| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
ORIGINAL ARTICLES |
From the Department of Health Psychology (K.J.P.), Department of Psychology (L.D.C.), Department of Medicine (C.J.E.), University of Auckland, New Zealand; Centre for Health Care Research (D.B.), University of Brighton, Brighton, and Unit of Psychology (J.W.), Guy’s, King’s, and St. Thomas’ School of Medicine, London, United Kingdom.
Address reprint requests to: Keith J. Petrie, Faculty of Medical and Health Sciences, Department of Health Psychology, The University of Auckland, Private Bag 92019, Auckland, New Zealand. Email: kj.petrie{at}auckland.ac.nz
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
|---|
DESIGN: In a prospective randomized study, 65 consecutive patients with their first MI aged were assigned to receive an intervention designed to alter their perceptions about their MI or usual care from rehabilitation nurses. Patients were assessed in hospital before and after the intervention and at 3 months after discharge from hospital.
RESULTS: The intervention caused significant positive changes in patients’ views of their MI. Patients in the intervention group also reported they were better prepared for leaving hospital (p< .05) and subsequently returned to work at a significantly faster rate than the control group (p< .05). At the 3-month follow-up, patients in the intervention group reported a significantly lower rate of angina symptoms than control subjects (14.3 vs. 39.3, p< .03). There was no significant differences in rehabilitation attendance between the two groups.
CONCLUSIONS: An in-hospital intervention designed to change patients’ illness perceptions can result in improved functional outcome after MI.
Key Words: myocardial infarction • illness perceptions • return to work • disability • rehabilitation
Abbreviations: MI = myocardial infarction;; CHD = coronary heart disease;; IPQ = Illness Perception Questionnaire;; LDL = low density lipoproteins.
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
|---|
Patients’ beliefs and perceptions about their illness are key determinants of recovery after a MI (6). In recent years, many studies investigating patients’ illness beliefs or perceptions have been based on Leventhal’s self-regulatory model (7). This starts from the premise that individuals are active problem solvers who make sense of a threat to their health, such as symptoms or an illness, by developing their own cognitive representation of the threat, which, in turn, determines how they then respond. There is now a convergence of evidence showing that these representations consist of five distinct but interrelated components that serve to define the nature of the health threat for the individual. The identity component comprises the label that the individual uses to describe the condition (eg, heart attack) and the associated symptoms (eg, chest pain, breathlessness), which are linked in a reciprocal way and illustrate the bilevel nature of illness representations (the abstract label and the concrete symptoms). The other linked components of the illness representation are the individual’s beliefs about the cause(s) of their condition and their expectations about its likely duration (timeline), its physical, social, and psychological effects (consequences), and the extent to which it is amenable to cure and/or control. These five components of illness representation form a schema that determines the patient’s coping procedures (eg, adhering or not adhering to medical advice). Patients’ illness representations vary considerably within any illness population; they not only determine the selection of illness-related behavior but also serve as a conceptual framework for making sense of information from health care professionals and for evaluating the appropriateness and efficacy of recommended treatment or advice.
In our earlier work with MI patients, we were able to show that patients’ perceptions of illness, assessed a few days after their MI, had important effects on different aspects of recovery. Those patients who believed that their MI would have more serious long-lasting consequences were found to have greater levels of illness-related disability and were slower to return to work (8). Similarly, those patients who had weaker beliefs in the control or cure of their heart condition were subsequently found to be less likely to attend cardiac rehabilitation (8, 9). In this context it is important to note that patients’ illness representations were not linked to objective indicators of MI severity nor did the latter significantly predict the outcomes that were predicted by illness representations.
The specificity of these belief-behavior links and the fact that they can be identified early on after the onset of the MI is important. Unlike other factors such as personality or sociodemographic variables, these links provide considerable potential for developing cognitively based interventions at an early stage after MI. Thus, if negative thinking about MI can be identified early in the recovery process and an intervention instituted to foster more adaptive models and expectations, then improved levels of functioning and return to work could be expected.
