Doctor of Philosophy

dissertationThis investigation sought to determine if a nursing intervention with first degree relatives (children, siblings, parents, and spouses) of victims of sudden cardiac death would promote change in high risk behaviors for coronary heart disease. The Nursing; intervention strategy was designed to assess, inform/educate and provide emotional support regarding familial/genetic risk factors, cardiovascular behavioral risk factors, and health beliefs. The study design was a two group experimental design using repeated measures of health beliefs and health behaviors with random assignment of subjects into groups. The sample consisted of 58 first degree relatives of sudden death victims referred for autopsy by the County Coroner. The outcome measures included changes in health beliefs, health behaviors and whether or not subjects elected screening for blood pressure and serum cholesterol. Approximately 65%, or 12 of 16 families demonstrated familial aggregation of cardiac diseases. Analysis of covariance was used to determine health behavior, health beliefs, and knowledge differences between groups on health beliefs. There were significant differences between sibling groups on how susceptible they reported their children to be to cardiac disease and how serious they perceived cardiac disease to be. Health habit differences included significant reductions in the experimental group on alcohol and meat consumption. There were no statistically significant group differences on knowledge, although the experimental group increased in knowledge while the control remained the same. Seventy-six percent of the experimental group did have blood pressure screening compared to 57% in the control. In the experimental group, 27% had serum cholesterol screening compared to 14% of the control group. Qualitative data were collected on the events leading to death for the sudden death victim, risk factors associated with sudden death, and the family member's perceptions of sudden cardiac death. Nursing intervention made a difference for experimental siblings (the highest risk group) on health beliefs (increased perceived susceptibility and severity) health behaviors (alcohol and meat consumption) and screening for blood pressure and serum cholesterol. Primary preventive intervention holds promise for reduction of cardiovascular mortality

Women and pre-hospital delays associated with myocardial infarction

The purposes of this study were to: (a) describe the prodromal and acute symptoms of myocardial infarction (MI) in women and the relationship to delays in seeking treatment, (b) comprehensively examine other factors associated with delays, and (c) explore novel concepts in relation to delay, such as temporal orientation, time duration estimation, and impulsivity. The theory of unpleasant symptoms served as the framework for this investigation. A cross-sectional, correlational, non-experimental research design was used. Fifty-six women (85% White, 11% Black, and 5% Native American) were recruited that had been discharged with an MI from a hospital in the southeastern United States. The women were interviewed either in person or by telephone using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS), a demographic data tool, the Time Orientation Scale, and the Barrett Impulsivity Scale 11 (BIS-11). The mean age was 70.2 (SD+11), with a range from37-92. The majority of the sample were currently unmarried (70%), unemployed (79%), and experiencing their first MI (79%). The median delay was 60 minutes, but delays ranged from 10 -20,160 minutes. Age was negatively correlated with symptom scores, with older women reporting lower scores. There was no correlation between symptom scores and delay. Similarly, there was no correlation between the symptom scores and impulsivity. There was no difference in the symptom scores between women who were present oriented and those who were future oriented. The patient’s reported delay in seeking treatment was positively correlated with the duration recorded in the medical record, except for those women who perceived their symptoms life-threating. Thus, perceived threat affected time duration estimation retrospectively. Women who perceived their symptoms as life-threatening delayed longer than those who did not and also underestimated their delays when compared with the delays recorded in the medical record. Age was the only predictor of all symptom score (prodromal, acute and total). None of the regression models were statistically significant for symptom scores predicting delay in this study. Age, race, first-degree relative with MI, modifiable risk factors, temporal orientation, or impulsivity were also not predictors of delay. Future research should investigate factors related to delay in men and women in rural and urban settings

Determinants of achieved LDL cholesterol and "Non-HDL" cholesterol in the management of dyslipidemias

Purpose of Review: The advent of combination therapy to provide LDL lowering beyond that achieved with statins necessitates the development of greater understanding of how drugs work together, what changes occur in key lipoprotein fractions, and what residual risk remains. Recent Findings: Clinical trials of agents that, when added to statins, generate profound LDL lowering have been successful in reducing further the risk of cardiovascular disease. LDL cholesterol can be now decreased to unprecedented levels, so the focus of attention then shifts to other apolipoprotein B-containing, atherogenic lipoprotein classes such as lipoprotein(a) and remnants of the metabolism of triglyceride-rich particles. “Non-HDL cholesterol” is used increasingly (especially if measured in the non-fasting state) as a more comprehensive index of risk. Summary: Metabolic studies reveal how current drugs act in combination to achieve profound lipid lowering. However, care is needed in interpreting achieved LDLc and non-HDLc levels in the emerging treatment paradigm

