Illness perceptions of adults with congenital heart disease and their predictive value for quality of life two years later

Can illness representations be used to understand pain experienced in breast cancer survivorship-a cross-sectional study

BACKGROUND

Chronic pain is a recognised long-term consequence associated with breast cancer and its treatment; however, it is often underdiagnosed and undertreated. This study aims to explore the associations between illness representations, chronic cancer pain, and HRQoL in women who have survived breast cancer.

DESIGN AND METHODS

A cross-sectional online survey design was used. Data from 182 women who participated in the survey were analysed.

RESULTS

Chronic cancer pain was reported by 66% of respondents. Using the BPI-SF (score 0-10), participants were categorised into one of four pain categories: no chronic pain (BPI score 0; 34.1%), mild pain (BPI score 1-3; 35.7%), moderate pain (BPI score 4-6; 25.3%), and severe pain (BPI score 7 + ; 4.9%). The main findings were that having a strong illness identity (IPQ-R subscale which assesses the number of symptoms an individual attributes to their illness) was found to be a significant predictor of pain severity (OR 1.21 (95% CI 1.07-1.37), p = 0.003). Furthermore, HRQoL was significantly associated and predictive of pain severity (OR 0.97 (95% CI 0.95-0.99), p < 0.001). An additional finding was that not being in paid work was strongly associated with being in a higher pain category (OR 5.92 (95% CI 1.84-19.05), p = 0.003).

CONCLUSIONS

The findings of this study highlight the high prevalence of chronic cancer pain experienced by this population. Results show that dimensions of illness representations are associated with chronic cancer pain experienced by breast cancer survivors. Furthermore, having a strong illness identity and HRQoL were found to be independent, significant predictors of pain severity.

IMPLICATIONS FOR CANCER SURVIVORS

These findings demonstrate that chronic pain is an unmet clinical need experienced by breast cancer survivors, which is associated with reduced overall HRQoL. Therefore, consideration is needed regarding the assessment and management of chronic pain experienced by this population.

Psychosocial Risk Factors for Health-Related Quality of Life in Adult Congenital Heart Disease

BACKGROUND

There is variability in the impact of adult congenital heart disease (ACHD) on health-related quality of life (HRQoL). A greater insight into the impact of ACHD may be gained from investigating HRQoL in various diagnostic groups and considering the importance of psychosocial risk factors for poor HRQoL.

OBJECTIVE

We compared the HRQoL of people with ACHD with normative data from the general population and among 4 diagnostic groups and identified risk factors for poor HRQoL in ACHD from a comprehensive set of sociodemographic, clinical, and psychosocial factors.

METHODS

We conducted a cross-sectional study with 303 participants from 4 diagnostic groups Simple, Tetralogy of Fallot, Transposition of the Great Arteries, Single Ventricle who completed measures of illness perceptions, coping, social support, mood, and generic and disease-specific HRQoL. Data were analyzed using 1-sample t tests, analysis of variance, and hierarchical multiple regressions.

RESULTS

There was diminished psychosocial HRQoL in the Simple group compared with the general population. Consistently significant risk factors for poor HRQoL included younger age, a perception of more severe symptoms due to ACHD, depression, and anxiety. Clinical factors were poor predictors of HRQoL.

CONCLUSIONS

The findings highlight the need to develop intervention studies aiming to improve HRQoL in people with ACHD and the routine assessment of illness perceptions and mood problems during key periods in people's lives. This will help address patient misconceptions that could be tackled by clinicians or specialist nurses during routine outpatient appointments and identify people in need of psychological support.

How do Adults With Congenital Heart Disease Evaluate Their Clinical Care?

BACKGROUND

Almost 90% of patients with congenital heart disease (CHD) now reach adulthood. How do they evaluate the care they received?

METHODS

Adults with CHD (ACHD) recruited for an international multi-center study (APPROACH-IS II) were posed 3 additional "questions" to determine their perceptions of the positive, negative, and areas for improvement of their clinical care. The findings underwent a thematic analysis.

RESULTS

Of the 210 recruited, 183 completed the questionnaire, 147 answered the 3 "questions." Most appreciated open communication and support, a holistic approach, continuity of and readily accessible care conducted by experts, and with good outcomes. Less than half reported negative concerns which included loss of autonomy, distress from multiple and/or painful investigations, restricted lifestyles, medication side-effects, and anxiety about their CHD. Others found their reviews time-consuming with long travel times. Some complained of limited support, poor accessibility to services in rural areas, shortage of ACHD specialists, absence of tailored rehabilitation programs, and at times their own as well as their clinicians' limited understanding of their CHD. Suggestions for improvement included better communication, further education about their CHD, availability of simplified written information, mental health and support services, support groups, seamless transition to adult care and providing better prognostications, financial assistance, flexible appointments, telehealth reviews, and greater access to rural specialist care.

CONCLUSIONS

In addition to providing optimal medical and surgical care for ACHD, clinicians need to be cognizant of their patients' concerns and proactive in addressing them.

Blood transfusion in haematology: A qualitative exploration of patients' and healthcare professionals' perceptions

OBJECTIVES

Repeated blood transfusions are indicated for the management of patients with cancer or blood disorders. Patients' perceptions about transfusions may be associated with decision-making and coping, which has been under-explored in the haematology context. This study therefore aimed to explore haematology transfusion patients' and HCPs' perceptions of blood transfusion, drawing on theory and previously identified themes of transfusion perceptions.

DESIGN

Semi-structured interview study with 14 adult blood transfusion patients and 14 HCPs (consultants, registrars, nurses) at two UK haematology units.

METHODS

Patient- and HCP-tailored topic guides were developed based on themes of blood transfusion perceptions identified in a systematic review: 'Health benefits', 'Safety/risk', 'Negative emotions', 'Alternatives' 'Decision making' and 'Necessity'. Transcripts were analysed using deductive and thematic analysis. Patient and HCP themes were compared using triangulation methods. Conceptual models (one for patients, one for HCPs) specific to haematology portraying the association between themes were developed.

RESULTS

Findings for patients and HCPs converged with transfusion reported as beneficial for patients, who were largely involved in the decision-making. Both groups also reported concerns about transfusion, including iron-overload, allergic reactions and challenges to deliver transfusions in time-pressurized services. Themes in the conceptual models included patient 'Burden' of receiving repeated transfusions and 'Supportive relationships', reflective of patients' positive interactions with other patients and HCPs in the haematology unit.

