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The attitudes toward the illness of patients after myocardial infarction undergoing rehabilitation
Sot. SC!. & Med., Vol. 9. pp. 237 to 239. Pergamon Press 1975. Printed m Great Bntam
THE ATTITUDES TOWARD THE ILLNESS OF PATIENTS AFTER MYOCARDIAL INFARCTION UNDERGOING REHABILITATION KAZIMIERZ WRZESNIEWSKI Centre of Cardiological
Rehabilitation,
Post-Hospital
Treatment, Inowroclaw. Poland
Abstract-The aim of this study was to characterize the attitudes toward the illness of patients after myocardial infarction, and to examine the relationship between rehabilitation in the sanatorium and such attitudes. An attitude scale was prepared. 160 males were investigated. following first myocardial infarction, and all were at the rehabilitation sanatorium following hospital treatment. The discriminative power of the scale items, their validity. reliability and provisional norms are discussed. It was possible to identify favourable and unfavourable attitudes for the course of treatment and rehabilitation. Organized. comprehensive rehabilitation in the sanatorium affected attitudes in a favourable way.
One of the suggestions in the final report of the Working Group on the Psychological Aspects of Rehabilitation of Cardiovascular Patients, organized by WHO (Warsaw, 1969) was the organization of research work concerning attitudes towards their illness of patients with myocardial infarction Cl]. Attitudes (ATI) toward both the illness (MI) and the situation produced by treatment and rehabilitation, play an essential role in the early stage of treatment, as well as later, when the patient resumes his vocational and social life. A subjective, improper assessment of a personal situation can cause complications in treatment, may even cause death [l-4] and may lead to disability not justified on health grounds alone [5--l I]. The aims of the present study were; (1) to characterize the AT1 of patients after MI at post-hospitalization rehabilitation in the sanatorium; and (2) to examine the relationship between rehabilitation in the sanatorium and ATI. On the basis of the literature Cl-213 of discussions with cardiologists and of our own observations made over 7 years of work with patients after myocardial infarction, six components were chosen for scrutiny; the degree of anxiety connected with the fact of MI. the adequacy of information the patient has on the subject of his illness and treatment, the degree of acceptance of diagnosis and medical recommendations, the patient’s images of his own future. the intensity of the care-demanding attitude and current mood. Each one of these elements was divided into 10 indicators for the construction of a questionnaire based on a Likert-type scale. There were 120 items, and subjects were asked to choose for each item one of five degrees of agreement. A pilot study was undertaken among 160 males aged under 60, all white-collar workers with secondary or tertiary education. all of whom had suffered a first MI within 3 months preceding the psychological examinations. The discriminative power of the scale items was determined on the basis of the results obtained. From 120 items, 43 were discriminative; the validity. reliability and the provisional norms of the scale were also determined. The ATI Scale was found to meet the basic requirements for psychometric tools.
In the experimental group there were 77 males, all white-collar workers, aged from 33 to 61 years (average age: 48.7 years) all of them had incurred their first myocardial infarction within the preceding 22157 days (average 54.7) and were dehospitalized from 1 to 97 days (average 20.2) before the first psychological examination. No coexisting diseases were present. Examinations were conducted before starting post-hospitalization rehabilitation in the sanatorium and towards its end. The following basic types of ATI were determined on the basis of the obtained results (Fig. 1). The attitude most favouring the treatment and rehabilitation process is characterized by: low level of fear connected with the fact of MI; high level of acceptance of the diagnosis and medical recommendations; optimistic expectations as to the future; lowlevel of the care-demanding attitude; and an eventempered mood (the terms “low” and “high” have
Attitude Untovomblo tur the course Of the trwtment and rehabilitation pmcess; -~hy$~ol~ical consequences, -motwoticm stmwbtmg to denrmmd 4wombk behavior
1 ~~nent
Fig. 1. Characteristic
237
]
1 :zel&
of ATI after myocardial
medical
1
infarction.
