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Treatment-seeking behavior for acute myocardial infarction symptoms in North America and Australia
ISSUES IN CARDIOVASCULAR NURSING
Treatment-seeking behavior for acute myocardial infarction symptoms in North America and Australia Sharon McKinley, RN, PhD,a Debra K. Moser, RN, DNSc,b and Kathleen Dracup, RN, DNSc,c Sydney, Australia, Columbus, Ohio, and Los Angeles, California OBJECTIVE: The goal of this study was to compare North American and Australian patients’ sociodemographic, clinical, cognitive, emotional, and social factors associated with behavior in seeking treatment for symptoms of acute myocardial infarction. PATIENTS: Subjects included 277 North Americans (mean age, 58 ± 12 years; 72% men) and 147 Australians (mean age, 62 ± 13 years; 66% men) with acute myocardial infarction. METHODS: Data were obtained with the Response to Symptoms Questionnaire and from the patients’ hospital records. RESULTS: In both groups, patients who delayed longer (P ≤ .05) had lower incomes, known diabetes mellitus, and symptom onset while at home; in addition, they appraised their symptoms as not serious, waited for symptoms to go away, and worried about troubling others. Additional factors associated with longer delay in North Americans (P ≤ .05) were older age, intermittent symptoms, and attribution of symptoms to a noncardiac cause; other contributing factors include not recognizing the symptoms as cardiac and fearing the consequences of seeking help. In Australians (P ≤ .05), contributing factors were fewer years of education, a history of hypertension, and embarrassment about seeking help. CONCLUSION: Programs to reduce delay in response to acute myocardial infarction symptoms must take account of cognitive and emotional processes and differences in response in the particular cultures of patients. (Heart Lung® 2000;29:237-47.)
T
hrombolytic therapy substantially reduces the mortality and morbidity associated with acute myocardial infarction (AMI).1,2 More recently primary percutaneous coronary angioplasty (PTCA) has been demonstrated to confer even greater benefits in reducing rates of mortality,3,4
From the aUniversity of Technology Sydney and Royal North Shore Hospital, Sydney; bOhio State University College of Nursing, Columbus; and the cUniversity of California School of Nursing, Los Angeles. Supported in part by a Fulbright Foundation Senior Scholar’s Award to Dr Dracup. Reprint requests: Sharon McKinley, RN, PhD, Intensive Care Unit, Level 6, Royal North Shore Hospital of Sydney, St. Leonards, NSW 2060, Australia. Copyright © 2000 by Mosby, Inc. 0147-9563/2000/$12.00 + 0 2/1/106940 doi:10.1067/mhl.2000.106940
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reinfarction, recurrent ischemia, and stroke,3 and it has been shown to reduce hospital charges and length of stay.3 The success and benefits of reperfusion therapy by either thrombolytics or primary PTCA relate inversely to time from symptom onset to treatment and diminish markedly when the intervention is received more than 6 hours after the onset of AMI symptoms.1,5 Survival rates are improved by up to 50% if thrombolytic therapy is given within 1 hour of the onset of symptoms and by 23% if it is given within 3 hours of symptom onset.1 Coronary reperfusion early after onset of AMI symptoms preserves myocardium and results in better cardiac function and lower morbidity, benefits that are also related to the length of time therapy is received after symptom onset.2,5 Although some reduction in mortality may result even when thrombolysis is received up to 12 hours
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after symptom onset, the potential benefit from thrombolytic therapy diminishes greatly after 6 hours.2 Similarly, PTCA performed between 6 and 12 hours after symptom onset in patients with continuing ischemia has been shown to be much less effective than early (<6 hours) PTCA in terms of vessel patency and reinfarction.5 Delay in arriving at the hospital is the major reason patients do not receive treatment to establish reperfusion,6 with reported median prehospital delay times ranging from 2.0 to 6.5 hours.7-12 They are largely a result of delay by patients in deciding to seek medical care.7 Thus the phase of symptom recognition and decision to seek care is the substantial period of prehospital delay in response to AMI symptoms, and the phase where most improvement could be achieved in patients receiving timely treatment to establish reperfusion and reduce the mortality and morbidity of AMI. Most research to date into delay in seeking treatment for evolving AMI has focused on the sociodemographic and clinical characteristics of patients who are likely to delay in seeking treatment when experiencing AMI symptoms.8,13 Recent research indicates the importance of also considering the patients’ cognitive and social processes and symptom appraisal as factors of increased delay times.12,14 Many reports concerned with delay in treatment seeking for AMI originate in the United States, but delay times have also been identified as a problem in other countries.13,15-17 Some researchers have considered whether ethnic and cultural factors make a difference in patients’ responses to AMI symptoms. Studies from the United States have shown that times from symptom onset to hospital arrival are longer for African Americans18,19 and Latinos.19 Similarly, in the United Kingdom south Asian patients with AMI symptoms have been reported to have longer delay times than whites.20 It has been suggested that cultural differences in the ways symptoms are expressed and interpreted might contribute to this.21 Evidence shows that racial differences in pathophysiology lead to less typical symptoms in south Asians20 and African Americans22 and that socioeconomic status and access to care are more important determinants of patients’ treatment-seeking behavior than ethnic status.19,23 Thus ethnic and cultural factors may be relevant concerns in planning programs to reduce prehospital delay. Studies to date have examined this question in single countries. Whether there are relevant variations between different countries that have different
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health care systems has not been studied. Therefore the aim of the present study was to compare sociodemographic, clinical, cognitive, emotional, and social factors in treatment-seeking behavior by North American and Australian patients with symptoms of AMI who arrived at the hospital within 6 hours of symptom onset. A secondary purpose of this article is to examine how the findings of the research can contribute to promotion of early response to AMI symptoms.
METHODS Patients North American patients (n = 277)14 were all participants in the GUSTO trial (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) that evaluated different thrombolytic protocols.24 Patients thus met that study’s entry criteria of eligibility for thrombolytic treatment (ie, arrival at the hospital less than 6 hours after the onset of AMI symptoms and chest pain lasting longer than 20 minutes, together with ≥0.1 mV ST-segment elevation in 2 or more electrocardiogram [ECG] limb leads or >0.2 mV ST-segment elevation in 2 or more contiguous precordial ECG leads). Exclusion criteria were contraindications to thrombolytic therapy, namely previous stroke, active bleeding, previous thrombolytic therapy, recent trauma or major surgery, or instrumentation requiring puncture of a noncompressible vessel.24 Only Australian patients who had arrived at the hospital within 6 hours of symptom onset were included in the present study (n = 147) to match the American sample from the GUSTO trial. Australian patients also met the diagnostic criteria for AMI described above, and the majority received thrombolytic therapy; however, patients with contraindications to thrombolytic therapy were not excluded.12 All patients were able to read and write English, were living independently, were free from malignancy or other complicating illnesses, were alert and oriented, and were within 24 to 72 hours of hospital admission. The study protocol was approved by appropriate institutional review boards or committees at all study sites, and all patients gave written informed consent. The North American study sites included 41 hospitals in the United States and 2 in Canada, where the coordinators of GUSTO study sites arranged participation in the substudy on delay in response to symptoms. The Australian study sites were 2 large, metropolitan tertiary university teaching hospitals and a medium-sized district hospital.