In this study, we tested whether a brief psychological hospital-based intervention designed to change inaccurate and negative illness perceptions of MI would result in an earlier return to work, less long-term disability, and improved cardiac rehabilitation attendance. The intervention was conducted during the normal hospital stay and used first-time MI patients who had not previously been exposed to cardiac care. It used the patient’s model of their illness as a starting point to deliver information. The intervention was specifically structured to change highly negative perceptions and to alter the patient’s views of the timeline and consequences of their MI.
In contrast with other interventions that typically deliver the same behavioral or cognitive intervention to each patient, the present study used an individualized approach in which the content of each patient’s intervention was based on an assessment of their perception of their MI. The latter was achieved by using the Illness Perception Questionnaire, a recently developed measure that assesses the five components of illness representation (10)
|
METHODS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
|---|
After being enrolled in the study, subjects completed the initial questionnaire and were randomly assigned to receive either standard care, which involved cardiac rehabilitation nurse in-hospital visits and standard MI educational material, or three 30- to 40-minute intervention sessions conducted by a psychologist in addition to the routine education material. A further research questionnaire was completed by 62 of the 65 patients before leaving hospital. Patients were contacted at 12 weeks and asked to complete a follow-up mail assessment. This questionnaire was returned by 56 patients (86%), and nonrespondents did not differ significantly from respondents on any baseline variables.
Intervention
The intervention contained a broadly equivalent structure for all patients, but its exact content was also individualized according to patients’ responses on the Illness Perception Questionnaire. The first session consisted of a brief explanation of the pathophysiology of MI, which included the use of drawings to provide a concrete image of the illness as well as an explanation of common MI symptoms and terminology. A distinction was drawn between cardiac and noncardiac symptoms because many patients ascribe all symptoms to their MI.
This session also explored the patient’s beliefs about the cause of the MI. Attention was given to addressing the common misconception that stress was singularly responsible for the patient’s MI and broadening the patient’s causal model by including the importance of lifestyle factors in the etiology of CHD underlying the MI. This was done by asking the patient to think of other factors that may have contributed to the development of the MI apart from stress (such as poor diet, smoking, lack of exercise) to try to expand the patient’s causal model and provide more avenues for future personal control and management of the disease.
The second session built on the causes identified by the patient and focused on developing a plan of minimizing future risk by altering risk factors relevant to the patient and increasing beliefs about control of the condition. This session used data from the patient’s scores on the consequences and time line subscales of the Illness Perception Questionnaire (see below) and focused on these aspects of the patient’s heart disease. Highly negative beliefs about the consequences of the MI, particularly the belief that the patient will need to significantly reduce activities over the long term, were challenged and a recovery action plan was developed personalized to the patient’s own circumstances. For example, the plan included an explicit plan of exercise, dietary change, and return to work tailored to the patient. The linking of the timeline and consequences of the illness was achieved by explaining that, as patients recovered from the illness, they could expect to return to their work and normal activities. The use of a written action plan for self-management has been used in a number of illnesses. A recent systematic review of asthma patients, eg, has shown that patients who had a personalized written plan were more adherent to medication, less likely to be hospitalized, and had better lung function than those who did not have a personalized plan (11).
In the third session, this action plan was reviewed and symptoms of recovery were discussed. Symptoms that are a normal part of the healing and recovery process were distinguished from symptoms that may be warning signs of a further MI. For example, symptoms that may be experienced during exercise, such as slight breathlessness but still being able to speak, were distinguished from symptoms that are not expected, such as severe chest pain. Concerns the patient had about their medication were also explored. The need to take medications consistently and the hazards of relying on symptoms as guides for medications were also discussed in this final session along with concerns about going home.
Measures
In-hospital assessment: IPQ.