238
KAZIM~ERZWRZESNIEWSKI Table 1. Results obtained by means of ATI Scale prior to starting and at the end of rehabilitation in sanatorium (N = 77) Examinations before rehabilitation
Examination at end of rehabilitation
Mean ATI scores
99.4
110.6
Standard deviation
23.1
19.5
Parameters
sense-their evaluation depends on the answers). Such an attitude was found in persons who had 117 or more points on the AT1 Scale. The type of attitude (II) least favourable for the process of treatment and rehabilitation can be manifested in two forms; (a) an attitude with anxiety predominant, in which the acceptance of the diagnosis and medical recommendations is low, the pessimistic anticipation of the future, the demand for high care, the mood low and (b) an attitude having an absence of acceptance of diagnosis and medical recommendations combined with absence of anxiety connected with the fact of MI, optimistic (often unrealistic) imagination of the future, low demand for care or currently raised mood. These attitudes were found in persons who had 80 or less points on the ATI Scale. Separation of persons with the attitudes II(a) from those with II(b) required the application of an additional clue, using 12 items. The third type of attitude was the ambivalent, containing elements of the other types. This was characteristic of persons scoring between 81 and 116 points on the AT1 Scale. It is assumed the favourable or unfavourable significance of the attitudes may result from physiological consequences (through emotional components) or due to the motivation mechanisms stimulating determination. It is useful to explore the relationship between the complex post-hospitalization rehabilitation meant as a kinesitherapy, a pharmacotherapy and a psychical rehabilitation [9, 18,201 and the ATI. The psychical rehabilitation includes individual and group psychotherapy and a kind of autogenic training (21). This complex rehabilitation is carried out in the special sanatorium, where patients stay for 28 days after hospitalization. The results obtained before and at the end of rehabilitation in the sanatorium are indicated in Table 1. These values differed in a statistically significant way (p
recorded by every 10 points and the following graph was traced (Fig. 2). If an axis is drawn through point 0, the resultant graph will have a bias to the right: most of the differences are positive. Closer analysis demonstrated that the number of persons in the unfavourable group fell significantly: while the number of persons in the ambivalent and favourable attitude groups rose in the course of rehabilitation. There arises a question of fundamental importance: is the time elapsed from the moment of MI without any organized rehabilitation, a factor causing a spontaneous change in the ATI’? The best way to answer this question would be the comparative results of patients at post hospital rehabilitation in the sanatorium with a control group containing matched pair subjects who did not attend the sanatorium but returned home after attending hospital. This was difficult to organize. If the mean period between the first and the second psychological investigation is 24 days, and during this time there was a change in the AT1 and if it depended upon the time interval only, then the patients who were 24 or more days at home after hospital treatment, before rehabilitation in the sanatorium would differ in the AT1 at the first examination from patients who come to the sanatorium immediately after hospitalization. This can be presented in the following way: Group I A...B...24 days...C Group II A’. . .about 24 days.. .B’. . .C AA’--the time of dehospitaliiation B,B-the time of the first psychological examination CC’---the time of the second psychological examination. From the whole group of 77 subjects two subgroups were separated: (I) patients who came to the sana-
-40
-20
0
20
40
60
xz-xI
Fig. 2. Distribution
of differences between the final and initial results.
Attitudes toward patients undergoing rehabilitation
239
Table 2. Results obtained by means of ATI scores of two groups differing by the period of infarction
Parameters Mean No. days between the moment of infarction and the first psychological
Shorter period from the moment of infarction (N = 20)
Longer period from the moment of infarction (N = 23)
378
74.9
88
36.8
examination
Mean No. days between the moment of dehospitalization and the first psychological examination Mean AT1 scores at the examination before the rehabilitation
105.6
92.1
Mean ATI scores at the examination at the end of the rehabilitation
117.9
108.7
Standard deviation at the examination before the rehabilitation
27.1
18.1
. Standard deviation at the examination
20.0
14.9
at the end of the rehabilitation
torium immediately after hospitalization (20 persons); (II) patients who stayed after hospitalization 24 or
more days at home before coming to the sanatorium, without organized rehabilitation (23 persons). The results are shown in Table 2. There was no significant differences between the results on the ATI Scale obtained by these subgroups either before or at the end of the rehabilitation in the sanatorium. These results indicate that an organised comprehensive rehabilitation after MI can affect the AT1 in a favourable way. This statement does not preclude the possibility of influence on the AT1 of other factors such as patient personality, his current financial, vocational and family situation, illness undergone at a previous date. Further systematic psychological studies in this connection are necessary. REFERENCES
1. Psychological
2.
3. 4. 5.
aspects of the rehabilitation of cardiovascular patients. Report on a Working Group, Warsaw 28-30. V. 1969. Regional Office for Europe WHO, Copenhagen, 1970. Croog S. H. et al. Denial among male heart patients: An empirical study. Psychosom. Med. 33, 385, 1971. Reiser M. F. Emotional aspects of cardiac disease. Am. J. Psychiat. 107. 781, 1951. Weiss E. et al. Emotional factors in coronary occlusion. AMA Arch. Int. Med. 99, 628, 1957. Braceland F. J. Psychiatric aspects. J. Rehab. 32, 53, 1966.
