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LI .ik. $1nntnb+ . . uwn§m¥fifi 1.1L $1.1.” .. “fllilllllflzilligllfliiilmfliflflil‘ ‘Wlll‘lj‘flll _ RAY : .Michigan State This is to certify that the thesis entitled Relationships Between Post-Myocardial Infarction Patient Knowledge at Hospital Discharge, and Knowledge and Compliance Six Weeks After Discharge presented by Janet H- Finkbeiner has been accepted towards fulfillment of the requirements for Mas ter' S degree in Nursing . "7 Jae/W: ,2941 / Major professor / Date ( I I 4/79“ / 0-7639 —__—-—”7 OVERDUE FINES m 25¢ PER DAY _ PER ITEM drop to remove Return to book from your record. this checkout @ Copyright by JANET HOGAN FINKBEINER 1979 RELATIONSHIPS BETWEEN POST MYOCARDIAL INFARCTION PATIENT KNOWLEDGE AT HOSPITAL DISCHARGE, AND KNOWLEDGE AND COMPLIANCE SIX WEEKS AFTER DISCHARGE By Janet Hogan Finkbeiner A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF NURSING School of Nursing I979 Cr 1C>Q'A551. ABSTRACT RELATIONSHIPS BETWEEN POST MYOCARDIAL INFARCTION PATIENT KNOWLEDGE AT HOSPITAL DISCHARGE, AND KNOWLEDGE AND COMPLIANCE SIX WEEKS AFTER DISCHARGE By Janet Hogan Finkbeiner A descriptive study of ll post myocardial infarction patients was undertaken to identify the relationships between knowledge at hospital discharge, and knowledge and compliance six weeks after dis- charge. Levels of knowledge and compliance were identified. Factors that potentially affected the levels of knowledge and compliance, the knowledge relationships, and knowledge and compliance relationships were discussed. Data analyses consisted of a combination of statistical and case study techniques which suggested indications and trends of larger populations. The findings indicated that a relationship existed between total knowledge at hospital discharge and compliance. No relation- ship existed between knowledge at two points in time. A significant relationship existed between total diet knowledge and total diet compliance. Other categories of knowledge and compliance six weeks after hospital discharge were not significantly correlated. Janet Hogan Finkbeiner Major implications are that current educational encounters or programs, especially in the six week interval, may not be pro» viding patients with the information that is needed to assist with compliance. To Gary and Misty 1'1 ACKNOWLEDGMENTS I would like to express my appreciation for the Helen Calder Scholarship and Professional Nurse Traineeship which made my grad- uate education possible. A special thank-you to my committee chairman, Dr. Barbara Given, Ph.D., who has supplied tremendous encouragement and emotional support during this endeavor. During the disappointments and frus- trations she was always there to sooth the wounds, suggest alterna- tives, and redirect a "frantic" student. I I wish to convey my appreciation to my committee members, Maria Klenk, Dorothea Milbrandt, Dr. Lou Anna Kimsey Simon, Ph.D., and Brigid Warren. Their assistance in directing my research effort was invaluable. Sincere thanks to LeAnn Slicer for completing many requested favors and for providing me with answers to innumerable questions. I am grateful to Rosa Lee Weinert and St. Lawrence Hospital for assisting me in the implementation of this research project. I would also like to thank the nursing staff from ICU/CCU, Two North- East, and Three North with special thanks to Terri Winslow, Cheryl Maddox, and May Withers. Their support and assistance made this research a reality. I wish to thank Dr. William Crano for his assistance with the development of the instruments and data analysis. A special thanks to June Angle for typing the final manu- script and making certain that everything was "perfect." I would also like to express my gratitude to Dick and Debbie Jankowski and Mira Strieter for assisting me in the final preparation of this manuscript. Their support and encouragement assisted the completion of this project. I am especially grateful to my husband, Gary, who has sacrificed much in order that I could pursue my ambitions and goals. His assistance enabled me to achieve the excellence I desired. TABLE OF CONTENTS LIST OF TABLES ........................ LIST OF FIGURES ........................ LIST OF APPENDICES . . . . . ................. Chapter I. THE PROBLEM ...................... Introduction .................... Purpose ....................... Statement of the Problem .............. Research Questions ............... . . Research Question I ............... Research Question II ............... Definition of Terms ................. Knowledge .................. Compliance ................. . . . Limitations of the Study ............ Assumptions of the Study ...... . . . . . . . . Overview of the Chapters .............. II. CONCEPTUAL FRAMEWORK .................. Introduction ................... . Compliance ..................... Relationship Between Knowledge and Compliance. . . . Knowledge ...................... Nursing Theory ................... Summary ....................... III. REVIEW OF THE LITERATURE ................ Introduction .................... Knowledge ...................... Patient Educational Programs ........... Knowledge Measurement Categories ..... Page viii Chapter Page Knowledge Measurement at Different Points in Time ...................... 38 Compliance ...................... 44 Compliance Methodology ............... 44 Variables Which Influence Compliance ........ 50 Relationship Between Knowledge and Compliance ..... 60 Conclusion ...................... 70 IV. METHODOLOGY AND PROCEDURE ................ 74 Overview ....................... 74 Population ...................... 76 Setting ........................ 77 Instruments ...................... 79 Knowledge Instrument ................ 79 Compliance Instrument ............... 84 Reliability .................... 90 Data Collection Procedure ............... 91 Scoring ........................ 98 Knowledge Instrument ................ 99 Compliance Instrument ............... lOl Demographic and Supportive Data .......... l04 Procedures for Data Analysis ............. lll Variables ..................... lll Presentation of Research Questions ......... ll3 Techniques for Data Analysis ............ ll5 Human Rights Protection. . .............. l20 Summary ........................ 120 V. PRESENTATION OF FINDINGS ................. 121 Overview ....................... 12] Presentation of Descriptive Data ........... 124 Population Data .................. 125 Demographic Data ............ . . . . . . 125 Selected Personal Supportive Data ......... l26 Selected Environmental Supportive Data. ...... 129 Presentation of Data Regarding Research Questions. . . 13] Summary ........................ l60 VI. SUMMARY AND IMPLICATIONS OF FINDINGS. . . . ..... . . 161 Overview ....................... l6l Summary and Interpretation of the Findings ...... 164 Summary Research Question I ........... . I64 Summary Research Question II ....... . . . . . I73 Limitations and Problems Encountered . . . . ..... l82 vi Page Chapter Implications for Nursing and Other Health Care Professions .................... 183 Recommendations for Future Studies .......... 194 BIBLIOGRAPHY .......................... 255 LISTS OF TABLES Table l Selected Demographic Data of the Study Population ..... 2 Selected Personal Supportive Data of the Study Population ....................... 3 Selected Environmental Supportive Data of the Study Population ....................... 4 Mean and Range Percent Correct Knowledge Scores at Hospital Discharge and Six Weeks After Hospital Discharge ....................... 5 Number and Percent of Patients Changing in Knowledge from Hospital Discharge to Six Weeks After Discharge ....................... 6 Number and Percent of Patients Below 70 Percent Knowledge ....................... 7 Spearman Rank Difference Correlations of Knowledge at Hospital Discharge and Knowledge Six Weeks After Discharge ...................... 8 Summary of Statistical Tests ............... 9 Mean and Range Percent Compliance Scores Six Weeks After Hospital Discharge ................... 10 Number and Percent of Patients Below 75 Percent Compliance ....................... ll Spearman Rank Difference Correlations of Knowledge at Hospital Discharge and Compliance Six Weeks After Discharge ................... lZ Spearman Rank Difference Correlations of Knowledge and Compliance Six Weeks After Hospital Discharge ..... viii Page l26 127 T30 132 133 T36 T38 T46 147 ISO 154 LIST OF FIGURES Figure l Schematic Representation of Research Questions Regarding the Relationships Between Knowledge and Compliance. . . 2 Study Flow Sheet ..................... 3 Occupational Scale .................... 4 Educational Scale ................... 5 Hollingshead Two Factor Index of Social Position ..... 6 Example of Hollingshead Two Factor Index of Social Position ........................ 7 Percent of Patients Changing in Knowledge from Hospital Discharge to Six Weeks After Discharge ......... Page 5 92 105 105 106 107 134 LIST OF APPENDICES Appendix A B C Knowledge Questionnaire .................. Compliance Questionnaire ................. Hospital Consent ................... Patient Consent Form .................. Encounter Introduction Sheets ............... Check List for Knowledge Questionnaire Administration. . Check List for Patients Admitted to the Study ....... Demographic and Supportive Data--Patient ......... Demographic and Supportive Data--Chart .......... Check List for Compliance Questionnaire Administration . Data After Hospital Discharge ............... Knowledge Instrument Scoring Example ........... Summarization of Risk Factors and Criteria ........ Severity Index ...................... Hypotheses Testing Schedule and Statistical Hypotheses . Scattergrams .............. . . . ...... Human Rights Protection .................. Page 199 2ll . 217 . 234 236 239 241 243 . 245 253 :A-avr. _,,. ,..... .‘J‘J‘EJ M CHAPTER I THE PROBLEM Introduction Diseases of the heart are ranked as the number one cause of mortality in the United States (U.S. Department HEW, 1968). Each year approximately 1,300,000 persons are diagnosed as having a myocardial infarction and about half of these people return home after a period of hospitalization (Smith and Lilienfeld, 1969; Treitel, 1970; National Heart and Lung Institute, 1974). During the first year following hospitalization there is approximately a 10 percent chance of a heart related death occurring (Bishop, 1978). Current therapy for post myocardial infarction patients involves prescriptions of medical and health regimens which may include medications, activity limitations, and reduction of modi- fiable risk factors such as hypercholesterolemia, hypertension, smoking, sedentary living, obesity, hyperlipidemia, diabetes mel- litis, personality type, and life-style. Significant risk factors unable to be modified include family history, aging, and male sex (American Heart Association Report, 1970; Simborg, 1970; McAlister et al., 1976; Glass, 1977; Thorn et al., 1977). It is widely accepted that if post myocardial infarction patients comply with these prescribed treatment regimens, morbidity and mortality will decrease and the outcome status will improve (Frank et al., 1966; Weinblatt et al., 1968; Kannel and Gordon, 1974; Werko, 1976). Compliance or adherence to prescribed recommendations is often difficult, especially if it involves complex behavioral changes. Davis (1966) in his review of the literature estimates that the incidence of noncompliance with prescribed treatment regi— mens is approximately 30-35 percent. Since post myocardial infarc- tion patients are frequently placed on treatment regimens that involve significant changes in behavior, compliance with these treatments may be exceedingly difficult. Knowledge is one factor frequently implicated as being influential in compliant behavior (Caldwell et al., 1970; Woodwark and Gautheir, 1972; Hulka et al., 1976). Patients need knowledge in order to make the behavioral changes that are required by treatment regimens. Educational programs which incorporate information of disease entity and treatment recommendations are, therefore, initiated during hospitalization. The purpose of the educational programs is to increase patient knowledge and thus potentially increase compliant behavior and health status. Periodic educational reinforcement and evaluation is accomplished in follow-up office and clinic visits. Patient education is deemed an integral component of the nursing role. As a result, nursing makes a substantial contribution to patient education in a variety of health care settings. Much Of this education is focused on self-care concepts which reinforce compliance with treatment regimens. Purpose A review of the literature reflects conflicting reports regarding the effect of knowledge on patient compliance with the recommended treatment regimens. Minimal information exists concern- ing the knowledge of disease entity, the knowledge of treatment regimens, and their subsequent relationship to compliant behavior. The purpose of this research is to study the relationships between post myocardial infarction patient knowledge at the time of discharge from the hospital, and knowledge and patient gtated compliance with treatment regimens six weeks after hospital dis- charge. An understanding of these relationships will assist the nursing profession in the development of myocardial infarction programs better suited to meet the educational needs of the patient and thus increase compliance with treatment regimens. This increased compliance will, in turn, increase patient health status and well- being. Statement of the Problem The central focus of this research project is a study of the relationships between post myocardial infarction patient knowledge at the time of discharge from the hospital, and knowledge and gtgteg compliance six weeks after hospital discharge. Research Questions The following section includes the questions studied rela- tive to the problem statement. These questions specifically focus on the patterns of knowledge and the patterns of compliance. The research questions developed for this study include the following: Research Question I. What are the patterns of knowledge in the study population? A. B. C. What are the levels of knowledge at two points in time? What are the factors that affect the levels of knowledge? What is the relationship between knowledge at hos- pital discharge and knowledge six weeks after hospital discharge? 1. What is the relationship between total knowledge at hospital discharge and total knowledge six weeks after hospital discharge? 2. What is the relationship between knowledge of disease entity at hospital discharge and knowledge of disease entity Six weeks after hospital dis- charge? 3. What is the relationship between knowledge of total treatment regimens at hospital discharge and know- ledge of total treatment regimens six weeks after hospital discharge (refer to Figure l for a sche- matic representation of the knowledge relationships studied). What are the factors that affect the relationship between knowledge at hospital discharge and knowledge six weeks after hospital discharge? Research Qgestion II. What are the patterns of compliance in the study population? A. What are the levels of stated compliance six weeks after hospital discharge? What are the factors that affect the levels of stated compliance? What is the relationship between knowledge at hospital discharge and stated compliance six weeks after hospital discharge? .mocmw_aeou wee mmeszocx cmozpmm mawgmeowpmpmm one mcwecmmmm meowummzo eucwmmmm to cowpmucmmmcqmm ovumEmzom--._ menace Ill . 8:37.58 O _ 3&4: r 1 is A, 2.3: % 5 Cr ... _ \/ nu Lfi memepov: ecchomch xu_a:u emomm_c 9. to mmumFZocx we monopzocx e _ -SJ L. rwxu /\ mcoewmmm ozoaucwch _ - co mman3ocx _ l— kw [v a _ ATulc _ >u_u:m mmmom_o F1111? co $8.305. h “ Sd C :33..ch Eggnog: LS: 283 x5 oagmgoflo p338: 1. What is the relationship between total knowledge at hospital discharge and stated compliance with total treatment regimens six weeks after hospital dis- charge? 2. What is the relationship between knowledge of disease entity at hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge? 3. What is the relationship between knowledge of total treatment regimens at hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge? (Refer to Figure l for a schematic representation of the knowledge and compliance relationships studied.) What are the factors that affect the relationship between knowledge at hospital discharge and stated com- pliance six weeks after hospital discharge? What is the relationship between knowledge six weeks after hospital discharge and stated compliance six weeks after hospital discharge? 1. What is the relationship between total knowledge six weeks after hospital discharge and stated com— pliance with total treatment regimens six weeks after hospital discharge? 2. What is the relationship between knowledge of disease entity six weeks after hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge? 3. What is the relationship between knowledge of total treatment regimens six weeks after hospital dis- charge and stated compliance with total treatment regimens six weeks after hospital discharge? (Refer to Figure l for a schematic representation of the knowledge and compliance relationships studied.) What are the factors that affect the relationship between knowledge six weeks after hospital discharge and stated compliance six weeks after hospital discharge? Definition of Terms The terms utilized in the research questions are defined both theoretically and operationally. The theoretical definitions are presented first and, when appropriate, are followed by the items from the questionnaire in which they are operationalized. Knowledge Knowledge is defined for this study as information or input processed cognitively by the patient that can be recalled and/or applied as factual information in future situations. This recall and application is evaluated by the administration of a written instrument to each patient at hospital discharge and six weeks after hospital discharge (see Questionnaire, Appendix A). The content of the instrument consists of total knowledge which in turn is divided into two major categories: knowledge of disease entity, and knowledge of treatment regimens. These categories are selected based on information from the review of the literature which sub- stantiates their importance in patient education. 1. Total knowledge refers to the knowledge of disease entity and knowledge of treatment regimens as measured by the know- ledge instrument. a. Knowledge of disease entity_includes: normal functions of the heart, etiology of the disease, the healing process, signs or symptoms of recurrence or complica- tions, and risk factors leading to heart disease (see Appendix A, questions 1-7). _ b. Knowledge of total treatment regimens is a summation of all treatment regimen knowledge which includes physical activity, total diet, and medication knowledge (see Appendix A, questions 8-48). (1) Physical activity knowledge includes: projected activity, progressive activity, methods of monitor- ing body response to activity, actions to be taken if monitoring relates abnormal body response, effects of exercise, and exercise methodology (see Appendix A, questions 14—20). (2) Total diet knowledge is a summation of general and specific diet knowledge (see Appendix A, questions 8—13 and 21-28). (a) General diet knowledge includes: general information related to the role and composi- tion of nutritionally balanced meals, rationale for spacing meals, strategies for weight main- tenance and control, and the relationship between food ingestion, digestion, and physi- cal activity (see Appendix A, questions 8—13). (b) Specific diet knowledge refers to low salt/ sodium diet knowledge and/or low cholesterol/ saturated fat diet knowledge. This specific diet knowledge includes: definitions of low salt/sodium diets and/or low cholesterol/ saturated fat diets, rationale for following diet prescriptions, common foods included and excluded, and appropriate methods of food preparation (see Appendix A, questions 21-28). (3) Medication knowledge includes: action, purpose, desired results, side effects, and pertinent infor- mation related to the medication (see Appendix A, questions 29-48). Type of knowledge refers to the knowledge of disease entity c)r' knowledge of treatment regimens as determined by the knowledge iristrument. Levels of knowledge refer to the amount of patient knowledge measured by the knowledge instrument which is displayed as a pro- ;nyrtion score for hospital discharge and six weeks after discharge. llua levels are displayed as: mean and range percent correct scores; the number of patients increasing, decreasing or remaining the same in knowledge; and the number of patients with less than 70 percent total or specific knowledge. Factors that affect the levels of knowledge and knowledge relationships are the demographic, and personal and environmental supportive variables which emerged from a review of the literature. These variables influence knowledge in a direct or indirect manner, and include: age; sex; marital status; race; social position; history of chronic illness; past experience of spouse or self with a MVocardial infarction; prior diet, medication, or activity pres- criptions or restrictions; past exercise patterns; risk factor assessment; family history of cardiovascular disease; severity of the ——'——'—” myocardial infarction; symptoms since discharge; number of days in the Intensive Care/Coronary Care Unit; number of days in the hos- pital; number of visits to the emergency room or physician since discharge; readmission to the hospital since discharge; sources of information since discharge; environment during knowledge question- riaire administration; and patient request for knowledge results. Patterns of knowledge consist of the relationships between lreport is less accurate than true compliance as measured by pill counts and urine studies. Hecht found that increased-nurse encounters increased objective compliance. Vincent (1971) utilized a structured interview to obtain irrformation from the patients regarding the scheduling of eye drops Enid compared this to prescribed treatments recorded in the chart. Irujividuals identifying noncompliance more than one time per month for each dosage were classified as noncompliant. Drug error rates were computed by Hulka and associates (15976) two weeks following an encounter with a health care provider affli were based on information from doctor-patient pairs regarding 'the prescribed medication regimen. Compliance was measured by patient Stated compliance and by evaluation of the patients prescription refills. 46 Heinzelmann (1962) measured compliance of rheumatic fever patients receiving prophylactic penicillin using a self-report method. Compliance was measured by open—ended questions concerning prophylactic behavior and specific action with regard to a sore throat. Other studies measured compliance with different treatment recommendations. Carpenter and Davis (1976) determined the extent of arthritic patient non-adherence with prescribed exercise programs based on patient report four months after hospital discharge. Open- ended questions inquired about the specific method and frequency of prescribed exercise programs at home. In a study by Watkins et a1. (1967), qualitative measures of compliance with diabetic treatments were assessed. Home management of diabetic patients was measured by structured protocals and obser- vation of psychomotor skills used in insulin administration, dosage calculations, and urine testing. Meal spacing and food care compli- ance were determined by a structured interview and self-report. Caplan and colleagues (1976), in a study involving 250 hypertensive patients, utilized a questionnaire for adherence infor- mation of specific compliance. Included in the instrument were questions regarding consumption of restricted foods, prompt pre- scription filling, prompt prescription refilling, adherence in taking medications, and self-report discrepancy between the number of pills taken versus those prescribed as recorded in the chart. Given (1976), utilizing a structured interview, obtained serlf—report compliance of hypertensive patients with medication, 47 activity, and diet recommendations. The results were tabulated as a proportion score of the total possible compliance score individ- ualized to each patient. In a study with congestive heart failure patients, Rosenberg (1971) used an objective strategy to measure adherence to low sodium diets. Urine testing was completed for assessment of sodium levels at six month intervals. Several studies were completed with regard to cardiac patients and compliance. Two such studies reported a measurement of compliance that included willingness or intent to comply. Willingness or intent was occasionally assessed along with specific behavioral aspects of compliance. Woodwark and Gauthei r (1972) based compliance on physician estimation of the patient's willingness to comply with diet, activity, and tobacco recommendations. Specific patient behavior was not assessed in this study. Three hundred and forty five first-time male myocardial infarction patients, ranging from 30 to 60 years of age, were studied by Croog and Levine (1977). A composite index of compliance was calculated by the ratio of Patient stated compliance or willingness to comply with the recom- mended advice as revealed by the patient. Compliance with different t1"eatment recommendations was measured individually by structured 1r"terview at three points in time. Measurements were made through the use of general statements concerning the extent to which patients Ware able to follow advice. At one and a half months and one year Post infarction, compliance with selected treatment regimens 48 displayed in rank order were identical indicating that compliance had not relatively changed over time. Several studies reported measuring cardiac patient compli- ance with recommended treatments. Bille (1977a, 1977b) identified compliance categories of diet, physical activity, stress, body weight and smoking, but reported only a total compliance score measured one month after discharge. Compliance was based on patient described regimens and the extent to which the patients reported following the regimens. Compliance was reported as ranges of the possible percent of compliance along with the mean percent for the group. Davis and Eichhorn (1963), in a longitudinal study, mea- sured compliant behavior via stated compliance concerning recalled treatments. Several categories were measured individually and the maximum percent adherence distribution was displayed. A self- report questionnaire on smoking and weight reduction was utilized by Pozen et a1. (1977) to determine compliance at hospital discharge and six months later for myocardial infarction patients. Johannsen and ccr-workers (1966) reported that for 127 patients admitted to the Cardiac Work Classification Unit, compliance with recommendations for true preceding six month period was determined by chart review. Results showed that for medical recommendations 92.7 percent of the tOtal population complied but for vocational and psychological l"ECOITInendations the results were 76.4 percent and 66.7 percent, respeCtively. In a few studies, the researchers measured compliance with treatment regimens in conjunction with follow-through of appointments 49 or referrals. Elling, Whittemore, and Green (1960) measured com- pliance of patients on rheumatic fever medication prophylaxis as participation in the clinic. Participation was determined by a com— posite of medications taken and by attendance at the clinic. The number of medications taken was determined by dividing the number of tablets purchased by the number of tablets prescribed and attend- ance was obtained from clinic records. For hypertensive patients, Inui and associates (1976) measured medication compliance by pill count while adherence to diet was measured by stated compliance. Follow—through appointment data were obtained from the records. The results of one study suggest that medical regimens were more difficult to adhere to than referrals or keeping appointments. Berkowitz and colleagues (1963), in a study of outpatient compli- ance, utilized physician determination of patient compliance by a general questionnaire. A comparison was made between the amount of compleate follow-through and the type of follow-through. The results were £15 follows: return appointments 86 percent, tests 85 percent, referr‘als 81 percent, medications 76 percent, treatments 75 percent, and Trestrictions 69 percent. Although a few questions were vali- dated by clinic records (appointments, test, referrals) and subse- qUEOt. readjustments were made, the remainder of the questions were purely subjective physician reports. In summary, the definitions of compliance were not standard— 129d~ These definitions referred to actual behavioral aspects of compliance or the willingness to comply. 50 The methods or approaches used to determine compliance were variable and imprecise which made generalizations and comparisons difficult. Compliance was assessed by objective measures, subjec- tive measures, or a combination of the two. The data for subjec- tive compliance was obtained from the patient, the physician, or both. Compliance questionnaires or structured interviews were fre- quently employed to collect data but such measures were general in nature. Also, there was inconsistency in the measurement intervals for compliance. Compliance was measured as the extent to which patients adhere to treatments or follow-through with appointments or refer- rals. Generally, the indices of compliance were based on treatments but even these results were difficult to compare due to the vari- abil ity of specific or total treatment regimens being measured. Furthermore, it was suggested that adherence to prescribed treatxnent regimens was more difficult than completing referrals and laib tests or keeping appointments. Therefore, emphasis for further research should continue to focus on the relationship of adherence with specific treatment regimens. Vfi‘jébl es Which Influence Compl i ance Many influencing variables have been studied regarding com- Pllant behavior. The major categories of variables discussed in this section are demographic data, disease characteristics, regimen characteristics, and psychosocial-behavioral characteristics. 51 Demographic Data.--Studies yielded inconsistent results con- cerning demographic variables that influenced compliance. In gen- eral, the majority of studies documented no association of selected demographic data such as age, sex, socioeconomic status, education, marital status, or race with compliance (Elling, Whittemore, and Green, 1960; Heinzelmann, 1962; Davis and Eichhorn, 1963; Donabedian and Rosenfeld, 1964; Johannsen, Hellmuth, and Sorauf, 1966; Davis, 1967, 1968a, 1968b; Watkins et al., 1967; Marston, 1970; Mitchell, 1974; Hulka et al., 1976; Sackett and Haynes, 1976). However, the results of a few studies have suggested some relationship of specific demographic variables to compliance. Bille (1977a) identified a direct relationship between age and com- pliance of post myocardial infarction patients. As age increased, reported compliance concomitantly increased. In contrast, Davis and Eichhorn (1963) reported that compliance of post myocardial infarc- tion patients was inversely related to age. Vincent (1971) related that women with glaucoma from 45-64 years of age were less likely to be noncompliant than men in the same age range. Davis (1966) found that women were more likely to default than men. In addition, marwded women tended to be more noncompliant than widows (Vincent, 1970). According to a few studies, lower socioeconomic groups com- pi’led less than upper socioeconomic groups (Johannsen, Hellmuth, and Sormauf, 1966; Davis, 1966). In relation to education, Davis and Eichhorn (1963) identified that increased education was associated Witt) noncompliance of cardiac patients. This was further corrobor- ated in a later study conducted by Davis (1966). However, Elling 52 and colleagues (1960) reported that lower education leads to poor understanding and cooperation in patients with rheumatic heart disease. In summary, there was no consistency in the reported results. Conflicting data existed related to the demographic factors and sub- sequent relationships to compliant behavior. Disease Characteristics.--The results of some studies indi- cated that characteristics of the disease demonstrate variable rela— tionships with compliance. Disease characteristics such as severity, synmtomatology, and duration of hospitalization are not associated wi th compliant behavior (MacDonald, Hagberg, and Grossman, 1963; Jcahannsen, Hellmuth, and Sorauf, 1966; Charney et al., 1967; Sar:kett and Haynes, 1976). Conversely, Donabedian and Rosenfeld (1964) identified a direct relationship between disease severity and ccnnpliance with treatment regimens for chronically ill patients. Heilizelmann (1962) found that as rheumatic fever patients exper— ienced increased severity of the disease, compliance increased. In further studies, Davis (1968a) indicated that cardiac patients with severe illnesses followed treatment regimens less than those with less severe illnesses. Differences were identified in the compliant behavior of chronic illness patients on long term treatment regimens and patients Wlth acute illness on episodic regimens. Blackwell (1973) related that Patients with chronic illnesses complied less than patients Wlth acute illnesses. Arthritis patients who had a good 53 understanding of the disease failed to increase compliance possibly because they were fully aware of the chronicity of the condition (Carpenter and Davis, 1976). Regimens for acute illness are trouble— some and necessitate behavioral changes, but the patient can realize that the treatment is temporary. In many chronic illnesses, treat- ments and necessary behavioral changes are prolonged and often permanent. Duration of hospitalization was implicated as a potential fax:tor affecting compliance with health advice. In a study of al<:oholic men, the results indicated that as the length of hospital— ization increased, the rate of compliance to abstinance after dis- (fiiarge decreased (Rae, 1972). The results suggested that an aspect of’ dependency possibly was fostered during prolonged hospital care wrrich was detrimental to compliance in the home setting. Negative associations were identified between symptoms of the disease and compliance with medication regimens of arthritic and neurotic patients. As the symptoms increased, compliance decreased (Joyce, 1962; Lipman et al., 1965). Another factor viewed as influencing compliant behavior is a Positive family history. Heinzelmann (1962) reported that when rheumatic fever patients also had a family history of rheumatic fever, prophylactic medication compliance increased. In summary, studies of compliance associated with severity of the cardiac disease and length of hospitalization provided con— fllClling data. No studies documented that the length of myocardial infarction hospitalization was associated with compliance. Chronic 54 illness long term regimens were more difficult to follow than episodic treatment regimens. Therefore, emphasis for further com- pliance studies should focus on chronically ill patients. Further- more, studies documented the relationship between symptoms of the disease and medication compliance, but no studies attempted to relate symptoms to other types of compliance such as diet, exercise, or other behaviors. In addition, family history was relevant for patients on rheumatic fever prophylaxis but studies that related family history to cardiac patient compliance were not found. Regimen Characteristics.