Predicting Self-Management Behaviors in Familial Hypercholesterolemia Using an Integrated Theoretical Model: the Impact of Beliefs About Illnesses and Beliefs About Behaviors

Patients with familial hypercholesterolemia (FH) are at markedly increased risk of coronary artery disease. Regular participation in three self-management behaviors, physical activity, healthy eating, and adherence to medication, can significantly reduce this risk in FH patients. We aimed to predict intentions to engage in these self-management behaviors in FH patients using a multi-theory, integrated model that makes the distinction between beliefs about illness and beliefs about self-management behaviors. Methods: Using a cross-sectional, correlational design, patients (N = 110) diagnosed with FH from a clinic in Perth, Western Australia, self-completed a questionnaire that measured constructs from three health behavior theories: the common sense model of illness representations (serious consequences, timeline, personal control, treatment control, illness coherence, emotional representations); theory of planned behavior (attitudes, subjective norms, perceived behavioral control); and social cognitive theory (self-efficacy). Results: Structural equation models for each self-management behavior revealed consistent and statistically significant effects of attitudes on intentions across the three behaviors. Subjective norms predicted intentions for health eating only and self-efficacy predicted intentions for physical activity only. There were no effects for the perceived behavioral control and common sense model constructs in any model. Conclusions: Attitudes feature prominently in determining intentions to engage in self-management behaviors in FH patients. The prominence of these attitudinal beliefs about self-management behaviors, as opposed to illness beliefs, suggest that addressing these beliefs may be a priority in the management of FH

Primary prevention of atherosclerosis and obesity in young adults using dietary and educational interventions

The purpose of the studies presented in this dissertation was to examine specific dietary and educational strategies to prevent atherosclerosis and obesity in young adults. The first study determined the effect of a single daily dose of soybean phytosterols added to ground beef on plasma total cholesterol total and LDL cholesterol concentrations in mildly hypercholesterolemic young men. In a 4-week study, 34 male college students were randomly assigned to the control (ground beef alone) or treatment (ground beef with 2.7 g of phytosterols) groups. Consumption of phytosterol-fortified ground beef lowered plasma total and LDL cholesterol by 9% and 15%, respectively, compared with the control group (p \u3c 0.001). The second study tested a hypothesis that a nutrition science course helps prevent weight gain during the first 16 months of college life. Forty female college freshmen were randomly assigned to the intervention (college course, n = 21) or control (no course, n = 19) groups. At the end of the course higher BMI (\u3e24) students in the intervention group (n = 11) consumed less fat (p = 0.04), protein (p = 0.03), and carbohydrate (p = 0.008) than did the higher BMI students in the control group (n = 6). Dietary changes reported by the higher BMI intervention students were associated with the maintenance of baseline body weight for one year in contrast with the higher BMI control students who gained 8.4 +/- 6.8 kg (p = 0.012). The third study examined college students\u27 concerns, attitudes, beliefs, and knowledge regarding body weight. A written questionnaire was administered to 220 undergraduate students. The results showed that 75% of students had a BMI \u3c25, yet 77% wanted to lose weight and 74% reported a history of weight loss attempts. Male and female students differed significantly in their perceived ability to control body weight and their reasons for weight concern. Students generally were aware of biologic and lifestyle factors influencing body weight and fatness but had limited understanding of the mechanisms by which these factors exert their effects

Associations Between Concepts of the Family Management Style Framework, and Measures of Child Adherence to Treatment for Heterozygous Familial Hypercholesterolemia

Background: Heterozygous Familial Hypercholesterolemia (HeFH) is an underdiagnosed, autosomal dominant, monogenic condition affecting ~1:250 individuals in the United States (U.S.), resulting in cardiovascular events 10-20 years earlier than in unaffected peers. Sample: Fifty-one parents of youth aged 2-18 years followed for HeFH in a pediatric specialty clinic. Purpose: Assess parental perceptions of HeFH, child adherence to treatment, and parenting in HeFH-affected households. Methods: A cross-sectional, descriptive, and correlational survey study congruent with elements of the Family Management Style Framework (FMSF). Pearson’s and Spearman’s correlations assessed linear relationships between parentally observed HeFH treatment adherence measures, parenting style, and parental perceptions of high cholesterol and risk for heart disease as applied to themselves or their families, and their children. Results: Participating parents were largely middle aged (mean 46.1 years, SD 5.6), mothers (78.4%), Caucasian (86.4%), highly educated (Bachelor’s or higher, 86.3%), and had personally received a diagnosis of genetically elevated high cholesterol (70%). Reference children were mostly adolescents (mean 13.4 years, SD 3.4), diagnosed with HeFH while school-aged (age 6.8 years, SD 4.1), and treated with a statin (80%). Median reported adherence to statins over past month was 94% (IQR 90-100). Missed doses were associated with forgetfulness (56.4%), carelessness (29%), or other reasons (41%). Illness perceptions differed between HeFH sub-concepts (high cholesterol and heart disease risk), respondent cholesterol status (+/-), and family position (parent/child). Patterns of association between illness perceptions and child treatment adherence, and illness perceptions and parenting styles, emerged along the same parameters. Parenting style generally did not directly correlate with observed child adherence, nor did child or family history with HeFH diagnosis and management. Conclusions: Parents largely reported adequate to excellent adherence to HeFH treatments among their children. High cholesterol and risk for heart disease were perceived differently and may be valuable individually in future research. Consistent with proposed relationships within the FMSF, adherence was correlated with many aspects of illness perceptions and varied by family position. Parenting styles were not directly correlated with adherence but were associated with illness perceptions within family positions, suggesting an avenue for moderation of the illness perceptions/adherence relationships deserving of further research

