The effect of a short one-on-one nursing intervention on knowledge, attitudes and beliefs related to response to acute coronary syndrome in people with coronary heart disease: A randomized controlled trial

Abstract

Background

Coronary heart disease (CHD) and acute coronary syndrome (ACS) remain significant public health problems. The effect of ACS on mortality and morbidity is largely dependent on the time from symptom onset to the time of reperfusion, but patient delay in presenting for treatment is the main reason timely reperfusion is not received.

Objectives

We tested the effect of an education and counseling intervention on knowledge, attitudes and beliefs about ACS symptoms and the appropriate response to symptoms, and identified patient characteristics associated with changes in knowledge, attitudes and beliefs over time.

Methods

We conducted a two-group randomized controlled trial in 3522 people with CHD. The intervention group received a 40 min, one-on-one education and counseling session. The control group received usual care. Knowledge, attitudes and beliefs were measured at baseline, 3 and 12 months using the ACS Response Index and analyzed with repeated measures analysis of variance.

Results

Knowledge, attitudes and beliefs scores increased significantly from baseline in the intervention group compared to the control group at 3 months, and these differences were sustained at 12 months (p = .0005 for all). Higher perceived control over cardiac illness was associated with more positive attitudes (p < .0005) and higher state anxiety was associated with lower levels of knowledge (p < .05), attitudes (p < .05) and beliefs (p < .0005).

Conclusion

A relatively short education and counseling intervention increased knowledge, attitudes and beliefs about ACS and response to ACS symptoms in individuals with CHD. Higher perceived control over cardiac illness was associated with more positive attitudes and higher state anxiety was associated with lower levels of knowledge, attitudes and beliefs about responding to the health threat of possible ACS.

Introduction

Coronary heart disease (CHD) remains a significant public health problem in the developed world. In 2004 in the United States (US) 15.8 million adults had CHD; it is estimated that in 1 year 700,000 Americans will have an acute myocardial infarction (AMI), and approximately 38% of those will die within a year (Rosamond et al., 2008). In-hospital mortality for AMI approaches 5% (Fox et al., 2007).

The effect of an AMI on mortality is largely dependent on the time from symptom onset to the time of reperfusion. Reperfusion therapy with either percutaneous coronary intervention or fibrinolytic drugs leads to lower mortality and fewer complications (Asseburg et al., 2007). Maximum benefit is achieved when reperfusion is performed in acute coronary syndrome (ACS) within 60 min of symptom onset (Moser et al., 2006). The benefit from both reperfusion techniques decreases markedly if they are received more than 3 h after symptom onset, although there may be some benefit up to 12 h after symptoms start (Ting et al., 2006).

The largest contributor to delayed time to receipt of reperfusion for ACS is patient delay in recognizing symptoms and deciding to seek treatment, in contrast to time of transport to a hospital and time from arrival at the hospital to commencement of reperfusion, both of which are quite short by comparison (Moser et al., 2006, Newby et al., 1996, Dracup et al., 1997). Patient delay times remain unacceptably long in the US and in other countries, with times of greater than 4 h for 40% or more of patients (McGinn et al., 2005, McKinley et al., 2004, Isaksson et al., 2008). Most studies of interventions to reduce delay in response to ACS symptoms have focussed on mass media campaigns and have shown modest success at best (Kainth et al., 2004). In one study, the Rapid Early Action for Coronary Treatment (REACT) trial, members of the community received one-on-one education primarily from their local health care providers, as well as other strategies (Raczynski et al., 1999), again with limited success (Luepker et al., 2000). In an effort to reduce patient prehospital delay times, we conducted a randomized controlled trial of a novel one-on-one education and counseling intervention designed for patients at risk for AMI, with the primary aim of promoting timely response to symptoms and reducing delay times over the 2-year period of follow-up (Dracup et al., 2006). A secondary aim, reported here, was to investigate the effect of the study intervention on knowledge, attitudes and beliefs about heart disease and ACS symptoms. The specific objectives in relation to this aim were (1) To compare knowledge, attitudes and beliefs about ACS and ACS symptoms, and the appropriate response to symptoms, at 3 and 12 months in patients at risk of ACS who received the educational and counseling intervention, and those who did not receive the intervention; (2) To identify patient characteristics associated with differences between the intervention and control groups in knowledge, attitudes and beliefs up to 12 months after enrolment in the study.