6. Croog S. H. et a[. The heart patients and recovery process: A review of the directions of. research on social and psychological factors. Sot. Sci. & Med. 2, 111. 1968. 7. Gentry W. D. S. et al. Denial as a determinant of anxiety and perceived health status in the coronary care unit. Psychosom. Med. 34, 39, 1972.
8. Goble A. J. et al. Rehabilitation of the cardiac patients. Med. J. Aust. 50, 975, 1963. 9. Goldwater L. J. et al. Study I75 “cardiacs” without heart disease. J. Am. Med. Ass. 148, 89, 1952. of the patient with 10. Hellerstein H. K. Rehabilitation coronary heart disease. In An Encyclopedia of the Cardiovascular System. McGraw-Hill, New York, 1959.
II. Wynn A. Unwarranted emotional distress in men with ischaemic heart disease. Med. J. Aust. 54, 847, 1967. 12. Miller C. K. Psychological correlates of coronary artery disease. Psychosom. Med. 27, 257, 1965. 13. Whitehouse F. A. Some psychological factors that influence rehabilitation of the cardiac. J. Rehab. 26, 4, 1960.
study of surviving 14. Bruhn J. G. et al. A psychosocial male coronary patients and controls followed over nine years. J. Psychosom. Res. 15, 305, 1971. 15. Burch G. E. and De Pasquale N. P. Potentials and limitations of patients after myocardial infarction. Am. Heart J. 6, 830, 1966.
16. Martin H. L. The significance of discussion with patient with coronary heart disease. Br. J. Med. Psychol. 40, 233, 1967. 17. Martin H. L. The relationship between premonitory distress state and rehabilitation in patients with coronary occlusion. Med. J. Aust. 54, 480, 1967. 18. Myocardial Infarction: How to prevent? How to rehabilitate? Sponsored by the Council on Rehabilitation International Society of Cardiology, Boehringer, Mannheim, 1973. 19. Rosen J. L. and Bibring G. J. Psychological reactions of hospital&d male patients to a heart attack. Psychosom. Med. 28, 808, 1966. 20. Materials for the Seminar on Rehabilitation of Patients with Cardiovascular Disease. Organized by the Regional Office for Europe WHO. Noordwijk aan Zee, Holland, 1967. 21. Wrzesniewskj K. Some psychological problems of the rehabilitation of patients after a recent myocardial infarction (in press).
THE ATTITUDES TOWARD THE ILLNESS OF PATIENTS AFTER MYOCARDIAL INFARCTION UNDERGOING REHABILITATION KAZIMIERZ WRZESNIEWSKI Centre of Cardiological
Rehabilitation,
Post-Hospital
Treatment, Inowroclaw. Poland
Abstract-The aim of this study was to characterize the attitudes toward the illness of patients after myocardial infarction, and to examine the relationship between rehabilitation in the sanatorium and such attitudes. An attitude scale was prepared. 160 males were investigated. following first myocardial infarction, and all were at the rehabilitation sanatorium following hospital treatment. The discriminative power of the scale items, their validity. reliability and provisional norms are discussed. It was possible to identify favourable and unfavourable attitudes for the course of treatment and rehabilitation. Organized. comprehensive rehabilitation in the sanatorium affected attitudes in a favourable way.
One of the suggestions in the final report of the Working Group on the Psychological Aspects of Rehabilitation of Cardiovascular Patients, organized by WHO (Warsaw, 1969) was the organization of research work concerning attitudes towards their illness of patients with myocardial infarction Cl]. Attitudes (ATI) toward both the illness (MI) and the situation produced by treatment and rehabilitation, play an essential role in the early stage of treatment, as well as later, when the patient resumes his vocational and social life. A subjective, improper assessment of a personal situation can cause complications in treatment, may even cause death [l-4] and may lead to disability not justified on health grounds alone [5--l I]. The aims of the present study were; (1) to characterize the AT1 of patients after MI at post-hospitalization rehabilitation in the sanatorium; and (2) to examine the relationship between rehabilitation in the sanatorium and ATI. On the basis of the literature Cl-213 of discussions with cardiologists and of our own observations made over 7 years of work with patients after myocardial infarction, six components were chosen for scrutiny; the degree of anxiety connected with the fact of MI. the adequacy of information the patient has on the subject of his illness and treatment, the degree of acceptance of diagnosis and medical recommendations, the patient’s images of his own future. the intensity of the care-demanding attitude and current mood. Each one of these elements was divided into 10 indicators for the construction of a questionnaire based on a Likert-type scale. There were 120 items, and subjects were asked to choose for each item one of five degrees of agreement. A pilot study was undertaken among 160 males aged under 60, all white-collar workers with secondary or tertiary education. all of whom had suffered a first MI within 3 months preceding the psychological examinations. The discriminative power of the scale items was determined on the basis of the results obtained. From 120 items, 43 were discriminative; the validity. reliability and the provisional norms of the scale were also determined. The ATI Scale was found to meet the basic requirements for psychometric tools.