CONCLUSION

Despite the challenges for patients receiving repeated transfusions, convergent perceptions suggest a shared understanding of patients' transfusion experiences. Identified challenges could inform ways to improve transfusion services and patients' experiences.

Heart Failure and Patient-Reported Outcomes in Adults With Congenital Heart Disease from 15 Countries

Background

Heart failure (HF) is the leading cause of mortality and associated with significant morbidity in adults with congenital heart disease. We sought to assess the association between HF and patient‐report outcomes in adults with congenital heart disease.

Methods and Results

As part of the APPROACH‐IS (Assessment of Patterns of Patient‐Reported Outcomes in Adults with Congenital Heart disease—International Study), we collected data on HF status and patient‐reported outcomes in 3959 patients from 15 countries across 5 continents. Patient‐report outcomes were: perceived health status (12‐item Short Form Health Survey), quality of life (Linear Analogue Scale and Satisfaction with Life Scale), sense of coherence‐13, psychological distress (Hospital Anxiety and Depression Scale), and illness perception (Brief Illness Perception Questionnaire). In this sample, 137 (3.5%) had HF at the time of investigation, 298 (7.5%) had a history of HF, and 3524 (89.0%) had no current or past episode of HF. Patients with current or past HF were older and had a higher prevalence of complex congenital heart disease, arrhythmias, implantable cardioverter‐defibrillators, other clinical comorbidities, and mood disorders than those who never had HF. Patients with HF had worse physical functioning, mental functioning, quality of life, satisfaction with life, sense of coherence, depressive symptoms, and illness perception scores. Magnitudes of differences were large for physical functioning and illness perception and moderate for mental functioning, quality of life, and depressive symptoms.

Conclusions

HF in adults with congenital heart disease is associated with poorer patient‐reported outcomes, with large effect sizes for physical functioning and illness perception.

Registration

URL: https://clinicaltrials.gov; Unique identifier: NCT02150603.

Differences in the prevalence of mental health disorders among Black American adults with sickle cell disease compared to those with non-heritable medical conditions or no medical conditions

Our aim was to determine differences in the prevalence of mental health disorders between Black Americans living with sickle cell disease (SCD) and Black Americans with other, non-heritable medical conditions, or no medical conditions. We examined the prevalence of mental health disorders among a non-institutionalized, community sample of Black adults in the US from the National Survey of American Life. We compared the odds of mental health disorders between Black American adults with SCD and those with other medical conditions, or no medical condition. Among the SCD group, 38·8% reported at least one mental health disorder: 17·6% endorsed a mood disorder, 24·7% an anxiety disorder, 2·4% an eating disorder, and 11·8% a childhood disorder. Compared to those with other medical conditions, Black Americans with SCD had greater poverty, more children in the household, and were less likely to be married/cohabitating (all P < 0·05). Yet, Black Americans with SCD were not at greater odds of having a mental health disorder compared to those with other medical conditions. When compared to the group with no conditions, however, individuals with SCD had 2·57 greater odds of mood disorder (95% confidence interval: 1·43-4·65; P = 0·002). The effect remained when controlling for socioeconomic status, marital status, and perceived physical health. In this study, almost 40% of Black American adults with SCD presented with a mental health disorder. Prevalence of mental health disorders was similar among those with non-heritable medical conditions, but those without a medical condition had a lower prevalence than in SCD. Among Black Americans, there appear to be unmeasured factors, common across medical conditions, that are linked to mental health disorders.

Atrial fibrillation, quality of life and distress: a cluster analysis of cognitive and behavioural responses

Purpose

Few studies have examined specific cognitive and behavioural responses to symptoms, which may impact health-related outcomes, in conjunction with illness representations, as outlined by the Common-Sense-Model. Patients with atrial fibrillation (AF) report poor quality-of-life (QoL) and high distress. This cross-sectional study investigated patterns/clusters of cognitive and behavioural responses to illness, and illness perceptions, and relationships with QoL, depression and anxiety.

Methods

AF patients (N = 198) recruited at cardiology clinics completed the AF-Revised Illness Perception Questionnaire, Atrial-Fibrillation-Effect-on-Quality-of-Life Questionnaire, Patient Health Questionnaire-8 and Generalized Anxiety Disorder Questionnaire. Cluster analysis used Ward’s and K-means methods. Hierarchical regressions examined relationships between clusters with QoL, depression and anxiety.

Results

Two clusters of cognitive and behavioural responses to symptoms were outlined; (1) ‘high avoidance’; (2) ‘low symptom-focussing’. Patients in Cluster 1 had lower QoL (M = 40.36, SD = 18.40), greater symptoms of depression (M = 7.20, SD = 5.71) and greater symptoms of anxiety (M = 5.70, SD = 5.90) compared to patients in Cluster 2 who had higher QoL (M = 59.03, SD = 20.12), fewer symptoms of depression (M = 3.53, SD = 3.56) and fewer symptoms of anxiety (M = 2.56, SD = 3.56).

Two illness representation clusters were outlined; (1) ‘high coherence and treatment control’, (2) ‘negative illness and emotional representations’. Patients in Cluster 2 had significantly lower QoL (M = 46.57, SD = 19.94), greater symptoms of depression (M = 6.12, SD = 5.31) and greater symptoms of anxiety (M = 4.70, SD = 5.27), compared with patients in Cluster 1 who had higher QoL (M = 61.52, SD = 21.38), fewer symptoms of depression (M = 2.85, SD = 2.97) and fewer symptoms of anxiety (M = 2.16, SD = 3.63).

Overall, clusters of cognitive and behavioural responses to symptoms, and illness perceptions significantly explained between 14 and 29% of the variance in QoL, depression and anxiety.

Conclusion

Patterns of cognitive and behavioural responses to symptoms, and illness perceptions are important correlates of health-related outcomes in AF patients.

Development and validation of the scoliosis misconception scale (SMS) for assessing level of misconception of patients with adolescent idiopathic scoliosis

BACKGROUND

Little is known about patients' understanding of adolescent idiopathic scoliosis (AIS). This paper aims to develop and validate the Scoliosis Misconception Scale (SMS) and to explore patients' level of misconception about AIS.

METHODS

A total of 195 patients who were newly referred with newly diagnosed AIS were recruited to assess their levels of misconception and psychological distress before and after their first consultation with a specialist. The 17-item SMS was administered to assess patients' level of misconception about AIS and the Kessler Psychological Distress Scale (K10) was used to measure their level of distress.

