Encouraging attendance at pulmonary rehabilitation: a qualitative exploration Dr Cathy Bulley, Dr...
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Transcript of Encouraging attendance at pulmonary rehabilitation: a qualitative exploration Dr Cathy Bulley, Dr...
Encouraging attendance at pulmonary rehabilitation: a
qualitative exploration
Dr Cathy Bulley, Dr Lisa Salisbury,
Ms Suzanne Whiteford,
Prof Marie Donaghy,Ms Elaine MacKay
Chronic Obstructive Pulmonary Disease
COPD involves limitation of expiratory airflow
shortness of breath, productive coughdeconditioning cycle, with fear and avoidance of
activities ↓ function, ↓ quality of life earlier death (Anto et al, 2001)
Medline Plus, 2004
Extent of the Problem
• Global prevalence estimate: 9.3/1000 for men; 7.3/1000 for women
• Expected that in 2020 this will be the third most prominent cause of death (WHO, 1995; Murray & Lopez, 1997)
• Sub-optimal management over-reliance on acute care (Wouters, 2003)
Supporting Self-Management
• ↑ emphasis on management of long-term conditions
• Individuals can learn better ways of coping with COPD
• Pulmonary rehabilitation aims to maximise function using: (BTS, 2001)
exercise training, education and support in symptom control
Evidence and Participation• There is strong evidence of the
efficacy of pulmonary rehabilitation (Lacasse et al, 2006)
• BUT benefits depend on participation – varies from 40% to 66% (e.g. Young et al, 1999)
• Minimal research into patterns of participation
Greater understanding of decisions is needed
This study…Aim:
• to explore individuals’ views regarding pulmonary rehabilitation PRIOR to attendance
Purpose:
• Increase understanding of influences of attendance at pulmonary rehabilitation
• Take action to optimise uptake and participation
Study Design• Qualitative; Phenomenological • Interpretative Phenomenological Analysis (IPA)
(Conrad, 1987)Gain understanding of the patient’s perspective
through co-construction between the participant and researcher
• Single semi-structured person-person interview in participant’s home (Grbich, 1999): 50-90 minutes
Participants• Individuals with COPD accepting referral to
Pulmonary Rehabilitation during clinic visit
• Purposive selection to ensure men and women
• 10 participants sought, 9 participated (5 men, 4 women)
• White Caucasians living in Glasgow, aged 59-82
• Ethical approval granted (Multi-Centre REC)
Analysis
• Interpretative Phenomenological Analysis framework
Classification of views and experiences (themes)
Interrelationships between themesQSR N6 package for data management2 researchers to increase trustworthiness
Results: 3 Master-Themes• Contrasting experiences and attitudes relating
to pulmonary rehabilitation:
1) ‘I want to walk and breathe better’
2) ‘Exercise will kill me’ versus
‘I can’t let it beat me’
1) ‘A waste of my time’ versus
‘Doctors know best’
‘I want to walk and breathe better’
• Individuals expressed a desire for professional advice and support in coping better
Independent development of self-management strategies
Not enough – more help is needed from experts and peers
Positive attitudes and realistic expectations Aim of increasing independence and
participation
Data: ‘I want to walk and breathe better’• I hope to be able to walk a bit better, to breathe
better... just a wee bit more independence. I know it's not going to be miracles, but I can only try and see if it helps. [John]
• Just....interested in something maybe just to help me...see how other people responding to it… [Jane]
• Hopefully there will be health professionals there that will advise us on I don't know, recovery, breathing… [David]
‘Exercise will kill me’ versus ‘I can’t let it beat me’
• Similarity in symptoms reactions
like panic, fear, loss of control
• Some react by avoiding activity/exercise
wariness about attending rehabilitation
• Some refuse to dwell on negative experiences determination to do anything that will help.