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All 3 were public hospitals in which patients are entitled to health care without charges under Australia’s national universal health insurance scheme, Medicare.
Materials and data collection procedure The Response to Symptoms Questionnaire was used to obtain time from symptom onset to arrival at the hospital and data on sociodemographic, cognitive, emotional, and social factors potentially contributing to delay. Clinical data were abstracted from the patients’ hospital records. The Response to Symptoms Questionnaire was developed to obtain data in 6 domains: (1) context in which AMI symptoms appeared; (2) antecedents of symptoms; (3) affective response to symptoms; (4) behavioral response to symptoms; (5) cognitive response to symptoms; and (6) response of others to patients’ symptoms.25 We modified the instrument to assess cognitive, symptom appraisal, and social factors surrounding a patient’s decision to seek care for AMI symptoms. The sections to obtain sociodemographic and clinical data used terminology appropriate for the respective countries. The questionnaire was judged by expert cardiac nurses in each country to have content validity to sample the domains of interest. Patients were interviewed by an investigator or a research assistant within 72 hours of admission to hospital. Patients either completed the Response to Symptoms Questionnaire themselves or agreed to be interviewed by one of the researchers with the questionnaire. Delay time was defined as the time from initial onset of AMI symptoms until the time of arrival at the hospital. The times of arrival at hospital and symptom onset recorded in the patient’s record were noted. Where the time of symptom onset differed from the patient’s account, serial ECGs and enzyme test results were reviewed to ascertain the most likely time of symptom onset.
Statistical methods Chi-square test was used to test differences between patient characteristics and past clinical histories in each group. Independent t tests or analysis of variance was used to analyze the effect of sociodemographic, clinical, cognitive, emotional, and social factors on time from symptom onset to arrival at the hospital. Two-way factorial analysis of variance was used to test interactions between patients’ country and factors contributing to delay. Delay time tendency is reported as the median
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time because of the marked skew toward relatively short times in both North American and Australian patients (ie, of patients from both countries who came to the hospital within 6 hours of AMI symptom onset, most presented very early, thus biasing the average delay time to be very short). For the purposes of parametric and multivariate analyses, delay time was subjected to logarithmic transformation to obtain a normally distributed measure of delay time.
RESULTS The 277 North American and 147 Australian patients were predominantly men (72% and 66%, respectively) with mean ages of 58 ± 12 years and 62 ± 13 years. Australians were older, had lower incomes, and fewer years of education. Ninety-one percent of American and 94% of Australian patients were white. More Australians had known histories of coronary artery disease (Table I). The summary of initial responses of patients to symptoms of evolving AMI is shown in Table II. The most frequent response of patients in both countries was to try to relax. Overall, the 5 most frequent responses were the same for patients from North America and Australia, but the relative frequencies varied. The most notable difference was the lower proportion of Australian patients who responded by hoping or praying that the symptoms would go away and the higher number who told a family member about their symptoms. The median time from symptom onset to arrival at the hospital was 90 minutes for both groups. Comparisons of North American and Australian delay times by patient factors are shown in Tables III, IV, and V. In summary, patients in both countries who delayed longer had lower incomes, known diabetes mellitus, symptom onset at home, and the following cognitive and emotional responses: appraised symptoms as not serious, waited for symptoms to go away, and worried about troubling others. Additional factors associated with longer delay in North American patients were older age, intermittent symptoms, and attribution of symptoms to a noncardiac cause; furthermore, not recognizing symptoms as cardiac and fearing the consequences of seeking help also were associated with longer delay times. Factors in Australian patients were fewer years of education, a history of hypertension, and embarrassment about seeking help.
DISCUSSION This study examined the treatment-seeking behavior of patients from 2 continents who had
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Table I Patient characteristics North America
Australia
n
%
n
%
P
M
198
72
95
66
F
76
28
50
34
29-40
19
7
9
6
41-60
132
48
49
35
61-86
123
45
84
59
201
77
102
73
61
23
38
27
<$20,000
57
25
60
44
≥$20,000
171
75
76
56
≤12
142
53
99
68
>12
125
47
46
32
<.01
AMI
40
15
40
29
<.001
Angina
82
31
57
41
<.05
CAGs
15
6
17
12
<.05
Sex NS
Age (y)
<.05
Present marital status Married Not married
NS
Income <.001
Education (y)
History of coronary artery disease
CAGs, Coronary artery grafts.
symptoms of evolving AMI and went to the hospital relatively promptly (ie, a median time of 90 minutes). It was found that the cognitive, emotional, and social responses of patients to symptoms are associated with decisions to seek treatment and that although many similarities were noted in the responses of North American and Australian patients, there were also notable differences. Some differences in the characteristics of the patients from the 2 continents were that the Australian subjects were older on the whole and more of them had past histories of coronary artery disease, possibly in part a result of the fact that Australian patients who were ineligible for thromboly-
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sis according to the GUSTO study criteria were retained in the study. However, these differences were likely to have had little influence on the results given that older age and history of coronary artery disease did not affect the delay time of Australian patients.
Response to the health threat of symptoms of AMI Few patients on either continent made an appropriate initial response to their symptoms (ie, called an ambulance or went to the hospital). The social context in which the symptoms of AMI first occur has been shown to be relevant to decisions about
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Table II Initial response to symptoms of acute MI North America Response
n
Australia
%
n
%
Tried to relax
85
30.7
36
24.5
Hoped or prayed symptoms would go away
60
21.7
11
7.5
Pretended nothing was wrong or tried to think of something else
18
6.5
12
8.2
Told a family member
25
9.0
30
20.4
Self-medicated
24
8.7
21
14.3
Tried not to think about it
11
4.0
2
1.4
Told a coworker
7
2.5
5
3.4
Went to physician’s office or hospital
7
2.5
1
0.7
They or family member called physician
6
2.2
1
0.7
They or family member called emergency medical services
5
1.8
2
1.4
Told a friend or stranger
5
1.8
5
3.5
Did nothing because feared would die
4
1.4
–
–
Other self-help
8
2.9
2
1.4
Other
12
4.4
14.5
9.5
Total*
282
97.9
142
96.8
*Does not total to 100% because of missing data.
how to respond to them.26 In this study patients from both continents delayed longer when their symptom onset occurred at home, even though twice as many Australians as North Americans initially responded to their symptoms by telling a family member about them. As in other studies,26,27 the average time it took before North American and Australian patients went to the hospital was not faster when a spouse or family member witnessed symptom onset. The factors unique to longer delay times in North American patients were (1) failure to recognize the symptoms as cardiac in origin and attributing them to another cause, (2) the intermittant nature of the symptoms, (3) age greater than 40 years, and (4) fear of the consequences of seeking help. Factors particular to Australians with longer delay times included embarrassment about seeking help and ≤ 12 years of education.