RESULTS

According to the Item Response Theory, all items were within the acceptable range from -3.69 to 2.39 for difficulty parameters, which determined the difficulty of the scale, while most of the items were within the acceptable range from 0.11 to 1.54 for the discrimination parameters, which determined the rate at which the probability of endorsing a correct item changes given ability levels. Internal consistency by marginal reliability was 0.66. One-sample t test revealed that participants on average scored 6.79 (SD = 2.12) before the first clinic session and 6.45 (SD = 2.51) after the first clinic session, both significantly higher than 0 [t(75) = 27.86, p < .001; t(75) = 22.43, p < .001].

CONCLUSIONS

Despite a longstanding clinical model that functions well to treat AIS, most patients still have significant misconceptions about the condition. This highlights the necessity to assess patients' knowledge level of a medical condition and potential generalisability of misconception-distress link to the forefront across other illnesses.

Psychological well-being and illness perceptions in patients with hypopituitarism

OBJECTIVE

The primary aim of the current study was to objectify a spectrum of persisting subjective psychological complaints in patients with hypopituitarism, at least six months after normalizing of the hormonal disturbances. Also, gender differences on these outcomes were investigated. The secondary aim was to identify illness perceptions and causal attributions within this patient group.

METHODS

A total of 42 adult participants (60% females) with treated hypopituitarism once filled out a number of psychological questionnaires. The Profile of Mood States (POMS) and the Hospital Anxiety and Depression Scale (HADS) assessed mood and the Symptom Checklist-90 (SCL-90) and the Work and Social Adjustment Scale (WSAS) assessed well-being. Illness perceptions were identified using the Illness Perceptions Questionnaire-Brief Dutch Language Version (IPQ-B DLV) and causal attributions by using the Causal Attribution List (CAL). Patient outcomes were compared to reference values of healthy norm groups.

RESULTS

Participants scored significantly worse on the POMS depression, anger, fatigue and tension subscales, the SCL-90 psychoneuroticism, depression, inadequacy of thinking and acting and sleeping problems subscales and all subscales of the WSAS when compared to reference data. Women also scored worse on depression (HADS) and somatic symptoms (SCL-90). Compared to other illnesses, patients with hypopituitarism have more negative and realistic illness perceptions on consequences, timeline, identity and emotions. Participants attributed their complaints more to physical causes than psychological causes.

CONCLUSION

Despite normalization of hormonal disturbances, patients with hypopituitarism in general can still experience problems during daily living, such as negative mood states and a decreased psychological well-being.

Phenotypes of adults with congenital heart disease around the globe: a cluster analysis

OBJECTIVE

To derive cluster analysis-based groupings for adults with congenital heart disease (ACHD) when it comes to perceived health, psychological functioning, health behaviours and quality of life (QoL).

METHODS

This study was part of a larger worldwide multicentre study called APPROACH-IS; a cross sectional study which recruited 4028 patients (2013-2015) from 15 participating countries. A hierarchical cluster analysis was performed using Ward's method in order to group patients with similar psychological characteristics, which were defined by taking into consideration the scores of the following tests: Sense Of Coherence, Health Behavior Scale (physical exercise score), Hospital Anxiety Depression Scale, Illness Perception Questionnaire, Satisfaction with Life Scale and the Visual Analogue Scale scores of the EQ-5D perceived health scale and a linear analogue scale (0-100) measuring QoL.

RESULTS

3768 patients with complete data were divided into 3 clusters. The first and second clusters represented 89.6% of patients in the analysis who reported a good health perception, QoL, psychological functioning and the greatest amount of exercise. Patients in the third cluster reported substantially lower scores in all PROs. This cluster was characterised by a significantly higher proportion of females, a higher average age the lowest education level, more complex forms of congenital heart disease and more medical comorbidities.

CONCLUSIONS

This study suggests that certain demographic and clinical characteristics may be linked to less favourable health perception, quality of life, psychological functioning, and health behaviours in ACHD. This information may be used to improve psychosocial screening and the timely provision of psychosocial care.

Genetic Variations and Health-Related Quality of Life (HRQOL): A Genome-Wide Study Approach

Simple Summary

Health-related quality of life (HRQOL) is associated with cancer prognosis as well as with age, sex, race, and lifestyle factors, including diet and physical activity. To investigate the hypothesis that HRQOL has genetic underpinnings in patients with cancer, we performed a genome-wide association study to evaluate genetic variants (single nucleotide polymorphisms, SNPs) associated with mental and physical QOL as measured by the PROMIS assessment tool in breast cancer survivors participating in a longitudinal cohort study, the Mayo Clinic Breast Disease Registry (MCBDR). Age and financial concerns were associated with worse physical and mental health, and previous receipt of chemotherapy was associated with worse mental health. SNPs in SCN10A, LMX1B, SGCD, PARP12, and SEMA5A were associated with physical and mental QOL, but none at the genome-wide significance thresholds of p < 5 × 10⁻⁸.

Abstract

Health-related quality of life (HRQOL) is an important prognostic patient-reported outcome in oncology. Because prior studies suggest that HRQOL is, in part, heritable, we performed a GWAS to elucidate genetic factors associated with HRQOL in breast cancer survivors. Physical and mental HRQOL were measured via paper surveys that included the PROMIS-10 physical and mental health domain scales in 1442 breast cancer survivors participating in the Mayo Clinic Breast Disease Registry (MCBDR). In multivariable regression analyses, age and financial concerns were significantly associated with global physical health (age: p = 1.6 × 10⁻²³; financial concerns: p = 4.8 × 10⁻⁴⁰) and mental health (age: p = 3.5 × 10⁻⁷; financial concerns: p = 2.0 × 10⁻⁶⁹⁾. Chemotherapy was associated with worse global mental health (p = 0.01). In the GWAS, none of the SNPs reached the genome-wide association significance threshold of 5 × 10⁻⁸ for associations with either global physical or global mental health, however, a cluster of SNPs in SCN10A, particularly rs112718371, appeared to be linked to worse global physical health (p = 5.21 × 10⁻⁸). Additionally, SNPs in LMX1B, SGCD, PARP12 and SEMA5A were also moderately associated with worse physical and mental health (p < 10⁻⁶). These biologically plausible candidate SNPs warrant further study as possible predictors of HRQOL.

