How and why a multifaceted intervention to improve adherence post-MI worked for some (and could work better for others): an outcome-driven qualitative process evaluation

Laura Desveaux, Marianne Saragosa, Kirstie Russell, Nicola McCleary, Justin Presseau, Holly O Witteman, J-D Schwalm, Noah Michael Ivers, Laura Desveaux, Marianne Saragosa, Kirstie Russell, Nicola McCleary, Justin Presseau, Holly O Witteman, J-D Schwalm, Noah Michael Ivers

Abstract

Objectives: To explore (1) the extent to which a multicomponent intervention addressed determinants of the desired behaviours (ie, adherence to cardiac rehabilitation (CR) and cardiovascular medications), (2) the associated mechanism(s) of action and (3) how future interventions might be better designed to meet the needs of this patient population.

Design: A qualitative evaluation embedded within a multicentre randomised trial, involving purposive semistructured interviews.

Setting: Nine cardiac centres in Ontario, Canada.

Participants: Potential participants were stratified according to the trial's primary outcomes of engagement and adherence, resulting in three groups: (1) engaged, adherence outcome positive, (2) engaged, adherence outcome negative and (3) did not engage, adherence outcome negative. Participants who did not engage but had positive adherence outcomes were excluded. Individual domains of the Theoretical Domains Framework were applied as deductive codes and findings were analysed using a framework approach.

Results: Thirty-one participants were interviewed. Participants who were engaged with positive adherence outcomes attributed their success to the intervention's ability to activate determinants including behavioural regulation and knowledge, which encouraged an increase in self-monitoring behaviour and awareness of available supports, as well as reinforcement and social influences. The behaviour of those with negative adherence outcomes was driven by beliefs about consequences, emotions and identity. As currently designed, the intervention failed to target these determinants for this subset of participants, resulting in partial engagement and poor adherence outcomes.

Conclusion: The intervention facilitated CR adherence through reinforcement, behavioural regulation, the provision of knowledge and social influence. To reach a broader and more diverse population, future iterations of the intervention should target aberrant beliefs about consequences, memory and decision-making and emotion.

Trial registration number: ClinicalTrials.gov registry; NCT02382731.

Keywords: health services administration & management; myocardial infarction; qualitative research.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