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In both continents, efforts to encourage less delay before going to the hospital after symptom onset should address known clinical and demographic factors associated with increased prehospital delay,7,8,17,26-29 some of which have emerged again in this analysis: older age; a history of hypertension, diabetes, or congestive heart failure; low emotional or somatic awareness; consultation with a spouse or other relative; consultation with a physician; and self-treatment. In addition, individualized and community-based attempts to change behavior should address emotional responses, such as concern about troubling others; in addition, inappropriate emotional responses characteristic of particular populations, such as embarrassment in Australians and fear of consequences in North Americans, need to be specifically addressed in those countries.
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Table III Delay times (min) according to sociodemographic and clinical characteristics North America
Australia
n
Mean ± SD
n
Mean ± SD
M
198
111 ± 79
95
112 ± 78
F
76
108 ± 71
50
140 ± 92
9
101 ± 84
Sex
Age (y) 29-40
19
66 ± 58*
41-60
132
105 ± 78
49
119 ± 87
61-86
123
122 ± 82
84
125 ± 83
201
110 ± 82
102
119 ± 84
61
113 ± 74
38
128 ± 819
<$20,000
57
136 ± 92†
60
135 ± 86‡
≥$20,000
171
103 ± 74
76
113 ± 84
≤12
142
114 ± 81
99
139 ± 90‡
>12
125
109 ± 79
46
83 ± 51
Yes
116
111 ± 74
61
143 ± 87‡
No
152
108 ± 82
78
107 ± 76
Yes
41
136 ± 92†
22
154 ± 84‡
No
226
105 ± 75
115
117 ± 82
Yes
82
113 ± 86
57
129 ± 88
No
186
108 ± 75
82
119 ± 79
Yes
40
97 ± 84
40
127 ± 83
No
228
111 ± 77
99
121 ± 83
Present marital status Married Not married Income
Education (y)§
History of hypertension
Diabetes
History of angina
Previous AMI
*Significant differences for North America compared with both other age groups (P ≤.05). †Significant differences for North America (P ≤.05). ‡Significant differences for Australia (P ≤.05). §Significant interaction between country and education (F = 7.17, P <.01).
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Table IV Delay times (min) according to social factors North America
Australia
n
Mean ± SD
n
Mean ± SD
Home
170
119 ± 79*
98
130 ± 83†
Outside home
102
95 ± 78
49
107 ± 85
Alone
104
104 ± 73
52
132 ± 84
Spouse or family member
127
116 ± 80
77
120 ± 83
Coworker, friend, or other
46
108 ± 88
18
103 ± 88
Suggested seeking help or called for help 88
101 ± 75
60
129 ± 93
Other behavior
114 ± 80
87
117 ± 76
Setting where symptoms occurred
Witness to symptom onset
Response of others to symptom onset 189
*Significant differences for North America (P ≤.05). †Significant differences for Australia (P ≤.05).
The finding that lower levels of education were associated with substantially longer delay times for Australian patients is notable, particularly in the group of patients studied here who went to the hospital relatively promptly (ie, within 6 hours of symptom onset). Research from other countries has shown that lower socioeconomic status is associated with delays in the decision to seek treatment,19,23 and patients with fewer years of education are likely to be those with lower incomes. In the Australian AMI population, income has been found to correlate with less education and been eliminated by education levels in a multiple regression analysis.12 Inconsistencies in findings were noted about effect of educational levels and other sociodemographic factors on delay times,30 to which this study adds. Zerwic30 comments that this lack of clarity is a function of differences in sample size and study design. Regardless, it would be sound to target this section of the Australian population with messages about seeking treatment presented in a manner that is sensitive to their educational levels. One potentially important difference in patients’ decisions to seek medical care for AMI symptoms is the system of payment for medical care. In the
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United States, sources and levels of health insurance cover vary, and some people have little or no coverage; in other countries, including Australia, all citizens are covered by universal health care insurance, paid for by a taxation levy. They therefore are not charged again for hospital care received in predominantly public hospital systems. In this study the length of time Australians delayed was not increased because of fear of the consequences of seeking help, as it was for North Americans. The study questionnaire did not elicit information about the nature of fears patients had about seeking help, but concerns about the financial burden of medical care and hospitalization are likely to be prominent (together with concerns about death and disability). Such an interpretation is consistent with other research suggesting that access to care has a greater influence on response to symptoms than does ethnic status,19,23 but additional investigation of cultural differences as potential contributors to delay in treatment is warranted.
Promoting treatment-seeking behavior The Leventhal self-regulatory model of illness behavior,31-33 which has been used to study treat-
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Table V Delay times (min) and symptom appraisal North America
Australia
n
Mean ± SD
n
Mean ± SD
1-7
105
107 ± 70
66
123 ± 86
8-10
162
112 ± 84
75
121 ± 83
Yes
74
130 ± 90*
56
143 ± 92
No
152
100 ± 74
90
110 ± 75
Not serious
112
123 ± 83*
54
145 ± 86†
Serious
159
102 ± 76
91
111 ± 80
72
113 ± 84
Pain severity
Assessed symptoms as intermittent
Appraisal of symptom seriousness
Symptom attribution Heart
90
96 ± 72*
Other
183
118 ± 81
74
129 ± 83
Yes
137
108 ± 80
63
103 ± 62
No
86
117 ± 83
83
138 ± 94
66
118 ± 78
Had knowledge of MI symptoms
Recognized symptoms as heart symptoms Yes
124
99 ± 75*
No
110
121 ± 82
80
127 ± 88
Yes
107
99 ± 76
50
101 ± 60
No
121
121 ± 82
95
134 ± 92
Yes
192
120 ± 81*
98
138 ± 90†
No
53
79 ± 62
48
93 ± 57
Yes
32
124 ± 98
39
162 ± 101†
No
193
107 ± 75
107
108 ± 71
Yes
101
131 ± 86*
78
151 ± 94†
No
127
94 ± 69
68
90 ± 54
Yes
97
124 ± 85*
89
129 ± 87
No
125
99 ± 73
56
110 ± 73
Realized the importance of symptoms
Waited for symptoms to go away
Was embarrassed to seek help
Worried about troubling others so did not seek help
Feared consequences of seeking help
*Significant differences for North America (P ≤.05). †Significant differences for Australia (P ≤.05).