Comparison of Health-Related Quality of Life in Adults Undergoing Transthoracic and Transcatheter Device Closure for Ventricular Septal Defects

This study aims to compare and analyze the health-related quality of life (HRQoL) of adult patients with ventricular septal defects (VSDs) who underwent transthoracic or transcatheter device closure.The HRQoL data of 30 patients who underwent transthoracic device closure for VSDs and 30 who underwent transcatheter device closure for VSDs were retrospectively evaluated before and one year after the procedure. The Medical Outcomes Study 36-Item Short-Form (SF-36), the Hospital Anxiety and Depression Scale (HADS), and a self-designed questionnaire were used as evaluation tools.After treatment, both groups showed significant improvements in SF-36 and HADS scores. After comparing the two groups regarding the SF-36, there was a significant difference in the two dimensions of vitality and mental health. There were no statistically significant differences in the HADS-A and HADS-D scores between these two groups. The results of the self-designed questionnaire also showed that the subjective feedback of the two groups was roughly the same. In the process of exploring the influential factors, we found that the scores of patients on most dimensions of the SF-36 in the two groups showed a significantly negative trend with increasing age. In terms of HADS scores, patients in both groups showed a tendency toward increasing scores with age.The HRQoL of adult patients undergoing transthoracic and transcatheter device closure for VSDs was similar, and the HRQoL was affected by the patient's own condition, so it is necessary to pay more attention to patients after device closure.

Health-related quality of life in adult CHD surgical patients in a low middle-income country: a mixed-methods study

BACKGROUND AND OBJECTIVES

This mixed-methods study aimed to assess health-related quality of life in young adults with CHD following surgery in a low middle-income country, Pakistan. Despite the knowledge that geographic, cultural and socio-economic factors may shape the way health and illness is experienced and managed and consequently determine a person's health-related quality of life, few health-related quality of life studies are conducted in low middle-income countries. This deficit is pronounced in CHD, so there is little guidance for patient care.

METHODS

The study utilised concurrent, mixed methods. Adults with CHD (n = 59) completed health-related quality of life surveys (PedsQLTM 4.0 Generic Core Scale, PedsQLTM Cognitive Functioning Scale and PedsQLTM 3.0 Cardiac Module). Semi-structured interview data were collected from a nested sub-sample of 17 participants and analysed using qualitative content analysis, guided by the revised Wilson-Cleary model of health-related quality of life.

RESULTS

The lowest health-related quality of life domain was emotional with the mean score (71.61 ± 20.6), followed by physical (78.81 ± 21.18) and heart problem (79.41 ± 18.05). There was no statistical difference in general or cardiac-specific health-related quality of life between mild, moderate or complex CHD. Qualitative findings suggested low health-related quality of life arose from a reduced capacity to contribute to family life including family income and gender. A sense of reduced marriageability and fear of dependency were important socio-cultural considerations.

CONCLUSIONS

CHD surgical patients in this low-income country experience poor health-related quality of life, and contributing factors differ to those reported for high-income countries. Socio-cultural understandings should underpin assessment, management and care-partnering with young adults with CHD following surgical correction.

Negative illness perceptions are related to poorer health-related quality of life among thyroid cancer survivors: Results from the PROFILES registry

BACKGROUND

Differentiated thyroid cancer (DTC) reports a poorer health-related quality of life (HRQoL) than a norm population. Patients' illness perceptions are modifiable and known associates of HRQoL in other cancers. The aim was to examine the relationship between illness perceptions and HRQoL among DTC survivors.

METHODS

DTC survivors registered in the Netherlands Cancer Registry diagnosed between 1990 and 2008, received a survey on illness perceptions (Brief-Illness Perception Questionnaire; B-IPQ) and HRQoL (European Organisation for Research and Treatment of Cancer, Quality of Life Questionnaire-Core 30; EORTC QLQ-C30). Multiple regression analyses were conducted investigating the relation between illness perceptions and HRQoL, while controlling for sociodemographic and clinical characteristics.

RESULTS

Two hundred and eighty-four DTC survivors were included. DTC survivors who believed their illness had many negative consequences; who perceived their illness as controllable by treatment; who had strong beliefs symptoms could be attributed to their illness; and who had strong beliefs their illness causes negative emotions, reported a poorer HRQoL.

CONCLUSIONS

Stronger negative illness perceptions are related to a poorer HRQoL among DTC survivors.

Complex Determinants of Work Ability in Adults With Congenital Heart Disease and Implications for Clinical Practice

BACKGROUND

"Work ability" is the employees' capacity to meet the demands of their job. As more patients with complex congenital heart disease (CHD) are now reaching adulthood, we assessed work ability and factors impacting livelihood in adult CHD.

METHODS

The work ability index (WAI) questionnaire and patient health questionnaire-9 (PHQ-9) were administered at 2 Midwest adult CHD centres from February 2017 to 2018.

RESULTS

Of the 267 participants (n = 157 males, 59%) with an average age of 35 ± 13 years, the majority (n = 204, 76%) were employed. Patients with complex CHD (n = 103, 39%) were less likely to have enrolled in college or completed a graduate degree (P = 0.0115), and more likely to have an annual income of < $50,000 (P = 0.0056) and lower WAI scores (P = 0.0026) than patients with simple and moderate CHD. Unemployed patients (n = 63, 24%) with complex CHD (n = 27, 43%) were more likely to have higher PHQ-9 scores (P = 0.0242) indicating mild, moderate, or severe depression (P = 0.0482) than unemployed patients with simple and moderate CHD. Patients with complex CHD had lower self-perception of work ability compared with patients with simple and moderate CHD (P = 0.0007). Finally, patients in NYHA Functional Class I had higher WAI scores than NYHA Class III-IV (P < 0.0001).

CONCLUSIONS

This study demonstrates that employed patients with complex CHD have lower education level, income, and work ability. Unemployed patients are more likely to exhibit symptoms of depression and have low self-perception of work ability. Occupational health programs focusing on promoting general health perception, increasing exercise capacity, and improving psychosocial health must be considered to improve work ability in patients with adult CHD to maintain livelihood.