On enrolling into the study and at hospital discharge, patients completed the IPQ (10) to assess the identity, time line, consequences, and cure/control dimensions that underlie the patient’s representations of illness. The IPQ provides a quantitative assessment of the nature and strength of their beliefs about each of the components of their illness representation. The identity subscale is the number of symptoms from a 15-item symptom checklist that the patient associates with the illness (scores range from 0 to 15). The timeline subscale contains four items (eg, "My illness is likely to be permanent rather than temporary"), with scores ranging from 4 to 20 and higher scores representing a belief that the illness is going to last for a longer time. The consequences subscale contains nine items (eg, "My illness will have major consequences on my life"), and scores ranged from 9 to 45, with higher scores representing a stronger belief that the illness will have serious consequences. The cure/control subscale contains seven items (eg, "My treatment will be effective in curing my illness," "There is very little that can be done to improve my illness"). Scores ranged from 7 to 35, with higher scores indicating a higher level of belief in control or potential for cure of the illness. Patients also rated their distress about their symptoms on a two-item scale ("The symptoms of my heart condition are distressing to me," "The symptoms of my heart condition are puzzling to me"; r = .82). Scores on this scale ranged from 2 to 10, with higher scores indicating greater distress.
The IPQ has been used quite extensively in different illness populations, including a number of studies of MI patients, and fairly extensive psychometric data have been published for all the subscales. The internal reliability for each subscale is satisfactory, with Cronbach alpha coefficients ranging from .73 to .82 in MI samples (8, 9). Similarly, good test–retest data for each subscale have been obtained in patients with established chronic illness, and a range of concurrent, discriminant, and predictive validity data have been published for different chronic illness groups, including patients with MI (10).
Hospital ratings.
At hospital discharge, patients were also asked to rate on a seven-point scale the following questions: "How satisfied were you with the information you received concerning your heart attack and heart condition?" "How satisfied were you with the amount of information that you received?" "How well do you understood the information given to you about your heart attack and heart condition?" "Do you feel prepared for leaving the hospital and returning to your normal activities and work?" "What extent do you still have questions about your heart attack and heart condition?" "How well do you feel you understand your heart attack and heart condition?" "How likely is it you will attend the rehabilitation program?"
Three-month assessment.
Information about the time taken until return to work was collected in the 3-month questionnaires. At 3 months, 13 control patients and 19 intervention patients who were employed at the time of hospitalization had returned to work and 6 others (3 from each group) who were employed at the time of hospitalization had not returned to work. Delay in return to work was calculated as the number of days from hospital discharge until the first day back to work.
At the 3-month follow-up, patients completed the IPQ and symptom distress scale and were also asked how often they had angina pain in the past week and, on average, how severe the pain was, rated on a seven-point scale from "not at all severe" to "extremely severe." Data on attendance at the six-session outpatient cardiac rehabilitation program were obtained from program records.
Data Analysis
The SPSS for Windows 9 statistical software package was used for all analyses. Treatment group differences in demographic and clinical characteristics were assessed with 
2 tests and one-way analysis of variance. One-way ANOVA was used to assess treatment group differences in baseline illness perception scores and evaluation ratings obtained at the time of discharge. Treatment-group differences in changes in illness perceptions by the time of discharge and at 3 months were assessed using analysis of covariance; in each analysis, the covariate was the baseline measure of the illness perception component in question. The Cox regression model with the forward stepwise procedure was used to identify demographic and medical variables that predict delay in return to work during the 3 months after discharge for the 38 patients who were employed at the time of hospitalization. These variables were then included as covariates in a Cox regression model assessing treatment-group differences in delay in return to work for the 38 employed patients.
|
RESULTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
|---|
2 (1, N= 65) = 9.23, p< .002). Marital/de facto relationship (yes/no) was therefore included as a covariate in preliminary analyses of experimental group differences in illness perceptions, program evaluations, angina symptoms, and return to work. However, it was not a significant covariate for any of these outcome measures and its inclusion did not alter the significance of the experimental group effects, so it was dropped in the final analyses.
|
|
2(1, N= 65) = 2.38, p< .13).
