Background
Design | Randomised controlled trial. |
Setting | General practices in Northern Ireland and Republic of Ireland. |
Participants | 903 patients with CHD within 48 practices. |
Patient eligibility | Existing CHD (myocardial infarction, coronary artery bypass graft or angioplasty, angina). Patients with significant mental or physical illness excluded. |
Intervention | Tailored care plans for practices (training in prescribing and behaviour change, administrative support, quarterly newsletter); tailored care plans for patients (motivational interviewing, goal identification, target setting, review four monthly until 18 month follow up). |
Outcome measures | Included: primary: blood pressure, total cholesterol, hospital admissions; secondary: body mass index, exercise (Godin Leisure-Time questionnaire), diet (DINE questionnaire), smoking status. |
Results | No significant differences between intervention and control groups relating to blood pressure and cholesterol. Hospital admissions for intervention group significantly decreased compared to control group. |
Methods
Background and the study
| Overall, what did you think of the Sphere study? |
In terms of the management of your heart disease, was it conducted any differently during the study than before the study began or after it ended? | |
What did you think of the visits you made to the study nurse (every 4 months) and the idea of setting goals and targets to change your exercise and diet? | |
The Patient Information Booklet
| What did you think of the booklet? In what way did it affect your motivation for change? How often did you refer to it? What did you think of the self-completion sections in the booklet? How useful were these to you? How could the booklet have been improved? |
For those who failed to increase exercise
| How much / what exercise do you currently do? |
Motivation:
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At the beginning of this study: when you set a goal to increase the level of exercise you do, how achievable did you think this goal was? What do you think stopped you from achieving that goal?How much do other worries/issues in your life contribute to a lack of motivation to exercise? | |
Why did your exercise levels decrease? If you did enjoy exercise in the past, can you remember why? | |
How do you think you would feel if you were successful in gradually increasing your exercise? | |
Health beliefs:
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How did you feel that doing more exercise would affect your health (physical/mental)? | |
How do you feel when your doctor tells you that more exercise will be good for your overall health? How much would it mean to you to feel better in your overall health? | |
For those who increased level of exercise
| How much / what exercise do you currently do? Before the study, how much exercise did you do? How did you increase your levels of exercise? How did you maintain that level? |
How did you overcome previous barriers to exercising more? | |
How does doing more exercise make you feel? (physically, mentally) | |
For those who failed to improve fibre intake
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Motivation:
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When you set a goal during this study to increase your fibre intake/fruit and vegetables, how achievable did you believe this goal was? When you tried to make the change, what do you think stopped you from achieving it? | |
Health beliefs:
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When your doctor/nurse explained that improving your diet would benefit your overall health, how motivated did that make you feel? | |
When it came to actually trying to achieve your goal, to what extent did you believe it would have real benefits? | |
For those who improved fibre intake
| What changes did you make to your diet? When you decided to make changes to your diet, did you believe that you could achieve this and maintain the changes? |
Why do you think you succeeded in making changes? How easy or difficult was it to make the changes, in terms of finding healthier food in the shops and buying it (more expensive, less or no difference)? |
Results
Invitees | Participants | |||
---|---|---|---|---|
Intervention | Control | Intervention (%)* | Control (%)* | |
Gender | ||||
M | 47 | 48 | 21 (44.7) | 17 (35.4) |