—-Specific characteristics of the regimen were identified as having variable influence on compliant behavior. These characteristics include duration, complexity, type of regimen, and prior experiences with regimens. A few studies reported that the duration of the regimen and prior experiences Showed no association with increased adherence (Davis and Eichhorn, 1963; Glick, 1965). There was disagreement regarding the propensity 01“ defaulting with medications and the length of time a particular madication was prescribed (Davis, 1966). Cardiac patients with long 171 me impairments were less likely to stop complying with treatments than patients impaired for less than nine years (Davis and Eichhorn, l963). Caldwell et al., (1970) found that newly diagnosed hyper- tefisive patients were more likely to drop out of medication treat- merit than those with a longer duration of the disease. Other inves- t1'Slators related that compliance declines over time (Charney et al., 1957; McKenny et al., 1973). Croog and Levine (1977) reported 55 that compliance with selected treatment regimens at one and one half months and one year post infarction were identical in rankings. Another characteristic potentially influencing compliance was the complexity of the regimen. Medication compliance studies reported a decrease in the accuracy of following prescribed medica- tion regimens as the number of regimens increases (Neeley and Patrick, 1968; Hulka et al., 1976). Francis, Korsch, and Morris (1969) iden- tified that patients were not likely to follow complex diet instruc— tions. Davis and Eichhorn (1963) reported that when more than one medical recommendation existed patients were not as likely to follow them. These results were further substantiated by Marston (1970) who reported that compliance was lower for patients whose treatment consisted of medications and other recommendations than for patients whose recommendations were simpler. There were identified differences in the types of regimens and the rate of compliance. Restrictions on behavior or changes in personal habits such as smoking were the most difficult to follow. Dietary and work changes were the next most difficult to implement. Taking prescribed medication was the easiest type of recommendation to follow (Berkowitz et al., 1963; Davis and Eichhorn, 1963; Davis, 1 966). Marston (1970) related the greatest decrease in compliance OVer time with prescribed diets. Recommendations regarding diets Showed less compliance than regulation of daily activities, admin- lstration of oral medications, and self-injection of insulin for Chronically-ill patients (Donabedian and Rosenfeld, 1964). In addition, Croog and Levine (1977) reported that cardiac patients at ¥ 56 one and one half months and one year post infarction complied best with medication recommendations. Compliance with exercise, diet, and weight reduction followed in descending order. Experiences with previous therapy and regimens demonstrated variable results with compliant behavior. Glick (1965) identified that prior experiences with medication therapy showed no relation- ship with completion of a four week medication treatment course for depressed patients. Others reported that prior experiences with treatment regimens positively influenced compliance (Lipman et al., 1965; Hecht, l974). Increases in compliance were possibly due, in part, to the familiarity of the patient with behavioral changes necessary to implement treatments. In surrmary, there were inconsistent results concerning the relationship of compliance and the duration of prescribed treatment regimens. Increasing noncompliance was clearly associated with an increased number of recommendations, possibly because patients were less likely to have accurate knowledge of their specific regimens as the number of regimens increased. Treatments which involved Significant behavioral changes such as restrictions on behavior, Changes in personal habits, or dietary changes were more difficult t0 follow than those that required minimal changes such as taking medication. Furthermore, there were differing results regarding the relationship between previous experiences with therapy and Clompl i ance. 57 Epychosocial-Bepavioral Characteristics.--The final category of variables which influenced compliance involves psychosocial- behavioral characteristics. These characteristics include patient perception of disease, attitudes, values and beliefs, work orienta— tion, support and influence from family and friends, patient- provider relationship, and knowledge of the disease and treatment regimens. Results from a study by Eichhorn (1962) revealed that patients who perceived themselves as having a heart condition, although they actually did not, followed some of the precautions that were consistent with those prescribed for cardiac patients. Charney and associates (1967) reported that mothers whose children were treated for otitis media, complied with medication regimens more when they perceived that their child was moderately to severely ill than when they thought the child was mildly ill or not ill at all. On the other hand, patients with chronic illness who perceived the condition as not serious demonstrated greater knowledge and con- tinuance of therapy (Tagliacozzo and Ima, 1970). Attitudes, values and beliefs played a significant role in adherence to treatment regimens. Becker (1972), in a study of pediatric patients with otitis media, reported that mothers who iden- tified a Specific susceptibility to disease, general susceptibility to disease, and efficacy of therapy complied more with treatment Pagirnens. Efficacy of therapy was a factor associated with increased comPl'iance of chronically ill patients according to Donabedian and ROSenfeld (1964). Heinzelmann (1962) reported that rhuematic fever 58 patients demonstrated increased prophylactic behavior when they perceived susceptibility to an attack, seriousness of an attack, and benefits of the course of action in order to avoid or minimize a health hazard. A few studies related that patients with a positive attitude toward health were more likely to continue complying with therapeutic advice and were less likely to stop complying (Davis and Eichhorn, 1963; Becker, Drachman, and Kersch, 1974). Another factor considered in relation to compliance was work orientation. Male cardiac patients with low work orientation complied to a greater degree than those with high work orientation (Davis and Eichhorn, 1963). Davis and Eichhorn's results confirmed the reports of Goldstein and Eichhorn (1961). In another study with post myocardial infarction patients, Willis and Dunsmore (1967) reported that the relationship between work orientation and compliance was negligible. Support or influence from family and friends contributed to compliant behavior. Davis and Eichhorn (1963) identified that Cardiac patients were influenced by relatives and friends to increase lZheir compliance. Patients who were most influenced by someone other than their doctor had a higher compliance rate over time. Donabedian and Rosenfeld (1964) reported that patients did not per- Ceive family members as influencing their noncompliance with therapy. In another study, patients with cardiac disease showed no signifi— Cant correlations between the influence of family and friends, and Compliance (Davis, 1967). Davis' results may be erroneous and can Potentially be explained by the fact that a composite index of ¥ _7 59 compliance was used, hence, all regimens were analyzed together and not treated separately. Several researchers deemed the patient-provider relationship as significant in promoting compliant behavior (Elling, Whittemore, and Green, 1960; Davis, 1967, 1971). Some investigators recognized the importance of conmunication and it's subsequent effects on com- pliance (Elling, Whittemore, and Green, 1960; Davis and Eichhorn, 1963). One study reported that a formal type of interaction with the doctor was more likely to result in compliance than a friendly one (Davis and Eichhorn, 1963). However, Charney et a1. (1967) found that a long standing warm relationship with a pediatrician correlated positively with follow-through of medical advice. Becker and associates (1974) indicated that having a child see the same physician on subsequent visits to the clinic had ameliorative effects on compliance. Davis (1971) specifically identified that passivity on the Part of the patient and giving on the part of the doctor induced Patient compliance. A positive correlation existed between compli- ance and preference for a strict or authoritarian doctor (Williams, Martin, and Hogan, 1967). Patient passivity or preference for a Strict or authoritarian doctor is consistent with identified roles ancl sick role behavior as discussed by Vincent (1971) and Becker, DY‘achman, and Kersch (1974). Patient satisfaction was an aspect of the patient-provider r‘elationship that influenced continuity of regimens. When ¥ I 6O satisfaction was demonstrated, compliance was increased (Francis, Korsch, and Morris, 1969; Becker, 1972). In summary, variations existed concerning the perceived severity of an illness and adherent behavior. Attitudes, values, and beliefs related to health and health care influenced patient compliance. The effect of work orientation on compliance behavior was still uncertain. Generally, family and friends positively influenced patients to follow treatment orders. While there was not complete agreement on exactly how the patient—provider relation- ship affected compliance, patients who assumed characteristics of sick role behavior and were satisfied with their care demonstrated higher compliance rates than those who did not. Relationship Between Knowledge and Compliance Knowledge is the last psychosocial—behavioral variable dis- cussed in relation to compliance. Studies supporting or refuting the relationship of knowledge to compliance were reported in the literature. In this review, major emphasis was placed on studies of chronic illnesses and recommended treatments. Several studies compared knowledge with prophylactic medica- tion compliance. The results of these studies indicated that a Positive relationship existed. Elling, Whittemore, and Green (1960) Utilized a pediatric population of 80 randomly selected rheumatic fiever patients and completed interviews to obtain information regard— llig medication compliance. Broken appointments were ascertained Triam the records. It was determined that increased understanding of ¥ —_———-—-——’ 61 Penicillin prophylaxis lead to increased compliance with medica- tions and appointment schedules. In another study, Heinzelmann (1962) found that college aged rheumatic fever patients who had higher scores on knowledge and belief questionnaires about rheumatic fever and treatment prophylaxis complied to a greater degree with medication schedules. A positive relationship between knowledge and compliance was demonstrated in chronic illness studies. In a study of 60 diabetic patients overall knowledge of diabetes and actual home management vvere evaluated by a structural protocol at a home visit. Psycho— Inotor skills required for insulin administration, calculation of insulin dosage, and urine testing were demonstrated by the patient. In addition, information was obtained about the spacing of meals and foot care. Patients who had higher scores on knowledge tests had better home management scores or more accurate compliance with (ordered treatments than those with low knowledge scores (Watkins e1: al., 1967). Hulka and co-workers (1976) completed a Si:udy with 357 diabetic or congestive heart failure patients. Eritrance into the study was determined by random sampling of physi- Ci an's offices. Two weeks after entrance into the study, a home V‘isit was completed and information regarding medication knowledge anxd compliance was obtained. This information was compared to Speecific orders as perceived by the physicians. Results indicated thiit discrepancies existed in the perceived orders and much non- COrnpliance was due to misunderstanding on the part of the patient. 62 It, therefore, seems essential that patients' knowledge and under- standing of treatments be assessed frequently. Many hypertensive patient compliance studies were completed (Caldwell et al., 1970; Caplan et al., 1976; Inui, Yourtee, and Williamson, 1976; Given, Given, and Simoni, 1978). Accurate know- ledge of the disease was identified by Caldwell et a1. (1970) as the most potent factor influencing continuation of therapy. In this study,42 patients who had developed a hypertensive emergency after discontinuing therapy were compared to a control group of 24 patients. The reasons for discontinuing therapy for the emergency group were identified by interviews. For the control group, reasons for con- tinuing therapy were inferred from responses elicited during inter- view sessions. No specific knowledge test was administered for measurement purposes. Because of the inferences made in this study, the validity of these results seem questionable. Caplan and associates (1976), in a quasi-experimental study, viewed the effects of social support and lecture content on compli- ance of 70 hypertensive patients from rural, city,and university clinics. The design consisted of pretesting and posttesting three treatment conditions. Two knowledge measures were tested: specific recommendations previously prescribed, and general information con- cerning hypertension. Prompt refilling of prescriptions at a later time was positively correlated with patient knowledge of the regimen at an earlier time (r = 36, p <.05). The scores on the knowledge of disease posttest were positively related (r = .23, p <.05) to attend- ance at meetings. Patients' knowledge of the regimen did not change 63 over time for the total sample but general knowledge increased from the pretest to posttest. Also, posttest measurements showed a trend for persons to report greater adherence in medication taking. Therefore, the results of this study indicated, in general, that knowledge of the treatment regimen and of the disease were posi- tively related to compliance. Although some measures of knowledge and compliance were identified, this study did not attempt to view the relationship of treatment regimen knowledge, general knowledge, or total knowledge with specific medication compliance or total compliance. Eighty-eight diagnosed hypertensive patients were interviewed at the beginning of medication therapy and five months later in a study conducted by Given, Given, and Simoni (1978). No experi- mental treatment was instituted in the interim. Correlation between the variables of knowledge, patient perception, and compliance were assessed by using Pearson Product Moment Correlations and Partial Correlations. Results indicated that knowledge of medication was found to be positively correlated with compliance at both points in time, r = .40 and r = .42, but that knowledge had a greater independ- ent assoication with compliance initially. The measurement of know- ledge incorporated both recall of medication regimens and general information concerning medications. However, the components, recall of the regimen and general information concerning medications, were not analyzed separately with compliance. In another study with hypertensive patients, Inui and associ- ates (1976) utilized a quasi-experimental design and measured the 64 knowledge and compliance of 220 patients prior and subsequent to physician educational sessions. Knowledge of recalled recommenda- tions and general knowledge of treatments such as diet and medica— tions were measured at the initial contact. Compliance with these treatments was measured at a home visit two months later. Results indicated that after experimental educational treatment with physi- cians, patients in the experimental group were more knowledgeable than the control group about medication regimens and diet require- ments. A greater number of treatment group patients (30) complied with medication recommendations than did the control group (17). However, there were similar numbers of patients complying with diet recommendations in both the experimental (28) and control (29) groups. Although individual indices of knowledge, recall and general infonnation, were determined they were not viewed concomitantly with compliant behavior. Hence, specific inter-relationships were not determined between recall or general knowledge categories, and specific compliance categories. Furthermore, knowledge was not reassessed at the time compliance was measured. Rosenberg (1971) studied 100 congestive heart failure patients who were assigned to experimental and control groups. Structured interviews were conducted initially and at six month intervals to determine knowledge and attitudinal changes. The experimental group received broad education and counseling concern- ing cardiac medications, diet, and disease process. Results indi- cated that six months after the group educational program, the experimental group demonstrated increased knowledge of low sodium 65 diets and medications and decreased intake of sodium measured via urine tests. It was difficult to identify whether compliance in this study was due to increases in knowledge or to the patient- provider interaction. Specific knowledge and compliance categories, diet and medications, were identified. However, no relationship was determined between medication knowledge and corresponding medi- cation compliance. In addition, knowledge of the disease was not assessed and total knowledge and total compliance were not deter— mined. The results of other studies indicated that no relationship existed between knowledge and compliance of chronically ill patients (Donabedian and Rosenfeld, 1964; Tagliacozzo et al., 1974; Sackett et al., 1975; Carpenter and Davis, 1976). Adherence of 54 rheuma- toid arthritic patients to exercise programs four months after hospital discharge was evaluated by Carpenter and Davis (1976). Structured interviews obtained information regarding the following of exercise regimens and understanding of the disease. Results indicated that 63 percent of the noncompliers had a good under- standing of their disease as compared to 48 percent of the complying group. It may be that chronicity of the condition may have reinforced the idea that an exercise program provided no improvement in the condition. In a study with 82 diabetic, arthritic, and cardiac patients, Donabedian and Rosenfeld (1964) determined that at three months there was no statistically significant relationship between the under— standing of the treatment recommendations and noncompliance with 66 the recommendations. Understanding of the recommendations was determined by a social worker during the home visit and was mea- sured by the accuracy and completeness by which the patient des- cribed recommendations. Compliance was based on self report during structured interview sessions. The results of a few studies report that an experimental treatment had either no effect or a negative effect on the rela- tionship between knowledge and compliance. Tagliacozzo et al., (1974) completed an experimental study with 192 chronically ill patients. All patients completed knowledge tests initially and at the end of the research period. These tests focused on the patient's specific primary diagnosis and included disease and treatment regimen questions. Patients in the experimental group were exposed to four nursing educational sessions. There were some increases in the knowledge of the primary disease but there was not a statistically significant or fundamentally different relationship between the two groups for those who attended at least two sessions. Knowledge was not analyzed separately as disease knowledge or treat- ment regimen knowledge but as total knowledge. Compliance was not different for the two groups in relation to attendance, regularity of attendance, medication taken, and attendance at requested visits to other clinics. However, weight loss Was increased for the con- trol group. Two hundred and thirty male Canadian steel workers with hypertension participated in a quasi-experimental study conducted by Sackett and colleagues (1975) that evaluated compliance and Inastery learning. Results indicated that at six months 85 percent 67 of those in the mastery learning group had mastered the information concerning the disease and treatments for hypertension while only 18 percent of the men in control group had done so. Mastery learn- ing did not, however, increase compliant behavior. Individual com- pliance rates demonstrated no relationship to total knowledge at entry to the study (r = -.03) or at six months (r = .08). No attempt was made to view a relationship between knowledge at entry into the study and compliance at a later time. Furthermore, knowledge categories such as disease knowledge or treatment regimen knowledge were not analyzed with compliance. In two studies conducted with diabetic patients, the researchers reported that increases in knowledge were not associ- ated with increased compliance (Bowen, Rich, and Schlotfeld, 1961; Etzwiler and Robb, 1972). Both studies reported increases in know- ledge following the experimental treatments of diabetic classes or teaching machines. Compliance in these studies was reported as con- trol of the disease and was measured indirectly by blood sugar levels, weight gain, and levels of sugar in the urine. Neither study directly inquired as to the extent to which patients followed prescribed treatments at home. Watkins and associates (1967), in another study of diabetic patient control of the disease, reported that increased compliance with treatment regimens was unrelated to diabetic control. These results may have been due to many physiological and psychological influencing variables that affect the control of diabetes. Because of the many influencing variables,adherence to treatment regimens 68 reflects only a portion of total disease control. Therefore, using control as a measure of diabetic compliance is not significantly valid and results should be interpreted cautiously. In addition to the general chronic illness studies dis- cussed, a few studies were reviewed that utilized cardiac popula- tions and measured the effects of experimental treatments on know- ledge and compliance (Woodwark and Gautheir, 1972; Bille, 1977a, 1977b; Pozen et al., 1977). The effect of a Nurse Rehabilitator was evaluated prospectively by Pozen et al. (1977). In this research study, 102 post myocardial infarction patients were randomized into control and treatment groups. At hospital discharge, the treatment group knew more than the control group about the disease and medications. One month after discharge, differences in the knowledge of medications between groups was negligible, possibly because the control group was learning more about medications. At this same testing,the study group still knew more about the disease. By six months after discharge,both groups had similar low scores on know- ledge of the disease and knowledge of medications. Compliance, reported only at six months, indicated that weight reduction was not significant for either group, however, more study group patients had discontinued smoking. Therefore, increased knowledge of medications at hospital discharge and increased knowledge of the disease at hospital discharge and one month after discharge were associated with smoking reduction compliance at six months. Knowledge tests of information specific for compliance categories were not measured and,therefore, not assessed in relation to corresponding specific 69 compliance categories. Only disease knowledge was viewed in associ— ation with smoking and weight reduction. A measure of compliance was not computed one month after discharge when knowledge was high. A study of 24 post myocardial infarction patients, con- ducted by Bille (1977a, 1977b), assessed the relationships between knowledge, compliance, and teaching format. The patients were assigned to control and treatment groups. The treatment group was given a structured one-to-one educational program that was developed based on objectives. The objectives,along with other written materials,were shared with the patient. In both groups,knowledge of the disease and treatment regimens were evaluated at hospital discharge. Compliance was measured at an interview one month after discharge by having the patient indicate his current medical regimen and the extent to which he followed it. The structured educational program was not associated with increases in patient knowledge and the correlation between knowledge and compliance was not statis- tically significant (r = -.336). Age was positively related to com- pliance (r = +.496) and inversely related to knowledge (r = -.512) Although this study measured the relationship of knowledge to com- pliance, total knowledge was used and separate knowledge categories such as disease knowledge and treatment regimen knowledge were not assessed. Testing of knowledge was not completed at the time com- pliance was measured and, therefore, correlations of present know- ledge and compliance were not computed. It is possible that sig— nificant changes in knowledge could have resulted in the time period prior to compliance testing. 7O Woodwark and Gautheir (1972) studied knowledge and compli- ance of 38 cardiac patients after an educational program. The patients were equally divided into control and treatment groups. The treatment group received educational instruction from lectures, slides, and frequent encounters with a nurse. Three weeks after discharge, all of those who had participated in the treatment group had higher knowledge scores than those in the control group. Sixteen patients in the treatment group had high compliance rates as com- pared to three patients in the control group. This study did not differentiate between knowledge of the disease and knowledge of treatment regimens and their specific relationships to compliance. It did suggest that those with higher total knowledge at three weeks comply more than those with lower total knowledge. In summary, chronic illness studies indicated positive, negative, and zero associations between a variety of knowledge and compliance measures. In general, the majority of studies reported that a positive relationship existed. However, minimal analysis was conducted regarding knowledge categories, compliance categories, and their interrelationships. Conclusion In conclusion, a review of the literature indicated numerous factors that were perceived as influential in promoting compliant behavior. These factors were categorized as demographic data, disease characteristics, regimen characteristics, and psychosocial- behavioral characteristics. Significant differences existed 71 concerning a variety of these characteristics and compliance. Knowledge was one characteristic that frequently was assessed in relation to compliance. The preceding review of the literature reported that differ- ences existed in the definitions and methodologies involved in mea— suring knowledge and compliance. Knowledge indices measured differ- ent knowledge categories such as knowledge of the disease, recall of treatments, general information regarding treatments, and total knowledge. Compliance indices measured adherence to specific or general treatments, total treatment regimens, or follow-through with appointments and referrals. Occasionally, compliance incor- porated the concept of willingness to comply thus adding a further dimension to the behavioral concept. Knowledge was measured by structured interview techniques or questionnaires. Compliance was assessed by objective measures, subjective measures, or a combination of both presented as a com— posite score. Knowledge and compliance were measured at various time intervals but infrequently at two points in time to allow for assessment of changes. When knowledge was measured at different Poirits in time, variations existed between the knowledge of the disease and the knowledge of treatment regimens. In most studies, including all cardiac studies, knowledge and compliance were measured after a specific educational treatment. Only one study measured knowledge, regardless of how obtained, Wlth compliance. ¥ 72 Other studies were reviewed in which researchers reported measuring the relationships between knowledge and compliance. One study correlated knowledge and compliance separately at two points in time, but no study was found that correlated knowledge at two points_in time with specific compliance. Studies indicated that knowledge indices were not always obtained at the same time as compliance measurements, hence, changes in knowledge may have occurred and remained undetected. No studies that were reviewed specifically analyzed the relationship between types of knowledge, disease knowledge or treatment regimen knowledge, at two points in time and their subsequent relationships to corresponding com- pliance. Due to the inconsistencies and ambiguities that exist con- cerning knowledge and compliance, it is exceedingly difficult to make generalizations or comparisons between these studies. Regard- less of the inconsistencies in measurement techniques, the majority of studies do suggest that a positive relationship exists between knowledge and compliant behavior. However, specific analysis of the knowledge category and compliance category relationships are not documented in the literature. According to Orem (1971) patient education is a major r‘esponsibility of nursing at the supportive-educative systems level. I“ an attempt to more fully emphasize information that is influential in Promoting compliant behavior of post myocardial infarction Patients, nursing must determine what relationships exist between knoWledge and compliance with treatment regimens. IIIIIl-.__, 73 Based on these needs and deficiencies identified in the literature, this exploratory research project will study the rela— tionships of knowledge at the time of discharge from the hospital, and knowledge and stated compliance six weeks after discharge for post myocardial infarction patients. In Chapter IV the methodology and procedures utilized in this study will be presented. The areas included are population, setting, instruments, data collection procedures, scoring of data, procedures for data analysis, and human rights protection. CHAPTER IV METHODOLOGY AND PROCEDURE Overview This research project is designed to study the relationships between post myocardial infarction patient knowledge at the time of discharge from the hospital, and knowledge and stated compliance six weeks after hospital discharge. A myocardial infarction patient population of a 204 bed private hospital is used. At hospital dis- charge a knowledge questionnaire developed by the researcher is utilized to collect data on patient knowledge (see Appendix A). Six weeks subsequent to hospital discharge, the same patients complete the same knowledge questionnaire as well as a researcher developed compliance questionnaire (see Appendix B). Knowledge and compliance are analyzed based on this data. The problem to be studied is further divided into two Specific research questions concerning the patterns of knowledge and the patterns of compliance. The patterns of knowledge and patterns 0f compliance are further divided into the levels of knowledge or levels of compliance, factors that affect the levels of knowledge or compliance, the relationship between knowledge at two points in time, factors that affect the relationship between knowledge at two P01nts in time, the relationship between knowledge and compliance, 74 ‘g 75 and factors that affect the relationship between knowledge and com- pliance. The specific knowledge or compliance categories are also investigated. This study is exploratory in nature and a combination of statistical and descriptive case study techniques are used for data analysis. The levels of knowledge and levels of compliance are com- puted based on proportion scores from the instruments. Mean percent scores and range percent scores are computed. Knowledge is also viewed in relation to the number of patients whose knowledge increases, decreases, or remains the same from hospital discharge to six weeks after discharge. The patients whose scores fell below 70 percent total or specific knowledge and 75 percent total or specific compliance are identified. The relationships between knowledge categories at two points in time, and knowledge and compliance categories are studied. Cor- relation mechanisms are used to test hypotheses about these rela- tionships in order to identify trends or indications. Since the population is small and randomization is not emPloyed, it cannot be assumed that characteristics of the population which affect knowledge and compliance are equally distributed across the population. Therefore, a case study approach is utilized to VIEW outlyers (extremes) and distinctive population patterns in Volation to factors that may affect the levels of knowledge and com- Pliance, knowledge relationships,and knowledge and compliance rela— tionships. The outlyers are defined as those patients who demon— Strate less than 70 percent knowledge, less than 75 percent 76 compliance, or show contrasting relationships from the general population as determined by scattergrams. Distinctive population patterns are particular patient groupings that are identified by scattergrams. The purpose of this chapter is to present the methodology and procedures utilized in this descriptive study. The areas included are population, setting, instruments, data collection pro- cedures, scoring, procedures for data analysis,and human rights protection. Population The population selected for the study included all consent— ing acute myocardial infarction patients admitted to a private 204 bed hospital during the months of August and September, 1978. Due to the anticipated small sample size randomization procedures were not utilized. Criteria for admission into the study included the following: 1. initial physician diagnosis of myocardial infarction as documented in the chart, and 2. patient home residence in or around the Greater Lansing area. For the final study population myocardial infarction patients were rdefined as patients who were diagnosed by the physician at hos- Pltal discharge as having had a myocardial infarction. This diagnosis was documented in the discharge summary. 