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ment-seeking behavior in response to symptoms, provides a coherent framework for interpreting the problem of delayed treatment of AMI symptoms. The self-regulatory model proposes that 3 stages regulate the behavior seen in response to a health threat. Each stage has a perceptual level and a cognitive level. The first stage, cognitive representation of the health threat, includes identifying the symptoms and labeling the threat, potential cause(s), and possible consequences of the threat. The second stage is the action plan or coping stage in which a plan of action is formulated and initiated. The motivation to engage in coping actions is self-generated in response to the individual’s representation of the health threat, the possibilities for coping, and the relationship between coping and threat.34,35 In the third stage the individual appraises the success of his or her coping actions, and if it is perceived that there is not enough progress, the representation of the problem (objective and perceptual) and the plans to cope with it are reassessed and may be changed. Coping plans are also generated to control the emotional experiences provoked at any stage of the response to the health threat. Thus there is a “danger control process” for the objectively represented health threat and an “emotion control process” for the subjectively represented emotional response to the health threat.34 Leventhal and colleagues34,35 have shown that the processes of coping with emotional reactions may be parallel to, but partially independent of, the cognitive processes of coping with the health threat. At the cognitive level, the representation of the health threat relies on objective knowledge, such as labels for illnesses, and the coping action is primarily one that is controlled. Perception of the health threat relies on subjective knowledge acquired through past personal experiences, such as prior illnesses, and the coping response is primarily automatic. The controlled and automatic coping processes may interact in ways that are mutually facilitating or mutually interfering.35 The findings of the current study and other research into patients’ responses to AMI symptoms can be better understood in the context of the Leventhal self-regulatory model of illness behavior. For example, cognitive representation of the problem as a possible AMI may be delayed when symptoms are intermittent, not considered serious, or not attributed to the heart. Even when there is cognitive representation of the symptoms as a serious health threat related to the heart, the emotional concerns about troubling others, embarrassment,
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or fear of the consequences of seeking help may lead to an initial decision not to seek medical attention, which is subsequently appraised as an unsuccessful action plan. The plan is revised and help is sought. In the present study the most frequent initial response to symptoms could be characterized as automatic in response to emotions, whereas objective controlled action was initially taken by few. Knowledge of the nature and seriousness of cardiac symptoms was again found to be an important factor for some patients in their decisions to delay, even though patients with medical histories of angina and previous AMI, who were therefore likely to be familiar with the symptoms, did not go to the hospital substantially sooner. This is also consistent with automatic emotional responses to the symptoms interfering with a controlled response on the basis of knowledge. Alonzo36 attributes the emotional response that contributes to these patients’ delay to the cumulative trauma of repeated AMI and other cardiovascular comorbidities, which leads to a form of posttraumatic stress disorder. Mass media campaigns aimed at increasing public knowledge in North America,37 and again recently in Australia,38 have been shown to make little or no difference in delay times. They are effective during their execution at reducing delays in going to the hospital with symptoms of AMI and increasing thrombolysis administration rates,17 but the effects do not persist beyond the campaign. This limitation of mass campaigns was evident in a recent study that combined mass media with direct mail, including messages aimed at social and emotional responses, because delay times were not reduced.39 An alternative to mass campaigns with potential to have some effect on this problem is more personalized programs for people at high risk for coronary artery disease. Leventhal’s35 self-regulatory model of illness behavior offers a sound theoretical framework for planning interventions in which patients and their partners are assisted in recognizing the diversity of symptoms of an evolving AMI, anticipating their response to symptoms, rehearsing appropriate behaviors, and appreciating the rewards of seeking help early, as recommended by the US National Heart Attack Alert Program.40 These strategies address the cognitive representation of the threat and the emotional reaction to it, promote a controlled coping response rather than an automatic emotional response, and emphasize the possibilities of successfully coping with the health threat. The inclusion of partners in the pro-
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gram addresses an important environmental factor that can stimulate appropriate action in response to AMI symptoms. The current study was limited to patients who sought treatment relatively quickly. Nevertheless, it shows that cognitive and emotional responses and social factors are important in patient decision making about responding to symptoms of an evolving AMI and that there may be different influences on decision making in different countries. The results of the study combined with Leventhal’s self-regulatory model of illness behavior reinforce the importance of considering the contribution of cognitive and emotional factors to delays in seeking treatment, in addition to clinical and sociodemographic factors. The study also provides evidence that emotional responses specific to national cultures should be considered in strategies aimed at prompt treatment-seeking behavior for AMI symptoms.
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11. Kereiakes DJ, Weaver WD, Anderson JL, Feldman T, Gibler B, Aufderheide T. Time delays in the diagnosis and treatment of acute myocardial infarction: a tale of eight cities. Report from the Pre-hospital Study Group and the Cincinnati Heart Project. Am Heart J 1990;120:773-80. 12. Dracup K, McKinley SM, Moser DK. Australian patients’ delay in response to heart attack symptoms. Med J Aust 1997;166:233-6. 13. Berglin Blohm M, Hartford M, Karlsson T, Herlitz J. Factors associated with pre-hospital and in-hospital delay time in acute myocardial infarction: a 6-year experience. J Int Med 1998;243:243-50. 14. Dracup K, Moser DK. Beyond sociodemographics: factors influencing the decision to seek treatment for acute myocardial infarction. Heart Lung 1997;26:253-62. 15. Bett N, Aroney G, Thompson P. Impact of a national educational campaign to reduce patient delay in possible heart attack. Aust NZ J Med 1993;23:157-61. 16. Pettersen KI. When time is precious—time lags as indicators of quality of care in acute myocardial infarction. Int J Qual Health Care 1995;7:3-10. 17. Gaspoz JM, Ungar PF, Urban P, Chevrolet JC, Rutishauser W, Lovis C, et al. Impact of a public campaign on pre-hospital delay in patients reporting chest pain. Heart 1996;76:150-5. 18. Cooper RS, Simmons B, Castaner A, Prasad R, Franklin C, Ferlinz J. Survival rates and prehospital delay during myocardial infarction among black persons. Am J Cardiol 1986;57(4):20811. 19. Ell K, Haywood LJ, deGuzman M, Sobel E, Norris S, Blumfield D, et al. Differential perceptions, behaviors, and motivations among African Americans, Latinos, and whites suspected of heart attacks in two hospital populations. J Assoc Acad Minor Phys 1995;6(2):60-9. 20. Lear JT, Lawrence IG, Pohl JE, Burden AC. Myocardial infarction and thrombolysis: a comparison of the Indian and European populations on a coronary care unit. J R Coll Physicians Lond 1994;28(2):143-7. 21. Chaturvedi N, Rai H, Ben-Shlomo Y. Lay diagnosis and healthcare-seeking behaviour for chest pain in south Asians and Europeans. Lancet 1997;350:1578-83. 22. Lee HO. Typical and atypical clinical signs and symptoms of myocardial infarction and delayed seeking of professional care among blacks. Am J Crit Care 1997;6:7-13. 23. Ell K, Haywood LJ, Sobel E, deGuzman M, Blumfield D, Ning JP. Acute chest pain in African Americans: factors in the delay in seeking emergency care. Am J Public Health 1994;84:965-70. 24. Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarcto. Six-month survival in 20,891 patients with acute myocardial infarction randomized between alteplase and streptokinase with or without heparin. GISSI-2 and International Study Group. Eur Heart J 1992;13:1692-7. 25. Burnett RE, Blumthal JA, Mark DB, Leimberger JD, Califf RM. Distinguishing between early and late responders to symptoms of acute myocardial infarction. Am J Cardiol 1995;75: 1019-22. 26. Alonzo AA. The impact of the family and lay others on careseeking during life-threatening episodes of suspected coronary artery disease. Soc Sci Med 1986;22:1297-311. 27. Reilly AT, Dracup K, Dattolo J. Factors influencing prehospital delay in patients experiencing chest pain. Am J Crit Care 1994;3:300-6. 28. Schmidt SB, Borsch MA. The prehospital phase of acute myocardial infarction in the era of thrombolysis. Am J Cardiol 1990;65:1411-5. 29. Karlson BW, Herlitz J, Sjolin M, Ekvall HE, Persson NG, Lindqvist J, et al. Clinical factors associated with delay time in suspected acute myocardial infarction. Am Heart J 1990;120:1213-5. 30. Zerwic JJ. Patient delay in seeking treatment for acute myocardial infarction symptoms. J Cardiovasc Nurs 1999;13:21-32.