F | 21 | 22 | 3 (14.3) | 4 (18.2) |
Total | 68 | 70 | 24 (35.3) | 21 (30.0) |
Age (yrs) | ||||
<60 | 6 | 6 | 2 (33.3) | 3 (50.0) |
60–70 | 25 | 30 | 10 (40.0) | 8 (26.7) |
>70 | 37 | 34 | 12 (32.4) | 10 (29.4) |
Godin | ||||
Baseline | ||||
Inactive (<24) | 35 | 33 | 12 (34.3) | 11 (33.3) |
Active (≥24) | 13 | 14 | 6 (46.2) | 4 (28.6) |
Score unavailable | 20 | 23 | 6 (30.0) | 6 (26.1) |
Increased at follow-up | 20 | 14 | 7 (35.0) | 5 (35.7) |
Decreased at follow-up | 12 | 20 | 6 (50.0) | 4 (20.0) |
No change at follow-up | 7 | 7 | 3 (42.9) | 3 (42.9) |
Score unavailable or N/A | 29 | 29 | 8 (27.6) | 9 (31.0) |
Increased at interview | 8 | 6 | ||
Decreased at interview | 6 | 3 | ||
No change at interview | 5 | 4 | ||
Score unavailable or N/A | 5 | 8 | ||
DINE | ||||
Baseline | ||||
Low fibre <30 | 21 | 17 | 10 (47.6) | 3 (17.6) |
Medium 30–40 | 24 | 26 | 8 (33.3) | 8 (30.8) |
High >40 | 21 | 25 | 6 (28.9) | 10 (40.0) |
Score unavailable | 2 | 2 | 0 | 0 |
Increased at follow-up | 21 | 21 | 7 (33.3) | 4 (19.0) |
Decreased at follow-up | 40 | 39 | 16 (40.0) | 15 (38.5) |
No change at follow-up | 1 | 2 | 1 (100) | 1 (50.0) |
Score unavailable | 6 | 6 | 0 | 1 (16.7) |
Increased at interview | 11 | 11 | ||
Decreased at interview | 12 | 7 | ||
No change at interview | 0 | 1 | ||
Score unavailable | 1 | 2 |
Professional support |
‘They (the health professionals) know the exercise I’m doing, which was good because sometimes when you do exercise you have no breath. You think ‘I’m going to kill myself” (F, 81, NI, G+16, D+8). |
‘I cannot speak highly enough of that practice … such great care, the time they have for you, they get to know you as a person.’ (M, 72, NI, G+24.5 (105), D NA (22)). | |
‘If I come in with a question they’ll go to a lot of trouble to answer.’ (M, 69, RoI, G+37 (76), D-4 (31)). | |
‘I bought a wok as opposed to the frying pan. It was Doctor (XX) who suggested the wok. He said you’ll eat healthier, and I did.’ (M, 56, NI, G0 (0), D+15 (59)). | |
Setting goals |
‘I had to face (nurse) every four months. I didn’t want to come in and put up the half a stone (target) when I could come in and have lost a few pounds … that was one of the most beneficial things, the target setting.’ (M, 69, RoI, G+37 (76), D-4 (31)). |
‘You don’t want to disappoint somebody when you’ve entered into some sort of pact … .’ (M, 56, NI, G0 (0), D+15 (59)). | |
Enjoyment |
‘I’d often be kind of down and you’d go out for a walk, meet someone.... maybe talk.... and when you come back you feel that bit better.’ (M, 65, RoI, G NA (21), D+20 (71)). |
‘I walk a couple of miles every other day there, up round the mountain.... it certainly helps.’ (M, 65, NI, G+3 (9), D-2 (17)). | |
‘I found I liked gardening, it’s got an objective.’ (M, 69, RoI, G+37 (76), D-4 (31)). | |
‘With fruit, it has its own taste and its own attraction.... you don’t have to add sauce, vinegar, salt or anything else to it. You get into the way of it, it tastes lovely.’ (M, 56, NI, G0 (0), D+15 (59)). | |
Fears |
‘I walk about 20 miles a week, I don’t want any trouble again.... if I can do anything to keep myself right I’ll do it, whatever the cost. Fear.... fear is a great thing.’ (M, 65, RoI, G NA, (21), D+20 (71)). |
‘You have to think about your family. What if something happens to you?’ (M, 65, NI, G+3 (9), D-2 (17)). | |
Social networks |
‘She does the cooking so she has control over what I’m eating. I do have an odd biscuit but instead of a packet a night it’s two or three a year…I would never have thought of walking up and down the house, she said oh that back corridor is 90 feet long, work that out in miles and do enough to walk a mile.’ (M, 69, RoI, G+37 (76), D-4 (31)). |
‘We would go for a walk in the park, you hear all the gossip (laughs). My friends … coaxing me into going (swimming).’ (F, 74, NI, G-3 (9), D-28 (57)) | |
‘It was very useful. Twenty of us met and discussed our problems between us.’ (M, 65, RoI, G NA (21), D+20 (71)). | |
‘Have to be (fit), because the wife’s very ill.’ (M, 74, NI, G NA (41), D+7 (29)). | |
‘I have a very demanding dog, I walk maybe six to eight miles every day. Without her I don’t think I’d be around at all.’ (M, 74, RoI, G+21 (63), D-6 (20)). |
Personal beliefs |
‘(Exercise) keeps my weight down. The lighter I am the less out of breath I’d be. I’ve started eating more fibre, more fish. I feel far more healthier. My cholesterol has even improved.’ (M, 65, NI, G NA (41), D+6 (29)) |