77 Complications such as arrhythmias, congestive heart failure, or cardiac arrest did not exclude patients from the study, although this data was obtained and included in the severity index. Since the population was small limitations were not placed on age, sex, chronic illness, or previous myocardial infarction. This information was obtained from the patient and the chart, and was recorded in the demographic and supportive data. Setting The setting used in the study was a private 204 bed hospital. The total number of patients admitted to the hospital in 1977 was 10,278, 89 of which were myocardial infarction patients. The designated number of Intensive Care/Coronary Care beds was 13. Written permission was obtained from the Assistant Adminis- trator for Nursing to secure a patient sample and view patient charts during the identified time period (see Appendix C). The study was also discussed with and approved by the Medical Director of the Intensive Care/Coronary Care Unit. Patients diagnosed with a myocardial infarction or possible myocardial infarction were routinely admitted to the Intensive Care/ Coronary Care Unit initially for observation. The usual length of stay in this unit for a myocardial infarction patient, determined by chart review, was approximately three to five days. The nursing care was provided on a primary nursing care basis by registered nurses (RN) and licensed practical nurses (LPN). The nurse-patient 78 ratio was approximately 1:1 to 1:3 and was adjusted according to the medical severity of the patients' condition. After the patients' condition stabilized, they were dis- charged from the Intensive Care/Coronary Care Unit to one of two medical or surgical units in the hospital. The usual length of stay in these units, determined by chart review, was approximately seven to ten days. One unit used for the study was a 37 bed medical unit utilizing team nursing care with RN's and LPN's. The nurse-patient ratio on the day shift was 1:8. The other unit used in the study was a 23 bed surgical unit utilizing primary nursing care delivered by RN's and LPN's. The nurse patient ratio on the day shift was 1:5. At the time of data collection the hospital myocardial infarction educational program was not specifically defined. No specific outline or objectives existed for defining educational con- tent. Each patient was given pamphlets provided by the American Heart Association and a cardiac teaching manual (Withers, 1978) prepared by the hospital. This manual was prepared for myocardial infarction patients and included information about anatomy and physiology, signs and symptoms, risk factors, complications, medica- tions, exercise, and activity. Patient education and counseling was implemented on a one-to-one basis in the Intensive Care/Coronary Care Unit. Subse- quently, educational encounters were completed when the patients were in the medical-surgical units. These subsequent educational encounters were conducted by the nurses from the Intensive Care/ Coronary Care Unit and occasionally by the medical/surgical unit 79 nurses. Instruction was based on reviewing content presented in the written materials and answering the patients' questions. A flip chart, The Heart (Elly, 1973) was frequently used as a guide for instruction. This chart consisted of information regarding cardio- vascular anatomy and physiology, complications of cardiac disease, commonly prescribed medications, signs and symptoms of cardiac disease or complications, methods of risk factor reduction, commonly pre— scribed activity levels,and exercise methodology. The dietitian counseled patients regarding diet prescriptions. Attempts were made for educational continuity and educational contacts were based on the needs of the patient. Instruments Two instruments were utilized in this study: a knowledge questionnaire and a compliance questionnaire. Both of the question- naires were developed based on a review of the literature and the stated operational definitions of knowledge and compliance. Knowledge Instrument Review of Knowledge Instruments.--A paucity of published myocardial infarction patient knowledge tests was identified after a review of the literature. Rahe (1975) published a Coronary Heart Disease Evaluation Form that was used to evaluate an in-hospital educational program. The test consisted of 83 true-false, multiple_ choice questions concerning disease and treatment related factors such as the nature of the disease, physical activity, diet and 80 smoking, psychological factors, and return to home and work. This test also incorporated information regarding emergency treatment of a myocardial infarction patient. The questions were most appropriate for patients ready to be discharged from the hospital, but inappro- priate for patients engaging in full rehabilitative processes. Some areas incuded in the test, such as emergency treatments and psychological factors, were not consistent with the content for this study. One other instrument testing myocardial infarction patient knowledge was reported. This test, developed by Bille (1977b), was a 40 question multiple-choice, true-false test which included ques- tions on disease process and healing, risk factors, warning symptoms, and actions to be taken if symptoms arose. The general emphasis of the test was on disease and healing. The test contained a mini— mal number of questions on diet and activities. Neither of the tests incorporated questions regarding medication knowledge. In this study the knowledge questions were to correspond with specific compliance categories. Hence, the relationship of specific knowledge with specific compliance could be assessed. Since an appropriate questionnaire was not available to accomplish this task, a knowledge instrument was developed. Knowledge Instrument Development.--A knowledge instrument (see Appendix A) composed of questions specific for disease entity knowledge and treatment regimen knowledge was developed based on the operational definitions. These definitions in turn were developed 81 through a review of the literature pertaining to tests, treatments, and appropriate educational programs for post myocardial infarction patients. The instrument consisted of 48 possible multiple-choice questions, each with four possible answers. The questions were answered by placing a check mark in front of each correct foil. A combination of recall and application questions were utilized through- out the instrument. The content of the instrument consisted of total knowledge, which in turn was divided into two major categories: knowledge of disease entity, and knowledge of treatment regimens. 1. Total knowledge referred to the knowledge of disease entity and knowledge of treatment regimens as measured by the knowledge instrument. a. Knowledge of disease entity included: normal func— tions of the heart, etiology of the disease, the healing process, signs or symptoms of recurrence or complications, and risk factors leading to heart disease (see Appendix A, questions 1-7). b. Knowledge of total treatmept regimens was a summation of all treatment regimen knowledge which included physical activity, total diet, and medication know- ledge (see Appendix A, questions 8-48). (1) Physical activity knowledge included: projected activity, progressive activity, methods of mon- itoring body response to activity, actions to be taken if monitoring relates abnormal body (3) 82 response, effects of exercise, and exercise methodology (see Appendix A, questions 14-20). Total diet knowledge was a summation of general and specific diet knowledge (see Appendix A, questions 8-13 and 21—28)- (a) General diet knowledge included: general information related to the role and com- position of nutritionally balanced meals, rationale for spacing meals, strategies for weight maintenance and control, and the relationship between food ingestion, digestion, and physical activity (see Appendix A, questions 8—13). Specific diet knowledge referred to low salt/sodium diet knowledge and/or low cholesterol/saturated fat diet knowledge. This specific diet knowledge included: definitions of low salt/sodium diets and/or low cholesterol/saturated fat diets, rationale for following diet prescriptions, common foods included and excluded, and appropriate methods of food preparation (see Appendix A, questions 21-28). Medication knowledge included: action, purpose, desired results, side effects and pertinent 83 information related to the medication (see Appendix A, questions 29-48). Generalized information questions were utilized due to the volume of questions that would have been necessary if testing had been individualized to specific treatment regimens of each patient. Furthermore, the specific treatment regimen knowledge questions were selected so that they would correspond to areas of longitudinal compliance. Knowledge Instrument Content Validity.--Content validity refers to ”the degree to which the sample of test items represents the content that the test is designed to measure" (Borg and Gall, 1971, p. 136). There was no statistical test for the determination of content validity. This validity was determined by subjective analysis. In an attempt to insure content validity, the areas and questions for knowledge evaluation were developed after reviewing knowledge instruments, treatments, and educational program emphasis from various settings. Two Cardiovascular Nurse Clinicians and a Cardiologist reviewed the developed instrument and all made signifi- cant contributions to its content refinement. A nurse responsible for myocardial infarction patient education at the hospital reviewed the instrument and verified that the content corresponded with the content presented to the patients. The content of the instrument was determined to be represen- tative of the necessary content by the researcher with the assistance 84 of cardiovascular experts and, hence, reflective of content validity. Knowledge Instrument Refinement.-—The instrument was eval- uated by committee members and a psychometrician for form, vocabu- lary, and readibility. Changes were made in the instrument based on the information received from these individuals. Knowledge Instrument Pretest.-—After changes were made, three patients recently discharged from the hospital with a myo- cardial infarction completed the knowledge questionnaire. They were asked to complete the instrument and to critically review it. After completion of the instrument they were interviewed to ascertain any difficulties in wording, clarity, or format. Minor revisions, which generally involved simplification of wording, were completed prior to the utilization of the instrument in the study. Compliance Instrument Review of Compliance Instruments.--Examples of compliance instruments were identified through a review of the literature. None of the instruments evaluated generalized recommended treatment compliance for the post myocardial infarction patient in the areas of activity, diet, and medications. Furthermore, none of the instru- ments used specific content structured questions for post myocardial infarction patients. Berkowitz and associates (1963, p. 17) designed a compliance questionnaire that measured physician estimates of their patients ———" 85 compliance. This questionnaire included one very non—specific question that measured adherence to recommended treatments. The possible responses included completely, partially, not at all, and not necessary. Other questionnaires more narrowly focused on the recommended treatments. However, they did not include specific actions the patients should or should not be completing based on their pre- scriptions. Croog and colleagues (1977, p. 193) in a structured interview, inquired as to whether patients had received advice on such matters as medications, diet, exercise, and other treatments. If affirmative answers were obtained the patients were asked, "How well have you been able to follow the doctor's advice?“ or "How well do you think you will be able to follow the doctor's advice?” The responses were coded as: completely, for the most part, some- what, or not at all. Carpenter and Davis (1976, p. 242), by a structured interview, utilized the following questions to measure arthritis patients'compliance with exercise programs: ”How often do you do your exercises? Have you changed your exercise schedule in any way? Are you doing exercises exactly as you were trained? What changes have you made?“ Other compliance studies were more specific, dealing with the actions that the patient should be completing related to treat- ment regimens. However, none of these studies utilized post myo- cardial infarction patient populations (Caplan et al., 1976; Given, 1975; Given, Given, and Simoni, 1978). 86 An example of a compliance question for post myocardial infarction patients was presented by Bille (1977b). Patients were asked to state what the doctors had recommended for them in areas such as diet, medications, physical activity, stressful situations, work, weight loss, smoking,and alcohol. Patients were asked to esti— mate the extent to which they were able to follow the recommenda- tions. The responses included the following: all the time, most of the time, about half of the time, very seldom, or none of the time. The results from questions for each area included numerous possible recommendations, therefore, the instrument did not indi- vidually identify adherence to specific recommendations. Although an example of a question used in this compliance instrument was presented, the completed questionnaire was not available for perusal. Compliance Instrument Development.--Due to the lack of an appropriate compliance questionnaire that measured specific com- pliance corresponding to previously identified knowledge areas, a compliance questionnaire was designed by the researcher (see Appendix B). The questionnaire was developed based on the operational definitions of compliance. These definitions in turn were developed through a review of the literature related to questionnaires, treat— ments, and appropriate educational programs for post myocardial infarction patients. The compliance instrument was composed of statements answered according to a five point Likert scale. Some statements were stated Positively and some negatively to prevent response modes from ¥ I ‘4 developing. 87 The scale utilized was developed and used in a previous compliance study by Davis (1968a). It consisted of five gradiated choices that include the following: all of the time, most of the time, less than half of the time, very seldom, and none of the time. The compliance instrument was composed of statements regard- ing physical activity, general and specific diets, and medications. 1. Total treatment regimen compliance referred to the sum- mation of physical activity compliance, total diet com— pliance, and medication compliance as measured by the compliance instrument. Compliance in these specific areas was determined by statements related to the following: a. b. Physical activity compliance included: engaging in physical activity at an appropriate level, assessing body response to physical activities, taking appro— priate action in relation to assessment, utilizing progressive activity, and utilizing appropriate exercise methodology (see Appendix B, statements 2, 4, 6, 7, 9, 11 and 13). Total diet compliance was a summation of general and specific diet compliance (see Appendix B, statements 1, 3, 5, 8, 10, 12 and 19-22). (1) General diet compliance included: spacing meals throughout the day, eating small and nutrion- ally balanced meals, avoiding physical activity immediately after meals, and taking measures to 88 lose or control weight (see Appendix B, state- ments 1, 3, 5, 8, 10 and 12). (2) Specific diet compliance included: following the prescribed low salt/sodium diet and/or low cholesterol/saturated fat diet, and adhering to appropriate methods of food preparation (see Appendix B, statements 19-22). c. Medication compliance included: administration of prescribed medication, administration of prescribed dosage and frequency, assessing for side effects, and following necessary actions or precautions based on medication desired results, side effects, or pertinent information (see Appendix B, statements 14—18). These areas were selected in order to correspond with the knowledge areas assessed and to measure longitudinal compliance. Compliance Content Validity --Content validity refers to "the degree to which the sample of test items represents the content that the test is designed to measure“ (Borg and Gall, 1971, p. 136). The determination of content validity was accomplished by subjective analysis since no statistical techniques were available. The areas and statements for compliance evaluation were developed directly from identified knowledge areas which, in turn, were identified from a review of the literature. Content refinement was based on the input received from two Cardiovascular Nurse 89 Clinicians and committee members. A nurse responsible for myo- cardial infarction patient education at the hospital reviewed the instrument and related that the content was representative of what patients are advised to do at home. Since no statistical tests were available for content validity, the compliance questionnaire was reviewed by the researcher with the assistance of cardiovascular experts and was determined to be representative of the necessary content. The instrument was then assumed to be reflective of content validity. Compliance Instrument Refinement.-—After the content was determined and the statements were developed, the instrument was evaluated by committee members. Changes were then made in format and wording. Additionally, the activity and general diet statements were alternated (see Appendix B, statements 1-13). Compliance Pretest.--Once the instrument was refined it was administered to three post myocardial infarction patients recently discharged from the hospital. They were asked to complete the questionnaire and to critically review it for difficulties in wording, c1arity,or format. After completion of the questionnaire they were interviewed to ascertain any difficulties. Minor revisions resulted from the information obtained from these three patients. The revi— sions included word simplification and clarification of the direc— tions. 9O Reliability Two types of reliability measures were available to analyze instrument reliability, internal consistency and temporal stability. Internal consistency describes the condition in which there is a high degree of interrelatedness among items in an instrument. This is not a valid measure of reliability when there is a small sample size and, therefore, was not computed for the knowledge and compli- _ ance instruments in this study (Crano and Brewer, 1973). Temporal stability assesses the degree to which the data obtained on an initial test administration resembles the data obtained on a second testing when the same scale and populations are employed. The data obtained at both administrations is corre- lated and a large positive correlation is taken as evidence of reliability. This assumes that the data at both administrations would be expected to remain the same. The test-retest method assesses temporal stability (Crano and Brewer, 1973). A major problem involved with test-retest reliability is the time interval employed. The second testing may be too soon and the respondents may remember previous responses and attempt to appear consistent in answering. On the other hand, if the time interval is too long changes in knowledge may result as a function of time (Ebbinghaus, 1913). This study presumes that changes in knowledge may occur over the six week interval and, therefore, test- retest reliability would not be a significant measure for the know- ledge instrument. 91 Data Collection Procedure After obtaining permission from the hospital, individual contact was made with the Intensive Care/Coronary Care Head Nurse, the Medical and Surgical Unit Head Nurses, and two of the Intensive Care/Coronary Care Unit nurses responsible for the myocardial infarc- tion patient education. A general explanation of the study was given which included only information from the consent form (see Appendix D) and the knowledge instrument introduction sheets (see Appendix E). In addition, the mechanisms involved with data collection (see Figure 2) were presented. The two myocardial infarction patient nurse educators were further oriented to the specifics of data collection (see Appendix F) and had consented to participate in discharge data collection if the researcher was unavailable. The specific procedures followed for the study were outlined in Figure 2 and a check list for the procedures was utilized (see Appendix G). Admission into the study was initiated through bi- weekly telephone contact with one of the myocardial infarction patient nurse educators. At this time patients with an initial diagnosis of myocardial infarction were identified. Further infor- mation was obtained regarding initiation of education, date of dis- charge to the floor, and room number. A weekly check of the Intensive Care/Coronary Care admission and discharge records served as a method for identifying all potential patients with a myocardial infarction diagnosis. 92 Call bi-weekly to ICU/CCU NO iv J'Yes Meeting criteria for study No lYes Consent signed. Demographic and supportive data obtained. J'Yes Medical-surgical unit contact to nurse or patient regarding discharge No date. lYes Administer knowledge questionnaire No at discharge 1, Yes Review chart No 1' Yes Administer knowledge questionnaire and compliance questionnaire at six weeks after discharge No Figure 2 --Study Flow Sheet. Not Included In Study Initial Data Analyzed ——i ,i..._i_ ___ - . 7 . 93 After discharge from the Intensive Care/Coronary Care Unit and prior to hospital discharge, patients fitting the study criteria were asked by the researcher to participate in the study. Only the researcher determined which patients would participate. The stand- ardized introductory information written on the consent form was related verbally and then presented for the patient to read (see Appendix D). The researcher answered the patient's questions regarding the questionnaires and/or follow-up. The participants were not informed that the follow-up knowledge questionnaire would be the same as the initial knowledge questionnaire. They also were not informed about the types of compliance questions which would be asked. If the patient consented to participate in the study a5 written consent form was signed at that time (see Appendix D). At the same encounter patients were interviewed via a structured inter- view to obtain selected demographic and supportive data (see Appendix H). In addition, selected demographic and supportive data were obtained from the chart (see Appendix I). The nurses and dietitians continued with patient education after discharge from the Intensive Care/Coronary Care Unit. This education included information related to disease entity and treat- ment regimens. Written materials from the American Heart Associa- tion and a cardiac teaching manual prepared by the hospital were given to each patient. Frequently, The Heart flip chart was used as a guide for instruction. At approximately three to five days after the patient was discharged from the Intensive Care/Coronary Care Unit, the researcher 94 made daily telephone or personal contact with either the medical or surgical unit nurses or the patient in an attempt to determine the patient discharge date. Once the discharge date was determined the researcher reviewed the progress notes and nurses discharge sheet for the documentation of patient education. This review was completed on the afternoon prior to hospital discharge. If documen— tation was not present, contact was made with the myocardial infarc- tion patient nurse educators to ascertain if educational encounters were complete. When the education was completed, the researcher viewed the chart to determine which specific questions the patient would receive regarding diet and medications. All patients were given the knowledge questions of disease entity, general diet, and activities (see Appendix A, questions 1-20). Patients who were taking prescribed medications that corresponded with the developed knowledge questions were asked to complete the appropriate medication questions (see Appendix A, questions 29-48). Patients who verbally related or whose chart documented the prescription of a low salt/sodium diet or low cholesterol/saturated fat diet were given the appropriate ques- tions to complete (see Appendix A, questions 21-24, 25—28). The patients were requested to complete the knowledge ques- tionnaire in their room according to a structured protocol (see Appen— dix F). No time limit was placed on administration of the question- naire. Patients were allowed to complete the questionnaire indi- vidually or have the questions read to them if necessary. The 95 standardized introduction sheet (see Appendix E) and questionnaire directions (see Appendix A) were presented verbally and in written form. Questions were answered regarding testing procedures or word clarifications but not on questionnaire content. The researcher remained in a secluded portion of the room and collected the ques— tionnaire when the patient was finished. The introduction sheet was then left with the patient. Additional information regarding the testing environment was recorded (see Appendix F). This infor- mation was obtained in order to assess potential environmental influences upon knowledge test results. A few weeks after the patient was discharged from the hos- pital, the researcher reviewed the chart to validate the diagnosis. The progress notes were also reviewed for evidence of any patient education that was completed after the initial knowledge testing. In addition, other data not completed on the chart information sheet was completed at this time (see Appendix I). Five weeks after discharge the researcher telephoned the patient and an appointment was made for the following week. The ressearchers telephone number was given to the patient at this time. The day of the visit the researcher called to reconfirm the aPpointment. This occurred during the sixth week after discharge frxani the hospital. At this time it was also related that a quiet en\/i ronment would be beneficial. During the second encounter, a second knowledge question- nairma (same as that administered initially) and a compliance ques— tionnaire were administered according to the check list for 96 compliance administration (see Appendix J). The standardized intro- duction sheet was presented verbally and in written form (see Appendix E). Then information related to the disease process, current regimens, and sources of information since hospital discharge was obtained by a structured interview (see Appendix K). The knowledge questions utilized in the second encounter were based on previous areas tested. All patients were given ques- tions on disease entity, general diet, and activities. Patients who were currently taking medications that had been tested pre- viously were retested on those medications. Patients who reported having a prescribed diet were again tested on those diets which had been previously tested. Directions for the knowledge test (see Appendix A) were then presented verbally and in written form. The researcher did answer questions related to testing procedure or word clarification but not on questionnaire content. The questionnaire was then administered in a quiet environment. Again, no time limits were placed on completion. The researcher remained at the house during the completion of the questionnaires. The introduction sheet was again left with the patient. After collection of the knowledge questionnaire, the reséaarther determined which compliance statements would be used. The <:omp1iance statements (see Appendix B) on general diet and aCti‘vities were completed by all patients. Specific diet and medi- Catiran compliance items were administered to patients who answered SPecific diet and medication knowledge questions at this time. The introduction sheet (see Appendix E) and instructions for the l—w—mf::,ii, i. 97 compliance questionnaire (see Appendix B) were presented verbally and in written form. Questions were answered regarding wording or instructions but not on questionnaire content. The researcher encouraged all patients to read each question carefully. In addi- tion, information regarding the testing environment was recorded. This information was obtained in order to assess potential environ— mental influences upon knowledge and compliance test results (see Appendix J). After administration of both questionnaires, the results of the initial or current questionnaires were reviewed at the request of the patient. Written knowledge and compliance questionnaires were chosen to assess knowledge and compliant behavior. Questionnaires were much more time efficient than structured or non-structured interview techniques. The questionnaire responses were standardized which allowed the patient to choose an already established response. In addition, standardized responses allowed for more ease in data analy- sis. Although stated compliance was less precise than objective compliance, stated compliance measures were utilized due to the dif— ficulty or inability to directly measure compliance with activity, diet, and medication behaviors in the home setting. A compliance index, which includes the relationship of actual prescribed treat— ments to compliance with treatment regimens, was not obtained due to the difficulty in obtaining and validating actual prescribed treatment regimens from the chart or physician. Furthermore, the goneral compliance categories and statements developed were 98 universal and, hence, applicable to all generalized treatment regimens of post myocardial infarction patients. Therefore, com— pliance measures in this study were obtained by questionnaire and stated compliance. The six week time frame for measuring compliance was chosen because it was assumed that by this time patients would have had time to adapt to and incorporate life-style changes. By this time, patients have usually returned to previous activity and work patterns. Patients usually are almost fully recovered physically and may not perceive any further immediate danger. Because patients have different physicians and return for follow-up visits at varying intervals, a home visit was selected for knowledge and compliance questionnaire administration six weeks after discharge from the hospital. This was done in an attempt to keep the time frame for the second encounter relatively constant. Also, a small sample population was anticipated and return from a mailed questionnaire would be minimal. Furthermore, if a mailed knowledge questionnaire was used there would have been no controls to prevent patients from obtaining information from books, pamphlets, family, friends, or other sources during the administration. m After the data were collected the process of scoring was initiated. The following section presents the mechanisms employed for scoring the knowledge instrument, the compliance instrument, and seleczted demographic data, personal supportive data and environmen- tal supportive data. JIIII-.___, 99 Knowledge Instrument The knowledge instrument (see Appendix A) was composed of 48 multiple choice questions. Each question contained four foils and points were allotted to each foil depending on whether the foil was answered correctly (1) or incorrectly (0). Each question con- tained a possible score of O to +4 (see Appendix L). The knowledge questions were then grouped into two major categories: knowledge of disease entity (questions 1—7) and know- ledge of treatment regimens (questions 8-48). The knowledge of treatment regimens included questions regarding general diet, specific diets, activities, and specific medications. The disease entity questions (see Appendix A, questions 1-7) totaled 28 possible points. All patients answered these Questions and the total points correct were calculated. A proportion score (Given, 1976) was then determined based on the number of questions that the patient answered correctly to the total possible number of points for the disease entity area. For example, if the patient obtained 24 of 28 possible points (24/28), then the score would be .86. This proportion score was utilized throughout the questionnaire and allows for questions to be individualized to each patient and yet comparable within each category. Questions related to diet were presented as total diet, general diet or specific diet. General diet knowledge (see Appendix A, ciuestions 8-13) was calculated for all patients. Specific diets were further divided into: (1) low salt/sodium or no added salt 100 diet (see Appendix A, questions 21-24) or (2) low cholesterol/ saturated fat diet (see Appendix A, questions 25-28). Specific diet knowledge was only obtained on patients with specific diets ordered. The total possible score for general diet questions was 24 points. The specific diet categories had a possible score of 16 points for each area or a total specific diet score of up to 32 points. The score tallied for total diet knowledge was a combina- tion score of all diet questions specific for the patient and was presented both as a total number and a proportion score. For example, the patient answered questions for general diet, low salt diet, and low cholesterol diet obtaining scores of 20, 14, and 10, respectively. General diet knowledge totaled 20 out of 24 points or .83, and specific diet knowledge totaled 24 out of 32 points or .75. Therefore, total diet knowledge was calculated to be 44 out of a possible 56 points or .79. Activity questions (see Appendix A, questions 14-20) totaled 28 possible points. All patients answered these questions and the total points were presented. In addition, a proportion score was also computed based on a ratio of the number of points the patient received in the activity category to the total possible number of POints in that category. Therefore, if a patient received 21 points out of a possible 28 points, a score of .75 was obtained. If medication questions were administered (see Appendix A, gues tions 29-48) a total number correct and proportion score were obtained. For example, the patient was administered questions on nitroglycerin and diuretics for a possible total score of 32 points. 