References

    1. Johansson S, Rosengren A, Young K, et al. . Mortality and morbidity trends after the first year in survivors of acute myocardial infarction: a systematic review. BMC Cardiovasc Disord 2017;17:53. 10.1186/s12872-017-0482-9
    1. Rapsomaniki E, Thuresson M, Yang E, et al. . Using big data from health records from four countries to evaluate chronic disease outcomes: a study in 114 364 survivors of myocardial infarction. Eur Heart J Qual Care Clin Outcomes 2016;2:172–83. 10.1093/ehjqcco/qcw004
    1. Jernberg T, Hasvold P, Henriksson M, et al. . Cardiovascular risk in post-myocardial infarction patients: nationwide real world data demonstrate the importance of a long-term perspective. Eur Heart J 2015;36:1163–70. 10.1093/eurheartj/ehu505
    1. Taylor RS, Brown A, Ebrahim S, et al. . Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med 2004;116:682–92. 10.1016/j.amjmed.2004.01.009
    1. Leon AS, Franklin BA, Costa F, et al. . Cardiac rehabilitation and secondary prevention of coronary heart disease: an American heart association scientific statement from the Council on clinical cardiology (Subcommittee on exercise, cardiac rehabilitation, and prevention) and the Council on nutrition, physical activity, and metabolism (Subcommittee on physical activity), in collaboration with the American association of cardiovascular and pulmonary rehabilitation. Circulation 2005;111:369–76. 10.1161/01.CIR.0000151788.08740.5C
    1. Perk J, De Backer G, Gohlke H, et al. . European guidelines on cardiovascular disease prevention in clinical practice (version 2012): the fifth joint task force of the European society of cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts). Int J Behav Med 2012;19:403–88. 10.1007/s12529-012-9242-5
    1. Stone JA, Arthur HM, Canadian Association of Cardiac Rehabilitation Guidelines Writing Group . Canadian guidelines for cardiac rehabilitation and cardiovascular disease prevention, second edition, 2004: Executive summary. Can J Cardiol 2005;21 Suppl D:3D–19.
    1. Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Am Heart J 2011;162:571–84. 10.1016/j.ahj.2011.07.017
    1. Martin B-J, Hauer T, Arena R, et al. . Cardiac rehabilitation attendance and outcomes in coronary artery disease patients. Circulation 2012;126:677–87. 10.1161/CIRCULATIONAHA.111.066738
    1. Sundararajan V, Bunker SJ, Begg S, et al. . Attendance rates and outcomes of cardiac rehabilitation in Victoria, 1998. Med J Aust 2004;180:268–71. 10.5694/j.1326-5377.2004.tb05923.x
    1. Cooper A, Lloyd G, Weinman J, et al. . Why patients do not attend cardiac rehabilitation: role of intentions and illness beliefs. Heart 1999;82:234–6. 10.1136/hrt.82.2.234
    1. Cooper AF, Jackson G, Weinman J, et al. . Factors associated with cardiac rehabilitation attendance: a systematic review of the literature. Clin Rehabil 2002;16:541–52. 10.1191/0269215502cr524oa
    1. LaRosa JC, He J, Vupputuri S. Effect of statins on risk of coronary disease: a meta-analysis of randomized controlled trials. JAMA 1999;282:2340–6. 10.1001/jama.282.24.2340
    1. Rasmussen JN, Chong A, Alter DA. Relationship between adherence to evidence-based pharmacotherapy and long-term mortality after acute myocardial infarction. JAMA 2007;297:177–86. 10.1001/jama.297.2.177
    1. Ho PM, Spertus JA, Masoudi FA, et al. . Impact of medication therapy discontinuation on mortality after myocardial infarction. Arch Intern Med 2006;166:1842–7. 10.1001/archinte.166.17.1842
    1. Abraham C, Kelly MP, West R, et al. . The UK National Institute for health and clinical excellence public health guidance on behaviour change: a brief introduction. Psychol Health Med 2009;14:1–8. 10.1080/13548500802537903
    1. Presseau J, Schwalm JD, Grimshaw JM, et al. . Identifying determinants of medication adherence following myocardial infarction using the theoretical domains framework and the health action process approach. Psychol Health 2017;32:1176–94. 10.1080/08870446.2016.1260724
    1. Ivers N, Schwalm J-D, Witteman HO, et al. . Interventions supporting long-term adherence aNd decreasing cardiovascular events (island): pragmatic randomized trial protocol. Am Heart J 2017;190:64–75. 10.1016/j.ahj.2017.05.007
    1. Glasziou P, Meats E, Heneghan C, et al. . What is missing from descriptions of treatment in trials and reviews? BMJ 2008;336:1472–4. 10.1136/bmj.39590.732037.47
    1. Hoffmann TC, Glasziou PP, Boutron I, et al. . Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ 2014;348:g1687. 10.1136/bmj.g1687
    1. Moore GF, Audrey S, Barker M, et al. . Process evaluation of complex interventions: medical Research Council guidance. BMJ 2015;350:h1258. 10.1136/bmj.h1258
    1. Michie S, Richardson M, Johnston M, et al. . The behavior change technique taxonomy (V1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med 2013;46:81–95. 10.1007/s12160-013-9486-6
    1. Witteman HO, Presseau J, Nicholas Angl E, et al. . Negotiating tensions between theory and design in the development of Mailings for people recovering from acute coronary syndrome. JMIR Hum Factors 2017;4:e6. 10.2196/humanfactors.6502
    1. Gale NK, Heath G, Cameron E, et al. . Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol 2013;13:117. 10.1186/1471-2288-13-117
    1. Smith J, Firth J. Qualitative data analysis: the framework approach. Nurse Res 2011;18:52–62. 10.7748/nr2011.01.18.2.52.c8284
    1. Ivers NM, Schwalm J-D, Bouck Z, et al. . Interventions supporting long term adherence and decreasing cardiovascular events after myocardial infarction (island): pragmatic randomised controlled trial. BMJ 2020;369:m1731. 10.1136/bmj.m1731
    1. Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res 2017;17:88. 10.1186/s12913-017-2031-8
    1. Sidani S, Epstein DR, Bootzin RR, et al. . Assessment of preferences for treatment: validation of a measure. Res Nurs Health 2009;32:419–31. 10.1002/nur.20329
    1. Kwasnicka D, Presseau J, White M, et al. . Does planning how to cope with anticipated barriers facilitate health-related behaviour change? A systematic review. Health Psychol Rev 2013;7:129–45. 10.1080/17437199.2013.766832
    1. Jackson L, Leclerc J, Erskine Y, et al. . Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors. Heart 2005;91:10–14. 10.1136/hrt.2004.045559
    1. Robertson D, Keller C. Relationships among health beliefs, self-efficacy, and exercise adherence in patients with coronary artery disease. Heart Lung 1992;21:56–63.
    1. French DP, Cooper A, Weinman J. Illness perceptions predict attendance at cardiac rehabilitation following acute myocardial infarction: a systematic review with meta-analysis. J Psychosom Res 2006;61:757–67. 10.1016/j.jpsychores.2006.07.029
    1. Schwarzer R, Lippke S, Luszczynska A. Mechanisms of health behavior change in persons with chronic illness or disability: the health action process approach (HAPA). Rehabil Psychol 2011;56:161–70. 10.1037/a0024509
    1. Cooper AF, Weinman J, Hankins M, et al. . Assessing patients' beliefs about cardiac rehabilitation as a basis for predicting attendance after acute myocardial infarction. Heart 2007;93:53–8. 10.1136/hrt.2005.081299
    1. Petrie K, Weinman J. Perceptions of health and illness: current research and applications. Amsterdam: Harwood Academic, 1997.
    1. Cameron L, Leventhal H. The self-regulation of health and illness behaviour. London: Routledge, 2003.
    1. Náfrádi L, Nakamoto K, Schulz PJ. Is patient empowerment the key to promote adherence? A systematic review of the relationship between self-efficacy, health locus of control and medication adherence. PLoS One 2017;12:e0186458. 10.1371/journal.pone.0186458
    1. Thombs BD, Bass EB, Ford DE, et al. . Prevalence of depression in survivors of acute myocardial infarction. J Gen Intern Med 2006;21:30–8. 10.1111/j.1525-1497.2005.00269.x
    1. Pedersen SS, Middel B, Larsen ML. Posttraumatic stress disorder in first-time myocardial infarction patients. Heart Lung 2003;32:300–7. 10.1016/S0147-9563(03)00097-9
    1. Cameron R, Gusman D. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Primary Care Psychiatry 2003;9:9–14.
    1. Tulloch H, Greenman PS, Tassé V. Post-Traumatic stress disorder among cardiac patients: prevalence, risk factors, and considerations for assessment and treatment. Behav Sci 2014;5:27–40. 10.3390/bs5010027
    1. Bambauer KZ, Aupont O, Stone PH, et al. . The effect of a telephone counseling intervention on self-rated health of cardiac patients. Psychosom Med 2005;67:539–45. 10.1097/01.psy.0000171810.37958.61

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