Data: ‘exercise will kill me’• I think you do panic... you think that it's going to be the
last time you're going to breathe to be honest, it just feels like it could be the last breath I'm going to take. [David]
• I mean breath is a thing you need that you need to keep you going whereas a sore arm doesn't or a sore leg... with your breathing you imagine you're going to die ‘cos you're not going to breathe… Aye, if I was able to breathe better I'd be able to ehh...do more. [Florence]
• Well I think there would be exercises but they would have to be gentle exercises you know. Exercises that a person who can't breathe properly could do. [Steven]
Data: ‘I can’t let it beat me’• I thought I was going to die off… but I don't
dwell on it, once it's past it's past. It doesn't make me frightened to go anywhere or do anything you know. [Elizabeth]
• I try to keep myself moving, and I'll not give in. [John]
• If there's anything that will maybe help to get me mobile I'll try it. I've always been a fighter… [John]
A ‘waste of my time’ versus ‘Doctors know best’
• Previous negative experiences of management low expectations of pulmonary rehabilitation
unsupported, dismissed, not listened topoor parking, exhausting walk, no benefit
• Previous positive experiences of management faith in health professionals and willingness to follow recommendations
supported, listened to, well advised
Data: ‘a waste of my time’
• I would go [to the clinic] every six months, … it would be someone different each time, and the only question they would ask me was "How do you feel?" and I'd say, "Well I'm fine thank you, normal...” I really couldn't see the point of attending… for the aggravation again trying to park down there, get myself home, it just wasn't worth it. [David]
• I think I would find out if I went there [rehabilitation] for maybe five or six weeks and found no benefit at all, I would just tell them...that I was wasting my time. But if I found it was giving me benefit, I would definitely carry it through right to the end. [Steven]
Data: ‘doctors know best’
• I must say I was very impressed… he was very nice… and made you feel… he was interested… he wasn't dismissive. I've always found that they were doctors that you could talk to… I've got a lot of faith in them... [Elizabeth]
• Surprisingly when I was at the Victoria on Friday past, the [physiotherapist] actually showed me a position to sit in and to.... a recovery position… and it's obviously worthwhile trying you know, and that's why I think the rehab would be of benefit. [David]
ConclusionsIndividuals recognise the potential to learn
better ways of copingFear of the burden of attending may outweigh
hopes of benefitThe aims and content of rehabilitation should
be very carefully explained on referralEnthusiastic referrals are importantAnxieties should be addressed
Sponsors:
School of Health Sciences, Queen Margaret University, Edinburgh
Centre for Integrated Healthcare Research, Edinburgh
References• Anto, J., Vermeire, P., Vestbo, J., & Sunyer, J. (2001). Epidemiology of chronic
obstructive pulmonary disease. Eur Respir J, 17, 982-994.• British Thoracic Society. (2001). BTS Standards of Care Subcommittee on Pulmonary
Rehabilitation. BTS Statement: Pulmonary Rehabilitation. Thorax, 56, 827-834.• Conrad, P. (1987). The experience of illness: Recent and new directions. Res Sociol
Health Care, 6, 1-31.• Grbich, C. (1999). Qualitative research in health: an introduction. London: Sage
Publications Ltd.• Lacasse, Y., Brousseau, L., Milne, S., et al. (2006). Pulmonary rehabilitation for chronic
obstructive pulmonary disease. The Cochrane Database of Systematic Reviews. (Issue 2, Art. No.: CD003793, DOI: 10.1002/14651858, CD003793)
• Medline Plus (2004) Medical Encyclopedia: Emphysema, National Library of Medicine (NLM). Online at: http://www.nlm.nih.gov/medlineplus/copyright.html [Accessed 19/03/2007].
• Murray, C., & Lopez, A. (1997). Alternative projections of mortality and disability by cause 1990-2020: Global burden of disease study. Lancet, 349, 1498-1504.
• World Health Organisation (WHO). (1995). World Health Statistics Annual. Geneva: WHO.
• Wouters, E. (2003). Economic analysis of the Confronting COPD survey: an overview of results. Respir Med, 97, S3-S14.
• Young, P., Dewse, M., Fergusson, W., et al. (1999). Respiratory rehabilitation in chronic pulmonary disease: predictors of nonadherence. Eur Respir J, 13, 855-859.