101 He received a score of 26 and,therefore, a proportion score of .81. The total treatment regimen knowledge score was determined by summing the scores for total diet, activities, and medications and by calculating a proportion score. For example, the patient received 44 points or .79 for total diet knowledge, 21 points or .75 for activity knowledge, and 26 points or .81 for medication knowledge. The total treatment regimen knowledge score was 91 or .78. Total knowledge was computed by summing the scores of the total treatment regimen knowledge and disease entity knowledge and calculating a proportion score. For example, the patients treatment regimen knowledge was 91 points or .78 and disease entity knowledge was 24 points or .86. Total knowledge was then calculated to be 115 points or .80. If any questions were skipped they were analyzed as any other question with each foil marked as either correct or incorrect. The reason for scoring in this manner is that it serves as a consis- tent measure, for there is no way of determining in other questions whether foils were not checked due to being overlooked. Com liance Instrument The compliance instrument (see Appendix B, questions 1-22) was composed of 22 statements. A Likert scale, the same as that used by [)avis (1968a), was used for scoring the items. The range of Possible responses consisted of the following: 102 all of the most of less than half none of time the time the time very seldom the time A possible range of points from O to +4 was assigned for each state- ment. Since some statements were negatively stated and others posi- tively stated, the scoring mechanism was adjusted to accommodate for this. For positively stated items (1, 2, 5, 6, 8, 9, 10, 12, 14, 15, l7, 18, 19, 21, 22) the following scoring mechanisms were employed: 4 all of the time 3 most of the time 2 less than half the time 1 very seldom 0 none of the time For negatively stated items (3, 4, 7, ll, 13, 16, 20) the scoring mechanisms were as follows: 0 all of the time 1 most of the time 2 less than half the time 3 very seldom 4 none of the time Four points were assigned for the greatest degree of compliance for each statement. The higher the total score, the greater the extent of compliance. The compliance instrument was viewed in relation to adherence in three areas: diet compliance, activity compliance, and medication compliance. The diet compliance statements were further categorized into general diet (see Appendix B, statements 1, 3, 5, 8, 10 and 12) and Specific diet (see Appendix B, statements 19-22). The scores range froni O to 24 for general diet compliance and O to 16 for specific diet compliance. All patients were assessed on general diet 103 compliance. The patients diet compliance score was then computed as a proportion score with respect to possible compliance in that category. The possible diet compliance score was variable with each patient depending on whether they had special diets prescribed. For example, the patient was on a low salt diet and obtained compliance scores and proportion scores of 20 points or .83 (general diet) and 16 points or 100 percent (specific diet). The total diet compli- ance was determined by summation score and corresponding proportions and, therefore, consisted of 36 points out of a possible 40 or .90. Activity compliance was measured by statements 2, 4, 6, 7, 9, ll,and 13 (see Appendix B). The total possible activity scores ranged from O to 20 or O to 28 depending on whether the patients had been taught to take their pulse. A proportion score was calculated by dividing the patients activity score by the patients total pos- sible activity score. If they had not been taught to take their pulse, statements 2 and 13 were deleted from the computations. For example, the patient had not been taught to take his pulse and, therefore, the total possible score was 20. The patients numerical score for the five items was 16 and a proportion score of .80 was assigned. The total range of possible scores for medication compliance was 0 to 20 (see Appendix B, statements 14-18). A proportion was calculated from this data. For example, the patient received a score of 19 for medication compliance. A proportion score was then determined to be 19/20 or .95. 104 Total compliance was then computed by summing the category scores and then calculating a proportion score. For example, the patient received 36 points or .90 for total diet compliance, 16 points or .80 for activity compliance, and 19 points or .95 for medi- cation compliance. The total score would then be 71 points or .88. If any compliance statements were not answered then the average score and proportion for the patient's total compliance was computed. This score was then assigned to the missed statement. In this way, a missed question did not significantly skew the data. Demographic and Supportive Data A considerable amount of demographic data, personal support- ive data, and environmental supportive data were collected on each patient, some of which were condensed via scoring mechanisms. This data was then used as descriptive data and to identify factors that may have affected the levels of knowledge and compliance, knowledge relationships, and knowledge and compliance relationships. The data scoring mechanisms of social position index, risk factor assessment, severity index, symptoms since discharge, and sources of information since discharge are presented in the following section. Social Position Index.--In order to determine social class '— the Hollingshead Two Factor Index of Social Position (see Figure 6) was utilized (Bonjean, Hill,and McLemore, 1967, p. 384). This index was composed of occupational and educational factors. Each patient was interviewed to determine which occupational and educational category was applicable (Figures 3 and 4). Since social position 105 Occppation 1. Major executives of large concerns, major profes- sionals, and proprietors. 2. Lesser professionals and proprietors, and business managers. 3. Administrative personnel, owners of small businesses and minor professionals. 4. Clerical and sales workers, and technicians. 5. Skilled trades. 6. Machine operators and semi-skilled workers. 7. Unskilled employees. Figure 3.--Occupational Scale. Education 1. Professionals (masters, doctorate or professional degree). 2. College graduates. 3. 1-3 years college or business school. 4. High school graduate. 5. 10-11 years of schooling. 6. 7-9 years of schooling. 7. Under 7 years of schooling. Figure 4.--Educational Scale. 106 reflects a value system developed over time, retired persons were categorized in the occupational status relative to past employment. The specific occupations that were categorized under each occupa- tional level were further described by Hollingshead (Bonjean, Hill, and McLemore, 1967, p. 442). This was used as a guide for specific placement of patients. Information from the occupational and educational scales were combined to determine the Social Position Index (see Figure 5). This was accomplished by determining the number from the occupational and educational levels on the scales (scale scores), and then mul- tiplying this by weightings. The weightings for the occupational and educational factors were 7 and 4, respectively. After occupa- tional and educational partial scores were determined, they were added together to get a total score. This total score was then compared to a range of scores and the appropriate social class was assigned. For example, to compute the Social Position Index score Factor Scale Score x Factor Weight = Partial Score Occupation x 7 = Education x 4 = Total Score Class Range of Scores I 11-17 II 18—31 III 32-47 IV 48-63 V 64-77 Figure 5.--Hollingshead Two Factor Index of Social Position. 107 of an owner of a small restaurant who had completed high school and one year of business school refer to Figure 6. The patient would be placed in Class III. Factor Scale Score x Factor Weight = Partial Score Occupation 3 x 7 = 21 Education 3 x 4 = 12 33 Total Score Class Range of Scores I 11-17 II 18-31 III 32-47 IV 48-63 V 64-77 Figure 6.--Example of Hollingshead Two Factor Index of Social Position. Risk Factor Assessment.—-The determination of risk factors and criteria related to cardiovascular disease was made based on a review of the literature (Simborg, 1970; McAlister et al., 1976; Glass, 1977; Alexander et al., 1978; Gotto et al., 1978; McIntosh, Eknoyan, and Jackson, 1978; McIntosh et al., 1978; McIntosh, Stamler, and Jackson, 1978). The risk factors and criteria were developed such that each person who met the criteria for a risk factor at entrance to the hospital was given a score of +1 (see Appendix M). The points calculated from the criteria assessment were totaled and compared to the following scale: 3 3 points = high risk < 3 points = low risk 108 For example, a 50 year old male who exercises less than three times a week and smokes a pack of cigarettes a day would be assigned a total score of three and considered at high risk. Severity.—-The severity index for myocardial infarcticns utilized in this study was based on a severity index developed by Peel and associates (1962), which graded the severity of infarction according to the mortality rates of the same population. This index was used for the assessment of severity in the first four days after hospital admission. The categories identified were age and sex, previous history, shock, cardiac failure, electrocardiogram changes, and rhythm disturbances. Weighted numbers were assigned by Peel and associates to the specific criteria of each category so that they corresponded with the mortality rates (see Appendix 1). For the purposes of this study, the severity index developed by Peel and associates (1962) was adapted to include other signs and symptoms in criteria levels and an additional category. The signs and symptoms added to the moderate shock criteria level included cyanosis and duskiness. The most severe failure criteria level included the addition of positive hepatojugular reflux (HJR) and pink tinged sputum. All of the categories, criteria, and weightings developed by Peel and associates (1962), with the addi- tion of some criteria, were utilized in this study for the assessment of the first four days of hospitalization. After the first four days of hospitalization complications can arise which may affect the severity rating. Therefore, an 109 additional category was added that allowed for the documentation of criteria such as signs and symptoms of shock, cardiac failure, electrocardiogram changes, and rhythm disturbances that occurred during the remainder of hospitalization. However, the category was added only when the criteria had not been accounted for previously. The weightings of the criteria in this last category were the same as those used in the scale for the assessment of the first four days (see Appendix N). The scoring consisted of weighted scores, developed by Peel and associates (1962), that were summed. If a patient qualified for two different criteria levels under a category, the higher weighted score was given. For example, a 60 year old male with a past history of a myocardial infarction exhibited mild shock at onset (nausea, vomiting,and sweating). He also demonstrated basilar rales, EKG changes confined to the RT or T waves, and sinus rhythm during the first four days of hospitalization. In addition, he experienced ventricular tachycardia one week after admission. Therefore, his severity score could be calculated in the following manner: Age and sex 2 Previous history 6 Shock 1 Failure 1 EKG l Rhythm 0 Other after four days _4 5 110 The severity levels were determined by identifying the highest and lowest severity scores for the study population. Equal range scores were then computed for high, medium,and low severity. The severity levels of high, medium, and low severity were based on the following scale: 11-15 = low 16-20 = medium 21-25 = high' Each patient was then assigned the high, medium,or low severity depending on their severity score. The patient in the previous example would be assigned a rating of low severity. Symptoms Since Hoppital Discharge.--Symptoms related to cardiac disease or congestive heart failure were identified (Thorn et al., 1977; Luckmann and Sorenson, 1974). Patients in a struc- tured interview were then asked to estimate the frequency with which they had experienced each symptom since hospital discharge (see Appendix K). The possible responses and corresponding scoring mechanisms were the following: never = O, occasionally = 1, and frequently = 2. All responses were then totaled. The categories of high, medium,and low symptoms since discharge were based on the following scale: 0-3 = low 4-6 = medium 3_7 = high Sources of Information Since Hospital Discharge.--An esti- mate was made of the frequency and sources of information obtained since hospital discharge. Patients in a structured interview were 111 asked to estimate the frequency with which they had obtained infor- mation from a variety of sources (see Appendix K). The possible responses and scoring mechanisms were the following: never = O, occasionally = l, and frequently = 2. A total response score was computed for each patient. High, medium,and low sources of informa- tion were calculated based on the following scale: low medium high lvm—a kOOO-l> u u u Procedures for Data Analysis After the demographic data, personal supportive data, environmental supportive data, and instruments were scored, the data were analyzed. This section presents the structure for data analysis and includes discussion of the variables and the presenta- tion of the research questions. In addition, the techniques for data analysis are presented. Variables The variables identified for this study were knowledge and compliance. The independent variable was knowledge at hospital discharge. This independent variable was not manipulated but mea- sured for purposes of comparison. The dependent variables included knowledge and compliance six weeks after hospital discharge. The knowledge variable was viewed as total knowledge or was further divided into knowledge of disease entity or knowledge of the treatment regimens. Knowledge of treatment regimens consisted of 112 total treatment regimen knowledge, total diet knowledge, general diet knowledge, specific diet knowledge, activity knowledge, and medication knowledge. The compliance variable was measured as total compliance or compliance with a specific category of recommendations. These categories included diet, activity, or medication compliance. Variables that directly or indirectly affect knowledge or compliance were identified in the demographic, personal supportive, and environmental supportive data and were used as descriptive mea- sures in the study (see Tables 1, 2, 3). These variables were deter- mined based on a review of the literature. The variables included: age; sex, marital status; race; social position; history of chronic illness; past experience of self or spouse with a myocardial infarc- tion; prior diet, medication, or activity prescriptions or restric— tions; past exercise patterns; risk factor assessment; family history of cardiovascular disease; severity of the myocardial infarction; symptoms since discharge; number of days in the Intensive Care/ Coronary Care Unit; number of days in the hospital; number of visits to the emergency room or physician since discharge; readmission to the hospital since discharge; environment during knowledge and com- pliance questionnaire administration; and patient request for know- ledge results (see Appendices H, I, and K for data collection sheets). Other direct or indirect influencing variables have been identified but are beyond the scope of this study. They include duration of the regimen, patient perception of disease, motivation, 113 attitudes and values, work orientation, support or influence from family or friends, and provider-patient relationship. Presentation of Research Questions The problem statement related that the central focus of this research project was a study of the relationships between post myocardial infarction patient knowledge at the time of discharge from the hospital, and knowledge and stated compliance six weeks after hospital discharge. The following section includes the questions studied rela- tive to the problem statement. These questions specifically focused on the patterns of knowledge and the patterns of compliance. The research questions developed for this study included the following: Research Question I. What are the patterns of knowledge in the study population? A. What are the levels of knowledge at two points in time? B. What are the factors that affect the levels of knowledge? C. What is the relationship between knowledge at hospital discharge and knowledge six weeks after hospital dis- charge? 1. What is the relationship between total knowledge at hospital discharge and total knowledge six weeks after hospital discharge? 2. What is the relationship between knowledge of disease entity at hospital discharge and knowledge of disease entity six weeks after hospital discharge? 3. What is the relationship between knowledge of total treatment regimens at hospital discharge and know- ledge of total treatment regimens six weeks after hospital discharge (Refer to Figure 1 for a schematic representation-of the knowledge relationships studied). D. 114 What are the factors that affect the relationship between knowledge at hospital discharge and knowledge six weeks after hospital discharge? Research Question II. What are theppatterns of compliance in the study population? A. What are the levels of stated compliance six weeks after hospital discharge? What are the factors that affect the levels of stated compliance? What is the relationship between knowledge at hospital discharge and stated compliance six weeks after hospital discharge? 1. What is the relationship between total knowledge at hospital discharge and stated compliance with total treatment regimens six weeks after hospital dis- charge? 2. What is the relationship between knowledge of disease entity at hospital discharge and stated compliance with total treatment regimens six weeks after hos- pital discharge? 3. What is the relationship between knowledge of total treatment regimens at hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge? (Refer to Figure 1 for a schematic representation of the knowledge and com— pliance relationships studied). What are the factors that affect the relationship between knowledge at hospital discharge and stated com- pliance six weeks after hospital discharge? What is the relationship between knowledge six weeks after hospital discharge and stated compliance six weeks after hospital discharge? 1. What is the relationship between total knowledge six weeks after hospital discharge and stated com- pliance with total treatment regimens six weeks after hospital discharge? 2. What is the relationship between knowledge of disease entity six weeks after hospital discharge and stated 115 compliance with total treatment regimens six weeks after hospital discharge? 3. What is the relationship between knowledge of total treatment regimens six weeks after hospital dis- charge and stated compliance with total treatment regimens six weeks after hospital discharge? (Refer to Figure 1 for a schematic representation of the knowledge and compliance relationships studied.) F. What are the factors that affect the relationship between knowledge six weeks after hospital discharge and stated compliance six weeks after hospital discharge? Techniques for Data Analysis This study was exploratory in nature and a combination of statistical and descriptive case study techniques were used for data analysis. Since the sample size was small the correlation coeffi- cient may have been unstable. Therefore, the statistical tests were used as indications and trends but not as strict hypothesis testing. Data analysis techniques were viewed from three perspectives: analysis of the levels of knowledge and the levels of compliance, analysis of relationships, and analysis of factors affecting know- ledge and compliance. Analysis of the Levels of Knowledge and the Levels of Com- pliance.--The level of knowledge was the amount of patient knowledge measured by the knowledge instrument which was displayed as a pro- portion score for hospital discharge and six weeks after discharge. The level of knowledge was analyzed by range percent correct scores and mean percent correct scores at hospital discharge and six weeks after discharge (Table 4). Also, frequency counts of the number of 116 patients whose knowledge increases, decreases, or remains the same between hospital discharge and six weeks after discharge were com- puted (Table 5 or Figure 6). The level of compliance was the amount of patient compliance six weeks after hospital discharge which was measured by the com- pliance instrument and displayed as a proportion score. The level of compliance was analyzed by range percent compliance scores and mean percent compliance scores six weeks after hospital discharge (Table 9). Low knowledge and low compliance scores were determined by the patients total or specific category scores of knowledge or com- pliance less than 70 percent and 75 percent, respectively. Outlyers were identified as those patients with less than 70 percent know- ledge and/or 75 percent compliance (see Table 6 and Table 10). A review of the literature failed to indicate the amount of knowledge required to positively influence compliant behavior. This review also failed to indicate the rate of compliance which posi— tively influences patients' health status (outComes) or to suggest a minimum rate of compliance that was acceptable. For the purposes of this study, less than 70 percent knowledge was chosen as the parameter by which to identify outlyers. This level was chosen because a minimum of 70 percent of the information related to disease and/or treatments must be obtained in order for a patient to comply. Furthermore, the optimal rate of compliance would be 100 percent but this is unrealistic. Therefore, outlyers were identified 117 as patients who were noncompliant and whose compliance scores fell below 75 percent compliance. Analysis of Relationships.--A correlation coefficient is the most appropriate statistical measure that can be used to address the research questions about relationships between two variables. There- fore, these research questions were analyzed by using the Spearman Rank Difference Correlation. This correlation is approximately the same as the Pearson r for the same data but is used when the number of subjects is less than 30. The Spearman Rank Difference Correla- tion can be viewed as the degree to which persons maintain their same relative ranks or positions on two variables. If the change is great, the correlation coefficient will be low; if there is little change, the correlation coefficient will be high (Borg and Gall, 1971; Stanley and Hopkins, 1972). The correlation coefficients (r) for the variables in the research questions regarding relation- ships are displayed in Table 7, Table ll,and Table 12. The Spearman Rank Difference Correlation (Stanley and Hop- kins, 1972) is computed by the formula: _ 6ZD2 r = l ranks N(N2-l) where 02 = the squared difference between the ranks for each individual N number of pairs of scores. Once computed, the interpretation of r is based on the strength of the linear relationship. Marascullo (1971, p. 433) identifies the relationships as the following: 118 Value of r Strepgth of the Relationship .01 none .1 :> very weak .2 .3 j) weak .4 .5 moderate .6 :> strong .7 .8 :> very strong .9 1.0 perfect The statistical hypotheses testing for research questions concerning relationships utilized a statistical hypotheses testing schedule (see Appendix 0). All statistical hypotheses were stated in the null form (see Appendix 0). The level of significance selected for this study was .10. This means that the results con- sidered significant at the .10 level have the probability of occur- ring by chance only ten times in 100. This level of significance was selected because of the exploratory nature of the study and because the chance of a type one error (rejecting a true null) is not potentially harmful to the research subject. In view of the fact that the sample number is small, scatter- grams were completed on all correlations in an attempt to identify extremes (outlyers) or distinctive population patterns (see Appendix P). Outlyers for relationships were defined as those patients who 119 demonstrate contrasting relationships from the general population as determined by scattergrams. Distinctive population patterns consisted of particular patient groupings that were identified by scattergrams. Analysis of Factors Affecting Knowledge and Compliance.—- A case study approach was utilized to view outlyers and distinctive population patterns in relation to factors that may have affected the levels of knowledge and compliance, knowledge relationships, and knowledge and compliance relationships. Outlyers were defined as those patients who demonstrated less than 70 percent knowledge and/or 75 percent compliance, or showed contrasting relationships from the general population as determined by scattergrams. The distinctive population patterns consisted of particular patient groupings that are identified by scattergrams. The factors that potentially influ— enced knowledge and compliance as viewed in this study, were the demographic, personal and environmental supportive variables which emerged from a review of the literature. These variables influenced knowledge and compliance in a direct or indirect manner and included: age; sex; marital status; race; social position; history of chronic illness; past experience of self or spouse with a myocardial infarc- tion; prior diet, medication, or activity prescriptions or restric- tions; past exercise patterns; risk factor assessment; family history of cardiovascular disease; severity of the myocardial infarction; symptoms since discharge; number of days in Intensive Care/ Coronary Care Unit; number of days in the hospital; number of visits 120 to the emergency room or physician since discharge; readmission to hospital since discharge; sources of information since discharge; environment during knowledge and compliance questionnaire adminis- tration, and patient request for knowledge results. Human Rights Protection This section discussed the measures taken to insure that the rights of the participants were protected. All participants were informed about the purpose of the study, the schedule for data collection, and the confidentiality of identity and results. All were informed that they had a right to refuse to participate, and that if they did consent to participate they had a right to withdraw at any time without penalty. Participation was voluntary with written consent obtained (see Appendix D). For a further review of the Human Rights Protection Procedures see Appendix 0. Summary Chapter IV has provided an overview of the methodology and procedures employed in the study. This discussion has included a presentation of the population, a description of the setting, the development of the instruments, the data collection procedure, the scoring mechanisms, the data analysis techniques, and the human rights protection. In Chapter V descriptive data and data addres- sing the previously identified research questions is presented. CHAPTER V PRESENTATION OF FINDINGS Overview In this chapter the descriptive data and the data addressing the research questions are presented. Data regarding the research questions are based on information obtained from demographic data, personalanulenvironmental supportive data, and knowledge and compli- ance questionnaires of post myocardial infarction patients. - The central focus of this research project is a study of the relationships between myocardial infarction patient knowledge at the time of discharge from the hospital, and knowledge and stated compli- apge_six weeks after hospital discharge. The major research ques- tions focus on the patterns of knowledge and the patterns of compli- ance in the study population. The specific research questions in this study include the following: Research Question I. What are the patterns of knowledge in the study population? A. What are the levels of knowledge at two points in time? B. What are the factors that affect the levels of knowledge? C. What is the relationship between knowledge at hospital discharge and knowledge six weeks after hospital dis- charge? 1. What is the relationship between total knowledge at hospital discharge and total knowledge six weeks after hospital discharge? 121 122 2. What is the relationship between knowledge of disease entity at hospital discharge and knowledge of disease entity six weeks after hOSpital discharge? 3. What is the relationship between knowledge of total treatment regimens at hospital discharge and know- ledge of total treatment regimens six weeks after hospital discharge (refer to Figure l for schematic representation of the knowledge relationships studied). What are the factors that affect the relationship between knowledge at hospital discharge and knowledge six weeks after hospital discharge? Research Question II. What are the patterns of compliance in the study population? A. What are the levels of stated compliance six weeks after hospital discharge? What are the factors that affect the levels of stated compliance? What is the relationship between knowledge at hospital discharge and stated compliance six weeks after hospital discharge? 1. What is the relationship between total knowledge at hospital discharge and stated compliance with total treatment regimens six weeks after hospital dis- charge? 2. What is the relationship between knowledge of disease entity at hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge? 3. What is the relationship between knowledge of total treatment regimens at hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge? (Refer to Figure 1 for schematic representation of the knowledge and compli- ance relationships studied.) What are the factors that affect the relationship between knowledge at hospital discharge and stated compliance six weeks after hospital discharge? 123 E. What is the relationship between knowledge six weeks after hospital discharge and stated compliance six weeks after hospital discharge? 1. What is the relationship between total knowledge six weeks after hospital discharge and stated compli- ance with total treatment regimens six weeks after hospital discharge? 2. What is the relationship between knowledge of disease entity six weeks after hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge? 3. What is the relationship between knowledge of total treatment regimens six weeks after hospital dis- charge and stated compliance with total treatment regimens six weeks after hospital discharge? (Refer to Figure l for schematic representation of the know- ledge and compliance relationships studied). F. What are the factors that affect the relationship between knowledge six weeks after hospital discharge and stated compliance six weeks after hospital discharge? This exploratory study utilizes a combination of statistical and descriptive case study techniques for data analysis. Descrip- tive data are presented initially. This descriptive data include population data, demographic data (Table 1), personal supportive data (Table 2), and environmental supportive data (Table 3). The data addressing the research questions are then discussed. Levels of knowledge and compliance are based on proportion scores from the instruments. Mean percent and range percent scores are presented. The number of patients whose knowledge increased, decreased, or remained constant is then discussed. The number of patients with less than 70 percent total or specific knowledge and less than 75 percent total or specific compliance are identified. 124 The relationship between knowledge categories at two points in time, and knowledge and compliance categories are analyzed. The Spearman Rank Difference Correlation (Borg and Gall, 1971; Stanley and Hopkins, 1972) is used to test hypotheses about relationships in order to identify trends or indications (see Appendix M). Since the population is small and randomization is not employed, the researcher cannot assume that characteristics of the population which affect knowledge and compliance are equally dis- tributed across the population. Therefore, a case study approach is utilized to view outlyers (extremes) and distinctive population patterns in relation to factors that may affect the levels of know- ledge and compliance, knowledge realationships, and knowledge and compliance relationships. The outlyers are defined as patients who demonstrate less than 70 percent knowledge and/or 75 percent compli- ance, or show contrasting relationships from the general population as determined by scattergrams. Distinctive population patterns con- sist of particular patient groupings that are identified by scatter- grams. This case study approach was used in order to establish indicators and trends along with the statistical information. Presentation of Descriptive Data The descriptive data discussed include population data, demographic data (Table 1), and supportive data (Tables 2, 3). The supportive data are further divided into personal and environmental supportive data. 125 Population Data The study population consisted of 11 post myocardial infarc- tion patients that were admitted to a 204 bed private hospital during August and September, 1978. All patients meeting the predetermined criteria for admittance into the study were asked to participate and all agreed. Two patients were not initially admitted to the study because their physicians did not confirm the diagnosis of myocardial infarction. The knowledge questionnaires at hospital discharge, and knowledge and compliance questionnaires six weeks after discharge were completed by all patients. Demographic Data Table 1 shows that the study population consisted of ten Caucasian males and one Caucasian female. There were four patients between 50-59 years of age, five patients between 60-69 years of age, and one patient each in the age categories of 70-79 years and 80 years or older. Eight of the patients were married while one patient was included in each of the single, widowed, and divorced/ separated categories. In the social position category, five patients were at level III, three patients at level IV, two patients at level V, and one patient at level II. No patient occupied the highest social position level. In summary, the population consisted of pre- dominately male Caucasian patients between 50 to 70 years of age. Most of the patients were in the medium to lower social positions. 