In the experimental group there were 77 males, all white-collar workers, aged from 33 to 61 years (average age: 48.7 years) all of them had incurred their first myocardial infarction within the preceding 22157 days (average 54.7) and were dehospitalized from 1 to 97 days (average 20.2) before the first psychological examination. No coexisting diseases were present. Examinations were conducted before starting post-hospitalization rehabilitation in the sanatorium and towards its end. The following basic types of ATI were determined on the basis of the obtained results (Fig. 1). The attitude most favouring the treatment and rehabilitation process is characterized by: low level of fear connected with the fact of MI; high level of acceptance of the diagnosis and medical recommendations; optimistic expectations as to the future; lowlevel of the care-demanding attitude; and an eventempered mood (the terms “low” and “high” have
Attitude Untovomblo tur the course Of the trwtment and rehabilitation pmcess; -~hy$~ol~ical consequences, -motwoticm stmwbtmg to denrmmd 4wombk behavior
1 ~~nent
Fig. 1. Characteristic
237
]
1 :zel&
of ATI after myocardial
medical
1
infarction.
238
KAZIM~ERZWRZESNIEWSKI Table 1. Results obtained by means of ATI Scale prior to starting and at the end of rehabilitation in sanatorium (N = 77) Examinations before rehabilitation
Examination at end of rehabilitation
Mean ATI scores
99.4
110.6
Standard deviation
23.1
19.5
Parameters
sense-their evaluation depends on the answers). Such an attitude was found in persons who had 117 or more points on the AT1 Scale. The type of attitude (II) least favourable for the process of treatment and rehabilitation can be manifested in two forms; (a) an attitude with anxiety predominant, in which the acceptance of the diagnosis and medical recommendations is low, the pessimistic anticipation of the future, the demand for high care, the mood low and (b) an attitude having an absence of acceptance of diagnosis and medical recommendations combined with absence of anxiety connected with the fact of MI, optimistic (often unrealistic) imagination of the future, low demand for care or currently raised mood. These attitudes were found in persons who had 80 or less points on the ATI Scale. Separation of persons with the attitudes II(a) from those with II(b) required the application of an additional clue, using 12 items. The third type of attitude was the ambivalent, containing elements of the other types. This was characteristic of persons scoring between 81 and 116 points on the AT1 Scale. It is assumed the favourable or unfavourable significance of the attitudes may result from physiological consequences (through emotional components) or due to the motivation mechanisms stimulating determination. It is useful to explore the relationship between the complex post-hospitalization rehabilitation meant as a kinesitherapy, a pharmacotherapy and a psychical rehabilitation [9, 18,201 and the ATI. The psychical rehabilitation includes individual and group psychotherapy and a kind of autogenic training (21). This complex rehabilitation is carried out in the special sanatorium, where patients stay for 28 days after hospitalization. The results obtained before and at the end of rehabilitation in the sanatorium are indicated in Table 1. These values differed in a statistically significant way (p
recorded by every 10 points and the following graph was traced (Fig. 2). If an axis is drawn through point 0, the resultant graph will have a bias to the right: most of the differences are positive. Closer analysis demonstrated that the number of persons in the unfavourable group fell significantly: while the number of persons in the ambivalent and favourable attitude groups rose in the course of rehabilitation. There arises a question of fundamental importance: is the time elapsed from the moment of MI without any organized rehabilitation, a factor causing a spontaneous change in the ATI’? The best way to answer this question would be the comparative results of patients at post hospital rehabilitation in the sanatorium with a control group containing matched pair subjects who did not attend the sanatorium but returned home after attending hospital. This was difficult to organize. If the mean period between the first and the second psychological investigation is 24 days, and during this time there was a change in the AT1 and if it depended upon the time interval only, then the patients who were 24 or more days at home after hospital treatment, before rehabilitation in the sanatorium would differ in the AT1 at the first examination from patients who come to the sanatorium immediately after hospitalization. This can be presented in the following way: Group I A...B...24 days...C Group II A’. . .about 24 days.. .B’. . .C AA’--the time of dehospitaliiation B,B-the time of the first psychological examination CC’---the time of the second psychological examination. From the whole group of 77 subjects two subgroups were separated: (I) patients who came to the sana-
-40
-20
0
20
40
60
xz-xI
Fig. 2. Distribution
of differences between the final and initial results.