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31. Cameron L, Leventhal EA, Leventhal H. Seeking medical care in response to symptoms and life stress. Psychosom Med 1995; 57:37-47. 32. Leventhal EA, Easterling D, Leventhal H, Cameron L. Conservation of energy, uncertainty reduction, and swift utilization of medical care among the elderly: study II. Med Care 1995;33:988-1000. 33. Cameron L, Leventhal EA, Leventhal H. Symptom representations and affect as determinants of care seeking in a community-dwelling, adult sample population. Health Psychol 1993;12:171-9. 34. Leventhal H, Safar MA, Panagis DA. The impact of communications on the self-regulation of health beliefs, decisions and behavior. Health Educ Q 1983;10:3-29. 35. Leventhal H, Cameron L. Behavioral theories and the problem of compliance. Patient Educ Couns 1987;10:117-38. 36. Alonzo AA. Acute myocardial infarction and posttraumatic stress disorder: the consequences of cumulative adversity. J Cardiovasc Nurs 1999;13:33-45.
37. Ho MT, Eisenberg MS, Litwin PE, Schaeffer SM, Damon SK. Delay between onset of chest pain and seeking medical care: the effect of public education. Ann Emerg Med. 1989;18: 727-31. 38. Bett JHN for the Clinical Cardiovascular Committee, National Heart Foundation. Delays preceding admission to hospital and fibrinolytic treatment [abstract]. Scientific Programme, 45th Annual Scientific Meeting of the Cardiac Society of Australia and New Zealand; 1997. 39. Meischke H, Dulberg EM, Schaeffer SS, Henwood DK, Larson MP, Eisenberg MS. “Call Fast, call 911”: a direct mail campaign to reduce delay in acute myocardial infarction. Am J Pub Health 1997;87:1705-9. 40. Dracup K, Alonzo AA, Atkins JM, Bennet NM, Braslow A, Clark LT, et al. The physician’s role in minimizing prehospital delay in patients at high risk for acute myocardial infarction: recommendations from the National Heart Attack Alert Program. Ann Intern Med 1997;126:645-51.
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Treatment-seeking behavior for acute myocardial infarction symptoms in North America and Australia Sharon McKinley, RN, PhD,a Debra K. Moser, RN, DNSc,b and Kathleen Dracup, RN, DNSc,c Sydney, Australia, Columbus, Ohio, and Los Angeles, California OBJECTIVE: The goal of this study was to compare North American and Australian patients’ sociodemographic, clinical, cognitive, emotional, and social factors associated with behavior in seeking treatment for symptoms of acute myocardial infarction. PATIENTS: Subjects included 277 North Americans (mean age, 58 ± 12 years; 72% men) and 147 Australians (mean age, 62 ± 13 years; 66% men) with acute myocardial infarction. METHODS: Data were obtained with the Response to Symptoms Questionnaire and from the patients’ hospital records. RESULTS: In both groups, patients who delayed longer (P ≤ .05) had lower incomes, known diabetes mellitus, and symptom onset while at home; in addition, they appraised their symptoms as not serious, waited for symptoms to go away, and worried about troubling others. Additional factors associated with longer delay in North Americans (P ≤ .05) were older age, intermittent symptoms, and attribution of symptoms to a noncardiac cause; other contributing factors include not recognizing the symptoms as cardiac and fearing the consequences of seeking help. In Australians (P ≤ .05), contributing factors were fewer years of education, a history of hypertension, and embarrassment about seeking help. CONCLUSION: Programs to reduce delay in response to acute myocardial infarction symptoms must take account of cognitive and emotional processes and differences in response in the particular cultures of patients. (Heart Lung® 2000;29:237-47.)
T
hrombolytic therapy substantially reduces the mortality and morbidity associated with acute myocardial infarction (AMI).1,2 More recently primary percutaneous coronary angioplasty (PTCA) has been demonstrated to confer even greater benefits in reducing rates of mortality,3,4
From the aUniversity of Technology Sydney and Royal North Shore Hospital, Sydney; bOhio State University College of Nursing, Columbus; and the cUniversity of California School of Nursing, Los Angeles. Supported in part by a Fulbright Foundation Senior Scholar’s Award to Dr Dracup. Reprint requests: Sharon McKinley, RN, PhD, Intensive Care Unit, Level 6, Royal North Shore Hospital of Sydney, St. Leonards, NSW 2060, Australia. Copyright © 2000 by Mosby, Inc. 0147-9563/2000/$12.00 + 0 2/1/106940 doi:10.1067/mhl.2000.106940
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reinfarction, recurrent ischemia, and stroke,3 and it has been shown to reduce hospital charges and length of stay.3 The success and benefits of reperfusion therapy by either thrombolytics or primary PTCA relate inversely to time from symptom onset to treatment and diminish markedly when the intervention is received more than 6 hours after the onset of AMI symptoms.1,5 Survival rates are improved by up to 50% if thrombolytic therapy is given within 1 hour of the onset of symptoms and by 23% if it is given within 3 hours of symptom onset.1 Coronary reperfusion early after onset of AMI symptoms preserves myocardium and results in better cardiac function and lower morbidity, benefits that are also related to the length of time therapy is received after symptom onset.2,5 Although some reduction in mortality may result even when thrombolysis is received up to 12 hours
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Treatment-seeking behavior for acute myocardial infarction
after symptom onset, the potential benefit from thrombolytic therapy diminishes greatly after 6 hours.2 Similarly, PTCA performed between 6 and 12 hours after symptom onset in patients with continuing ischemia has been shown to be much less effective than early (<6 hours) PTCA in terms of vessel patency and reinfarction.5 Delay in arriving at the hospital is the major reason patients do not receive treatment to establish reperfusion,6 with reported median prehospital delay times ranging from 2.0 to 6.5 hours.7-12 They are largely a result of delay by patients in deciding to seek medical care.7 Thus the phase of symptom recognition and decision to seek care is the substantial period of prehospital delay in response to AMI symptoms, and the phase where most improvement could be achieved in patients receiving timely treatment to establish reperfusion and reduce the mortality and morbidity of AMI. Most research to date into delay in seeking treatment for evolving AMI has focused on the sociodemographic and clinical characteristics of patients who are likely to delay in seeking treatment when experiencing AMI symptoms.8,13 Recent research indicates the importance of also considering the patients’ cognitive and social processes and symptom appraisal as factors of increased delay times.12,14 Many reports concerned with delay in treatment seeking for AMI originate in the United States, but delay times have also been identified as a problem in other countries.13,15-17 Some researchers have considered whether ethnic and cultural factors make a difference in patients’ responses to AMI symptoms. Studies from the United States have shown that times from symptom onset to hospital arrival are longer for African Americans18,19 and Latinos.19 Similarly, in the United Kingdom south Asian patients with AMI symptoms have been reported to have longer delay times than whites.20 It has been suggested that cultural differences in the ways symptoms are expressed and interpreted might contribute to this.21 Evidence shows that racial differences in pathophysiology lead to less typical symptoms in south Asians20 and African Americans22 and that socioeconomic status and access to care are more important determinants of patients’ treatment-seeking behavior than ethnic status.19,23 Thus ethnic and cultural factors may be relevant concerns in planning programs to reduce prehospital delay. Studies to date have examined this question in single countries. Whether there are relevant variations between different countries that have different
238
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health care systems has not been studied. Therefore the aim of the present study was to compare sociodemographic, clinical, cognitive, emotional, and social factors in treatment-seeking behavior by North American and Australian patients with symptoms of AMI who arrived at the hospital within 6 hours of symptom onset. A secondary purpose of this article is to examine how the findings of the research can contribute to promotion of early response to AMI symptoms.