126 Table l.--Selected Demographic Data of the Study Population. Characteristic Numbeiatiengzrcent 5.92: Male 10 91 Female 1 9 Ass Less than 50 years 0 0 50-59 years 4 36 60-69 years 5 45 70-79 years 1 9 80 years or older 1 9 Race Caucasian 11 100 Marital Status Single 1 9 Married 8 73 Widowed l 9 Divorced/Separated l 9 *Social Position Index I O 0 II 1 9 III 5 45 IV 3 27 V 2 18 * Hollingshead Two Factor Index of Social Position. Selected Personal Suppprtive Data Selected personal supportive data were obtained regarding the patients. Examination of Table 2 reveals that 91 percent or ten of the patients had a history of chronic illness. These chronic illnesses included hypertension, cancer, cerebral vascular accidents, diabetes, and emphysema in descending order of occurrence. None of 127 Table 2.--Selected Personal Supportive Data of the Study Population. . . Patients Characteristic Number Percent History of Chronic Illness 10 9] Positive Past Experience with Myocardial Infarction Spouse 0 0 Self 6 55 Prior Prescriptions or Restrictions None 2 18 Diet 0 O Medications 6 55 Activities 0 0 Diet and Medications 2 18 Diet and Activities 0 O Medications and Activities 0 0 All 1 9 Current Prescriptions or Restrictions None 0 0 Diet 0 O Medications 0 0 Activities 1 9 Diet and Medications O 0 Diet and Activities 1 9 Medications and Activities 0 0 All 9 82 Past Exercise Patterns Less than one time per week 8 73 Between one and four times per week 2 18 Greater than or equal to four times per week 1 9 Risk Factor Assessment High 11 100 Low 0 0 Family History of Cardiovascular Disease Positive 9 82 Severity Index of Myocardial Infarction High 2 18 Medium 7 64 Low 2 l8 128 Table 2.--Continued. . . Patients Characteristic Number Percent Symptoms Since Discharge High 3 27 Medium 2 18 Low 6 55 Patient Request for Questionnaire Results Yes 3 27 the spouses had ever experienced a myocardial infarction, while six or 55 percent of the patients had myocardial infarctions in the past. Two of the patients (18 percent) had never experienced diet, medication, or activity prescriptions or restrictions. Six or 55 percent of the patients had only medication prescriptions prior to hospital admission. Patients with medication and diet recommenda— tions prior to hospitalization totalled two or 18 percent. Only one patient had previous diet, medication, and activity prescriptions or restrictions prior to hospital admission. In regard to current prescriptions and restrictions, 82 percent or nine of the patients had diet, medication, and activity recommendations. One patient currently had only activity recommendations and another patient had only diet and activity prescriptions or restrictions. The majority of patients, eight or 73 percent, had a past exercise pattern of less than once a week. All patients demonstrated a high risk factor assessment (see risk factor assessment, p. 107). A positive family history of cardiovascular disease was present for nine patients (82 129 percent). Seven patients (64 percent) had myocardial infarctions of medium severity (see severity index, p. 108), while two patients (18 percent) had myocardial infarctions of high severity and two patients (18 percent) had myocardial infarctions of low severity. Low symptoms since hospital discharge (see symptoms, p. 110) were exper- ienced by six patients (55 percent), while two (18 percent) and three (27 percent) of the patients experienced medium or high symptoms, respectively, since discharge. Only three patients (27 percent) requested the results of the questionnaire. Selected Environmental Supportive Data In examining Table 3, it can be seen that the number of days in the Intensive Care/Coronary Care Unit was almost equally divided between less than five days (five patients or 45 percent) and greater than or equal to five days (six patients or 55 percent). Fifty-five percent or six of the patients experienced less than 15 total days in the hospital while five patients (45 percent) had 15 days of hospitalization or more. Variations existed in the number of visits to the physician since discharge. Three patients (27 percent) had three visits, two patients (18 percent) had two visits, two patients (18 percent) had four or more visits, and four patients (36 percent) had O-l visit. Only one patient was readmitted to the hospital after discharge for a cardiac catheterization. Seven patients (64 percent) demonstrated medium sources of information since discharge from the hospital (see sources of information, p. 130 Table 3.--Selected Environmental Supportive Data of the Study Population. Patients Number Percent Number of Days in the Intensive Care/ Coronary Care Unit Less than five days 5 45 Greater than or equal to five days 6 55 Number of Days in the Hospital Less than 15 days 6 55 Greater than or equal to 15 days 5 45 Visits to Emergenpy Room or Physician Since Discharge O-l time 4 36 2 times 2 18 3 times 3 27 4 or more times 2 18 Readmission to the Hoepital Since Discharge _ Yes 1 9 Sources of Information Since Discharge High 1 9 Medium 7 64 Low 3 27 110). Three patients (27 percent) demonstrated low sources of information and one patient (9 percent) demonstrated high sources. 131 Presentation of Data Regarding Research Questions The previous section discussed the descriptive data of the study. In this section the findings from the data analysis are pre- sented to address the research questions posed for this project. Research Question I. What are the patterns of knowledge in the stugy pppulation? This question was further divided into four specific ques— tions. These specific questions were examined prior to the examina- tion of research question I. I-A. What are the levels of knowledge at twoppoints in time? The levels of knowledge were interpreted based on: the range and mean percent correct scores of the knowledge instrument; the number of patients whose knowledge increased, decreased, or remained the same; and the number of patients who had less than 70 percent total knowledge or specific knowledge. By examining Table 4, it can be noted that at hospital dis- charge and six weeks after discharge the highest mean percent scores were specific diet knowledge (89 percent and 87 percent, respectively). The lowest mean percent scores were medication knowledge both at hospital discharge (75 percent) and six weeks after discharge (80 percent). Specific diet knowledge was the highest knowledge cate- gory and medication knowledge was the lowest category at both hos- pital discharge and six weeks later, indicating that patients gen- erally knew most about specific diets and least about medications at two points in time. Total knowledge was 81 percent at hospital 132 Table 4.--Mean and Range Percent Correct Knowledge Scores at Hospital Discharge and Six Weeks After Hospital Discharge. Knowledge Knowledge Scores at Knowledge Scores 51x Categoriesa Hospital Discharge Weeks after Discharge Range % Mean % Range % Mean % Correct Correct Correct Correct Disease Entity 61-93 82 68-96 81 Total Treatment Regimen 76-88 80 77-88 84 Diet Total 73-93 83 78-92 84 General 67-92 80 67-92 81 Specificb 75-94 89 75-94 87 Activity 71-93 81 68-93 84 MedicationC 67-88 75 75-85 80 Total Knowledge 72-88 81 77-89 83 aThe number of patients in each knowledge category was 11 (n=ll) unless specified. bn=9 Cn=8 discharge and 83 percent six weeks after discharge. The scores for disease entity knowledge ranged from 61 percent to 93 percent at hospital discharge and 68 percent to 96 percent six weeks after dis- charge. These ranges indicated that wide variations existed in the disease entity knowledge in this population. Any increase or decrease in the knowledge score was con- sidered a change. Examination of Table 5 and Figure 6 shows that more patients increased in total knowledge, total treatment regimen 133 Table 5.--Number and Percent of Patients Changing in Knowledge From Hospital Discharge to Six Weeks After Discharge. KNOWLEDGE Knowledge Increasing Remaining Decreasing Categoriesa From Onset the Same From Onset Number % Number % Number % Disease Entity 4 36 2 18 5 45 Total Treatment Regimen 8 73 1 9 2 18 Diet Total 6 55 5 45 General 6 55 5 45 Specificb 2 22 5 55 2 22 Activity 6 55 l 9 4 36 MedicationC 6 75 1 12 l 12 Total Knowledge 6 55 l 9 4 36 aThe number of patients in each knowledge category was 11 (n=1l) unless specified. bn=9 Cn=8 knowledge, and specific treatment regimen knowledge (excluding speci- fic diet knowledge) than decreased in knowledge of these areas. Five patients showed decreases in disease entity knowledge while four patients showed increases. In the area of increases in knowledge from onset, a majority of patients showed increases in total treat- ment regimen knowledge (eight patients or 73 percent) and medica- tion knowledge (six patients or 75 percent).. The specific diet knowledge category showed the highest number of patients whose 134 .omcasomwo Louc< mxooz xwm oe emceeomwo repeamo: soc; monopzocx cw mewmcmeu mueowema co pcoocoa--.e ocsmwe mmoPcommpmu omcoF3ocx mmea_zoex space coco . pm_o cmecaam peas seeped Pmpoe ecceumowcmz a w>wpo<, owcwcma iihmcocmo nemwum.Fmpoe mmmmmeo I.‘ u. D .... .o u . , ... a. a on... v . ...: l .. .55 so .. .qe 5”, a.“ ... .«A ,c em 0 N no. I ones. ... of. “as... L, a ,v if: '0 h v A o. a. on us... 0. ease-oo- 4., o .. ..... ... .. . .......... n... ...a .. chF - «cu-D no... J‘ o. cocoon-n .. . .... \. ..... .......i «...... U o .0 on. i a. a on n I a. a... a” °\ ‘I ...-00 on u .0. a... flan-L “...-m - Om F .. ... .. o . ... .. v. ... . .....H o o o no a s o o .- on a. -H .o . .. se.-.13“ u .... a 1:11. \vON so ”a c. .- .....o ...-.usu O o. o u o “In. I. o on u... ”no ”u. .0 o... .... Rva .0 o o n a u :0 . ...-... «s. u ...-n. . rat. I” on noov ’ °\ N. ‘00.... .....l ......1 com I?! c .10.. co I. \o no- . o o o n q no . .Au . ..r ;;. as. smm o a . . a ., .00 I a .- . .oo ”.35... W e. .... o o. o s ... ... ..e. U . Cw, . .. . . . o the he .zs. new" “av ace ...]me W§60¢ou nuance-”.- CI-“oIvOI °\°m¢ m ...r. ~ no I. —n cu. . o O . O sow a O smm eon ewe ecu ewe eom wuco Q.<|—-l—4LLJZl-‘ u: m a cameo 50cc meemmmcomo “an 63:89.... 33:: 27.5 I mm; .6338 23 .9: mEEmEom I omeopzocx some cw mpcmcpma co amass: ween pomco scam mewmoocoeH eoo_ 135 knowledge remained the same (five patients or 55 percent). In the area of decreases in knowledge from onset, disease entity knowledge (five patients or 45 percent), total diet knowledge (five patients or 45 percent),and general diet knowledge (five patients or 45 percent) were the categories that demonstrated the highest number of patients decreasing. An examination of Table 6 indicates that patients demonstrated less than 70 percent knowledge in four knowledge categories. The categories were disease entity knowledge, general diet knowledge, activity knowledge, and medication knowledge. Knowledge below 70 percent was demonstrated by four patients. Two patients scored less than 70 percent knowledge in two categories. One patient had low knowledge scores in activity and medication knowledge and the other patient had low knowledge scores in general diet and disease entity knowledge. No one scored less than 70 percent knowledge in total treatment regimen knowledge, total diet knowledge, specific diet knowledge, or total knowledge. I-B. What are the factors that affect the levels of know- 129923 Patients with less than 70 percent knowledge were identified. No patients demonstrated less than 70 percent total knowledge. The specific categories of disease entity, general diet, activity, and medication included patients with less than 70 percent knowledge (Table 6). Some important factors were identified for patients with less than 70 percent knowledge. The patients were generally younger than the total group and currently were following diet, 136 Table 6.--Number and Percent of Patients Below 70 Percent Knowledge. Less than 70% Knowledge Knowledge Categoriesa Patients Number Percent Disease Entity 2 l8 Total Treatment Regimen 0 0 Diet Total 0 0 General l 9 Specific 0 0 Activity l 9 MediciationC 2 25 Total Knowledge 0 O aThe number of patients in each knowledge category was ll (n=ll) unless specified. bn=9 Cn=8 medication, and activity prescriptions or restrictions. Three out of four of the low knowledge patients had prior individual experience with myocardial infarctions. Out of three patients who requested the results for the knowledge questionnaires, two of these patients had less than 70 percent knowledge in a specific area. I-C. What is the relationship between knowledge at hospital discharge and knowledge six weeks after hospital discharge? This question was subdivided into three questions that further delineate the relationship measured. These three questions were answered prior to answering question I—C. 137 I-C-l. What is the relationship between total knowledge at hospital discharge and total knowledge six weeks after hospital discharge? Total knowledge at hospital discharge correlated with total knowledge six weeks after discharge .38 (Table 7). The null statis- tical hypothesis was accepted since t = l.24 and no statistical significance was demonstrated at a .l0 alpha level (Table 8). There- fore, no significant relationship existed between total knowledge at hospital discharge and six weeks after discharge (see Figure l). I-C-2. What is the relationship between knowledge of disease entity at hospital discharge and knowledge of disease entity six weeks after hospital discharge? Table 7 shows that knowledge of disease entity at hospital discharge and knowledge of disease entity six weeks after discharge were moderately correlated at .47. The disease entity correlation was not significant at the .lO level (t = l.59), therefore, the null statistical hypothesis was accepted (Table 8). A significant rela- tionship does not exist between disease entity knowledge at hospital discharge and six weeks after discharge (see Figure l). I-C-3. What is the relationship between knowledge of total treatment regimens at hospital discharge and knowledge of total treatment regimens six weeks after hospital discharge? Table 7 indicates that there were no significant relation- ships between total treatment regimen or specific treatment regimen knowledge at hospital discharge and six weeks after discharge (see Figure l). Total treatment regimen knowledge correlation was r = .28. 138 wuco mucn .cmwtwowgm mmo_:: A__u:v FF we; xgommumo mmcm_3ocx comm cw mpcmwpma to Lmn53c mzpm ._a>m_ c_. pa peao_cwemwm &. mm. mmnmmzocx Pmpop Pm.- ucowpmukumz mo. sbw>wou< om. aa_c_oaam mF. _mgmcmo o_. _MHOH pate mm. cmswmwm pamEummLH Page» Ne. zpwpcu mmmmmrm mmumPZocx Fmpop aeowpaowumz spw>pou< cmawmmm pcmEpmmeh zuwpcm m o mmmmmwo mmmgmsumwo anywamoz an F a P mmwgommpmu mmvmpzocx nowmwumam _mgwcmo Peach pm_a papa pm_o mmmgmcomwo mew< mxmmz xwm mmweommpmo mmnm_3o:¥ .mmemsomwo me$< mxmmz xwm mmchzocx new mmgmzomwo quwamoz pm monopzocx mo meowuumeeou mocmxmemwo xcmm :mEmeam--.m mpnmh l39 Table 8.--Summary of Statistical Tests. . Decision Regarding HypotheSis Calculated t Null Hypotheses* I-C: I-C-l: TK1 + TK2 1.24 accept I—C-Z: DE1 + DE2 l.59 accept I-C-3: TTR1 + TTR2 .87 accept II-C II-C-l: TK1 + TTRC 2.03 reject II-C-Z: DE1 + TTRC .20 accept II-C-3: TTR1 + TTRC l.49 accept II-E: II-E-l: TK2 + TTRC l.43 accept II-E-2: DE2 + TTRC .l2 accept II-E-3: TTR2 +TTRC .96 accept TD2 + TDC 3.l4 reject *Significant at the .10 level. TK1 TK2 DE1 = Disease entity knowledge at hospital discharge Total knowledge at hospital discharge Total knowledge six weeks after discharge DE2 = Disease entity knowledge six weeks after discharge TTR1 = Total treatment regimen knowledge at hospital discharge TTR2 = Total treatment regimen knowledge six weeks after discharge TD2 = Total diet knowledge six weeks after discharge TTRC = Total treatment regimen compliance TDC = Total diet compliance 140 The test statistic was t = .87. Therefore, the null statistical hypothesis was accepted indicating that no significant relationship existed (Table 8). All of the specific treatment regimen knowledge relationships, excluding medication, were positively related indi- cating that patients tended to maintain their relative ranks on the treatment regimen knowledge categories from hospital discharge to six weeks after discharge. A weak negative relationship existed between medication knowledge at hospital discharge and six weeks after discharge indicating that there were changes in the relative ranks of medication knowledge. Patients ranking high on medication knowledge at hospital discharge tended to rank lower six weeks after discharge, and patients ranking low at hospital discharge tended to rank higher six weeks later. In addressing the research Question I-C, there were no significant relationships noted between the relative ranks of know- ledge at hospital discharge and knowledge six weeks after discharge. However, all relationships were weakly positive except for a weak negative relationship found between medication knowledge at hospital discharge and six weeks after discharge. I-D. What are the factors that affect the relationship between knowledge at hospital discharge and knowledge six weeks after hospital discharge? Outlyers were individuals differing from the general popula- tion as identified by scattergrams. Distinctive population patterns consisted of groups of patients who demonstrated clusterings on the l4l scattergrams (see scattergrams I--Appendix P). The factors for these’individuals or groups of patients were assessed. For disease entity, only one patient showed a difference fiwnn the group. This patient changed from ranking high in disease entity knowledge to ranking lowest. Some important factors were identified for this patient such as age, prior restrictions, and past exercise patterns. This patient was generally older than the other patients, had a past exercise pattern of four or more times a week, claimed no past prescriptions or restrictions, and related only current activity recommendations. Two patients showed considerable change in medication know- ledge. These patients reversed from being ranked first to last and last to first. Both patients had also experienced the most severe myocardial infarctions (see severity index, p. l08). The patient who decreased his rank was married, had no experience with a past myocardial infarction, and had never been placed on prescriptions or restrictions prior to this myocardial infarction. The patient who increased in rank was divorced, requested the results of his know- ledge questionnaire, had experienced a past myocardial infarction, and had prior experience with diet and medication recommendations. Two groups of patients were identified from the scattergrams of total knowledge and activity knowledge. The two groups were patients maintaining relatively high ranks in knowledge and patients maintaining relatively low ranks. All patients maintaining their relative high or low ranks had current diet, medication, and activity prescriptions or restrictions. 142 Patients who maintained their high ranks in total knowledge (three patients) were those who generally had high severity indices (see severity index, p. 108), demonstrated low symptoms (see symptoms, p. 110), and had greater than 15 days of hospitalization. Patients who maintained their low relative ranks in total knowledge (five patients) all had myocardial infarctions of medium severity and demonstrated higher symptoms. In relation to activity knowledge, those patients who main- tained relative high knowledge (two patients) had experienced a past myocardial infarction and demonstrated low symptoms. The four patients who maintained low activity knowledge generally had no experiences with myocardial infarctions in the past, had prior experience with medication recommendations, related past exercise patterns of less than once a week, and demonstrated high or low symptoms. Research Question I can now be answered. The patterns of knowledge identified in this study were based on findings from the data analysis. Examination of Table 4 shows that at hospital dis- charge and six weeks after discharge specific diet knowledge demon- strated the highest mean percent scores (89 percent and 87 percent, respectively). Medication knowledge demonstrated the lowest mean percent scores (75 percent and 80 percent, respectively). Medication knowledge and specific diet knowledge maintained their relative positions over time. Total knowledge was 81 percent at hospital discharge. Six weeks after discharge total knowledge was 83 percent. Wide variations existed in the range of scores for disease entity 143 knowledge at hospital discharge (61 percent to 93 percent) and six weeks after discharge (68 percent to 96 percent) indicating that some patients knew'more about the disease entity than others. A larger number of patients showed increases in total know- ledge (six or 55 percent), total treatment regimen knowledge (eight or 73 percent), total diet knowledge (six or 55 percent), general diet knowledge (six or 55 percent), activity knowledge (six or 55 percent), and medication knowledge (six or 75 percent) rather than decreases (Table 5). The number of patients decreasing in disease entity knowledge was greater than the number of patients increasing. Therefore, more patients showed increases in treatment regimen know— ledge (excluding specific diets) and total knowledge rather than decreases, and more patients showed decreases in disease entity knowledge rather than increases. Total treatment regimen knowledge (eight patients or 73 percent) and medication knowledge (six patients or 75 percent) were the two knowledge categories that showed a majority of patients increasing from onset. For those patients remaining the same in knowledge from onset, specific diet knowledge was the category that included the highest number of patients (five or 55 percent). In the area of decreases in knowledge from onset disease entity knowledge (five patients or 45 percent), general diet knowledge (five patients or 45 percent), and total diet know- ledge (five patients or 45 percent) were the categories that showed the largest number of patients decreasing from onset. Some factors were significant for those patients with less than 70 percent knowledge. This group tended to be young and 144 (nxrrently following diet, medication, and activity prescriptions arui restrictions. The majority of patients in this group had past myocardial infarctions. In addition, two out of three patients who requested the knowledge test results were from this group. No significant relationships existed between the relative ranks of knowledge at hospital discharge and knowledge six weeks after discharge for any of the categories. However, all relation- ships were weakly or very weakly positive except for medication knowledge which demonstrated a weak negative association. Some factors were identified concerning the relationship between knowledge at hospital discharge and knowledge six weeks after hospital discharge. One patient demonstrated a change from a high rank to a low rank in disease entity knowledge. This individual was generally older than the other patients, had a past exercise pattern of four or more times a week, claimed no past prescriptions or restrictions, and related only current activity recommendations. Two patients completely reversed their rankings for medica- tion knowledge from first to last and last to first. Both patients had experienced the most severe myocardial infarctions (see severity index, p. 108). The patient decreasing in rank was married, had no previous experience with myocardial infarctions, and had never been placed on prescriptions or restrictions before this myocardial infarction. The patient increasing in rank was divorced, requested the results of his knowledge questionnaire, had experienced a past myocardial infarction, and had prior experience with diet and medi- cation recommendations. 145 Two groups of patients were identified from the scattergrams (If total knowledge and activity knowledge. The groups were patients Inaintaining relatively high ranks in knowledge and patients main- taining relatively low ranks. All patients maintaining their rela- tive high or low ranks had current diet, medication, and activity prescriptions or restrictions. For total knowledge, patients who maintained their high ranks generally had high severity indices, demonstrated low symptoms (see symptoms, p. 110), and had more than 15 days of hospitalization. Patients who maintained their low relative ranks in total knowledge all had myocardial infarctions of medium severity and demonstrated higher symptoms. In relation to activity knowledge, patients who maintained relative high knowledge had experienced a past myocardial infarction and demonstrated low symptoms. Patients who maintained low activity knowledge generally had no experiences with myocardial infarctions in the past, had prior experience with medications, related past exercise patterns of less than once a week, and demonstrated either high or low symptoms. Research Question II. What are thegpatterns of compliance in the study population? This question was further divided into specific questions which were analyzed prior to the analysis of research question 11. II-A. What are the levels of stated compliance six weeks after hospital discharge? 146 The levels of compliance were analyzed based on the range and mean percent scores of the compliance instrument and the number and percent of patients who had less than 75 percent total or specific treatment regimen compliance. Examination of Table 9 shows that the highest mean percent score was medication compliance (96 percent) and the lowest mean percent scores were activity compliance (78 percent) and general diet compliance (79 percent). Patients complied more with medication Table 9.--Mean and Range Percent Compliance Scores Six Weeks After Hospital Discharge. Compliance Scores . . a Compliance Categories Range % Mean % Compliance Compliance Total Treatment Regimen 63- 95 83 Diet Total 63-100 82 General ' 63-100 79 Specificb 63-100 86 Activity 46-100 78 Medicationc 85-100 95 ¥ aThe number of patients in each compliance category was 11 (n=ll) unless specified. bn=9 Cn=8 recommendations than they did with activity or general diet recommen- dations. The range for medication compliance was 85 percent to 147 100 percent, demonstrating a high compliance rate for all patients. Activity compliance showed a wide variation in range (46 percent to 100 percent) indicating that some patients had high compliance rates while others had low compliance rates. Table 10 shows that all compliance categories, except medication compliance, included patients with less than 75 percent compliance. There was a total of five patients with less than 75 percent compliance in at least one category. These compliance results indicated that patients complied more with medication recommendations than with diet or activity recommendations. 0f Table lO.--Number and Percent of Patients Below 75 Percent Compliance. Less than 75% Compliance Compliance Categoriesa Number of Percent of Patients Patients Total Treatment Regimen l 9 Diet Total 3 27 General 4 36 Specific. 2 22 Activity 2 18 MedicationC 0 0 aThe number of patients in each compliance category was 11 (n=ll) unless specified. bn=9 Cn=8 148 those patients with less than 75 percent compliance, two patients had low compliance in only one category (general diet or activity), one patient had low compliance in two categories (general diet and total diet), one patient had low compliance in three categories (specific diet, total diet, and activity), and one patient had low compliance in all of the categories (total treatment regimen, total diet, general diet, specific diet, and activity). II-B. What are the factors that affect the levels of stated compliance? Patients with less than 75 percent total and specific com- pliance were identified (Table 10). Important factors indicated that all of the patients were married, had a myocardial infarction of high or medium severity (see severity index, p. 108), demonstrated low or medium sources of information (see sources of information, p. 110), and were following diet, medication, and activity recom- mendations. The patient not complying in six categories did not demonstrate any different factors affecting compliance than the other low compliers. II-C. What is the relationship between knowledge at hospital discharge and stated compliance six weeks after hospital discharge? This question was subdivided into three specific questions related to the knowledge and compliance relationship. These specific questions were answered prior to answering question II-C. II-C-l. What is the relationship between total knowledge at hospital discharge and stated compliance with total treatment regi- mens six weeks after hospital discharge? 149 Total knowledge at hospital discharge was moderately related to total treatment regimen compliance at r = .56 (Table 11). The null statistical hypothesis was rejected because there was statis- tical significance at the .10 level of significance with a t = 2.03 (Table 8). A significant relationship does exist between total knowledge at hospital discharge and compliance six weeks after dis- charge (see Figure 1). Patients in this population who had higher 'total knowledge scores at hospital discharge tended to comply more \Nlth total treatment regimens six weeks after discharge. Patients vvith low knowledge were less compliant at six weeks. This signifi- <:ant positive relationship could be viewed as an indication of the rwelationship between knowledge and compliance in larger populations. II-C-2. What is the relationship between knowledge of crisease entity at hospital discharge and stated compliance with ‘tc>tal treatment regimens six weeks after hospital discharge? Examination of Table 11 indicates that disease entity at hcasrrital discharge correlated with total treatment regimen compliance 61: ..07. The null statistical hypothesis was accepted with the t == .20 which is less than the critical value at the .10 alpha level (Talble 8). Therefore, no significant relationship existed between dl'Sease entity knowledge at hospital discharge and compliance six weeks after discharge (see Figure 1). II-C-3. What is the relationship between knowlegge of total IEEEQJZflent regimens at hospital discharge and stated compiiance with IEIEQJ_;§reatment regimens six weeks after hospital discharge? 150 mncu n: m e .vmwevumam mmmpcs Appucv FF mm; xeommpao comm cw mpcmvpaa mo Logan: mgpm ._a>mF op. 653 pa peau_e.em_m k. .em. mmem_3oe¥ _aoop NN. ueowpaoeemz om. xgv>wuo< om.- goeewomam Ne. Pmemcmw mm. Pmuop pawn me. cmewmwm peprmmep Pm¢OH no. Awwpcm mmmmwwo emewmmm eowpauwemz spe>_eu< noveeomam Faemeaw fleece Semapamep mmemcomwo Pmpwamoz pm 8 quOH mmmweommumu mmuszocx papa pave “are mmmgmzom_o emp$< mxmmz xvm mmweommpou mocmwpano .mmgmzumwo Lou$< mxmmz xmm mocmw_qsou new mmemzom_o Fmpwamoz pm mmcmpzocx yo mcovpm_mggoo mocmem*%_e xzmx cmaecmqm--.__ m_an 151 Table 11 shows that no significant relationship existed between knowledge of total treatment regimens at hospital discharge and total treatment regimen compliance six weeks after discharge (see Figure 1). This correlation (r = .45) was not significant at the .10 level of significance (t = 1.49) and the null statistical hypotheses was accepted (Table 8). The specific treatment regimen knowledge categories showed no significant relationship with corresponding compliance. Correla- tions of specific knowledge with corresponding compliance were weak or'very weak. The correlations were the following: total diet, .42; specific diet, r = —.20; activity, r .35; general diet, r = Therefore, in general, weak and r~ .30; and medications, r = .22. veery weak positive correlations existed between specific categories crf'knowledge at hospital discharge and compliance six weeks after cfischarge, except for the specific diet relationship which showed a veery weak negative correlation. These positive relationships indi- cated that patients with higher specific knowledge at hospital dis- charge tended to have higher corresponding compliance six weeks after discharge, and patients with lower knowledge tended to have lower compliance. However, patients with high specific diet know- 1eClge at hospital discharge tended to have low diet compliance six weeks after discharge, and patients with low specific diet knowledge tended to have high diet compliance. Research question II-C can be answered based on the relation- Sth) identified between knowledge at hospital discharge and stated C0mpliance six weeks after discharge. Total knowledge was the only 152 significant relationship and was positively related to total treat- ment regimen compliance at .56. Patients with high total knowledge complied more with all recommendations than patients with low total knowledge. The specific knowledge categories and corresponding com- pliance showed positive relationships, except for specific diet knowledge and corresponding compliance which showed an inverse relationship. II-D. What are the factors that affect the relationship between knowledge at hospital discharge and stated compliance six weeks after hospital discharge? The outlyers were patients who were different than the general population as identified by scattergrams. Distinctive population patterns consisted of groups of patients who demonstrated clusterings on the scattergrams (see scattergrams II--Appendix P). The factors for these individuals or groups of patients were then assessed for significance. Total knowledge and total treatment regimen knowledge relationships with compliance demonstrated two significant groups of patients. Patient groups consisted of patients with high knowledge and high compliance, and low knowledge and low compliance. The three high knowledge and high compliant patients from both the total treatment regimen knowledge and total knowledge cate- gories were the same individuals. All were married and demonstrated low symptoms (see symptoms, p. 110). This high knowledge and high compliance group included the two patients with no prior prescrip- tions or restrictions. 