|
2(1, N= 56) = 0.1), NS), but it was positively associated with an anterolateral site of the MI (2(1, N= 56) = 5.96, p< .02) and high LDL levels at baseline (point biserial correlation r= .33, p< .05). Intervention subjects (14.3%) were significantly less likely than control subjects (39.3%) to report angina pain at 3 months (2(1, N= 56) = 4.46, p< .05). A binary logistic regression assessed whether this experimental group difference would remain significant after controlling for the effects of MI site and LDL levels. The three variables were entered simultaneously, and the results revealed a trend for MI site to predict angina pain reports (B= 1.20, SE B= 0.74, Wald (df= 1) = 2.63, p< .10, exp B= 3.32) and a significant effect of LDL levels on angina pain reports (B = 0.84, SE B 0.39, Wald (df= 1) = 4.68, p< .04, exp B = 2.31). This analysis further revealed that, controlling for these two variables, the group effect on angina pain reports was significant (B= 1.96, SE B= 0.88, Wald (df= 1) = 4.89, p< .03, exp B= 7.08). Analysis of pain severity ratings reported by subjects experiencing angina pain revealed no significant difference between intervention subjects (M= 2.50) and control subjects (M= 2.18); t(13) = -0.76, NS.
Preliminary Cox regression analyses individually assessed the significance of each of the demographic and clinical variables (Table 1) in predicting delay in return to work for the patients employed full time before their MI (control N= 16; intervention N= 22). These analyses revealed that delay in return to work was significantly predicted by longer hospital stays and higher triglyceride levels. The final Cox model (2 (3, N= 38) = 11.82, p< .01), which included hospital stay, triglyceride levels, and experimental group, revealed that all three variables were significantly associated with delay in return to work. Consistent with the preliminary analyses, longer length of hospital stay was positively associated with longer delays in return to work (B= -0.18, SE B= 0.06, Wald (df= 1) = 9.21, p< .01, exp B= 0.84). For every additional day spent in hospital, the relative risk of returning to work was .84. Similarly, there was a significant effect of triglyceride levels on delay in return to work (B= -0.29, SE B= 0.14, Wald (df= 1) = 4.15, p< .04, exp B= 0.74). Every increase in triglyceride level by one unit was associated with a relative risk of return to work of .74. Controlling for these factors, the intervention group had a shorter delay in return to work rate (B= -0.80, SE B= 0.40, Wald (df= 1) = 4.03, p = .05, exp B= 0.45). This effect indicates that the estimated rate (risk) of returning to work for the control group was 0.45 times the rate (risk) of returning to work for the intervention group. The addition of treatment group to the model yielded a significant increase in prediction over the model containing only the two covariates (2 (3, N= 38) = 4.18, p< .05). The Cox regression survival curves estimating delay in returning to work for the two groups are shown in Figure 1.
|
|
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
|---|
At 3 months, there was a significant difference between the intervention and control groups in the speed at which patients returned to work. Patients in the intervention group started to return to work earlier, and this difference was maintained over the follow-up period. In addition, the reported rates of angina symptoms were also significantly different between the two groups, with the control group reporting symptoms at a higher frequency. The intervention, while significantly increasing patients’ intentions to go to the rehabilitation program, also resulted in higher attendance at rehabilitation, but this difference did not reach significance in this relatively small sample.
The illness-perception intervention has a number of differences from conventional approaches to improving recovery after MI. Most formal rehabilitation programs after MI are not theoretically based but tend to comprise a number of fixed components, usually including education about cardiac disease as well as advice regarding exercise and lifestyle change. It is not always clear what patient attitudes are being targeted and what components are critical to achieving behavior change. In contrast, the illness perception program used the patient’s view of his/her illness as a starting point for the intervention and built the material around these existing perceptions. Illness perceptions provide both an initial target for change and a way of evaluating the effectiveness of the intervention, as we know that these beliefs are related to later recovery of function and behavioral change (8, 12).
The reduction of angina symptoms in the intervention group is an interesting finding. Note that reported angina pain may represent chest pain due to cardiac or noncardiac origin. Fewer angina symptoms may be due to the lower level of worry about symptoms in the intervention group or may be associated indirectly through the higher levels of confidence and work functioning in this group. The frequency of chest pain does seem to be critical in the decision to return to work (5), so the time spent in the intervention discussing symptoms expected during recovery may have normalized the symptom experience for patients in the intervention group.
