Primary Prevention Study
RCN RESEARCH SOCIETY AKINSANYA AWARD
ENGAGING FAMILIES WITH A PREMATURE FAMILY HISTORY OF HEART DISEASE:
A PRIMARY PREVENTION STUDY FOR CORONARY HEART DISEASE
Background
Coronary heart disease (CHD) is the commonest cause of death in the United Kingdom (UK)
(Allender et al., 2007). Mortality rates from CHD, in the UK, have been falling since the 1970s
(Petersen et al., 2005), but morbidity rates are increasing (Allender et al., 2007). The Impact model
proved that 40% of the mortality decline is attributable to medication and interventions, while 51%
is attributable to improving lifestyle (Capewell et al., 1999). UK primary prevention studies
showed that risk reduction achievable in a clinical setting is limited, especially when matched
against cost (Wood et al., 1994; OXCHECK Study Group 1995; Hilton et al., 1999).
Since premature family history (PFH) of heart disease was acknowledged to be an independent
risk factor for CHD, inclusion of this population in preventative management for CHD has been
recommended (CHD NSF 2000; Wood et al., 2005). However, preventative studies involving this
population has been limited (Kavanagh et al., 2000; Becker et al., 2005; Tonstad et al., 2005; Wood
et al., 2004), while qualitative research looking specifically at the experience of family members
with a PFH of CHD has not been undertaken.
Aims
This research study had two aims; firstly to understand the experience of individuals when their
parent or sibling had been diagnosed with heart disease; secondly to develop and evaluate a
nurse-led primary prevention health promotion programme for these people.
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Primary Prevention Study
Methods
There were three phases to the study; phase one, narrative interviews; phase two, the two year
health promotion programme; phase three, evaluation. The study was conducted in a district
general hospital where 28 people were recruited of whom 20 participants completed the two year
study. Non-probability sampling was used; patients with premature CHD (before the age of 55
years for men, and 65 years for women) were identified during their treatment in the hospital.
Their first-degree relatives (siblings and adult children), with no personal history of CHD, were
invited to participate in the study.
The health promotion programme was nurse-led and doctor supported. Education and support
was provided in the programme for individuals and families, and the transtheoretical model
(Prochaska et al., 1992) was used to assess participant’s readiness to change in relation to specific
behaviours. The participants’ physical and behavioural changes were reviewed ever six months,
for two years.
FIGURE 1 The health promotion programme
Education for CHD
→ epidemiology
→ overview
→ explanation
→ risk factors
Lifestyle assessment
- alcohol intake: blood pressure,
heart rate: blood lipids and
glucose: diet: physical
measurements: physical activity:
smoking: stress.
Lifestyle options
& medical care
(referrals, investigations,
medication)
Participant
Choosing health
Personalisation
→ advice
→ support
→ encouragement
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Primary Prevention Study
The design for the research was case study and narrative. Data from each phase of the study was
collected, as detailed in figure 2. Salutogenesis (Antonovsky 1987), which focuses on the causes of
health and well-being, was the theoretical framework in which the narratives were discussed and
theory generated.
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Primary Prevention Study
FIGURE 2 Study data for each phase
-
Sex
Age
Social Class
Travel Distance
Time since
diagnosis
Family Mapping
Demographics
Phase 1
Narrative 1
Lifestyle Data
-
Base line
Interim (1 yr)
Final
-
Alcohol
Cardiovascular
Lipid Profile
Glucose
Exercise Grading
Physical measurements
Smoking
Psychosocial Stress
Phase 2
Personal Data
Qualitative
behaviour data
-
medical history
medication
referrals
other
Narrative 2
Phase 3
Evaluation
questionnaires
Salutogenesis – SOC
questionnaire
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Diet
-
Salt
Fruit
Vegetables
Fluids
Carbohydrates
Fats
Primary Prevention Study
Results
The narratives show how people are aware of risk factors associated with heart disease, but still
seek professional support and advice in relation to their own lifestyle and behaviour. Individual
lifestyle changes were achieved by most participants, which translated into significant findings for
blood pressure and alcohol consumption; positive changes were seen in physical activity, smoking,
diet and psychosocial stress. There were some improvements in individual lipid profiles. The
importance of the acute event in motivating people to make positive lifestyle changes, and the key
roles of family, friends and health professionals in this process of change and maintenance, is
identified from the narratives.
Conclusion
Collating individual changes during the programme showed that 72 positive changes were
achieved. These changes may, for some, only have been small. However, as recommended by the
Government initiative ‘Small changes, big difference,’ (DH 2006) which is based upon the research
of Professor Khaw (Khaw et al., 2008), these small but combined changes can result in substantial
long-term health improvements.
Factors identified from the narratives can be seen as health promoting resources (Antonovsky
1990) which can be used by nurses in their consultations. A salutogenic orientation to health
promotion ensures that a holistic approach is adopted. Nurses can help people come to terms with
this familial diagnosis, providing advice and support for individuals and their families, in order
for them to achieve a healthy lifestyle.
Discussion and Contribution
The narratives provided insight into the experience of people living with a PFH of CHD. Health
resources were identified which could enhance progress and maintenance of a healthy lifestyle.
Through screening these high-risk people and involving them in a health promotion programme,
their own risk profile can be improved and their future chances of developing cardiovascular
diseases reduced.
Key issues which illustrate the unique contribution of this research:
-
by analysing the experience of these people, health resources have been identified
which may be used to enhance the clinical encounter.
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Primary Prevention Study
-
this is a high risk group of people who have seldom been the focus for research, yet the
familial cardiovascular diagnosis is rarely a new one.
-
participation in a two year health promotion programme can result in positive changes,
leading to healthier lifestyles.
-
salutogenesis can be used as an approach to cardiovascular health promotion.
-
smoking and physical activity assessment scores have been developed which, as a
standard data collection tool, can ensure parity of audit data collected in clinical
practice.
-
this screening technique and health promotion programme can be extended to include
additional premature cardiovascular diseases.
-
nurses can play a key role in improving the knowledge and subsequent health
behaviours of people at high-risk from developing CHD and cardiovascular disease.
The thesis discusses the need for a preventative approach in health care, which includes
primordial and primary prevention. The issues are reflective upon current government focus to
develop preventative health services which actively engage people in health management.
Cardiovascular Prevention Programme
Funding has been awarded for two years to establish a nurse-led prevention clinic for first–degree
relatives of patients diagnosed with premature cardiovascular disease. The health promotion
programme remains the same as the one established in the thesis and screening has been extended
in order that the service receives referrals from the spectrum of cardiovascular specialists.
References
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Antonovsky, A. (1987) Unravelling the Mystery of Health. How People Manage Stress and Stay Well, 1st edn. Josey-Bass, London
Antonovsky, A. (1990) Studying Health Vs. Studying Disease. Congress for Clinical Psychology and Psychotherapy. Conference Proceeding
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Department of Health (2006) Small changes, big difference
http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Smallchangebigdifference/DH_4134038.
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