153 Five patients had low total treatment regimen knowledge and low treatment regimen compliance. All of the patients who requested the results of the knowledge questionnaire and all patients with low sources of information were in this group (see sources of informa- tion, p. 110). Important factors in relation to the low total know- ledge and low total compliance relationship included lack of experi- ence with past myocardial infarctions, prior medication prescrip- tions, and current diet, medication, and activity recommendations. II-E. What is the relationship between knowledge six weeks after hospital discharge and stated compliance six weeks after hospital discharge? This question was divided into three specific questions con- cerning the knowledge and compliance relationship. These questions were examined before the research question II-E was analyzed. II-E-l. What is the relationship between total knowledge six weeks after hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge? Examination of Table 12 reveals that a significant relation- ship does not exist between total knowledge and total treatment regimen compliance six weeks after hospital discharge (see Figure l). The correlation was r = .43 and the null statistical hypothesis was accepted with t = 1.43 which was less than the critical value at the .10 alpha level (Table 8). II-E—2. What is the relationship between knowledge of disease entity six weeks after hospital discharge and stated compliance with total treatment regimens six weeks after discharge? 154 wncu mucn .vm_wwumam mmmpcz AFPncv FF mm; agomoumu some cw mnemFHma to Logan: ween ._m>o_ mmo. on peao_c_emwm .3, .Fm>w_ o_. pm peeowcwemwm x. me. mmempzoee _mooe em.- ucowpmowumz Pm. pr>vuu< mo. aweeuaem mm. a chmemw kkmfi. Peach were om. :mewmma HemEpwmep payee eo. xpwpcm wmmmm_o :wewmmm ocowemowumz pr>wpu< nuwwwwmam chwflmw mmwwe pamEpmmLH ammemcumwo p .o p .o 3 .o _aeoe Levee meme: x_m mm_gommpmu mmeszocx .wmmemzumwo emgw< mxmoz xwm mmweommumo mucmwpaeou .mmemgomwo quwamo: empe< mxmwz x_m mocmw_aeou can mmanzocx mo mcorpm_mceou mocmemewwo xemm casemmqm--.mp mpnmh 155 Disease entity knowledge six weeks after hospital discharge was not correlated significantly (r = .04) with total treatment regimen compliance six weeks after hospital discharge (Table 12). The t score was .12, showing no statistical significance at the .10 level of significance. The null statistical hypothesis was accepted (Table 8) indicating that no significant relationship existed (see Figure l). II—E-3. What is the relationship between knowledge of total treatment regimens six weeks after hospital discharge and compliance with total treatment regimens six weeks after hospital discharge? Table 12 indicates that the correlation between total treat- ment regimen knowledge and compliance six weeks after discharge was r = .30. A significant relationship did not exist between total treatment regimen knowledge and total treatment regimen compliance (see Figure l). The t score was .96 and, therefore, the null hypotheses was accepted at the .10 level of significance (Table 8). A positive relationship was evident between total diet know- ledge and total diet compliance (r = .72) at the .025 level of significance. This level of significance indicated that the proba- bility of this relationship occurring by chance was 2.5 times in 100. The hypothesis was rejected because there was statistical signifi- cance with a t value of 3.14 (Table 8). Patients with higher total diet knowledge scores six weeks after discharge tended to comply more with total diet regimens. Patients with low total diet know- ledge at six weeks were less compliant with diets at six weeks. The total diet results can be viewed as indications or trends of the 156 relationship between knowledge and compliance in larger popula- tions. Activity knowledge and medication knowledge at six weeks were correlated with corresponding compliance at r = .51 and r = -.54, respectively. These correlations were not significant at” the .10 level of significance but were considered moderate relation— ships. All treatment regimen knowledge correlated positively with corresponding compliance, except for medication knowledge and com- pliance which was inversely related. This inverse relationship indicated that as medication knowledge six weeks after hospital discharge increased, the compliance decreased and as knowledge decreased, the compliance increased. The answers to research question II-E were based on the rela- tionships identified between knowledge at hospital discharge and cor- responding compliance as identified in Table 12. Only one significant relationship existed. The knowledge of total diets was correlated with total diet compliance at r = .72. This relationship indicated that patients with high total diet knowledge at six weeks tended to comply more with diet advice than patients with low total diet know- ledge. All of the knowledge categories, excluding medication, were positively related to corresponding compliance indicating that as knowledge at six weeks increased, compliance concomitantly increased and as knowledge decreased, compliance also decreased. The relation- ships of activity and medication knowledge with corresponding com- pliance demonstrated moderate associations. Medication knowledge 157 showed a moderate negative correlation with compliance. As medica- tion knowledge at six weeks increased, corresponding compliance decreased and as knowledge decreased, corresponding compliance increased. II-F. What are the factors that affect the relationship between knowledge six weeks after hospital discharge and stated com- pliance six weeks after hospital discharge? An outlyer was identified in the relationship between medi- cation knowledge six weeks after discharge and medication compliance. This outlyer was an individual who fell outside of the negative sloping relationship of medication knowledge and compliance. There were no differences in the factors associated with this individual than factors associated with other patients (see scattergrams III, Appendix P). The patterns of compliance, research question 11, can now be discussed. From Table 9 it can be seen that compliance mean per- cent scores were highest for medications (96 percent) and lowest for activity (78 percent) and general diet (79 percent). Mean percent compliance was greater for medication recommendations than for activity and general diet recommendations. In general, patients followed medication recommendations more than activity and general diet recommendations. Examination of Table 10 shows that all categories of compli- ance, except medication compliance, included persons with less than 75 percent compliance. Medication compliance was greater than other treatment regimen compliance such as total diet, general diet, 158 specific diet, or activity compliance. There was no specific pattern of patients that complied with individual or multiple cate- gories. I Some factors were significant for patients with less than 75 percent compliance. In this group all were married and were following diet, medication, and activity recommendations. Patients in this group had experienced myocardial infarctions of high or medium severity (see severity, p. 108), and demonstrated low or medium sources of information (see sources of information, p. 110). The results in Table 11 demonstrated a significant relation- ship between knowledge at hospital discharge and compliance six weeks after discharge. A significant relationship existed between total knowledge and total treatment regimen compliance (r = .56). Patients with high total knowledge tended to comply with all treatment recom- mendations and patients with low total knowledge complied less with all treatment recommendations. The remainder of the relation- ships were very weak, weak, or moderately positive, except for specific diet knowledge and corresponding diet compliance which demonstrated a very weak negative relationship. The relationship between total knowledge or total treatment regimen knowledge at hospital discharge with compliance demonstrated two distinctive groups of patients. Patient groups were those with high knowledge and high compliance and patients with low knowledge and low compliance. The high knowledge patients and high compliers from both total treatment and total knowledge categories included the same 159 patients. All were married and demonstrated low symptoms (see symptoms, p. 110). This high knowledge and high compliant group included the two patients with no prior prescriptions or restric- tions. The low total treatment regimen knowledge and low treatment regimen compliance group included all the patients who requested the results of the knowledge questionnaire and patients with low sources of information. Important factors in relation to the low total knowledge and low total compliance relationship were laCk of experience with past myocardial infarctions, prior medication prescriptions, and current diet, medication, and activity recommendations. From Table 12 it can be seen that a significant relationship did exist between knowledge of total diets six weeks after hospital discharge and total diet compliance (r = .72). This relationship indicated that patients with high total diet knowledge tended to comply more with diet advice than those with low total diet know— ledge. All of the knowledge categories, excluding medication, were positively correlated with corresponding compliance indicating that as knowledge increased, compliance increased and as knowledge decreased, compliance also decreased. The relationships of activity and medication knowledge with corresponding compliance demonstrated moderate associations. Medication knowledge showed a moderate negative correlation with compliance. As medication knowledge increased, corresponding compliance decreased and as knowledge decreased, compliance increased. 160 No important factors were identified in relation to the outlyer in the relationship between medication knowledge and compli- ance six weeks after hospital discharge. Summary In Chapter V an overview was presented which described the major emphasis and organization of the chapter. The descriptive data were presented next. This descriptive data included population data, demographic data, personal supportive data, and environmental supportive data. The data addressing the research questions regard- ing the patterns of knowledge and patterns of compliance were then presented. A combination of statistical and case study methods were used to analyze the data. In Chapter VI the summary of findings and implications will be presented. Specifically this chapter will focus on the summary and interpretation of findings, limitations and problems encountered, implications for nursing and other health related professions, and recommendations for future studies. CHAPTER VI SUMMARY AND IMPLICATIONS OF FINDINGS Overview The purpose of this research project is to study the rela- tionships between myocardial infarction patient knowledge at the time of discharge from the hospital, and knowledge and stated com- pliance six weeks after hospital discharge. In a review of the literature, the researcher found that differing results exist regarding knowledge relationships and knowledge and compliance relationships. Furthermore, multiple factors are reported as influ- encing knowledge and compliance. Based on the reported results, the major research questions posed for this study focus on the patterns of knowledge and the patterns of compliance in the study population. The present study is implemented to address the follow- ing specific research questions: Research Question I. What are the patterns of knowledge in iiye study population? A. What are the levels of knowledge at two points in time? B. What are the factors that affect the levels of knowledge? C. What is the relationship between knowledge at hospital discharge and knowledge six weeks after hospital dis- charge? 161 D. 162 What is the relationship between total knowledge at hospital discharge and total knowledge six weeks after hospital discharge? What is the relationship between knowledge of disease entity at hospital discharge and knowledge of disease entity six weeks after hospital discharge? What is the relationship between knowledge of total treatment regimens at hospital discharge and know- ledge of total treatment regimens six weeks after hospital discharge (refer to Figure l for a schematic representation of the knowledge relationships studied). What are the factors that affect the relationship between knowledge at hospital discharge and knowledge six weeks after hOSpital discharge? Research Question II. What are the patterns of compliance in the study pgpulation? A. What are the levels of stated compliance six weeks after hospital discharge? What are the factors that affect the levels of stated compliance? What is the relationship between knowledge at hospital discharge and stated compliance six weeks after hospital discharge? 1. What is the relationship between total knowledge at hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge? What is the relationship between knowledge of disease entity at hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge? What is the relationship between knowledge of total treatment regimens at hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge? (Refer to Figure l for a schematic representation of the knowledge and compliance relationships studied.) 163 D. What are the factors that affect the relationship between knowledge at hospital discharge and stated com- pliance six weeks after hospital discharge? E. What is the relationship between knowledge six weeks after hospital discharge and stated compliance six weeks after hospital discharge? 1. What is the relationship between total knowledge six weeks after hospital discharge and stated com- pliance with total treatment regimens six weeks after hospital discharge? 2. What is the relationship between knowledge of disease entity six weeks after hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge? 3. What is the relationship between knowledge of total treatment regimens six weeks after hospital dis- charge and stated compliance with total treatment regimens six weeks after hospital discharge? (Refer to Figure l for a schematic representation of the knowledge and compliance relationships studied.) F. What are the factors that affect the relationship between knowledge six weeks after hospital discharge and stated compliance six weeks after hospital discharge? Data for addressing the research questions is obtained from demographic data, personal and environmental supportive data, and knowledge and compliance questionnaire results fmmnll post myocardial infarction patients. Data analysis consists of a combination of statistical and case study techniques which suggest indications and trends that may exist in larger populations. Results are pre- sented for each of the research questions developed for the study. The following sections present the summary and interpreta- tions of the findings, limitations and problems encountered, impli- cations for nursing and other health care providers, and recommenda- tions for future studies. 164 Summary and Interpretations of the Findings In this section findings from the study are discussed and analyzed. The two major research questions are presented and the specific research questions are discussed under the appropriate major question. Summary Researcthuestion I What are the_patterns of knowledge in the study population? The patterns of knowledge included the levels of knowledge, factors that affect the levels of knowledge, the relationship between knowledge at two points in time, and factors that affect the relationship. Levels of knowledge were determined by: mean and range percent correct scores; the number of patients whose knowledge increased, decreased, or remained the same; and the number of patients with less than 70 percent total or specific knowledge. Changes in the levels of knowledge could result from the phenomena of regression toward the mean and, therefore, should be kept in mind when reviewing the results. Mean and range percent correct scores demonstrated that specific diet knowledge was the highest of all the knowledge cate— gories both at hospital discharge and six weeks after discharge (89 percent and 87 percent). Initial high levels may be attributed to program emphasis, prior knowledge, or the perceived relevancy of the information in general. Since low cholesterol/saturated fat diets and low salt/sodium diets have received considerable emphasis through the mass media in the last few years, it seems logical that 165 people may have retained that information due to reinforcement. Media emphasis may have also influenced the patient's perception of relevant information by suggesting that diet was a significant factor to be followed in order to decrease risk factors for cardio- vascular disease. Also, hospital education programs routinely included information on diets as part of the content. Specific diet remained the highest knowledge category at the second encounter and suggests patients retained or gained the information over time. The reasons for increased specific diet know- ledge initially continue to apply to increased specific diet know- ledge six weeks after discharge. It seems consistent with the liter- ature that applying knowledge will in fact positively influence retention. Patients problem-solve and make decisions regarding diet throughout the day which suggests that they may have frequently applied information learned. Medication knowledge demonstrated the lowest mean percent correct scores both at hospital discharge and six weeks after dis- charge (75 percent and 80 percent). Medication knowledge may have been low due to the lack of emphasis placed on medication knowledge or high anxiety levels which hampered the information attained during hospitalization. Patients may not have viewed the information as meaningful or may have preferred to deny the importance of knowing about medications. Patients may have felt that they had little independent control over medication decisions and, therefore, rele- gated total responsibility to the health care providers. Since taking medications does not really involve much daily decision-making, 166 except to take the medication or not, there may have been less appli- cation and reinforcement of knowledge than in other areas such as activity and diet compliance; In the area of changes in knowledge from onset, a majority of patients showed increases in the total treatment regimen know— ledge (eight patients or 73 percent) and medication knowledge (six patients or 75 percent). This finding supports the results reported in the literature that knowledge which was applied reinforced learn- ing or stimulated new inquiry. The number of patients who decreased in disease entity knowledge was only one patient greater than the number of patients who increased (five patients or 45 percent). It was, therefore, difficult to substantiate that disease entity knowledge decreased more than increased, or that disease entity knowledge decayed over time. The findings did suggest further exploration of disease entity knowledge. For knowledge concerning specific diet, a larger number of patients retained the same relative position at both knowledge testings than the number of patients who increased or decreased (five patients or 55 percent). Once patients were given a certain amount of information regarding specific diets further information was possibly not sought. The mean percent correct for specific diet knowledge at two points in time was the highest, suggesting that a maximum amount of knowledge needed by the patient may be reached. Some patients demonstrated less than 70 percent total or specific knowledge. Important factors which may have affected knowledge adversely were identified. Patients with less than 70 167 percent total or specific knowledge were younger than the general study population and may not have been ready to accept the disease process as readily as those who were older. Literature also suggested that the six week interval may not have been enough time for patients to accept the disease. If there was a lack of readi- ness to learn, knowledge would be low. In addition, patients may not have viewed knowledge as important. All patients with less than 70 percent knowledge were following diet, medications, and activity prescriptions or restric- tions. Patients had more information to retain due to a large number of prescriptions or restrictions and their knowledge may have been lower due to information overload and possible confusion. This result further substantiated literature reports of lower knowledge being associated with an increased number of treatment regimens. The majority of patients with less than 70 percent knowledge had experienced myocardial infarctions in the past. A previous myocardial infarction associated with low knowledge refuted the principle of relearning and retention which related that retention was greater if information was relearned rather than learning of new information (Craig, Mehrens, and Clarizio, 1975). However, if the patients did not perceive the information as important previously, they may not have learned the material at that time. Patients may not have implemented previous regimens or understood the importance of the regimens. Thus, patients with past myocardial infarctions may have been learning large amounts of new material during hospital- ization and six weeks after discharge. 168 If low knowledge demonstrated by this group indicated that they did not have adequate knowledge, their compliance may have also been lower. The lower compliance rate may have precipitated the current myocardial infarction. After the second myocardial infarc- tion, information regarding disease and treatment regimens may have been more accepted which may explain why two of the three patients who requested the knowledge test results were from this group. Patients requesting information concerning knowledge may have been attempting to attain greater control over the disease. Some patients with low knowledge may not have been ready to learn information earlier than six weeks. An opportunity to interact with a nurse at a time when patients were ready to learn provided a stimulus for some patients to seek answers. At this time knowledge may have been more meaningful (Cronbach, 1977). The relationship between knowledge at hospital discharge and knowledge six weeks after discharge was not significant. All rela- tionships, except medication knowledge, were positively weak or very weak. This finding indicated patients with high knowledge at hospital discharge tended to rank high on knowledge six weeks after discharge, and patients with low knowledge at hospital discharge tended to remain low at six weeks. Medication knowledge demonstrated a weak negative correlation (-.31) which indicated patients with low medication knowledge at hospital discharge tended to have high know- ledge at six weeks, while patients with high medication knowledge at hospital discharge tended to have low knowledge at six weeks. However, the non-significance of these knowledge results indicated 169 no particular knowledge relationships existed over time and changes were variable. Knowledge, therefore, needs to be reassessed at different points in time. The knowledge results also suggested that many factors were involved with the learning and retention of knowledge. The factors are very individual and may differ for each patient making it dif- ficult to generalize about methods of increasing knowledge. Further studies should attempt to isolate factors which may contribute to knowledge retention. Some important factors concerning the relationship between knowledge at hospital discharge and knowledge six weeks after dis- charge were identified. One patient changed from a high rank to a low rank in disease entity knowledge which was different from the remainder of the study population. The patient who changed in rank was generally older than the others, had a past exercise pattern of four or more times a week, related no past prescriptions or restric- tions, and only current activity recommendations. This patient did not retain or seek to increase disease entity knowledge pos- sibly due to patient perception or from emphasis on activity prescrip- tions from hospital education programs. This change in disease entity knowledge seems consistent with the fact that disease know- ledge may not be important to everyday living. Two patients completely reversed their ranking for medica- tion knowledge from first to last and last to first. One patient increased greatly in knowledge and the other declined. The decline may suggest that the patient did not really learn the information. 170 Both patients had experienced the most severe myocardial infarctions (see severity index, p. 108) indicating severity of the infarction may influence the need for medication knowledge. Treatment such as medication administration may not have been viewed by some patients as totally their responsibility. Patients with severe infarctions may have relegated responsibility to the health care provider and, in doing so, may not have sought information in this area. However, a patient may have viewed increased knowledge of the medical aspects of treatment regimens as an increasing factor in the control of the disease process. A study involving these two perceptions and knowledge should be implemented. The patient decreasing in medication knowledge rank was married, had no previous experience with myocardial infarctions, and had never been placed on prescriptions or restrictions before this infarction. Lack of past experience with a myocardial infarction may have contributed to the decay or loss of knowledge regarding medications (Craig, Mehrens, and Clarizio, 1975). The patient may have felt that medication knowledge was less important to know than other knowledge. Such feelings could have resulted when patients believed only in the need to follow medication orders without under- standing the implications. Therefore, the meaningfulness of the lanowledge may have been decreased. It is possible that this patient may have experienced a knowledge overload which influenced prolonged retention. The patient increasing in medication rank was divorced, requested the results of his knowledge questionnaire, had experienced 171 a past myocardial infarction, and had prior experience with diet and medication recommendations. Past experience may have influ- enced the amount of knowledge retained and may have allowed the patient to focus on relevant information about medications. This patient may have felt the need to be self-sufficient since no significant others were available for support. This self-sufficiency may have stimulated the patient to seek information in order to gain control over the disease. If the patient was complacent after the first myocardial infarction this pattern may be reversed now in an attempt to prevent further occurrences. Two groups of patients were identified from the scattergrams of total knowledge and activity knowledge. The groups included patients maintaining relatively high ranks in knowledge and patients maintaining relatively low ranks in knowledge. All patients main- taining their relative high or low ranks had current diet, medica- tions, and activity prescriptions or restrictions. Patients who maintained total knowledge high ranks were those who generally had high severity indices, demonstrated low symptoms (see symptoms,[3.110) and were hospitalized for more than 15 days. The propensity to retain total knowledge remained high for patients with severe myocardial infarctions. Patients may have viewed knowledge as a method of control over a severe disease process. Because these patients experienced more days of hospital- ization than the average, it was possible that they received more total knowledge instruction than other patients. Increased hospital- ization may have resulted in more provider-patient interaction 172 indicating an interest in patient learning. The perception of provider interest may have influenced knowledge retention and attain- ment. Low symptoms could have been a result of increased total knowledge. Patients with increased total knowledge were possibly more accurate in preventing symptoms from occurring or interpreting symptoms more appropriately when they did occur. Patients who maintained low relative ranks in total know- ledge all had myocardial infarctions of medium severity and demon- strated higher symptoms. Since medium severity may not have posed as much of a threat as high severity, patients may not have felt the need to acquire overall knowledge. Also, higher symptoms may have been a function of low total knowledge. Patients who had decreased total knowledge may not have been aware of methods or strategies which could have been used to prevent, avoid, or manage symptoms. In relation to activity knowledge, patients who maintained relative high knowledge experienced a past myocardial infarction and demonstrated low symptoms. Patients with a past myocardial infarction may have had more knowledge about activities because activity prescriptions and restrictions would have been prescribed previously. Activity knowledge may have been influenced by relearn— ing, reinforcement, and application principles. The level of symptoms could have been directly related to activity compliance. If patients knew how to accurately implement activities, monitor Progress, and adjust activities the appearance of symptoms may have. possibly been lower. 173 Patients who maintained low activity knowledge generally had no experience with myocardial infarctions in the past, had prior experience with medications, related past exercise patterns of less than once a week, and demonstrated high or low symptoms. Activity knowledge may have remained low due to the lack of prior learning, reinforcement, and application over time. Patients in this group did have prior experiences with medications. If they did not seek information related to medications previously, they may have carried over lack of inquiry into the activity knowledge area. Since applying information tends to reinforce learning, if past activity patterns were low activity knowledge may also remain low. Summary Research Question II What are the patterns of compiiance in the study population? The patterns of compliance included the levels of compliance, factors that affect the levels of compliance, the relationship between knowledge at hospital discharge and compliance six weeks after discharge, factors that affect the relationship between know- ledge at hospital discharge and compliance six weeks after discharge, the relationship between knowledge and compliance six weeks after discharge, and factors that affect the relationship between knowledge and compliance six weeks after discharge. Levels of compliance were determined by range and mean percent scores and the number of patients with less than 75 percent total or specific treatment regi- men compliance. 174 Mean and range percent compliance scores showed medication compliance (96 percent) was the highest, and activity (78 percent) and general diet (79 percent) compliance were lowest. All categories of compliance, except medication compliance, included persons with less than 75 percent compliance which indicated that patients followed medication recommendations more than other treatment regi- men recommendations. Activity and general diet recommendations were followed the least. These results were consistent with the reports in the literature and indicated there was higher compliance with medication recommendations and lower compliance with activities requiring significant or long standing behavioral or life-style changes (Berkowitz et al., 1963; Davis and Eichhorn, 1963; Davis, 1966). Activity compliance was one of the most important categories of compliance for the cardiac patient. Since the results of this study indicated that activity compliance was low, further studies should be conducted to identify methods of increasing activity com- pliance. Compliance could also have been influenced by the value the patient placed on medical recommendations versus those over which he had more control. Some factors were identified that possibly affected the levels of compliance. Patients with less than 75 percent compliance were married and followed diet, medication, and activity recommenda- tions. These patients had also experienced myocardial infarctions of high or medium severity (see severity index, p. 108) and 175 demonstrated low or medium sources of information (see sources of information, p. 110). All of the patients with less than 75 percent compliance were married. The literature suggested that patients with support from significant others complied to a greater degree. The marriage relationship may not have provided patients with the support they needed to carry out treatment recommendations. Since the majority of the study population were males, spouses who were usually respon- sible for meal preparation may not have followed treatment recom- mendations. However, spouses may have encouraged patients to follow recommendations only to have been met with resistance by the patient. If patients viewed the treatment regimens as interfering with inde- pendence, they may have resisted complying regardless of the conse- quences. It would be important for nursing to study family rela- tionships and personality types with regard to compliance rates. This could assist nursing in developing methodologies for offering supportive relationships to patients in many different situations. All of the patients with less than 75 percent compliance were following diet, medication, and activity recommendations. The results that increasing numbers of regimens were associated with noncompliance was consistent with the literature which reported compliance decreasing as the complexity or number of regimens increased (Davis and Eichhorn, 1963). It was easier for patients to follow minimal recommendations, for as the number increased there were more chances of confusion or misinterpretation. Also, a large 176 number of recommendations may be overwhelming and influence patients' nonadherence. Patients with less than 75 percent compliance had exper- ienced myocardial infarctions of high or medium severity. This. result was consistent with studies of cardiac patients with severe illnesses who followed treatment regimens less than patients with less severe illnesses (Davis, 1968a). Constant life threatening aspects of the disease may have precipitated denial. Denial would have discouraged compliant behavior. However, patients may have had a fatalistic outlook on life and may not have perceived treatment regimens as important. Low or medium sources of information were demonstrated by patients with less than 75 percent compliance. Patients had minimal contact with information concerning myocardial infarctions. Either patients did not actively seek information or were not given infor- mation frequently. A study is needed to identify the differences in compliance for patients who seek information versus patients who do not seek information. Frequent provider-patient contacts for educa- tional encounter sessions should be studied in relation to subse- quent effects on compliant behavior. Some of the relationships between knowledge at hospital dis- .gherge and compliance six weeks after discharge_demonstrate signifi- cance. A significant relationship exists between total knowledge and total treatment regimen compliance (r .56). Patients with high total knowledge tended to comply with all treatment recommenda- tions and patients with low total knowledge complied less. Patients 177 with adequate knowledge of the disease and treatments at hospital discharge were more inclined to comply with recommendations at a later time. Patients were given information in the hospital so that they could make informed decisions regarding their treatment regimens in the future. Hospitalization and educational programs reinforced the seriousness of the disease process which may have stimulated patients to attain significant amounts of overall information. Increased information may have increased patient compliance in an attempt to overcome the impending threat of death. All of the relationships of knowledge at hospital discharge and compliance six weeks after discharge were very weak, weak, or moderately positive, except for specific diet knowledge and corres— ponding compliance which demonstrated a very weak negative relation- ship. In most knowledge and compliance categories increased know- ledge tended to be important. However, the amount of knowledge which was essential was unknown. Differences may have existed between knowledge categories and the amounts of knowledge needed or required to influence compliance. The negative relationship between specific diet knowledge at hospital discharge and diet compliance indicated that as specific diet knowledge increased, diet compliance decreased and as specific diet knowledge decreased, diet compliance increased. Giving too much specific diet information at hospitalization may have tended to overload or possibly confuse patients. 