This intervention differs from normal cardiac rehabilitation programs in that it is conducted within the patient’s normal hospital stay. We believe this has a number of therapeutic advantages. First, previous research suggests patients’ perceptions of their MI are already developed before hospitalization, possibly from previous contact with MI patients or from media depictions of MI (8). The hospital intervention allows for misperceptions and negative beliefs to be modified early in the recovery process. Second, immediately after a major illness or health threat, such as a heart attack, individuals are often more amenable to interventions that encourage changes in behaviors. During this window of vulnerability, future risks are seen less optimistically and individuals are more receptive to change (13). Third, many patients with high levels of risk factors for future MI fail to attend outpatient rehabilitation program and so do not get exposed to a formal intervention process. Although an outpatient cardiac rehabilitation service is available to Auckland Hospital patients, a recent audit found 56% of patients did not attend any session and only 19% completed the six sessions (14).
Generalization from this study is limited by a small sample size and by the postal nature of the follow-up assessment. The focus of this study is on illness perceptions and return to work rather than quality of life and depression after MI, and the effect of the intervention on these outcomes needs to be evaluated in future research. Furthermore, the importance of individual differences such as anxiety level in the response to the intervention is also an area that needs further work.
This study suggests that an inpatient intervention program designed to change behavior by altering patients’ illness perceptions of MI has considerable potential to reduce work-related disability. The intervention is acceptable to patients and results in patients feeling better prepared for leaving hospital. It also appears to be compatible with other aspects of inpatient MI treatment. Furthermore, this approach provides a theoretical framework within which inpatient rehabilitation efforts can be directed and evaluated. Further work is needed to evaluate the extent to which the illness perception approach may be usefully incorporated into current hospital treatment regimens for MI patients to complement existing rehabilitation programs.
|
ACKNOWLEDGMENTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
|---|
Received for publication December 5, 2000.
Revision received July 20, 2001.
|
REFERENCES |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
|---|
This article has been cited by other articles:
 |
|
 |
|
  L. Plug, B. Sharrack, and M. Reuber Seizure, Fit or Attack? The Use of Diagnostic Labels by Patients with Epileptic or Non-epileptic Seizures Applied Linguistics, February 1, 2010; 31(1): 94 - 114. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Giri, J. Poole, P. Nightingale, and A. Robertson Perceptions of illness and their impact on sickness absence Occup. Med., December 1, 2009; 59(8): 550 - 555. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. Williams and L. Cameron Images in health care: potential and problems J Health Serv Res Policy, October 1, 2009; 14(4): 251 - 254. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. van Dijk, M. Scharloo, A. A. Kaptein, M. S. Y. Thong, E. W. Boeschoten, D. C. Grootendorst, R. T. Krediet, F. W. Dekker, and for the NECOSAD Study Group Patients' representations of their end-stage renal disease: relation with mortality Nephrol. Dial. Transplant., October 1, 2009; 24(10): 3183 - 3185. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. K. McCorry, M. Dempster, C. Clarke, and R. Doyle Adjusting to Life After Esophagectomy: The Experience of Survivors and Carers Qual Health Res, October 1, 2009; 19(10): 1485 - 1494. [Abstract] [PDF]
|
|
|
|
 |
|
 G. J. Molloy, C. Gao, D. W. Johnston, M. Johnston, M. D. Witham, A. D. Struthers, and M. E.T. McMurdo Adherence to angiotensin-converting-enzyme inhibitors and illness beliefs in older heart failure patients Eur J Heart Fail, July 1, 2009; 11(7): 715 - 720. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Halford and T. Brown Cognitive-behavioural therapy as an adjunctive treatment in chronic physical illness Adv. Psychiatr. Treat., July 1, 2009; 15(4): 306 - 317. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. A. Kaptein and A. C. Lyons The Doctor, the Breath and Thomas Bernhard: Using Novels in Health Psychology J Health Psychol, March 1, 2009; 14(2): 161 - 170. [Abstract] [PDF]