METHODS Patients North American patients (n = 277)14 were all participants in the GUSTO trial (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) that evaluated different thrombolytic protocols.24 Patients thus met that study’s entry criteria of eligibility for thrombolytic treatment (ie, arrival at the hospital less than 6 hours after the onset of AMI symptoms and chest pain lasting longer than 20 minutes, together with ≥0.1 mV ST-segment elevation in 2 or more electrocardiogram [ECG] limb leads or >0.2 mV ST-segment elevation in 2 or more contiguous precordial ECG leads). Exclusion criteria were contraindications to thrombolytic therapy, namely previous stroke, active bleeding, previous thrombolytic therapy, recent trauma or major surgery, or instrumentation requiring puncture of a noncompressible vessel.24 Only Australian patients who had arrived at the hospital within 6 hours of symptom onset were included in the present study (n = 147) to match the American sample from the GUSTO trial. Australian patients also met the diagnostic criteria for AMI described above, and the majority received thrombolytic therapy; however, patients with contraindications to thrombolytic therapy were not excluded.12 All patients were able to read and write English, were living independently, were free from malignancy or other complicating illnesses, were alert and oriented, and were within 24 to 72 hours of hospital admission. The study protocol was approved by appropriate institutional review boards or committees at all study sites, and all patients gave written informed consent. The North American study sites included 41 hospitals in the United States and 2 in Canada, where the coordinators of GUSTO study sites arranged participation in the substudy on delay in response to symptoms. The Australian study sites were 2 large, metropolitan tertiary university teaching hospitals and a medium-sized district hospital.
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All 3 were public hospitals in which patients are entitled to health care without charges under Australia’s national universal health insurance scheme, Medicare.
Materials and data collection procedure The Response to Symptoms Questionnaire was used to obtain time from symptom onset to arrival at the hospital and data on sociodemographic, cognitive, emotional, and social factors potentially contributing to delay. Clinical data were abstracted from the patients’ hospital records. The Response to Symptoms Questionnaire was developed to obtain data in 6 domains: (1) context in which AMI symptoms appeared; (2) antecedents of symptoms; (3) affective response to symptoms; (4) behavioral response to symptoms; (5) cognitive response to symptoms; and (6) response of others to patients’ symptoms.25 We modified the instrument to assess cognitive, symptom appraisal, and social factors surrounding a patient’s decision to seek care for AMI symptoms. The sections to obtain sociodemographic and clinical data used terminology appropriate for the respective countries. The questionnaire was judged by expert cardiac nurses in each country to have content validity to sample the domains of interest. Patients were interviewed by an investigator or a research assistant within 72 hours of admission to hospital. Patients either completed the Response to Symptoms Questionnaire themselves or agreed to be interviewed by one of the researchers with the questionnaire. Delay time was defined as the time from initial onset of AMI symptoms until the time of arrival at the hospital. The times of arrival at hospital and symptom onset recorded in the patient’s record were noted. Where the time of symptom onset differed from the patient’s account, serial ECGs and enzyme test results were reviewed to ascertain the most likely time of symptom onset.
Statistical methods Chi-square test was used to test differences between patient characteristics and past clinical histories in each group. Independent t tests or analysis of variance was used to analyze the effect of sociodemographic, clinical, cognitive, emotional, and social factors on time from symptom onset to arrival at the hospital. Two-way factorial analysis of variance was used to test interactions between patients’ country and factors contributing to delay. Delay time tendency is reported as the median
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time because of the marked skew toward relatively short times in both North American and Australian patients (ie, of patients from both countries who came to the hospital within 6 hours of AMI symptom onset, most presented very early, thus biasing the average delay time to be very short). For the purposes of parametric and multivariate analyses, delay time was subjected to logarithmic transformation to obtain a normally distributed measure of delay time.
RESULTS The 277 North American and 147 Australian patients were predominantly men (72% and 66%, respectively) with mean ages of 58 ± 12 years and 62 ± 13 years. Australians were older, had lower incomes, and fewer years of education. Ninety-one percent of American and 94% of Australian patients were white. More Australians had known histories of coronary artery disease (Table I). The summary of initial responses of patients to symptoms of evolving AMI is shown in Table II. The most frequent response of patients in both countries was to try to relax. Overall, the 5 most frequent responses were the same for patients from North America and Australia, but the relative frequencies varied. The most notable difference was the lower proportion of Australian patients who responded by hoping or praying that the symptoms would go away and the higher number who told a family member about their symptoms. The median time from symptom onset to arrival at the hospital was 90 minutes for both groups. Comparisons of North American and Australian delay times by patient factors are shown in Tables III, IV, and V. In summary, patients in both countries who delayed longer had lower incomes, known diabetes mellitus, symptom onset at home, and the following cognitive and emotional responses: appraised symptoms as not serious, waited for symptoms to go away, and worried about troubling others. Additional factors associated with longer delay in North American patients were older age, intermittent symptoms, and attribution of symptoms to a noncardiac cause; furthermore, not recognizing symptoms as cardiac and fearing the consequences of seeking help also were associated with longer delay times. Factors in Australian patients were fewer years of education, a history of hypertension, and embarrassment about seeking help.