178 The factors which may have affected the relationship between knowledge at hospital discharge and compliance six weeks after discharge were viewed in relation to two distinctive groups of patients. These groups included patients with high knowledge and high compliance and patients with low knowledge and low compliance. The high knowledge patients and high compliers from both total treat- ment and total knowledge categories were the same patients. This demonstrated some consistency in the characteristics of the high knowledge and high compliant patients. All high knowledge and high compliant patients were married and demonstrated low symptoms. The group also included the two patients with no prior prescriptions or restrictions. The marriage relationship, when associated with specific total knowledge and total treatment knowledge categories, may have offered support for compliant behavior. However, support may not have been based on whether the patient was married but whether a relationship with a supportive significant other was available. A study determining factors of support could also assist in the development of a nursing assessment tool. Further studies could them assess the relationships between supportive significant others, nursing interventions, and subsequent compliance. Highly compliant patients with high total knowledge and high total treatment regimen knowledge, demonstrated low symptoms (see SYmptoms, p. 110). If patients knew more about the disease and treatments and followed the recommendations they would most probably eXperience fewer symptoms because of adherence. Patients with 179 increased knowledge about necessary treatments may have been aware of strategies to prevent symptoms and of how to manage symptoms appropriately when experienced. All the patients who requested the results of the knowledge questionnaire and all patients with low sources of information had low total treatment regimen knowledge and low treatment regimen compliance. Patients who knew less about treatments complied less. However, patients in this category may not have necessarily wanted to be less compliant. They may not have had the opportunity to attain necessary knowledge or they may not have been ready to learn necessary information during their hospitalization. Sources of information were also low indicating that in the six week interval contacts with others were minimal or patients did not individually seek information regarding the disease and treatments. Further studies should be conducted to assess these two parameters. Important factors in relation to the low total knowledge and low total treatment regimen compliance relationship were lack of experience with past myocardial infarctions, prior medication prescriptions, and current diet, medication, and activity recommenda- tions. Patients who have not had myocardial infarctions in the past may not have learned or retained as much information at hospital discharge as those who had prior experiences. Patients also who had a myocardial infarction for the first time may be denying the significance of the disease process and possible recurrence. Since patients with low total knowledge and low total treat- ment regimen compliance generally had prior medication prescriptions, 180 this may have influenced their knowledge and compliance with other recommendations. If experience with medications in the past was based on a dependent relationship with a health care provider and was not accompanied by patient inquiry behavior, this same type of behavior may be presently utilized with other types of treatment recommendations. Patients demonstrating low relationships between total knowledge and total treatment regimen compliance had current treat— ment regimen recommendations including diet, medications, and activities. The results support other studies which reported less compliance with complex and increasing numbers of recommendations. The more recommendations patients received, the more information they were presented. This information may have lead to overload or confusion. As a result, compliance may have been lower due to confusion or lack of understanding regarding appropriate treatments. With increasing numbers of recommendations, patients may have become overwhelmed and may have decided to only follow some of the recom- mendations. A significant relationship existed between knowledge six weeks after hospital discharge and compliance at six weeks. Total diet knowledge was correlated (r = .72) with total diet compliance. Patients with high total diet knowledge at six weeks tended to com- ply more with diet advice than those with low total diet knowledge. Adhering to diet recommendations often involves significant behavioral changes which make compliance difficult. To increase the ease of adhering to diet recommendations patients may have 181 attempted to increase their knowledge base. Increased knowledge may have reinforced compliance with diet recommendations. Further- more, patients who then complied with diet recommendations may have increased their knowledge in the dietary area. All of the knowledge categories at six weeks were positively correlated with corresponding compliance, except medications. These positive relationships were very weak, weak, or moderate indicating that in most categories increased knowledge tended to be important. However, the amount of knowledge necessary to influ— ence compliance and the amount of knowledge needed in different categories are questionable. The negative relationship between medication knowledge at hospital discharge and compliance indicated that as medication knowledge increased, corresponding compliance decreased and as know- ledge decreased, compliance increased. Giving patients increased information about medications may have been detrimental to their following of prescriptions. Informing patients about medication actions and side effects may have influenced the patients to not take the medications. Such findings may affect our responsibility toward patient self-care and well being. If patients are provided lNlth increased information and are encouraged to be self-sufficient and make decisions, then we must be aware that patients may decide not to follow recommendations. If patients have made informed decisions then health care providers must respect these decisions. 182 Limitations and Problems Encountered The limitations and problems encountered in this study are presented in this section. A major problem was the small sample size due to the limited availability of myocardial infarction patients (n=ll). The selection of the patient population was based on availability at one hospital and randomization was not employed. Therefore, variables not measured cannot be assumed to have been normally distributed and a potential for systematic bias exists. In general, the population consisted of predominately male Caucasian patients between 50-70 years of age. Most patients were in the medium to lower socioeconomic positions. The results are general- izable only to a population with the same characteristics as the study population. Another problem encountered was that reliability of the instruments was unable to be calculated due to the small sample size. There were not enough patients in the study to use internal consis- tency measures and obtain significant results. The correlation coefficients would have been very low and unstable. In addition, test-retest reliability was not calculated for the knowledge ques- irLonnaire because it was presumed that knowledge would change over time. The sample size was small and the knowledge and compliance relationship correlation coefficients may have been unstable. Thus, statistical tests were used as indications and trends but not as strict hypothesis testing. Regardless of the limitations and 183 problems encountered during the study, the findings do support the literature and do suggest implications for health care providers, especially for nursing. Implications for Nursing and Other - Health Care Professions The results of this study suggest implications for nurses and other health care providers. Nursing stresses the importance of patient self-care (Orem, 1971). This self-care was defined by Orem (1971, p. 13) as "a practice of activities that individuals personally initiate and perform on their own behalf in maintaining life, health and well being.” Knowledge and compliance with recom- mended treatments were viewed as components of self-care. Nursing, during the supportive-educative system (Orem, 1971), contributed to the process of patient self-care by supplying information and educating patients in the hospital and after discharge. Education was completed so that the patients were provided with the knowledge and skills to take better care of themselves and to comply with treatment regimens. The major implications for nursing resulting from this study are that current educational encounters and programs especially in the interim from hospital discharge to six weeks after discharge, may'not be providing patients with information or strategies that are needed to assist them With compliant behavior. No relationships existed between knowledge at hospital discharge and knowledge six weeks after discharge which implied that individual differences do exist for changes in knowledge over time. Total knowledge at 184 hospital discharge was associated with total treatment regimen compliance six weeks after discharge, suggesting that hospital educa- tion programs providing disease entity knowledge and treatment regi- men knowledge positively influenced compliance. Only total diet knowledge at six weeks was positively related to compliance. How- ever, it cannot be assumed that knowledge is not essential for other areas of compliance at six weeks. The kind of knowledge needed at six weeks may not be appropriately attained. Patients may need knowledge of specific strategies to assist with implementation of behavioral and life-style changes. Emphasis should possibly be placed on process components such as problem-solving, behavior modification, and anticipatory guidance rather than knowledge of disease entity and treatment regimens. Nursing is in a unique position to assist patients with knowledge needs and to further assess factors which influence knowledge attainment and compliance. Significant results and associated implications are presented in the following section. A significant relationship existed between total knowledge at hospital discharge and total treatment regimen compliance six weeks after discharge. Patients with ade- quate knowledge of the disease entity and treatment regimens at dis- charge were more inclined to comply with treatment regimens at a later time. Implications are evident for hOSpital and primary care run~ses. Hospital education programs for patients with a myocardial infarction should continue to provide information regarding the disease entity and treatment regimens. Hospital rounds by primary 185 care nurses might be instituted on post myocardial infarction patients to reinforce information regarding disease entity and treatment regimens. Continuity can then be provided on follow-up visits. The knowledge questionnaire could be utilized at hospital discharge to assess patient knowledge and to specify individualized educational needs. Educational instruction could then be based on identified needs. The knowledge questionnaire may also stimulate patient inquiry of the disease entity or treatment regimens. Increased contact-time and interpersonal relationships during admin- istration and discussion of the knowledge questionnaire may posi- tively influence future compliance. Nursing studies are needed to determine if increased contact-time and interpersonal relationships increase adherence. Some factors have been identified which may have influenced the relationships between low total knowledge at hospital discharge and low total treatment regimen compliance. Patients who have not experienced a myocardial infarction in the past may need frequent contacts and educational reinforcement from health care providers. Literature reports that high anxiety may negatively influ- ence learning. Hospitalization may be anxiety provoking for patients. Encouraging verbalizations and making frequent attempts to answer patient questions, therefore, should be accomplished in hospital and out-patient settings. Patients with past medication experiences may follow similar luqowledge and compliance patterns with other recommendations. 186 Health care providers, therefore, should assess past compliance patterns of patients with past medication prescriptions. Emphasis should be placed on how other treatment regimen compliance may be different from compliance with medication recommendations. In addition, nurses should assist patients with identifying effective strategies for behavioral and life-style changes. Such strategies may include behavior modification. These behavior modi- fication techniques can be adjusted to individual patient needs. Also education encounters could include anticipatory guidance and problem-solving experiences for the patient. Reports in the litera- ture indicate that patients with increased numbers of treatment regimens demonstrated less knowledge and compliance. Nurses should offer support and encouragement to patients on complex treatment regimens by providing opportunities for frequent contacts which provide positive feedback and positive reinforcement. Patients should be supplied with information regarding the disease entity, treatment regimens, and consequences and should be assisted in decision-making concerning priority setting. Furthermore, health care providers should prioritize prescribed treatment regimens rather than ordering many treatment regimens at one time. In addition, nurses may encourage family participation in educational sessions which may offer significant support for the patient. The knowledge assessment from hospital discharge to six weeks after discharge showed that various changes in disease entity and treatment regimen knowledge existed, none of which were significant. Knowledge does change over time but changes are very individualized. 187 Studies should be conducted to look at factors affecting individual changes in knowledge. Some of the factors that should be evaluated are: severity of myocardial infarction; marital status; supportive relationships; past experience with myocardial infarctions; past diet, activity, and medication prescriptions and restrictions; current prescriptions or restrictions; number of hospitalization days; symptoms of the disease; provider-patient encounters; and patient personality. Because knowledge changes are highly variable and cannot be totally predicted, nurses should utilize the knowledge questionnaire at different points in time during follow-up visits. Assessment of knowledge could reinforce past knowledge and stimulate further patient inquiry. More frequent administration of the knowledge questionnaires may increase the time necessary for patient encounters. A significant positive relationship existed between total diet knowledge and compliance six weeks after hospital discharge. Patients with high total diet knowledge at six weeks tended to comply more with diet advice than those with low total diet know- ledge. Strategies used for diet education seem beneficial and utilization of similar strategies for education regarding other treatment regimens may be advantageous. Examination of diet educa- tion revealed a strong orientation to application. Content is Presented along with discussions on how to use the information. Patients are encouraged to ask questions based on past experiences. This same educational strategy could be used with medication and activity education. Posing of problem-solving questions can be 188 used for patients who do not initiate questions themselves. This strategy could begin at hospital discharge and continue through follow-up visits. Nurses should reinforce disease entity and treatment regi- ment knowledge six weeks after hospital discharge. Furthermore, nurses should continue to assist patients to more easily identify individualized strategies for behavioral and life-style changes. This assistance should be offered to patients over time. Specific diet knowledge was high both at hospital discharge and six weeks after discharge. A very weak negative relationship existed between specific diet knowledge at hospital discharge and compliance. As specific diet knowledge increased, compliance decreased and as specific diet knowledge decreased, compliance increased. Further studies should be conducted to reassess specific diet knowledge and compliance. Giving too much specific diet infor- mation at hospital discharge may tend to overload or confuse patients. The overall implication for diet knowledge at hospital dis- charge is that health care providers should present patients with only essential information regarding general and specific diets. Six weeks after hospital discharge total and specific diet can be verinforced and further information concerning specific diets can be presented. Patients will have had an opportunity to apply informa- tion and experience problems so that additional information will be more meaningful . All of the knowledge categories tended to be important in Positively influencing compliance six weeks after hospital discharge. 189 However, knowledge of disease entity and treatment regimens may not be the most important at this time. The most important focus may be on strategies for behavioral and life-style changes. Patients may need assistance in directly implementing treatment recommenda- tions that have been prescribed. Patients who increase knowledge because of their own knowledge-seeking behavior or due to frequent contacts with health care providers have increased compliance. Further studies are needed concerning information-seeking behaviors of patients and increased patient contacts with regard to compliance. A concerned health care provider during the six week interval and beyond may positively influence compliance. Hospital education programs provide increased patient con- tacts and high total treatment knowledge at hospital discharge was related to high total treatment regimen compliance. Therefore, an experimental study should be implemented using educational encounters during the six week interval. Patients could have an opportunityv to ask questions and obtain needed information and an assessment of relationships between knowledge and compliance could then be made. Confusion exists regarding the amount of knowledge needed to influence compliance. It is possible that different amounts of knowledge in different knowledge categories or different kinds of knowledge are required to influence compliant behavior. Nursing and other disciplines should conduct studies to identify the appro- priate knowledge that is needed for compliance. 190 Further studies are needed to determine relationships between medication knowledge from hOSpital discharge to six weeks after discharge, and medication knowledge and compliance six weeks after discharge. These relationships demonstrated negative associ- ations but were not significant. Medication knowledge demonstrated the lowest mean percent correct at hospital discharge and six weeks after discharge. Longitudinal studies are needed, therefore, to determine the amount of medication knowledge which most positively influences compliance. Further studies should also focus on patient perceptions, medication knowledge, and compliance. Some patients demonstrated low levels of knowledge and com- pliance. Factors related to these low levels suggest health care providers should reinforce knowledge with younger myocardial infarc- tion patients. Time should be spent discussing patient feelings and perceptions of the disease and treatments. The reality of the disease, and behavioral and life-style changes should be emphasized. The majority of patients with less than 70 percent knowledge had experienced a myocardial infarction in the past. A lack of knowledge is associated with reinfarction, therefore, prior knowledge experiences do not necessarily influence learning or behavior in a positive way. Health care providers must not assume that patients with prior myocardial infarctions have already obtained necessary information and should assess their knowledge level just as they would with newly diagnosed patients. Even though patients have less than 70 percent knowledge it cannot be assumed they did not want information. This was 191 evidenced by the fact that two out of three of the patients with less than 70 percent knowledge requested the results of the knowledge questionnaire. Health care providers need to assess patient know- ledge periodically and provide opportunities for patients to ask questions. Providers should be prepared to discuss patient con- cerns in an unhurried and calm environment. The lowest mean percent compliance category was activity compliance. Activity compliance is an essential compliance category for the purpose of preventing further cardiac difficulties. Based on the literature review, compliance is most difficult when it involves behavior and life-style changes. Activity compliance frequently includes these necessary changes and is, therefore, often difficult. Health care providers should spend extra time with patient education and discussion of specific strategies for activity behavior and life-style changes. It is essential that an atmosphere of acceptance exists where patients are supported and encouraged in their endeavors concerning behavior and life-style changes. In addition, provider-patient continuity may be critical. Patients with less than 75 percent compliance demonstrated some important factors. A married person may not have support in the implementation of treatment regimens. The health care provider Inust assess the significant supportive relationships for each patient. If these supportive relationships are lacking, it may be necessary to increase provider-patient contacts in an attempt to assist with compliance. 192 As with knowledge, increased numbers of recommendations may adversely influence compliance. Health care providers may promote compliance by prescribing only essential treatment regimens and prioritizing these regimens when ordered. Continually reinforcing the necessity of these regimens is also necessary. Patients vary in the amount of dependence versus independence exhibited. Assessment of past patient independent behavior and patient perception of independence in relation to prescribed treat- ment regimens is needed to adjust treatment regimen strategies appropriately. Patients should be included in the decision-making regarding treatment regimens. Because severity of the myocardial infarction is inversely related to compliance, health care providers should more closely assess patients with severe myocardial infarctions. Many of these patients may prefer to deny the existence of the disease process. Such patients should be encouraged to verbalize their feelings. Since denial may be detrimental to the well being 0f the cardiac patient, it would be important for nursing to assist patients in identifying reality. This could be accomplished through discussions of reality and confronting patients with reality if behavior is detrimental. The provider should present possible consequences of treatment recommendation non-adherence to the patient, but must respect the patients decision to follow or not to follow treatment. Patients with low compliance also demonstrated low or medium sources of information. Frequent contact is needed with such patients and they should be encouraged to ask questions. 193 Information could be discussed with each patient in order to meet individual needs. Barriers can also prevent compliance. Discussions of cur- rent or anticipated barriers may lead to problem-solving strategies and, hence, greater compliance. Nursing practice is based on the philosophy of "self-care” (Orem, 1971). Self-care is accomplished in the home environment by the post myocardial infarction patient because the patient takes personal responsibility for adhering to prescribed treatment regi- mens. Knowledge and compliance with recommended treatments can be viewed as components of self-care activities. Nurses, during the supportive-educative system, are in strategic positions to posi- tively influence knowledge and compliance with recommended treat- ments both at hospital discharge and six weeks after discharge. Educational encounters have traditionally been concerned with imparting information about the disease entity and treatment regimens. Since increased compliance is desired, increasing the knowledge of disease entity and treatment regimens may not be sufficient. Educators may need to transend these traditional methodologies and also assist patients with developing strategies for making behavior and life-style changes. Nurses can assist the patients by providing anticipatory guidance and problem-solving experiences, encouraging open expression of feelings, and assisting with the development of behavior modification techniques. 194 This section has focused on significant results of the study and implications for nursing and other health care profes- sionals. In the following section recommendations for future studies are made. Recommendations for Future Studies 1. Replication of the study should be conducted using a larger population and different settings. 2. The knowledge and compliance instruments should be used with larger populations so that validity and reliability of the instruments can be determined. Once valid and reliable instruments are identified, further studies can be conducted with more meaning- ful results. 3. There is a need for consistency in the definitions and research methodologies associated with the measurement of knowledge, compliance, and knowledge and compliance relationships. Replication of existing studies should be a priority in order to generalize. 4. More studies should be conducted to measure a combina- tion of specific knowledge categories and specific compliance categories to determine if relationships exist. 5. Exploratory studies are needed to assess the amount of knowledge in specific knowledge categories which most effectively influence compliance. 6. Studies should be conducted to assess the characteristics (If patients who do or do not comply. The characteristics should iruilude those utilized in this study with the addition of the 195 following: duration of the regimen, patient perception of the disease and treatments, motivation, attitudes, values and beliefs, work orientation, denial versus acceptance of the disease, person- ality type, dependant versus independent needs, support or influence from family or friends, and provider-patient relationship. 7. The knowledge instruments should be used by health care providers to assess knowledge prior and subsequent to educational contacts. This would also serve as a stimulus for the patient to ask questions and identify educational needs. Sections of the knowledge questionnaire also could be used with other patients and not just limited to use with cardiac patients. 8. The compliance instrument should be used by health care providers to assess the compliance of patients on prescribed treat- ment regimens. This would then help to identify compliance deficiencies in order to individualize education and counseling. Sections of the compliance questionnaire could also be used to assess compliance of many patients other than cardiac patients. 9. Other research studies should be undertaken six weeks after hospital discharge to assess knowledge and compliance after specific interim educational programs which incorporate behavior modification techniques, anticipatory guidance, and problem-solving. lO. Longitudinal studies should be conducted on knowledge and compliance to identify if patterns exist regarding changes in these variables. 11. Studies should be conducted to further assess knowledge (facts versus application questions) and compliance. 196 12. Exploratory studies are needed to assess the relation- ships between specific diet knowledge at hospital discharge and compliance, and medication knowledge at hospital discharge and six weeks thereafter and compliance. 13. A study should be conducted to view patient perceptions of provider responsibility versus individual responsibility for medical aspects of treatment and associated compliance. 14. Additional studies should focus on the family supportive relationships, nursing interventions, and independence with regard to compliance. 15. Patients who actively seek information concerning the disease or treatment during the six week interim time and those who do not should be studied in regard to compliant behavior six weeks after myocardial infarction. 16. It seems feasible that the number of patient contacts with health care providers may influence knowledge and compliance. These relationships should be studied in the future. This study has raised many additional questions related to the levels of knowledge and compliance, relationships between know- ledge at two points in time, relationships between knowledge and compliance, and the factors that affect the levels and relationships. The results of this study indicate that certain relationships do exist between myocardial infarction patient knowledge at the time of discharge from the hospital, and knowledge and stated compliance six weeks after hospital discharge. The results suggest that current educational programs or encounters, especially in the 197 interim from hospital discharge to six weeks after discharge, may not be providing patients with all that is needed to assist them with compliance. The results of_this study can be viewed as indications and trends which exist in larger populations. The findings add to the developing knowledge base concerning the relationships between knowledge and compliance. APPENDICES 198 APPENDIX A KNOWLEDGE QUESTIONNAIRE 199 Directions: attack and treatments. each response that is correct. answer to each question, so check all that apply. The following are general questions about a heart Please answer the questions by checking (I) There may be more than one correct Answer each ques- tion Before going on to the next. There is no penalty for guessing. Answer the questions yourself. 1) 2) 3) 4) 5) Do not ask others to help you. My heart ___a) b) :c> d) Because __a> __b) C) :m A heart _a) __b) C) d) In the ___a) ___b) c) d) Persons _a> ___b) c) :m is a muscle. stores excess water in my body. pumps oxygen to all my body tissues. pumps blood through my blood vessels. I had a heart attack my whole heart is damaged for a short period of time. a part of my heart is damaged for a short period of time. my whole heart is damaged forever. a part of my heart is damaged forever. attack can be caused by not enough oxygen getting to the heart. a slow build up of fat in the blood vessels (arteries) over many years. a closing (narrowing) of the blood vessel(s) that supply the heart. not enough blood getting to the lungs. (arteries) healing process after my heart attack, my heart heals slowly and forms a scar after 6 to 8 weeks. forms new blood vessels (arteries) to supply blood to the damaged area. heals only when I'm completely inactive and confined to bed. has healed completely when I no longer have chest pain. that are likely to have a heart attack are those who smoke 2 packs of cigarettes a day. have a regular exercise program at least twice a week. are 20-30 pounds overweight. have high blood pressure. turn to next page 200 201 Answer the following questions by checking (V) each response that is correct. There may_be more than one correct answer to each ques- tion, so check all that apply. 6) Chest pain a) :m 0 d) always means I'm having a heart attack. frequently means that my activity level is more than my heart can take. is caused by too little blood and oxygen getting to my heart muscle. will go away if I keep active and try to forget about it. 7) Angina is another term for a) b) c) d) shortness of breath. chest pain. heart attack. kidney failure. 