Quality-of-life research in adult patients with congenital heart disease: current status and the way forward

Over the past four decades, the number of papers on quality of life (QoL) in congenital heart disease (CHD) has grown exponentially. However, firm conclusions have been hard to draw, because conceptual issues occurred and methodological differences prevented direct comparisons of studies. In general, QoL in CHD patients is good and it can be even better than in healthy peers when measured as life satisfaction. When QoL is measured as physical functioning, patients with complex CHD do worse than patients with moderate or mild defects or healthy individuals. APPROACH-IS was a large-scale international project that confirmed international variations in QoL, with Australian patients reporting the best QoL. Poor QoL was predicted by older age, being a job seeker, unemployed or disabled, never having married and those with worse functional status. Perceived illness and religion and spirituality were also significant predictors for QoL. On the other hand, country-specific characteristics and healthcare system factors did not play a significant role in explaining variances in QoL of patients with CHD around the globe. Future studies should rely on a sound conceptual basis, use longitudinal research designs, be conducted in international, multi-centre settings and evaluate interventions that promote patients' QoL.

Perception of illness among patients with heart failure is related to their general health independently of their mood and functional capacity

Purpose

To explore the relationship between illness perceptions and self-reported general health of patients with chronic heart disease, using some core elements from the Common Sense Model.

Methods

Patients with heart failure (New York Heart Association [NYHA] Functional Class I-III) from five outpatient clinics in Eastern Norway were invited to participate in this cross-sectional study. Two research nurses collected socio-demographic data (age, sex, education and work status) and standardized questionnaires in structured interviews. Patients’ self-reported general health was measured with the Euro-Qual Visual Analogue Scale (EQ-VAS), illness perceptions were measured with the 8-item Brief Illness Perception Questionnaire (BIPQ), and mood was assessed using the Hospital Anxiety and Depression Scale.

Results

Among the 220 patients who were recruited into this study (98% response rate), the mean age was 67.5 years (SD ± 12.5), and 65.9% were men. Patients were classified as NYHA Class I (8.7% with no activity limitations), Class II (47.6% with slight limitations), or Class III (43.8% with marked limitations). Mean EQ-VAS score was 58.8 (SD ± 21.0). Three of the eight perception of illness items (consequences, personal control and identity) were associated with the patients’ general health rating, controlling for their NYHA Class, mood and other BIPQ items.

Conclusions

Our findings suggest that patients’ perceptions of their illness have an independent and substantial relationship to the self-rated general health of patients with chronic heart failure. Peoples’ illness perceptions are beliefs that have been shown to be modifiable in clinical interventions. Thus, targeted interventions aimed to modify these, such as patient education courses, ought to be developed and tested, as they may be helpful for improving perceived health status.

Illness perceptions in adolescents with chronic fatigue syndrome and other physical health conditions: Application of the common sense model

BACKGROUND

The common sense model (CSM) proposes that illness perceptions guide coping and illness management, which subsequently affects outcomes. Chronic fatigue syndrome (CFS) is associated with severe functional impairment. CFS is distinct from other physical health conditions in that individuals can experience high levels of uncertainty, stigma and disbelief from others. This study aimed to compare illness perceptions in adolescents with CFS with other physical health conditions, using a cross-sectional, between-groups design.

METHODS

Adolescents (aged 11-18) with CFS (n = 49), type 1 diabetes (n = 52) and juvenile idiopathic arthritis (n = 42) were recruited through National Health Service (NHS) clinics and online, and completed a series of questionnaires.

RESULTS

Adolescents with CFS differed on the perceived consequences, timeline, personal control, treatment control, identity and understanding dimensions of illness perceptions. Except for identity, these dimensions were predicted by health condition even when accounting for age, gender, fatigue, physical functioning, anxiety and depression.

CONCLUSIONS

Results offer preliminary evidence for the applicability of the CSM in adolescents, with implications for supporting adolescents with physical health conditions. Results suggest that psychological interventions targeting perceived control, understanding and identity may have particular utility for adolescents with CFS.

First real-world experience with mobile health telemonitoring in adult patients with congenital heart disease

BACKGROUND

Arrhythmias and heart failure are common and invalidating sequelae in adult patients with congenital heart disease (CHD). Mobile health (m-Health) enables daily monitoring and a timely response that might prevent deterioration. We present an observational prospective registry to evaluate feasibility of an m‑Health telemonitoring program for managing arrhythmia, heart failure and blood pressure in symptomatic adults with CHD.

METHODS

Symptomatic adult patients with CHD are enrolled in an m‑Health telemonitoring program, which evaluates single-lead ECG, blood pressure and weight measurements. In case of symptoms extra measurements could be performed. Data are collected by mobile apps, matched with individualised thresholds. Patients are contacted if thresholds were exceeded or if arrhythmias were found, for treatment adjustments or reassurance. Data on emergency care utilisation, hospitalisation and patient-reported outcome measures are used to assess quality of life and self-management.

RESULTS

129 symptomatic CHD patients were invited to participate, 55 participated. Reasons for refusing consent included too time consuming to participate in research (30) and to monitor vital signs (14). At baseline 22 patients were in New York Heart Association class ≥ II heart failure, 43 patients had palpitations or documented arrhythmias, and 8 had hypertension. Mean follow-up was 3.0 months, one patient dropped out, and adherence was 97%.

CONCLUSION

The first results indicate that this program is feasible with high adherence.

A multinational observational investigation of illness perceptions and quality of life among patients with a Fontan circulation

OBJECTIVE

First, to compare QOL and illness perceptions between patients with a Fontan circulation and patients with anatomically simple defects (ie, atrial septal defects [ASD] or ventricular septal defects [VSD]). Second, to explore illness perceptions as a mediator of the association between congenital heart disease (CHD) diagnosis and QOL.

DESIGN

Cross-sectional observational study.

SETTING

Twenty-four cardiology centers from 15 countries across five continents.

PATIENTS

Four hundred thirty-five adult patients with congenital heart disease (177 Fontan and 258 ASD/VSD) ages 18-83 years.

OUTCOME MEASURES

QOL and illness perceptions were assessed by the Satisfaction With Life Scale and the Brief Illness Perceptions Questionnaire, respectively.

RESULTS

Patients with a Fontan circulation reported lower QOL (Wald Z = -3.59, p = <.001) and more negative perceptions of their CHD (Wald Z = -7.66, p < .001) compared with patients with ASD/VSD. After controlling for demographics, anxiety, depressive symptoms, and New York Heart Association functional class, path analyses revealed a significant mediation model, αβ = 0.15, p = .002, 95% CI = 0.06-0.25, such that CHD diagnosis was indirectly related to QOL through illness perceptions.