DISCUSSION This study examined the treatment-seeking behavior of patients from 2 continents who had
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McKinley, Moser, and Dracup
Table I Patient characteristics North America
Australia
n
%
n
%
P
M
198
72
95
66
F
76
28
50
34
29-40
19
7
9
6
41-60
132
48
49
35
61-86
123
45
84
59
201
77
102
73
61
23
38
27
<$20,000
57
25
60
44
≥$20,000
171
75
76
56
≤12
142
53
99
68
>12
125
47
46
32
<.01
AMI
40
15
40
29
<.001
Angina
82
31
57
41
<.05
CAGs
15
6
17
12
<.05
Sex NS
Age (y)
<.05
Present marital status Married Not married
NS
Income <.001
Education (y)
History of coronary artery disease
CAGs, Coronary artery grafts.
symptoms of evolving AMI and went to the hospital relatively promptly (ie, a median time of 90 minutes). It was found that the cognitive, emotional, and social responses of patients to symptoms are associated with decisions to seek treatment and that although many similarities were noted in the responses of North American and Australian patients, there were also notable differences. Some differences in the characteristics of the patients from the 2 continents were that the Australian subjects were older on the whole and more of them had past histories of coronary artery disease, possibly in part a result of the fact that Australian patients who were ineligible for thromboly-
240
sis according to the GUSTO study criteria were retained in the study. However, these differences were likely to have had little influence on the results given that older age and history of coronary artery disease did not affect the delay time of Australian patients.
Response to the health threat of symptoms of AMI Few patients on either continent made an appropriate initial response to their symptoms (ie, called an ambulance or went to the hospital). The social context in which the symptoms of AMI first occur has been shown to be relevant to decisions about
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Table II Initial response to symptoms of acute MI North America Response
n
Australia
%
n
%
Tried to relax
85
30.7
36
24.5
Hoped or prayed symptoms would go away
60
21.7
11
7.5
Pretended nothing was wrong or tried to think of something else
18
6.5
12
8.2
Told a family member
25
9.0
30
20.4
Self-medicated
24
8.7
21
14.3
Tried not to think about it
11
4.0
2
1.4
Told a coworker
7
2.5
5
3.4
Went to physician’s office or hospital
7
2.5
1
0.7
They or family member called physician
6
2.2
1
0.7
They or family member called emergency medical services
5
1.8
2
1.4
Told a friend or stranger
5
1.8
5
3.5
Did nothing because feared would die
4
1.4
–
–
Other self-help
8
2.9
2
1.4
Other
12
4.4
14.5
9.5
Total*
282
97.9
142
96.8
*Does not total to 100% because of missing data.
how to respond to them.26 In this study patients from both continents delayed longer when their symptom onset occurred at home, even though twice as many Australians as North Americans initially responded to their symptoms by telling a family member about them. As in other studies,26,27 the average time it took before North American and Australian patients went to the hospital was not faster when a spouse or family member witnessed symptom onset. The factors unique to longer delay times in North American patients were (1) failure to recognize the symptoms as cardiac in origin and attributing them to another cause, (2) the intermittant nature of the symptoms, (3) age greater than 40 years, and (4) fear of the consequences of seeking help. Factors particular to Australians with longer delay times included embarrassment about seeking help and ≤ 12 years of education.
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In both continents, efforts to encourage less delay before going to the hospital after symptom onset should address known clinical and demographic factors associated with increased prehospital delay,7,8,17,26-29 some of which have emerged again in this analysis: older age; a history of hypertension, diabetes, or congestive heart failure; low emotional or somatic awareness; consultation with a spouse or other relative; consultation with a physician; and self-treatment. In addition, individualized and community-based attempts to change behavior should address emotional responses, such as concern about troubling others; in addition, inappropriate emotional responses characteristic of particular populations, such as embarrassment in Australians and fear of consequences in North Americans, need to be specifically addressed in those countries.
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Table III Delay times (min) according to sociodemographic and clinical characteristics North America
Australia
n
Mean ± SD
n
Mean ± SD
M
198
111 ± 79
95
112 ± 78
F
76
108 ± 71
50
140 ± 92
9
101 ± 84
Sex
Age (y) 29-40
19
66 ± 58*
41-60
132
105 ± 78
49
119 ± 87
61-86
123
122 ± 82
84
125 ± 83
201
110 ± 82
102
119 ± 84
61
113 ± 74
38
128 ± 819
<$20,000
57
136 ± 92†
60
135 ± 86‡
≥$20,000
171
103 ± 74
76
113 ± 84
≤12
142
114 ± 81
99
139 ± 90‡
>12
125
109 ± 79
46
83 ± 51
Yes
116
111 ± 74
61
143 ± 87‡
No
152
108 ± 82
78
107 ± 76
Yes
41
136 ± 92†
22
154 ± 84‡
No
226
105 ± 75
115
117 ± 82
Yes
82
113 ± 86
57
129 ± 88
No
186
108 ± 75
82
119 ± 79
Yes
40
97 ± 84
40
127 ± 83
No
228
111 ± 77
99
121 ± 83
Present marital status Married Not married Income
Education (y)§
History of hypertension
Diabetes
History of angina
Previous AMI
*Significant differences for North America compared with both other age groups (P ≤.05). †Significant differences for North America (P ≤.05). ‡Significant differences for Australia (P ≤.05). §Significant interaction between country and education (F = 7.17, P <.01).
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Table IV Delay times (min) according to social factors North America
Australia
n
Mean ± SD
n
Mean ± SD
Home
170
119 ± 79*
98
130 ± 83†
Outside home
102
95 ± 78
49
107 ± 85
Alone
104
104 ± 73
52
132 ± 84
Spouse or family member
127
116 ± 80
77
120 ± 83
Coworker, friend, or other
46
108 ± 88
18
103 ± 88
Suggested seeking help or called for help 88
101 ± 75
60
129 ± 93
Other behavior
114 ± 80
87
117 ± 76
Setting where symptoms occurred
Witness to symptom onset
Response of others to symptom onset 189
*Significant differences for North America (P ≤.05). †Significant differences for Australia (P ≤.05).
The finding that lower levels of education were associated with substantially longer delay times for Australian patients is notable, particularly in the group of patients studied here who went to the hospital relatively promptly (ie, within 6 hours of symptom onset). Research from other countries has shown that lower socioeconomic status is associated with delays in the decision to seek treatment,19,23 and patients with fewer years of education are likely to be those with lower incomes. In the Australian AMI population, income has been found to correlate with less education and been eliminated by education levels in a multiple regression analysis.12 Inconsistencies in findings were noted about effect of educational levels and other sociodemographic factors on delay times,30 to which this study adds. Zerwic30 comments that this lack of clarity is a function of differences in sample size and study design. Regardless, it would be sound to target this section of the Australian population with messages about seeking treatment presented in a manner that is sensitive to their educational levels. One potentially important difference in patients’ decisions to seek medical care for AMI symptoms is the system of payment for medical care. In the
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United States, sources and levels of health insurance cover vary, and some people have little or no coverage; in other countries, including Australia, all citizens are covered by universal health care insurance, paid for by a taxation levy. They therefore are not charged again for hospital care received in predominantly public hospital systems. In this study the length of time Australians delayed was not increased because of fear of the consequences of seeking help, as it was for North Americans. The study questionnaire did not elicit information about the nature of fears patients had about seeking help, but concerns about the financial burden of medical care and hospitalization are likely to be prominent (together with concerns about death and disability). Such an interpretation is consistent with other research suggesting that access to care has a greater influence on response to symptoms than does ethnic status,19,23 but additional investigation of cultural differences as potential contributors to delay in treatment is warranted.
