE, HARE DL, HO BP NEWMAN RW, MCNEIL JJ. Coaching patients On Achieving Cardiovascular Health (COACH): a multicenter randomized trial in patients with coronary heart disease. Archives of internal medicine 2003;163: 2775-83.         [ Links ]

45.    ROSENSTOCK IM, STRECHER VJ, BECKER MH. Social learning theory and the Health Belief Model. Health education quarterly 1988;15: 175-83.         [ Links ]

46.    BANDURA A. Social foundations of thought and action: A social cognitive theory. New York. NY:Prentice-Hall. 1986.         [ Links ]


Recibido 21 de diciembre 2015/Aceptado 29 de diciembre 2015    

Corresponding author:

Claudia Bambs, M.D. M.Sc.

Phone number: 23543038

cbambs@med.puc.cl

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