CONCLUSIONS

The Fontan sample's more negative perceptions of CHD were likely a reflection of life with a more complex defect. Illness perceptions appear to account for unique differences in QOL between groups of varying CHD complexity. Psychosocial screening and interventions may be important treatment components for patients with CHD, particularly those with Fontan circulations.

Health condition and familial factors associated with health-related quality of life in adolescents with congenital heart disease: a cross sectional study

Background

The focus of clinical care after the repair of congenital heart disease has shifted from saving life of the patient to the patient’s quality of life. The purpose of this study was to examine the health condition and familial factors associated with the health related quality of life of adolescents with congenital heart disease.

Methods

Ninety-eight adolescents aged 13–19 years were collected from a congenital heart clinic from July 22 to August 23, 2013. Perceptions of parental rearing behaviors, health related quality of life of adolescent with congenital heart disease, and general characteristics were measured. We used multiple linear regression analysis to explore factors that are associated with the health related quality of life of adolescents with congenital heart disease.

Results

New York heart association class (Adj R² = .186, p = .000), presence of siblings (Adj R² = .240, p = .010), and mother’s emotional warmth (Adj R² = .265, p = .043) were significantly associated with the health related quality of life of adolescents with congenital heart disease.

Conclusions

Emotionally warm parental rearing behaviors and the presence of siblings were important familial factors that were positively associated with HRQOL in adolescents with CHD. Therefore, it is important for healthcare providers to develop a greater sensitivity to, and awareness of, the familial influences that may be impacting a subject’s HRQOL, as well as the exigencies of the CHD, itself.

Nurses' Perceptions of Quality of Life for Adolescents with Congenital Heart Disease

The purpose of this study was to understand nurses' perceptions and experiences regarding Quality of Life (QOL) of adolescents with complex congenital heart disease (CHD). Interpretive, hermeneutic, phenomenology was used to explore the perceptions and experiences of nurses who care for adolescents with complex CHD. The participants included 6 female registered nurses with experience taking care of adolescents with complex CHD. Data were collected using semi-structured interviews. Data analysis revealed 4 themes: QOL depends on how the psychological and social issues are interwoven with the physical; finding that balance between overprotection and too much freedom; setting goals to envision a future; and not being defined by a CHD. These results indicate that understanding nurses' perspectives and experiences may contribute to effective guidance for adolescents with complex CHD transitioning into adulthood.

[The Relationships among Perceived Parental Bonding, Illness Perception, and Anxiety in Adult Patients with Congenital Heart Diseases]

PURPOSE

The purposes of this study were to identify the relationships among perceived parental bonding, illness perception, and anxiety and to determine the influences of perceived parental bonding and illness perception on anxiety in adult patients with congenital heart diseases.

METHODS

In this study a descriptive correlational design with survey method was utilized. The participants were 143 adult patients with congenital heart disease being cared for in the cardiology out-patient clinic of A medical center. Data were collected using the Parental Bonding Instrument, Illness Perception Questionnaire Revised Scale, and Cardiac Anxiety Questionnaire Scale. Data were analyzed using descriptive statistics, independent t-test, one-way ANOVA, Pearson correlation analysis, and hierarchial regression analyses.

RESULTS

There showed significant positive relationships of anxiety with maternal overprotection, consequences, and personal control respectively. Among predictors, maternal overprotection (β=.45), consequence (β=.26), and personal control (β=-.03) had statistically significant influence on anxiety.

CONCLUSION

Nursing interventions to decrease maternal overprotection and negative consequence, and to enhance personal control are essential to decrease the anxiety of adult patients with congenital heart diseases.

Differences Across Illness Perceptions in Inflammatory Bowel Disease and Their Relationships to Psychological Distress and Quality of Life

Patients with greater inflammatory bowel disease activity readily identify poorer psychosocial outcomes; however, the role of gender, disease type, and individual illness perceptions facets are less well known. This study aimed to characterize the role of illness perceptions, gender, and disease type on anxiety, depression, and quality of life. Eighty-one patients diagnosed with inflammatory bowel disease (39 men, mean age 35 years) attending a tertiary hospital outpatient clinic were studied. Questionnaires used included the Manitoba Index, the Brief Illness Perceptions Questionnaire, Hospital Anxiety and Depression Scale, and the World Health Organization Brief Quality of Life Scale. Female patients with active disease tended to report increased anxiety, depression, and reduced quality of life. Regarding illness perceptions, patients with Crohn disease reported significantly more concerns about its chronicity, while female patients reported being significantly more concerned about the impact of their illness on identity, chronicity, overall concern, and having a greater emotional impact. Hierarchical regression indicated that 36% of depression, 42% of anxiety, and 57% of quality of life could be accounted for by disease activity and type, gender, and illness perceptions. The findings suggest that in addition to a patient's perceived disease status, gastroenterology nurses should also be aware that patient gender and their perceptions of illness play a significant impact not only on anxiety and depression but also on quality of life. Increased disease activity is associated with more severe anxiety and depression and reduced quality of life. Female patients are also at a greater risk of reporting negative illness perceptions and increased levels of anxiety, depression, and lower quality of life.

Quality of life among elderly patients undergoing transcatheter or surgical aortic valve replacement- a model-based longitudinal data analysis

Background

Quality of life (QoL) measurements reported in observational studies are often biased, since patients who failed to improve are more likely to be unable to respond due to death or impairment. In order to observe the development of QoL in patients close to death, we analyzed a set of monthly QoL measurements for a cohort of elderly patients treated for aortic valve stenosis (AS) with special consideration of the effect of distance to death.

Methods

QoL in 169 elderly patients (age ≥ 75 years), treated either with transcatheter aortic valve replacement (TAVR; n = 92), surgical aortic-valve replacement (n = 70), or drug-based therapy (n = 7), was evaluated using the standardized EQ-5D questionnaire. Over a two-year period, patients were consulted using monthly telephone interviews or outpatient visits, leading to a total of 2463 time points at which QoL values, New York Heart Association (NYHA) Functional Classification and their status of assistance were assessed. Furthermore, post-procedural clinical events and complications were monitored. Linear and ordered logistic regression analyses with random intercept were carried out, taking into account overall trends and distance to death.

Results

QoL measures decreased slightly over time, were temporarily impaired at month 1 after the initial episode of hospitalization and decreased substantially at the end of life with a measurable effect starting at the sixth from last follow-up (month) before death. Many clinical complications (bleeding complications, stroke, acute kidney injury) showed an impairment of QoL measurements, but the inclusion of lagged variables demonstrated medium term (three months) QoL impairments for access site bleeding only. All other complications are associated with event-related impairments that decreased dramatically at the second and third follow-up interviews (month) after event.