|
|
|
|
|
|
M. S. Y. Thong, S. van Dijk, M. Noordzij, E. W. Boeschoten, R. T. Krediet, F. W. Dekker, A. A. Kaptein, and for the NECOSAD Study Group Symptom clusters in incident dialysis patients: associations with clinical variables and quality of life Nephrol. Dial. Transplant., January 1, 2009; 24(1): 225 - 230. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. Stafford, H. J. Jackson, and M. Berk Illness Beliefs About Heart Disease and Adherence to Secondary Prevention Regimens Psychosom Med, October 1, 2008; 70(8): 942 - 948. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N Robertson, N Javed, N J Samani, and K Khunti Psychological morbidity and illness appraisals of patients with cardiac and non-cardiac chest pain attending a rapid access chest pain clinic: a longitudinal cohort study Heart, March 1, 2008; 94(3): e12 - e12. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): e1 - e157. [Full Text] [PDF]
|
|
|
|
|
|
J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): 652 - 726. [Full Text] [PDF]
|
|
|
|
 |
|
 E. D. Hale, G. J. Treharne, and G. D. Kitas The Common-Sense Model of self-regulation of health and illness: how can we use it to understand and respond to our patients' needs? Rheumatology, June 1, 2007; 46(6): 904 - 906. [Full Text] [PDF]
|
|
|
|
 |
|
 M. R. Rose and J. Weinman Quality of life: Listen to, change, or shoot the messenger? Neurology, April 3, 2007; 68(14): 1095 - 1096. [Full Text] [PDF]
|
|
|
|
 |
|
 M J Fischer, M Scharloo, J J Abbink, A Thijs-Van, A Rudolphus, L Snoei, J A Weinman, and A A Kaptein Participation and drop-out in pulmonary rehabilitation: a qualitative analysis of the patient's perspective Clinical Rehabilitation, March 1, 2007; 21(3): 212 - 221. [Abstract] [PDF]
|
|
|
|
|
|
A F Cooper, J Weinman, M Hankins, G Jackson, and R Horne Assessing patients' beliefs about cardiac rehabilitation as a basis for predicting attendance after acute myocardial infarction Heart, January 1, 2007; 93(1): 53 - 58. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. M. DICKENS, L. McGOWAN, C. PERCIVAL, B. TOMENSON, L. COTTER, A. HEAGERTY, and F. H. CREED Contribution of depression and anxiety to impaired health-related quality of life following first myocardial infarction The British Journal of Psychiatry, October 1, 2006; 189(4): 367 - 372. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Frostholm, P. Fink, E. Oernboel, K. S. Christensen, T. Toft, F. Olesen, and J. Weinman The Uncertain Consultation and Patient Satisfaction: The Impact of Patients' Illness Perceptions and a Randomized Controlled Trial on the Training of Physicians' Communication Skills Psychosom Med, November 1, 2005; 67(6): 897 - 905. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Frostholm, P. Fink, K. S. Christensen, T. Toft, E. Oernboel, F. Olesen, and J. Weinman The Patients' Illness Perceptions and the Use of Primary Health Care Psychosom Med, November 1, 2005; 67(6): 997 - 1005. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Dunning, C. Heath, and J. M. Suls Flawed Self-Assessment: Implications for Health, Education, and the Workplace Psychological Science in the Public Interest, December 1, 2004; 5(3): 69 - 106. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. W. Ketterer, G. Mahr, J. J. Cao, M. Hudson, S. Smith, and W. Knysz What's "Unstable" in Unstable Angina? Psychosomatics, June 1, 2004; 45(3): 185 - 196. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S Newman Engaging patients in managing their cardiovascular health Heart, June 1, 2004; 90(suppl_4): iv9 - iv13. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 U. Schnyder, H. Moergeli, R. Klaghofer, T. Sensky, and S. Buchi Does Patient Cognition Predict Time Off From Work After Life-Threatening Accidents? Am J Psychiatry, November 1, 2003; 160(11): 2025 - 2031. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A.-M. Biggs, Q. Aziz, B. Tomenson, and F. Creed Do Childhood Adversity and Recent Social Stress Predict Health Care Use in Patients Presenting With Upper Abdominal or Chest Pain? Psychosom Med, November 1, 2003; 65(6): 1020 - 1028. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S Newman The psychological perspective: a professional view Heart, May 1, 2003; 89(90002): ii16 - 18. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 OTHER ARTICLES NOTED (Nov 01 to 18 Oct 02) Evid. Based Nurs., January 1, 2003; 6(1): e1 - 1. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
