Causal attributions, lifestyle change, and coronary heart disease: Illness beliefs of patients of South Asian and European origin living in the United Kingdom

doi:10.1016/j.hrtlng.2007.03.004

Heart & Lung

Volume 37, Issue 2, March–April 2008, Pages 91-104

https://doi.org/10.1016/j.hrtlng.2007.03.004 Get rights and content

Objective

We examined and compared the illness beliefs of South Asian and European patients with coronary heart disease (CHD) about causal attributions and lifestyle change.

Methods

This was a qualitative study that used framework analysis to examine in-depth interviews.

Sample

The study comprised 65 subjects (20 Pakistani-Muslim, 13 Indian-Hindu, 12 Indian-Sikh, and 20 Europeans) admitted to one of three UK sites within the previous year with unstable angina or myocardial infarction, or to undergo coronary artery bypass surgery.

Results

Beliefs about CHD cause varied considerably. Pakistani-Muslim participants were the least likely to report that they knew what had caused their CHD. Stress and lifestyle factors were the most frequently cited causes for CHD irrespective of ethnic grouping, although family history was frequently cited by older European participants. South Asian patients were more likely to stop smoking than their European counterparts but less likely to use audiotape stress-relaxation techniques. South Asian patients found it particularly difficult to make dietary changes. Some female South Asians developed innovative indoor exercise regimens to overcome obstacles to regular exercise.

Conclusion

Misconceptions about the cause of CHD and a lack of understanding about appropriate lifestyle changes were evident across ethnic groups in this study. The provision of information and advice relating to cardiac rehabilitation must be better tailored to the context of the specific needs, beliefs, and circumstances of patients with CHD, regardless of their ethnicity.

Section snippets

Causal attribution

One facet of illness representation is belief about cause (causal attribution): the factors that individuals typically attribute to the development of their illness. The majority of studies on patients with CHD have focused almost exclusively on men recovering from acute myocardial infarction (AMI) in Western countries. Findings indicate that patients most commonly believed that stress, worry, tension, and overwork caused their CHD. A systematic review identified that 41% of studies found

Methods

We defined “South Asian” people as those individuals originating from the Indian subcontinent and “European” people as all those of white European descent. This definition is consistent with other studies.²⁰ A qualitative methodology was chosen because this research topic has been largely unexplored. Such a method is especially useful in understanding how people make sense of what is happening to them, within a social context.²¹

Results

This section presents data across ethnic groupings to illustrate participants’ beliefs about causal attributions and their experiences of lifestyle change. Excerpts are labeled and coded according to the ethnicity, gender, hospital site, and heart condition of the patient. In this way, WMDC08 relates to an interview conducted with a European man who was admitted to a hospital to undergo a coronary artery bypass surgery and was the eighth member of this particular subsample.

Generally there was

Discussion

There was considerable variation in patients’ understanding about CHD, both within and across ethnic groups. Knowing what caused their CHD influenced the way in which participants managed their condition and helped them to make decisions about lifestyle modification. Although some patients were equipped with relevant information and advice to make such changes, others lacked motivation and the appropriate support to improve their lifestyle.

South Asian patients, particularly Pakistani-Muslim

Limitations

This study has a number of limitations, including its retrospective design and lack of information about participants’ coronary risk factor profiles. The latter would have been valuable in enhancing the interpretation of participants’ health beliefs and behaviors. The small sample size of each individual group also represented a limitation. The findings, although not generalizable, offer important insights that have implications for both the in-hospital care and the cardiac rehabilitation of

Conclusions

The findings from this comparative study suggest that South Asian and European patients with CHD articulate many similar concerns, worries, and needs. The challenge for those involved in providing cardiac rehabilitation services to these patients is to offer information and advice that is tailored to their particular circumstances and to bear in mind that not every problem or difficulty a person encounters can be attributed to his or her ethnic background. The key to progression in this arena

References (34)