Conclusions

Distance to death shows clear effects on QoL and should be taken into account when analyzing QoL measures in the elderly patients treated for aortic valve stenosis.

Trial registration

German Clinical Trial Register Nr. DRKS00000797

Parental perception of functional status and impact on the family of children with congenital heart surgery

AIMS

To assess the functional status and the family impact of children with congenital heart defects (CHD), using the parental Functional Status II (FS-II) and the Impact on Family (IOF) questionnaires.

METHODS

In this prospective observational study, parents of children who underwent surgery for CHD during the first year of life completed the FS-II and the IOF questionnaires. Genetic syndromes and prematurity <32weeks were exclusion criteria. The FS-II generates a total score and age specific general health (GH), activity (A) and, responsiveness (R) subscales. The IOF generates a total scale and financial and sibling subscales.

RESULTS

Our cohort (n=100), comprised 54% males; the median (IQR) age was 32 (10-56) months. Eighteen children had age-specific scores in the 1-2 SD below mean range (n=17) or more than 2 SD below the mean (n=1) for "ill children". There were significant negative correlations between the total FS-II and total IOF (r=-0.35, p<0.001) and financial IOF (r=-0.35, p<0.001). RACHS-1 category of CHD 4-6 was associated with higher likelihood of lower functional status.

CONCLUSIONS

More complex CHD was associated with lower functional status, which correlated with a greater impact on the families. Parental questionnaires may be useful instruments for developmental surveillance in this population.

Identificação de transtornos traumáticos cumulativos em portuários para o raciocínio clínico

Resumo Objetivo Relacionar os transtornos traumáticos cumulativos autorreferidos por trabalhadores portuários e seus condicionantes socioambientais. Métodos Estudo transversal com 232 portuários (136 em terra e 96 a bordo) com média de idade de 48,7 anos. Os transtornos traumáticos cumulativos foram autorreferidos; a intensidade foi medida pela atribuição de uma nota de 1 a 4. Foi realizada análise do coeficiente de Spearman para relacionar intensidade dos transtornos e variáveis de caracterização, e teste qui quadrado de Pearson foi usado para relacionar grupos de trabalhadores aos transtornos. Resultados Ambas as categorias de portuários destacaram lombocitalgias (36,8% em terra e 28,1% a bordo) e tendinite (27,9% em terra e 31,3% a bordo de navio). Houve correlação estatística entre a idade e tempo de trabalho com a intensidade dos adoecimentos. Conclusão A autorreferência de adoecimentos ressaltou doenças lombares e tendinosas que inferiram causalidade às doenças autorreferidas, cuja clínica deve integrar o processamento do raciocínio clínico da enfermagem.

Adult Congenital Heart Disease Patients Experience Similar Symptoms of Disease Activity

BACKGROUND

There is a lack of objective data on the symptoms characterizing disease activity among adults with congenital heart disease (ACHD). The purpose of this study was to elicit the most important symptoms from patients across the spectrum of ACHD and to examine whether reported symptoms were similar across the spectrum of ACHD as a foundation for creating a patient-reported outcome measure(s).

METHODS AND RESULTS

We constructed a 39-item survey using input from physicians specializing in ACHD to assess the symptoms patients associate with disease activity. Patients (n=124) prospectively completed this survey, and the results were analyzed based on underlying anatomy and disease complexity. A confirmatory cohort of patients (n=40) was then recruited prospectively to confirm the validity of the initial data. When grouped based on underlying anatomy, significant differences in disease-related symptom rankings were found for only 6 of 39 symptoms. Six symptoms were identified which were of particular significance to patients, regardless of underlying anatomy. Patients with anatomy of great complexity experienced greater overall symptom severity than those with anatomy of low or moderate complexity, attributable exclusively to higher ranking of 5 symptoms. The second patient cohort had symptom experiences similar to those of the initial cohort, differing in only 5 of 39 symptoms.

CONCLUSIONS

This study identified 6 symptoms relevant to patients across the spectrum of ACHD and remarkable homogeneity of patient experience, suggesting that a single disease-specific patient-reported outcome can be created for quality and outcome assessments.

The impact of illness perceptions and disease severity on quality of life in congenital heart disease

BACKGROUND

Despite an increasing prevalence of adults living with a CHD, little is known about the psychosocial impact of CHD. We sought to investigate the relative impact of disease severity and patients' perceptions about their condition on depression, anxiety, and quality of life over a period of a year.

METHODS

A total of 110 patients aged over 16 years completed an initial questionnaire containing measures for anxiety, depression, quality of life, and illness perceptions when they attended the Adult Congenital Heart Disease Clinic. Cardiologists rated the patients' disease severity and illness course. A year later, patients were invited to complete the same measures. Regression analyses were performed to determine the relative impact of illness perceptions and disease severity on psychological outcomes a year later.

RESULTS

At baseline, 23% of the study population had depressive symptoms and 30% had elevated trait anxiety. After controlling for associations with disease-related variables, illness perceptions explained 28% of the variance in depression, 40% anxiety, and 27% overall quality of life at baseline. Baseline illness perceptions bivariately predicted quality of life, cardiac anxiety, and depression 1 year later, and regression analyses controlling for other factors showed that they were significant predictors of outcomes 1 year later.

CONCLUSION

Symptoms of depression and anxiety are common among adults with CHD. Patients' illness perceptions are related to psychological outcomes, especially cross-sectionally. Future research could investigate whether an intervention to discuss patients' perceptions about their CHD can improve mental health and quality of life.

In Search for the Genetic Basis of Quality of Life in Healthy Swedish Women--A GWAS Study Using the iCOGS Custom Genotyping Array

BACKGROUND

Quality of life (QoL) is increasingly measured in both research and clinical practice. QoL-assessments are built on a long, empirically-based, and stringent approach. There is ample evidence that QoL is, in part, heritable. We therefore performed a GWAS relating genetic variation to QoL in healthy females.

METHODS

In 5,142 healthy females, background characteristics (e.g. demographic, clinical, lifestyle and psychological factors) and QoL by means of the EORTC QLQ-C30 were measured. Moreover, women were genotyped using a custom array including ~210,000 single nucleotide polymorphisms (SNPs). Initially, SNPs were related to each QoL-domain, by means of partially adjusted (controlling for age and population stratification) and fully adjusted (controlling for age, population stratification, and background characteristics) regression analyses. Additionally, gene-based analyses were performed relating the combined effect of SNPs within each gene to QoL using the statistical software package VEGAS.