The current status of primary prevention in coronary heart disease

During the second part of the twentieth century, research advances caused a substantial decline in the rate of coronary heart disease. The decline lasted from the mid-1960s until the early 1990s and occurred primarily in Western countries. However, an unfavourable trend in coronary heart disease related mortality has gradually developed during the 1990s, with cardiovascular diseases anticipated to remain the main cause of overall mortality for the foreseeable future. The present paper aims at analyzing the current status of the main determinants of population-wide coronary heart disease prevention

Awareness of dementia risk reduction among current and future healthcare professionals: A survey study

Background: The total number of people affected by dementia worldwide is increasing rapidly. Recent studies provided evidence for the contribution of modifiable risk and protective factors to dementia risk. Although healthcare professionals could play an essential role in informing the general public about the relationship between lifestyle and dementia, it is unclear what they know about this relationship. Therefore, this study assesses the awareness of dementia risk reduction among current and future healthcare professionals.Design and methods: An online survey was carried out among 182 healthcare students from Maastricht University and 20 general practitioners (GPs) and practice nurses in Limburg, The Netherlands. The survey assessed the knowledge about risk and protective factors of dementia and identified needs, wishes and barriers concerning dementia risk reduction strategies.Results: The majority of current (75.0%) and future (81.9%) healthcare professionals indicated that dementia risk reduction is possible. Among students, awareness of cardiovascular risk factors of dementia (e.g., coronary heart disease (44.5%), hypertension (53.8%)) was low. Most participants (>70.0%) would like to receive more information about dementia risk reduction.Conclusions: The majority of current and future healthcare professionals were aware of the relationship between lifestyle and dementia risk. However, there are still substantial gaps in knowledge regarding individual dementia risk factors. Given the essential role of healthcare professionals in providing lifestyle advice, there is a need to increase awareness by providing educational programs focused on dementia risk reduction

How do the experiences and beliefs of adults and children with heterozygous familial hypercholesterolaemia influence their adherence to treatment?:A systematic review of qualitative evidence protocol

Abstract Background Heterozygous familial hypercholesterolaemia (FH) is a genetic disorder characterised by elevated levels of low density lipoprotein (LDL) cholesterol from birth, estimated to affect 1 in 250 of the UK population. Left untreated, FH substantially increases an individual’s risk of premature coronary heart disease (CHD) and associated mortality. This risk can be minimised with timely diagnosis and successful treatment with medication and lifestyle changes, as advocated in national and international guidelines. Despite these recommendations, the limited research available suggests adherence to treatment may be sub-optimal. This review will identify and synthesise the available qualitative research regarding the experiences and beliefs of adults and children with FH in relation to their condition and its treatment, and the influence of these upon treatment adherence. Methods The following electronic databases will be searched from their inception: Cochrane library, MEDLINE, Embase, PsycINFO (via OVID) and CINAHL. Studies available in English and reporting primary qualitative data will be included. Database searching will be supplemented with searches in relevant specialist websites. The references of identified papers will also be hand searched. Two reviewers will independently screen titles and abstracts of identified studies, with full texts of potentially relevant papers retrieved for review against pre-defined inclusion and exclusion criteria. The Critical Appraisal Skills Programme (CASP) Qualitative Research checklist will be used to assess quality of the included studies, and the results will be taken into consideration when reporting the findings. A data extraction tool will be created for use in this review to extract study findings relevant to the review questions. A thematic synthesis approach will be taken to analyse the results. Discussion Adherence to treatment recommendations is crucial for the successful management of FH and subsequent decrease in risk of CHD later in life. Common identified themes could provide an understanding of the beliefs and experiences which influence adherence to treatment recommendations and provide an insight into perceived barriers and facilitators. The findings are intended to be used in the development of future interventions or guidelines regarding treatment of children and adults with FH. Systematic review registration PROSPERO registration number: CRD4201808594