Y. Fukuoka et al.
Illness attribution among Japanese patients with acute myocardial infarction
Heart Lung
(2004)
J.J. Zerwic et al.
Perceptions of patients with cardiovascular disease about the causes of coronary artery disease
Heart Lung
(1997)
N. Chaturvedi et al.
Lay diagnosis and health-care-seeking behaviour for chest pain in south Asians and Europeans
Lancet
(1997)
V.C. Kuppuswamy et al.
Excess coronary heart disease in South Asians in the United Kingdom
BMJ
(2005)
S. Wild et al.
Cross sectional analysis of mortality by country of birth in England and Wales, 1970-92
BMJ
(1997)
British Heart Foundation (BHF) warns of urgent need for South Asians to address heart health 29th (January 2003)
J.A. Skelton et al.
Mental Representations in Health and Illness
(1991)
H. Leventhal et al.
The common sense representation of illness danger
M.F. Coutu et al.
Illness representation and change in dietary habits in hypercholesteremia patients
J Behav Med
(2003)
R. Horne et al.
Patients’ interpretation of symptoms as a cause of delay in reaching hospital during acute myocardial infarction
Heart
(2000)

C. Cherrington et al.

Illness representation after acute myocardial infarction: impact on in-hospital recovery

Am J Crit Care

(2004)

K.J. Petrie et al.

Role of patients view of their illness in predicting return to work and functioning after myocardial infarction longitudinal study

BMJ

(1996)

D.P. French et al.

Causal attributions for heart disease: a systematic review

Psychol Health

(2002)

R.A. Webster et al.

The experiences and needs of Gujarati Hindu patients and partners in the first month after a myocardial infarction

Eur J Cardiovasc Nurs

(2002)

A. Farooqi et al.

Attitudes to lifestyle risk factors for coronary heart disease amongst South Asians in Leicester: a focus group study

Fam Pract

(2000)

F. Astin et al.

Heart disease attributions of patients prior to elective percutaneous transluminal coronary angioplasty

J Cardiovasc Nurs

(2004)

B. Murphy et al.

Causal attributions for coronary heart disease among female cardiac patients

J Cardiopulm Rehabil

(2005)

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: The study was funded by The Community Fund and the British Heart Foundation (Grant Number RB217616).

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Issues in cardiovascular nursingCausal attributions, lifestyle change, and coronary heart disease: Illness beliefs of patients of South Asian and European origin living in the United Kingdom

Objective

Methods

Sample

Results

Conclusion

Section snippets

Causal attribution

Methods

Results

Discussion

Limitations

Conclusions

Heart Lung

Heart Lung

Lancet

Excess coronary heart disease in South Asians in the United Kingdom

BMJ

Cross sectional analysis of mortality by country of birth in England and Wales, 1970-92

BMJ

British Heart Foundation (BHF) warns of urgent need for South Asians to address heart health 29th (January 2003)

Mental Representations in Health and Illness

The common sense representation of illness danger

Illness representation and change in dietary habits in hypercholesteremia patients

J Behav Med

Patients’ interpretation of symptoms as a cause of delay in reaching hospital during acute myocardial infarction

Heart

Illness representation after acute myocardial infarction: impact on in-hospital recovery

Am J Crit Care

Role of patients view of their illness in predicting return to work and functioning after myocardial infarction longitudinal study

BMJ

Causal attributions for heart disease: a systematic review

Psychol Health

The experiences and needs of Gujarati Hindu patients and partners in the first month after a myocardial infarction

Eur J Cardiovasc Nurs

Attitudes to lifestyle risk factors for coronary heart disease amongst South Asians in Leicester: a focus group study

Fam Pract

Heart disease attributions of patients prior to elective percutaneous transluminal coronary angioplasty

J Cardiovasc Nurs

Causal attributions for coronary heart disease among female cardiac patients

J Cardiopulm Rehabil

Issues in cardiovascular nursing
Causal attributions, lifestyle change, and coronary heart disease: Illness beliefs of patients of South Asian and European origin living in the United Kingdom