RESULTS

None of the associations between QoL and genetic variation (i.e. individual SNPs and genes) reached the bonferroni corrected significance level.

CONCLUSION

Reasons for a lack of association between genetic markers and QoL could be low variation in QoL-scores; selecting genetic markers not tagging QoL; or that the genetic effect that impacts one's QoL is mediated through biological pathways rather than the effect of single SNPs or genes. Therefore, we opt for a pathway-based or system biology approach as a complementary and powerful approach to analyze the combined effect of genes and their biological implications in future studies focusing on QoL-issues.

Illness perceptions within 6 months of cancer diagnosis are an independent prospective predictor of health-related quality of life 15 months post-diagnosis

OBJECTIVE

Studies have found that illness perceptions explain significant variance in health outcomes in numerous diseases. However, most of the research is cross-sectional and non-oncological. We examined, for the first time in breast, colorectal and prostate cancer patients, if cognitive and emotional illness perceptions near diagnosis predict future multidimensional health-related quality of life (HRQoL).

METHODS

UK-based patients (N = 334) completed the illness perception questionnaire-revised within 6 months post-diagnosis and the quality of life in adult cancer survivors scale 15 months post-diagnosis. Sociodemographic and clinical data were obtained from medical records. Hierarchical multiple regression analyses were conducted.

RESULTS

The sociodemographic and clinical factors collectively significantly predicted 8/12 HRQoL domains, although for 5/8 accounted for <10% of the variance. For all 12 HRQoL domains, illness perceptions collectively explained significant substantial additional variance (∆R(2) range: 5.6-27.9%), and a single illness perception questionnaire-revised dimension was the best individual predictor of 9/12 HRQoL domains. The consequences dimension independently predicted 7/12 HRQoL domains; patients who believed their cancer would have a more serious negative impact on their life reported poorer future HRQoL. The emotional representations and identity dimensions also predicted multiple HRQoL domains.

CONCLUSIONS

Future research should focus on realising the potential of illness perceptions as a modifiable target for and mediating mechanism of interventions to improve patients' HRQoL.

The genetic basis of quality of life in healthy Swedish women: a candidate gene approach

BACKGROUND

Quality of life (QoL) is an increasingly important parameter in clinical practice as it predicts mortality and poor health outcomes. It is hypothesized that one may have a genetic predisposition for QoL. We therefore related 139 candidate genes, selected through a literature search, to QoL in healthy females.

METHODS

In 5,142 healthy females, background characteristics (i.e. demographic, clinical, lifestyle, and psychological factors) were assessed. QoL was measured by the EORTC QLQ-C30, which consists of 15 domains. For all women genotype information was available. For each candidate gene, single nucleotide polymorphisms (SNPs) were identified based on their functional (n = 2,663) and physical annotation (n = 10,649). SNPs were related to each QoL-domain, while controlling for background characteristics and population stratification. Finally, gene-based analyses were performed relating the combined effect of 10,649 SNPs (selected based on physical annotation) for each gene, to QoL using the statistical software package VEGAS.

RESULTS

Overall, we found no relation between genetic variations (SNPs and genes) and 14 out of 15 QoL-domains. The strongest association was found between cognitive functioning and the top SNP rs1468951 (p = 1.21E-05) in the GSTZ1 gene. Furthermore, results of the gene-based test showed that the combined effect of 11 SNPs within the GSTZ1 gene is significantly associated with cognitive functioning (p = 2.60E-05).

CONCLUSION

If validated, the involvement of GSTZ1 in cognitive functioning underscores its heritability which is likely the result of differences in the dopamine pathway, as GSTZ1 contributes to the equilibrium between dopamine and its neurotoxic metabolites via the glutathione redox cycle.

Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease - International Study (APPROACH-IS): rationale, design, and methods

BACKGROUND

Data on patient-reported outcomes (PROs) in adults with congenital heart disease (CHD) are inconsistent and vary across the world. Better understanding of PROs and their differences across cultural and geographic barriers can best be accomplished via international studies using uniform research methods. The APPROACH-IS consortium (Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease - International Study) was created for this purpose and investigates PROs in adults with CHD worldwide. This paper outlines the project rationale, design, and methods.

METHODS/DESIGN

APPROACH-IS is a cross-sectional study. The goal is to recruit 3500-4000 adults with CHD from 15 countries in five major regions of the world (Asia, Australia, Europe, North and South America). Self-report questionnaires are administered to capture information on PRO domains: (i) perceived health status (12-item Short-form Health Survey & EuroQOL-5D); (ii) psychological functioning (Hospital Anxiety and Depression Scale); (iii) health behaviors (Health-Behavior Scale-Congenital Heart Disease); and (iv) quality of life (Linear Analog Scale & Satisfaction With Life Scale). Additionally, potential explanatory variables are assessed: (i) socio-demographic variables; (ii) medical history (chart review); (iii) sense of coherence (Orientation to Life Questionnaire); and (iv) illness perceptions (Brief Illness Perception Questionnaire). Descriptive analyses and multilevel models will examine differences in PROs and investigate potential explanatory variables.

DISCUSSION

APPROACH-IS represents a global effort to increase research understanding and capacity in the field of CHD, and will have major implications for patient care. Results will generate valuable information for developing interventions to optimize patients' health and well-being.

REGISTRATION

ClinicalTrials.gov: NCT02150603.

Psychosocial adjustment and quality of life of adolescents and adults with congenital heart disease

The incidence of people living with congenital heart disease (CHD) has been increasing every year owing to remarkable advances in surgical and catheter intervention techniques and devices, and improved knowledge of critical care for patients with CHD. However, these patients continue to face physical, psychosocial, and environmental challenges, and a number of studies have shown higher rates of depression and anxiety disorders than the general population. To improve psychosocial functioning and quality of life for adults with CHD, health care providers are recommended to inform CHD patients of an accurate diagnosis, and overall treatment process, beginning in adolescence to facilitate a smooth transition from adolescence to adulthood. Active cooperation with psychiatrists, psychologists, social workers, chaplains, and family members is highly recommended to help CHD patients feel normal and optimistic and to promote good social interactions, close family relationships, and a strong sense of coherence.