Promoting treatment-seeking behavior The Leventhal self-regulatory model of illness behavior,31-33 which has been used to study treat-
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Table V Delay times (min) and symptom appraisal North America
Australia
n
Mean ± SD
n
Mean ± SD
1-7
105
107 ± 70
66
123 ± 86
8-10
162
112 ± 84
75
121 ± 83
Yes
74
130 ± 90*
56
143 ± 92
No
152
100 ± 74
90
110 ± 75
Not serious
112
123 ± 83*
54
145 ± 86†
Serious
159
102 ± 76
91
111 ± 80
72
113 ± 84
Pain severity
Assessed symptoms as intermittent
Appraisal of symptom seriousness
Symptom attribution Heart
90
96 ± 72*
Other
183
118 ± 81
74
129 ± 83
Yes
137
108 ± 80
63
103 ± 62
No
86
117 ± 83
83
138 ± 94
66
118 ± 78
Had knowledge of MI symptoms
Recognized symptoms as heart symptoms Yes
124
99 ± 75*
No
110
121 ± 82
80
127 ± 88
Yes
107
99 ± 76
50
101 ± 60
No
121
121 ± 82
95
134 ± 92
Yes
192
120 ± 81*
98
138 ± 90†
No
53
79 ± 62
48
93 ± 57
Yes
32
124 ± 98
39
162 ± 101†
No
193
107 ± 75
107
108 ± 71
Yes
101
131 ± 86*
78
151 ± 94†
No
127
94 ± 69
68
90 ± 54
Yes
97
124 ± 85*
89
129 ± 87
No
125
99 ± 73
56
110 ± 73
Realized the importance of symptoms
Waited for symptoms to go away
Was embarrassed to seek help
Worried about troubling others so did not seek help
Feared consequences of seeking help
*Significant differences for North America (P ≤.05). †Significant differences for Australia (P ≤.05).
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ment-seeking behavior in response to symptoms, provides a coherent framework for interpreting the problem of delayed treatment of AMI symptoms. The self-regulatory model proposes that 3 stages regulate the behavior seen in response to a health threat. Each stage has a perceptual level and a cognitive level. The first stage, cognitive representation of the health threat, includes identifying the symptoms and labeling the threat, potential cause(s), and possible consequences of the threat. The second stage is the action plan or coping stage in which a plan of action is formulated and initiated. The motivation to engage in coping actions is self-generated in response to the individual’s representation of the health threat, the possibilities for coping, and the relationship between coping and threat.34,35 In the third stage the individual appraises the success of his or her coping actions, and if it is perceived that there is not enough progress, the representation of the problem (objective and perceptual) and the plans to cope with it are reassessed and may be changed. Coping plans are also generated to control the emotional experiences provoked at any stage of the response to the health threat. Thus there is a “danger control process” for the objectively represented health threat and an “emotion control process” for the subjectively represented emotional response to the health threat.34 Leventhal and colleagues34,35 have shown that the processes of coping with emotional reactions may be parallel to, but partially independent of, the cognitive processes of coping with the health threat. At the cognitive level, the representation of the health threat relies on objective knowledge, such as labels for illnesses, and the coping action is primarily one that is controlled. Perception of the health threat relies on subjective knowledge acquired through past personal experiences, such as prior illnesses, and the coping response is primarily automatic. The controlled and automatic coping processes may interact in ways that are mutually facilitating or mutually interfering.35 The findings of the current study and other research into patients’ responses to AMI symptoms can be better understood in the context of the Leventhal self-regulatory model of illness behavior. For example, cognitive representation of the problem as a possible AMI may be delayed when symptoms are intermittent, not considered serious, or not attributed to the heart. Even when there is cognitive representation of the symptoms as a serious health threat related to the heart, the emotional concerns about troubling others, embarrassment,
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or fear of the consequences of seeking help may lead to an initial decision not to seek medical attention, which is subsequently appraised as an unsuccessful action plan. The plan is revised and help is sought. In the present study the most frequent initial response to symptoms could be characterized as automatic in response to emotions, whereas objective controlled action was initially taken by few. Knowledge of the nature and seriousness of cardiac symptoms was again found to be an important factor for some patients in their decisions to delay, even though patients with medical histories of angina and previous AMI, who were therefore likely to be familiar with the symptoms, did not go to the hospital substantially sooner. This is also consistent with automatic emotional responses to the symptoms interfering with a controlled response on the basis of knowledge. Alonzo36 attributes the emotional response that contributes to these patients’ delay to the cumulative trauma of repeated AMI and other cardiovascular comorbidities, which leads to a form of posttraumatic stress disorder. Mass media campaigns aimed at increasing public knowledge in North America,37 and again recently in Australia,38 have been shown to make little or no difference in delay times. They are effective during their execution at reducing delays in going to the hospital with symptoms of AMI and increasing thrombolysis administration rates,17 but the effects do not persist beyond the campaign. This limitation of mass campaigns was evident in a recent study that combined mass media with direct mail, including messages aimed at social and emotional responses, because delay times were not reduced.39 An alternative to mass campaigns with potential to have some effect on this problem is more personalized programs for people at high risk for coronary artery disease. Leventhal’s35 self-regulatory model of illness behavior offers a sound theoretical framework for planning interventions in which patients and their partners are assisted in recognizing the diversity of symptoms of an evolving AMI, anticipating their response to symptoms, rehearsing appropriate behaviors, and appreciating the rewards of seeking help early, as recommended by the US National Heart Attack Alert Program.40 These strategies address the cognitive representation of the threat and the emotional reaction to it, promote a controlled coping response rather than an automatic emotional response, and emphasize the possibilities of successfully coping with the health threat. The inclusion of partners in the pro-
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gram addresses an important environmental factor that can stimulate appropriate action in response to AMI symptoms. The current study was limited to patients who sought treatment relatively quickly. Nevertheless, it shows that cognitive and emotional responses and social factors are important in patient decision making about responding to symptoms of an evolving AMI and that there may be different influences on decision making in different countries. The results of the study combined with Leventhal’s self-regulatory model of illness behavior reinforce the importance of considering the contribution of cognitive and emotional factors to delays in seeking treatment, in addition to clinical and sociodemographic factors. The study also provides evidence that emotional responses specific to national cultures should be considered in strategies aimed at prompt treatment-seeking behavior for AMI symptoms.
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