8) After my heart attack, my meals a) b) C) d) are always digested slower. should be eaten just before physical exercise. should include foods from the basic food groups. may be easier on my body if divided into smaller and more frequent meals a day. 9) Eating a good nutritious diet will ___a) help to heal and repair my body tissue. b) provide my body with the most important foods that it needs. c) help my body to grow new tissue. d) always make me lose weight. 10) Which of the following are the best example(§) of a nutrition- ally balanced meal a) chicken and gravy, potatoes, green beans and milk. b) hamburg, french fries and coke. c) peanut butter sandwich, apple and orange slices, ice cream. d) crackers and cheese, ham slices and iced tea. ll) Digestion of big meals a) may cause me to have chest pain. b) may be easier on my body if I rest after eating. c) makes my heart work harder. d) is helped when I do exercise. turn to OEXt page 202 Answer the following questions by checking (J) each response that is correct. There may be more than one correct answer to each ques- tion, so check all that apply. 12) l3) 14) 15) 16) 17) Weight gain a) b) C) d) 1 depends only on the amount of food eaten. is the same for everyone. depends only on the kind of food eaten. depends on a balance between food eaten and activity. Which foods will most likely cause a gain in weight if eaten frequently? a) tomatoes, lettuce, carrots. b) apples, oranges, iced tea. c) breads, cakes, pies. d) fried chicken, gravy, potato chips. After a heart attack, a) a person should not get angry or excited. b) most people eventually can return to previous activities. c) physical activity levels will always be limited. d) most people eventually return to their previous sexual activities. After a heart attack, mild exercise such as walking, golfing, swimming, etc. a) b) c) d) l are not good for the body. should be done on a regular schedule. are started and increased in gradual steps. should be done only when a person thinks of it. When doing physical activities, it is important that I a) b) ___c) __a) If my a) ___b) ___c) __d> use sudden bursts of energy to start activities. not push or pull heavy objects. hold my breath during the activity to give me more strength. not lift 15-20 pound objects. body is able to tolerate (handle) an activity, my pulse (heart beat) will be back to normal within 5 minutes after I stop the activity. I may develop chest pain or pressure. my heart may beat faster than 170 during the activity. I may be weak at the end of the day or on the following day. turn to next page 203 Answer the following questions by checking (J) each response that is correct. There may be more than one correct answer to each ques- tion, so check all that apply. 18) I should stop what I am doing and restlif I a) (101,1 feel tired, weak or dizzy. get short of breath. have a pounding in my chest. have chest pain or chest pressure. 19) If I have chest pain while walking up stairs, I should a) b) C) 0.. sit on the stairs and rest. keep going to the top and then rest. never try going up stairs again. go to the top only after IYve rested and the pain has stopped. 20) If I have chest pain or chest pressure that does not go away within 15 minutes after resting or taking nitroglycerin, if ordered, I should a) :b) C) __a) not do anything until I talk to my doctor. wait 3 to 4 hours to see if the pain gets worse before going to the hospital. go off to be by myself and rest without telling others of my pain. have someone drive me to the hospital. 204 Low Salt Diet/No Added Salt Diet Directions: The following questions are about a low salt or no added salt diet. Answer them by checking (V) each response that is correct. There may be more than one correct answer to each ques— tion, so check all that apply. 21) 22) 24) Eating salt may a) make the body hold water. b) lower the amount of fat in the blood. c) make a person lose weight. d) make extra work on a weakened heart. Another name for a low salt diet is ___a) low cholesterol diet. ___b) low fat diet. ___c) low sodium diet. d) weight reduction diet. While on a low salt diet, I should order which of the follow- a) hot dogs and sauerkraut. ___b) baked chicken and potatoes. ___c) ham and cheese sandwich. d) steak and carrots. When lowering the amount of salt I eat, I should 9' ) not add salt to my food at the table. b) avoid eating bouillon. c) avoid eating onions. d) avoid eating garlic salt. 205 Low Cholesterol Diet/Low Saturated Fat Diet Directions: Iow saturated fat diet. that is correct. The following are questions about a low cholesterol/ Answer them by checking (V) each response There may be more than one correct answer to each question, so check all that apply. 25) Cholesterol a) is a fat-like substance. b) is made by the body. c) is in foods. d) is not needed by the body. 26) A low cholesterol, low saturated fat diet a) may help to lower future fat levels in my blood. b) increases the amount of water in my body. c) may help to keep my blood vessels from getting narrower. d) may be helpful for all my family members. 27) I should limit eating which of the following foods when on a low cholesterol/low saturated fat diet? a) fish and poultry. b) whole milk and cheese. c) bacon and eggs. d) vegetables and fruits. 28) I can lower cholesterol and saturated fat in my diet by a) cooking and baking with solid shortening and butter. b) buying lean meats and cutting off excess fat. c) using a rack to bake or broil meats and fish. d) skimming fat off cooled soups and graviesh 206 Nitroglycerin Directions: The following questions are about the medicine nitro- glycerin. Answer them by checking (VW each response that is cor- rect. There may be more than one correct answer to each question, so check all that apply. ' 29) Nitroglycerin ___a) makes all the muscles of my body relax. ___b) dilates (opens) the blood vessels (arteries) that supply my heart. ‘___c) makes my blood clot slower. ___d) increases the blood and oxygen getting to my heart. 30) Nitroglycerin is used to lessen ___a) headaches. b) stomach pains. c) backaches. d) chest pain. 31) Negative (bad) effects of this medicine may be a) dizziness. leg pains. c) headaches. d) warm flushed feeling. 0‘ 32) When taking nitroglycerin, it is important to know that a) I can take another tablet, if I accidently swallow the first. ) I should go to the nearest hospital if my pain does not go away in 15 minutes after resting and taking 3 tablets. c) I won't feel a sting when the medicine is dissolving if the medicineeis too old. d) When it is necessary for me to do an activity that causes chest pain (walking, climbing stairs, sexual intercourse), I should take a nitroglycerin before that activity. .. l Diuretics Directions: 207 The following questions are about diuretic medicines (water pills). Answer then by checking (V) each response that is COIIECt . There may be more than one correct answer to each ques- tion, so check all that apply. 33) Diuretics work by ___a) ___b) __c> _d) making my body get rid of salt and water. making all the muscles of my body relax. dilating (opening) the blood vessels (arteries) of my heart. making my heart beat stronger. 34) Diuretics _a> __b) C) :1» lower the amount of water in my body. make my body hold extra fluid. make my heart work harder. lower the work load on my heart. 35) When taking diuretics, I should a) :b) _c> _d) weigh myself every day. report a 3 pound gain of weight if it happens in one week or sooner. limit the amount of fluid I drink to 3 glasses a day. take my medicine just before I go to bed. 36) Important negative (bad) effects of diuretics that I should report to my doctor are a) b) c) d) general muscle weakness. leg or abdomen cramps. increased urine output (passing water). increased hunger. 208 Digitalis Directions: The following questions are about the medicine digitalis (heart pill). Answer them by checking (V) each response that is cor- rect. There may be more than one correct answer to each question, so check all that apply. 37) 38) 39) 40) Digitalis works by IQOIU‘W making my blood clot slower. slowing my heart beat. making my heart beat stronger. dilating (Opening) the blood vessels supply my heart. (arteries) that When taking digitalis, I should call my doctor immediately if a) ___b) __C) d) Digitalis can cause the heart to slow too much. my pulse (heart beat) changes from a regular to irregu- lar beat. my pulse (heart beat) is less than 50-60 beats a minute. I have nausea, vomiting, or diarrhea that lasts for longer than a day.’ my pulse (heart beat) is faster than 120 beats a minute. If this occurs, I may notice __..a> __b) _c> d) a pulse (heart beat) of less than 30 to 40 beats a minute. a difficulty breathing when resting or doing an activity. an increased surge of energy. severe weakness. When taking digitalis, I should a) :m C) :1) take my pulse (heart beat) regularly as I've been told. contact my doctor before taking my next dose if my pulse (heart beat) is less than 50-60 beats a minute. take my medicine at the same time every day. take a double dose if I have forgotten a dose. 209 Anticoagulants Directions: The following questions are about anticoagulants medi- c1nes (blood thinners). that is correct. Answer them by checking (V) each response There may be more than one correct answer to each question, so check all that apply. 41) 42) 43) 44) Anticoagulants a) stop my chest pain. ___b) make my blood clot slower. c) dilate (open) the blood vessels (arteries) of my heart. d) reduce the amount of salt in my body. It is important to know that anticoagulants a) may prevent further clotting of my blood. b) dissolve clots in my blood. c) may cause me to bruise easily. d) will make me bleed easier and for a longer time than normal. When taking anticoagulants, I should tell other doctors and my dentist that I'm taking this medicine. not take medicines containing aspirin. ask the pharmacist about over-the-counter medicines if I'm not sure that they have aspirin in them. call my doctor whenever I out myself. I should contact my doctor immediately if ___a) __b) c) :::d) my urine (water) is red or dark brown. my appetite increases. my stools (bowel movements) are black or tarry. I suddenly develop joint pain or swelling. Isordil Directions: Answer them may be more that apply. 210 The following are questions about the medicine Isordil. by checking (V) each response that is correct. There than one correct answer to each question, so check all 45) Isordil works by a) _b) c) :m dilating (Opening) the blood vessels (arteries) that supply my heart. making my blood clot slower. making my heart beat stronger. increasing the blood and oxygen getting to my heart. 46) When taking Isordil, negative (bad) effects may include 00"“) d) headaches. leg pains. dizziness. warm flushed feeling. 47) Negative (bad) effects of Isordil, like those in question #46 ___a) ___b) __c) 48) It is will last forever. should go away within a few weeks. should be reported to the nurse or doctor if they do not go away. will stay for 6 months. important to know that Isordil prevents all future chest pain. may let me do more activities in comfort. may reduce the number of times I have chest pain. may reduce the time that chest pain lasts. APPENDIX B COMPLIANCE QUESTIONNAIRE 2)) This questionnaire will identify to what extent you were able to follow the treatment orders, advice, and information that you received from the doctors, nurses, and reading materials after your heart attack. It is difficult to follow all of the treatment orders, advice, and information, there- fore, please answer each statement honestly. It is important that you answer according to whatyyou do, and not what you think you should be doing. There is no right or wrong answer. This information is strictly confidential for the purposes of this study and your doctors and nurses will not be informed of your answers. 212 J- of s‘. DIECTICY‘I'S: Below are 2. attack patients. Answer and information that you your heart “*‘ack. EQUV series -tements base: on general treatnents for .eart acheck (J? in the box under the no t ...,u. so“: Read each statement carefully and then places - appropriate o.te5o§y that represents the extent to which you have done the followi. g statements based on the treatment orders, advice. received from the doctors. nurses, and reading materials after the statement indicates. , h h ‘ , approximately 6 weeks ago. The categoriesi include: all the time. nost of the time, less than half the time, very seldom, and none of the time. Please check only one box for each statement. Do not skip any statements. Please indicate the extent to which you do the following since your discharge from the hospital: I all of Isost of ve- ' none of the time the time seldom the timc b h F—: —I “’ <_v f I) I space my meals throughout the day. . F , Li ,L_______ 2) I take my pulse (heart beat) after , , ‘ physical activities and/or exercise ' r as I was told. ___.____.J. ___J __i.._.___ 3) I do physical activities and/or exercise ‘ r) I rightm ter eating meals. ‘ | ,. J h) I start physical sotivities and/or exer- . A H cise with sudden bursts of energy. .. l I . _D _D *' ‘W 5) I rest a half hour or more after meals. I, ,n ,,J“__,_,, (i ,‘ ii 6) I modify physical activities and/or exer- ,, , , cise based on how my body feels :r tol- ‘ I] erates it. (I _.,,,.,_ _,, l___.,_,_, ___ , ,, , next page 213 214 DIRECTI C33 : Answer each statement by placing a check (J§ in the box under the most aporopriatg caterggz that represents the extent to which you have done what the statement indicates s nce your d scharve “non the hos ta , approximately 6 weeks ago. Please check only one box for each statement. Do not skip any statements. Please indicate the extent to which you do the following since your discharge from the hospital: 7) I“! '4 should avoid. eat small meals. I change 1y physical activities and/or exercise the way I was told. 9) I eat seals that contain of the basic food group:. 10) do physical exercise less than 'A H \J (a H \J \J take 1y pulse {heart beat) .A do physical activities and/or exercise foods from all times week. (swimming, golfing. walking. etc. aotivity and/or exercise ‘ all of ost of the time he time ' U [I U ll 11 L1 1 D very seldom H H U H H 11111 of “-§ V‘s-A [none the (111) Ill) 11 ~.-- «nan-a: V O d-.\_u-- I“. _ Answer each statement by placing a \v 215 «H neck (4H in the box under the most agtgcggiate caterorz that represents the extent to which you have done what the statement indicates , approximately 6 weeks ago. Please check only one box for each statement. The following statements on medicines should be answered case on on the cines Wm Elitroelycerin diureticsfiater pills digitalis ‘“ figs-"Pa ¢ A Do not skip any statements. (heart pills).anticoagulants (blood thinners). Isordil. Inderai] Please indicate the extent to which you do the following since your discharge from the hospital: I“) I take all the medicines ordered for me. 15) I take the amount or dosage ordered for :8. 16) forget to take my medicine(s) at the 17) times I should take them. I watch for negative (bad) effects of my :edicines. 19) I follow the necessary actions (precau- tions) 'that I should.with-ny medicines. [Examplesz nitroglycerin-—keep-tablets in a dark place, diuretics (water pills) ---weigh self daily, digitalis antic 075‘ 41% I ‘ ints (blood thinners)--avoid asprin, etc pill)--take pulse frequently, (heart all of the time H H H II most of the time Ll lless th half ‘the t m Ll H H H H Ll H H very seldom H H HH l H l ' none of the tint III l l l 1 I l 216 DIRECTIOKS: answer each statement by placing a check (J5 in the box under the most accronriate categorv that represents the extent to which you have done what the statement indicates “<+~1 since your disc “we ’ron th approximately 6 weeks ago. Please check only one box for each statement. Do not skip any statements. The following statements on diet should be answered based on the specific diet restrictions-- low salt, low sodium, low cholesterol, low saturated fat, or weight reduction. Please indicate the extent to which you do the following since your discharge from the hospital: 19) I follow the diet ordered for me. 20) I eat the foods that I was told to avoid. 21) I eat foods cooked and prepared the way was told. P1 22) I season foods the way I was told. all of the tire m: H 1! LI H H H H very seldom H H H H 1 none '3 the time H H H H APPENDIX C HOSPITAL CONSENT 217 219 1210 WEST SAGlNAW TELEPHONE LANSING. MlCHIGAN 48914 AREA CODE 517/372-3610 '1 \/ {A t I St. [jaw/re nee HOSPITAL Septanber 29, 1978 Jan Firflcbeiner R.N. Family Nurse Clinician Student: Michigan State University 1558 Hillside Drive Okams, deugan l+8861; Dear Jan: This istoconfirmyotmrequestedextaisionoftimeforyomresearch project, "'me Relationship of meledge and Compliame to Post- Myocardial Infarction Patients". You are approved to cmtinue utilizing the patient population at St. Lawrence Hospital for your study though October 15, 1978, and to have access to patient charts through Decanber 31, 1978. This approval is effective October I, 1978. Sincerely, Rosa Lee Weinert R.N. Assistant Ackninistrator-Nmsing RLW/ Cb APPENDIX D PATIENT CONSENT FORM 220 Michigan State University School of Nursing For: Master's Thesis After a heart attack, patients are given information about the heart attack and ordered treatments. I am studying what patients know about their heart attack and treatments, both when going home from the hospital and six (6) weeks after going home. I would like to see if this information is related to how patients follow treat- ment orders when they are at home. By collecting and analyzing this data, I hepe to help future heart attack patients after their dis- charge from the hospital. This study will involve completing a lO-lS minute questionnaire before you go home from the hospital. I will administer another 20-30 minute questionnaire in your home six (6) weeks after you go home from the hospital. Five (5) weeks after you go home, I will call you to set up an appointment. at your convenience. for the following week. Additional information (age, marital status, etc.) will also be obtained from you now and at the home visit. Your name will never be associated with the data and your iden- tity will remain confidential. You are free to withdraw at any time without penalty. If you are interested, your results can be shared with you at the home visit. Thank you for your time and cooperation. Jan Finkbeiner, R.N. Family Nurse Clinician Student Telephone: 349-1216 I voluntarily consent to participate in this study on both occasions. I have had an opportunity to ask questions. Signature of Subject Date 221 APPENDIX E ENCOUNTER INTRODUCTION SHEETS 222 This is the first questionnaire of the study in which you‘have agreed to participate. This study will look at the information patients have about their heart attacks and treatments when they are ready to go home from the hospital, and information they have at six (6) weeks after discharge from the hospital. Also, this study will see if this information is related to how people follow treatment orders when they go home. The researcher will call you in five (5) weeks to set up an appointment, at your convenience, for a visit the following week (sixth week). Your name will never be associated with the data and your identity will remain confidential. The results of this question- naire can be shared with you at the home visit. If you have questions after completing the questionnaire, please contact your doctor, the nurse who has given you informa- tion before, or call 372-6310, extension 1385 (ICU/CCU). Thank you for your time and cooperation. Jan Finkbeiner, R.N. 223 APPENDIX F CHECK LIST FOR KNOWLEDGE QUESTIONNAIRE ADMINISTRATION 225 Check List for Questionnaire Administration Check on diet & medications - - - Get appropriate questions Place sign on door Ask patient's visitors to leave for 10 minutes Alone Yes No who in room Ask if ok to turn TV off for 10 minutes Off Yes No Ask if ok to turn radio off for 10 minutes Off Yes No Read introduction sheet & instructions for the questionnaire Explain additional tests Give to patient to read Allow him to read Ask if any questions o-Answer questions on wording or intruetions- NOT ON CONTENT Shut door Pick up questionnaire in 10-15 minutes Any interruptions Phone Medications Visitors Nurses Doctors Other Leave introduction sheet with patient Remove sign on door (Return this with questionnaire) 226 APPENDIX G CHECK LIST FOR PATIENTS ADMITTED TO THE STUDY 227 CHECK LIST OF PATIENTS ADMITTED TO THE STUDY MI Reside around Lansing E discharge Education initiated Consent form signed Demographic data & support data patient chart Education completed Administer knowledge test at discharge date Call at 5 weeks (week) date date Appointment for 6 weeks (week) date date Follow-up call morning of appointment date Obtain demographic & supportive data Administer knowledge test at 6 weeks Administer compliance questions at 6 weeks Requested results of test Comments: 228 APPENDIX H DEMOGRAPHIC AND SUPPORTIVE DATA --PATIENT 229 Patient name Address: Phone: Marital status 3 Height weight M Sep w Div Occupation _1) 2) :3> Major executives of large concerns, major professionals, and proprietors Lesser professionals and proprietors,and business managers Administrative personnel, owners of small businesses and minor professionals ___4) Clerical and sales workers,and technicians ___5) Skilled trades ___6) Machine operators and semi-skilled workers ___7) Unskilled employees Education scale Were you on any specific diet or did you have any diet restrictions ___i) Professionals (masters, doctorate or professional degree) ___2) College graduates ' ___d) l-3 years college or business school ___4) High school graduates ___5) 10-11 years of schooling ‘___6) 7-9 years of schooling ___7) Under 7 years of schooling before this heart attack? Yes No What were they? Were you on any medicines before this heart attack? Yes No What were they? How many times a day taken Did you have any activity restrictions before this heart attack? Yes No What were they? Before this heart attack, did you do exercise (swimming, walking, golfing) beyond your activities of daily living and household activi- ties? Less than 1 time/week Greater than 1 time/week 230 231 Do you smoke? Yes ___ No Cig ___}/day Pipe ___#/day Cigar ___}/day Have you had a heart attack before? Yes No Has your spouse had a heart attack in the past? Yes No Has anyone in your family had high blood pressure, heart attacks, hardening of the arteries or strokes? Yes No What were the ages when they occurred? Heart Hardening Hi BP Attacks of Arteries Strokes Father Children APPENDIX I DEMOGRAPHIC AND SUPPORTIVE DATA --CHART 232 Patient Chart GENERAL INFORMATION Chart # Admission date Date # days CCU Age Discharge date Sex # days in hospital Marital Status Race Weight Height __ ) 20 lbs Yes No _ Community referral Yes No Chronic illnesses: Diabetes Yes No Cancer Yes No Arteriosclerosis Yes No High blood pressure Yes No Kidney disease Yes No Other " Highest cholesterol Highest triglycerides SPECIFICS OF MI Complications Arrhythmias Yes No l) lethal Yes No 2) major Yes No 3) minor Yes No Cardiac arrest Yes No Cardiogenic shock Yes No lowest blood pressure CHF Yes No Angina Yes No Other: DISCHARGE INFORMATION Discharge diet 4__ fluid restriction Yes No medications MI Chronic diseases 233 APPENDIX J CHECK LIST FOR COMPLIANCE QUESTIONNAIRE ADMINISTRATION 234 Check list for Compliance Administration Read introduction sheet e tbtain ienogreph o and supportive iata alone 7? on family present a : a! .. .her -nterup.-ons Determine knowledge questions 223d instruction for knowledge questionn ire Ezplain addit‘anal questions Have patient read ‘ I .not :n c 3‘ ar---' wnnmaw‘ o O -.U --- -.. 5-. O .,‘, «no .-‘J‘e- 2V on radio on "he“ “:1: ‘-‘I-- .LJ a": 2.3-”-22 :cnpliance4 rs 4' ‘3 .. 'o.- _' .cr compi-ance qsestiennaire 2'. ‘.3 T 48a. ‘ -xp-i-n ii--.icna- questions . 4.: . 3 : o ' Answer : es--cns :n xord-ng or -ns.ructi:ns :rtar“ C- C V A ’ a. 31C. "3 235 APPENDIX K DATA AFTER HOSPITAL DISCHARGE 236 Patient Date Disease process How may times have you had office visits or emergency room visits with your doctor since you went home from the hospital after your heart attack? Have you been readmitted to the hospital since your discharge after your heart attack? No Yes Reason How often have you had any of the following symptoms since you went home from the hospital after your heart attack? Chest pain or pressure without radia- tion Chest pain or pressure with radiation Shortness of breath Difficulty breathing when lying flat Paroxysmal nocturnal dyspnea Swelling of ankles Increased heart rate (pounding in chest) New irregular heart beat (pulse) Current regime Are you currently on a Na restricted diet Yes No Chol restricted diet Yes No weight reduction diet Yes No Are you currently on a fluid (water, juices, etc.) restriction? Yes No 237 238 What are your current medicines? Bottle check Statement l l Additional information attainment Have you attended classes in the community for heart attack patients? Yes No Specify How often have you obtained information about a heart attack and/or treatments from Occ Never Books Magazines Newspaper Radio TV Friends Family Doctor Nurse (hospital, doctor's office, friend) Visiting Nurses Association Public Health Nurse Community Agency (American Heart Association, etc.) Other APPENDIX L KNOWLEDGE INSTRUMENT SCORING EXAMPLE 239 KNOWLEDGE INSTRUMENT SCORING EXAMPLE For example, in the following question foils a, b, and c were correct answers. The patient may have answered the question in the following manner: 3. A heart attack can be caused by __[_ a. not enough oxygen getting to the heart. ___ b. a slow build up of fat in the blood vessels (arteries) over many years. _1;_c. a closing (narrowing) of the blood vessel(s) (arteries) that supply the heart. _g;_d. not enough blood getting to the lungs. Therefore, the scoring of this question would result in: (a) l, (b) 0, (c) l, (d) 0, for a total of two points. 240 APPENDIX M SUMMARIZATION OF RISK FACTORS AND CRITERIA 241 SUMMARIZATION OF RISK FACTORS AND CRITERIA Risk Factor age sex weight illness elevated cholesterol elevated triglycerides exercise per week smoking (cigarettes, or inhaled pipe or cigar smoke) family history of hypertension, myocardial infarctions, or arteriosclerosis 242 Criteria > 60 male 3_20 pounds overweight as deter- mined by the Metropolitan Life Insurance Company's Desirable Weights Table. diabetes, hypertension, past myocardial infarctions and/or arteriosclerosis cholesterol 300 mgm/lOO ml or stated history triglycerides l70 mgm/lOO ml or stated history < 3 times per week 2.1 pack per day parents and/or siblings APPENDIX N SEVERITY INDEX 243 Severityglndex Are and Sex: £22. 22222 .5 54 years O S 64 years 2 F5-59 years 1 z 65 years 3 60-64 years 2 65 years 3 _Previous History: past MI 6 other cardiovascular diseases or history of exertional dyspnea QtBP, peripheral vascular disease, CV2, cor pulmonale, valvular disease, arrhythmia) 3 angina only 1 no cardiovascular disease 0 shock: absent 0 mild-- Shock at or soon after the onset of the attack manifest by transient pallor, faintness, sweating, nausea, or vomit, ing; and subsiding spontaneously within 15-30 minutes. 1 moderate-- Signs of shock still present on examination, including duskiness or or cyanosis, but subsiding with rest and sedation. 5 severe-- Shock percisting despite rest and sedation, leading to the use of or con- templation of the use of pressure drugs. Oliguria present. 7 Failure: absent 0 few basilar rales only 1 any one or more of the following: breath- lessness, acute pulmonary edema, ortho- pnea or dyspnea, gallop rhythm, hepato- megaly, edema, angular vein distention, positive HJR, pink tinged sputum. 4 2:2: normal QRS, changes confined to R-T or T wave 1 in addition to R-T or T wave changes, QR complexes present in one or more leads other than aVR, and :5 complexes are not present in any lead. If QR complex- es are present in lead III, they must persist on full inspiration (lead IIIR) or must be accompanied by distinct Q waves in lead II or aVF. 3 Q5 complexes in one or more leads, either with or without QR complexes in other leads, and with the usual RT/T pattern of cardiac infarction. bundle-branch block (BBB) 4 th : sinus 0 any or more of the following: atrial rib., atrial flutter, PAT, simple tachy (per- sistent 110 or)_), freq. extra systole, nodal rhythm, V tachy., or-heart block. 4 Other after A davs: none 0 shock, failure, or rhythm disturbances after 4 days (score same as category above Total Severity Score 244 APPENDIX 0 HYPOTHESES TESTING SCHEDULE AND STATISTICAL HYPOTHESES 245 "1 Statistical Evpotheses Testing Schedule 1) Ho: p30 2) 31:13.40 3) “--.10 (bidirectional alternative hypotheses) 4) Critical region: df-9 t critical - g 1.833 df-6 t critical p 3 1.943 5) Test statistic: .. . 3222:...— 111—2 1- ranks 6) Decision: if (t(>(c( Reject Ho 1: ”We; Do not reject Ho Erickson (1970, p. 262) 246 I‘C-1e 1-0-20 I‘C"3 e II’C‘10 II-C—Z. II’C‘}. II-E-TO 11.3.20 11.3.30 II—E-Sa. 247 Statistical Evpotheses There is no significant relationship between total knowledge at hospital discharge and total knowledge six weeks after hospital discharge. There is no significant relationship between knowledge of disease entity at hospital discharge and knowledge of disease entity six weeks after hospital discharge. There is no significant relationship between knowledge of total treatment regimens at hospital discharge and knowledge of total treatment regimens six weeks after hospital discharge. There is no significant relationship between total knowledge at hospital discharge and stated compliance with total treatment regimes six weeks after hospital discharge. There is no significant;relationship between knowledge of disease entity at hospital discharge and stated 2 compliance with total treatment regimens six weeks after hospital discharge. There is no significant relationship between knowledge of total treatment regimens at hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge. There is no significant relationship between total knowledge six weeks after hospital discharge and stated compliance with total treatment regimens six weeks :‘ after hospital discharge. There is no significant relationship between knowledge of disease entity six weeks after hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge. There is no significant relationship between knowledge of total treatment regimens six weeks after hospital discharge and stated compliance with total treatment regimens six weeks after hospital discharge. There is no significant relationship between knowledge of total diet six weeks after hospital discharge and stated compliance with total diet regimens six weeks after hospital discharge. APPENDIX P SCATTERGRAMS 248 TTRC TDC GDC SDC AC MC 4 Lesggd for Scattergrams Disease entity knowledge at hospital discharge Total treatment regimen knowledge at hospital discharge Total diet knowledge at hospital discharge General diet knowledge at hospital discharge Specific diet knowledge at hospital discharge Activity knowledge at hospital discharge Medication knowledge at hospital discharge Total knowledge at hospital discharge Disease entity knowledge six weeks after hospital discharge Total treatment regimen knowledge six weeks after hospital discharge Total diet knowledge six weeks after hospital discharge General diet knowledge six weeks after hospital discharge Specific diet knowledge six weeks after hospital discharge Activity knowledge six weeks after hospital discharge medication knowledge six weeks after hospital discharge Total knowledge six weeks after hospital discharge Total treatment regimen compliance Total diet compliance General diet compliance Specific diet compliance Activity compliance Medication compliance Knowledge at hospital discharge Knowledge six weeks after hospital discharge 249 m g 10 e Ranks K2 4 2 Specific Diet 1O 1O 8 ° 8 6 ' Rank 6 K0 4 3 ' b 4 2 2 e2. 1 i . ‘6 . g '16: .ank K1 Medications 1O _ 10 8- T . 8 6 n Rank 6 41? 4 2 4- O 2 dr- 0 1—2 I I1 6 11 El ) #6: Rank K O O .. O I O a o Rank K1 Activity 0 § ° : es 0 e O réh'161éq10; man: [1 Total Knowledgg O Q «POI e O r? A‘é §L1ofi Rank n Rank TDC Rank SD C Rank MC mr 8 . 6 0 Rank cm 4. 2 e 'Tz‘lfgiefifi‘ Rank TD", «.0 f 5+ ‘ T p ' Flank 6T w 0 4% 2 t O . +§"i°6%s m* Rank SD1 w E e , ° an 6 TTRC 4 O O O a e 2 :ivaraa— :a m mr ' ‘ 8 D 6 e O p 4 e 2 O ‘+Lf+ #% t‘ 2 4 6 8 1O RankGI)1 10 ° 8 . 6T : A} . 21 . ‘f‘f*é*éfh' Fank' A1 10 . O 8 0 e 61 . 4 . 2 . ' ;*,L;:f:::~1 2 4 6 8 1O RankTK 252 Knowledge and §ggttergram III 7 1 Rank Rank TTRC TTRC 10 ~ 1 8 , , ’ Rank 6 ' Rank TDC . . GDC i 2 e trrrr'fir'rfi. 2 4 6 i 10 1O 1 O 8 e 0 Rank 6 Rank SDC 0 AC 4 2 O O s s I a; ‘2 I 6 a 170' Rank SD2 1O 1O 8 . 8 Rank 6 , Rank 6 MC TTRC AI , 4 O o 0 I 2 2 *2‘555' is eo‘ Rank Compliance Six weeks After Hospital Discharge I 2 4 '6 's '10‘ Rank TTR2 [ d '2‘4'E‘s‘fiA hank GDZ Jf . 1 0 § . ' "22336 't‘ 10‘ Rank AC2 O O I O O 0 Rank T APPENDIX Q HUMAN RIGHTS PROTECTION 253 PROCEDURES TO BE USED IN THE PROJECT TO OBTAIN CONSENT AND TO SAFEGUARD THE RIGHTS AND WELFARE OF RESPONDENTS Potential Risks to Sample: There are no physical risks involved in this study, and at any point the subjects are free to withdraw. There is a possibility that the questionnaires will increase aware- ness of the subject regarding the topics identified. Therefore, all subjects are given a standardized verbal and written introduc- tion sheet, during both questionnaire sessions, that includes refer- rals to appropriate persons (a phone number is provided) so that support can be obtained and additional questions may be answered. (copy enclosed) Consent Procedures: Participation in the study is voluntary. Writ- ten consent will be obtained by this researcher after all subjects have had an opportunity to have all questions answered. They may withdraw from the study at any point. (copy enclosed) Protectinquespondents: The identity and responses of all subjects will remain confidential. Names will never be associated in dis- cussion or displayed with data. Potential Benefit of Study: This study may stimulate the subjects to increase their‘knowledge related to the topics identified and may contribute to increased patient activation. Furthermore, it may stimulate the subjects to become more compliant with identified treat- ments. Additionally, it may identify support systems in the commun— ity that are available to the subjects. The information will provide nursing with an increased understanding of the needs in relation to education of the post myocardial patient. The outcomes will be bene- ficial to future education programs. 254 BIBLIOGRAPHY 255 BIBLIOGRAPHY Alexander, J.; Fred, H.; Wright, K.; Turell, D.; Jackson, R.; and Jackson, D. 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