Afflicted by an acute myocardial infarction : patients' thoughts, feelings and actions prior to care-seeking

Sammanfattning: Introduction: Acute myocardial infarction (AMI) is the most prevalent cause of death in Europe. The primary aim of early medical contact when afflicted by an AMI is to be able to treat fatal arrhythmias and to save heart muscle and thereby decreasing morbidity and mortality. In Sweden, the delay from symptom onset to medical treatment has decreased over time, with a currant median delay time of 170 min. This means that almost half of the patients have a longer delay than three hours. Huge efforts to improve pre-hospital care have been performed. However, the initial patient delay seems hard to counteract. Aim: The overall aim of this thesis was to increase the knowledge of patients’ behavioural responses that may influence the decision to seek medical care when afflicted by an acute myocardial infarction. Methods: Studies I and II have a qualitative design using focus group discussions and semi-structured individual interviews respectively as data collection methods. The analysis of the group discussion data was conducted using a theoretical model – the Self-Regulatory Model of illness behaviour. The interview data was analysed using qualitative content analysis. Study III had a cross-sectional design with development and psychometric testing of the Patients’ Appraisal, emotions and action tendencies (PA-AMI) questionnaire. The questionnaire was validated using exploratory factor analysis and principal component analysis. Study IV had a cross-sectional design using the developed questionnaire (PA-AMI) as data collection method. The impact of the subscales and individual items on patient delay was analysed by Projection to Latent Structures (PLS) regression. Results: Study I showed that patients had difficulty in clarifying the exact time point of symptom onset. A pertinent shift in appraisal was identified, the turning point, when the patients change from self-regulative illness behaviour to care-seeking. This shift seems to be affected by several partly contradictory influences and it takes a considerable time for the patients to reach this point. Study II showed that patients’ emotional reactions are important and may influence the patients’ pre-hospital behaviour. Study III showed satisfactory psychometric properties of the PA-AMI questionnaire. Three core dimensions emerged: ‘symptom appraisal’, ‘perceived inability to act’ and ‘autonomy preservation’. In study IV, the subscales ‘symptom appraisal’ and ‘perceived inability to act’ and their items had a major influence on patient delay. Conclusions: The thesis contributes with knowledge on the influence of patients’ appraisal of symptoms and behavioural responses on patient delay when afflicted by an AMI. It is important that this knowledge should be used in the primary and secondary prevention of patients with risk for, or an already manifest coronary heart disease. An altering in patients’ behavioural response when afflicted by an AMI should have a great potential to reduce patient delay and thereby reduce heart muscle loss and mortality.