Attitudes toward patients undergoing rehabilitation
239
Table 2. Results obtained by means of ATI scores of two groups differing by the period of infarction
Parameters Mean No. days between the moment of infarction and the first psychological
Shorter period from the moment of infarction (N = 20)
Longer period from the moment of infarction (N = 23)
378
74.9
88
36.8
examination
Mean No. days between the moment of dehospitalization and the first psychological examination Mean AT1 scores at the examination before the rehabilitation
105.6
92.1
Mean ATI scores at the examination at the end of the rehabilitation
117.9
108.7
Standard deviation at the examination before the rehabilitation
27.1
18.1
. Standard deviation at the examination
20.0
14.9
at the end of the rehabilitation
torium immediately after hospitalization (20 persons); (II) patients who stayed after hospitalization 24 or
more days at home before coming to the sanatorium, without organized rehabilitation (23 persons). The results are shown in Table 2. There was no significant differences between the results on the ATI Scale obtained by these subgroups either before or at the end of the rehabilitation in the sanatorium. These results indicate that an organised comprehensive rehabilitation after MI can affect the AT1 in a favourable way. This statement does not preclude the possibility of influence on the AT1 of other factors such as patient personality, his current financial, vocational and family situation, illness undergone at a previous date. Further systematic psychological studies in this connection are necessary. REFERENCES
1. Psychological
2.
3. 4. 5.
aspects of the rehabilitation of cardiovascular patients. Report on a Working Group, Warsaw 28-30. V. 1969. Regional Office for Europe WHO, Copenhagen, 1970. Croog S. H. et al. Denial among male heart patients: An empirical study. Psychosom. Med. 33, 385, 1971. Reiser M. F. Emotional aspects of cardiac disease. Am. J. Psychiat. 107. 781, 1951. Weiss E. et al. Emotional factors in coronary occlusion. AMA Arch. Int. Med. 99, 628, 1957. Braceland F. J. Psychiatric aspects. J. Rehab. 32, 53, 1966.
6. Croog S. H. et a[. The heart patients and recovery process: A review of the directions of. research on social and psychological factors. Sot. Sci. & Med. 2, 111. 1968. 7. Gentry W. D. S. et al. Denial as a determinant of anxiety and perceived health status in the coronary care unit. Psychosom. Med. 34, 39, 1972.
8. Goble A. J. et al. Rehabilitation of the cardiac patients. Med. J. Aust. 50, 975, 1963. 9. Goldwater L. J. et al. Study I75 “cardiacs” without heart disease. J. Am. Med. Ass. 148, 89, 1952. of the patient with 10. Hellerstein H. K. Rehabilitation coronary heart disease. In An Encyclopedia of the Cardiovascular System. McGraw-Hill, New York, 1959.
II. Wynn A. Unwarranted emotional distress in men with ischaemic heart disease. Med. J. Aust. 54, 847, 1967. 12. Miller C. K. Psychological correlates of coronary artery disease. Psychosom. Med. 27, 257, 1965. 13. Whitehouse F. A. Some psychological factors that influence rehabilitation of the cardiac. J. Rehab. 26, 4, 1960.
study of surviving 14. Bruhn J. G. et al. A psychosocial male coronary patients and controls followed over nine years. J. Psychosom. Res. 15, 305, 1971. 15. Burch G. E. and De Pasquale N. P. Potentials and limitations of patients after myocardial infarction. Am. Heart J. 6, 830, 1966.
16. Martin H. L. The significance of discussion with patient with coronary heart disease. Br. J. Med. Psychol. 40, 233, 1967. 17. Martin H. L. The relationship between premonitory distress state and rehabilitation in patients with coronary occlusion. Med. J. Aust. 54, 480, 1967. 18. Myocardial Infarction: How to prevent? How to rehabilitate? Sponsored by the Council on Rehabilitation International Society of Cardiology, Boehringer, Mannheim, 1973. 19. Rosen J. L. and Bibring G. J. Psychological reactions of hospital&d male patients to a heart attack. Psychosom. Med. 28, 808, 1966. 20. Materials for the Seminar on Rehabilitation of Patients with Cardiovascular Disease. Organized by the Regional Office for Europe WHO. Noordwijk aan Zee, Holland, 1967. 21. Wrzesniewskj K. Some psychological problems of the rehabilitation of patients after a recent myocardial infarction (in press).