‘If your thinking doesn’t change you’re not really doing it for the right reasons. You’re either press ganged or somebody’s, you know, coercing or duress.’ (M, 56, NI, G0 (0), D+15 (59)) | |
‘I’d be concerned that I’d drop dead if I did too much. At my age I feel there’s nothing to be gained by it.’ (F, 77, RoI, G-6 (0), D-5 (36)). |
Lack of professional support |
‘(GP) never mentions it (diet). Maybe he’s given up.’ (M, 61, RoI, G +2.5 (39), D -9 (26)). |
‘If you’re going to them you will have to pay for it – my doctor’s 70 euros.’ (M, 54, RoI, G NA (13), D-3 (49)). | |
Temptations and treats |
‘I was just bored, I’ve fallen into sneaking (sweets).’ (M, 61, NI, G0 (0), D+22 (32)) |
‘I should do these exercises which I find very boring – sometimes I just don’t bother.’ (F, 74, NI, G-3 (9), D-28 (57)). | |
Unhelpful social contacts |
‘I’ve a grandchild, she’ll come over and we’ll have chips, and then we’ll have chocolate....’ (M, 54, RoI, G NA (13), D-3 (49)). |
‘I would to get into the early morning swim but the wife isn’t too keen (laughs), on anything with me getting up so early.’ (M, 73, NI, G+18 (3), D-1 (20)). | |
‘Your mates all used to tease you… they just tormented you… laughed at me with fish in the morning for breakfast.’ (M, 74, NI, G NA (0), D-1 (13)). | |
‘If I take one cigarette out of my wife’s packet I’m back again, it’s making it harder for me.’ (M, 61, S, G-22, D-7). | |
‘My daughter, if she’s having a beer or a glass of wine I’ll have a beer. If she wasn’t .... I probably would take less.’ (M, 61, S, G +2.5, D -9). | |
Personal problems |
‘With my breast removed I don’t like to go swimming.’ (F, 74, NI, G-3 (9), D-28 (57)). |
‘I would feel embarrassed at not being able to do it myself.’ (M, 56, NI, G0 (0), D+15 (59)). | |
‘I have arthritis.... I can’t go for a walk, the legs hurt.’ (M, 78, RoI, G NA (15), D-10 (75)). | |
‘Because I’m a diabetic, it’s more frightening.... my feet are a problem and my sight’s another thing. The heart would be the least of my troubles.’ (F, 77, RoI, G-6 (0), D-5 (36)). | |
‘We used to go walking almost every day, but the past four months with this building it all fell by the wayside. It’s a nightmare, it’s really destroyed our lifestyle.’ (M, 66, RoI, G+2.5 (39), D-9 (26)). |
Valued information |
‘I talked to the doctor and the dietician, I dropped to ten and a half stone, I listened to what she said.’ (M, 74, NI, G NA (41), D+7 (29)). |
‘I thought the (SPHERE) booklet was a good help… the practice nurse went through it with me… then I went through it periodically when I came across it in the house.’ (M, 65, NI, G NA (41), D+6 (29)).
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Inadequate information |
‘Where do you go when you want to know something? I mean, somebody says you can look it up on the computer.... but where....?’ (F, 77, RoI, G-6 (0), D-5 (36)). |
‘Some people say white bread’s bad for you, brown bread’s good for you, others say the opposite so who do you believe?’ (M, 65, NI, G NA, D-20 (20)). | |
‘In the brochures from the heart association they had a thing about.... beta blockers were a waste of time.... you never know, you could be taking the wrong tablet.’ (M, 75, NI, G+63 (119), D-3 (60)). | |
‘Some of it can be very difficult to read. They could.... cut away a lot of the medical terms.’ (M, 54, RoI, G NA (13), D-3 (49)). | |
‘Something where you don’t have to get a dictionary out to look up the words.’ (F, 63, RoI, G NA, D+35 (45)). | |
‘They didn’t know.... whether it was the stomach, whether it was the heart.’ (M, 71, NI, G-3 (21), D-1 (28)). | |
‘Some say it was a heart attack and some say it was a stroke.’ (M, 65, NI, G NA, D-20 (20)). | |
Information not translated into practice |
‘I read the Daily Mail from cover to cover. Tuesday’s Mail is medical health and sometimes it’s very good.’ (F, 86, NI, G NA, D-10 (30)). |
‘When you go to your doctor you can say I was reading about this on the net and he can explain it to you.’ (M, 54, RoI, G NA (13), D-3 (49)). | |
‘It (SPHERE booklet) sets out everything you need to know… it’s an excellent booklet… I didn’t refer to it that much… I would have had a look through it at the very, very beginning.’ (M, 48, RoI, G-5 (35), D-9 (28)).
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