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Title: Understanding illness and treatment perceptions, coping, quality of life, depression and anxiety in patients with persistent atrial fibrillation undertaking procedural treatments
Author: Taylor, Elaina Charlotte
ISNI:       0000 0004 8500 6216
Awarding Body: King's College London
Current Institution: King's College London (University of London)
Date of Award: 2019
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Background: Patients with persistent atrial fibrillation (AF) experience poor quality of life (QoL), high anxiety and depression. Procedural treatments, such as catheter ablation and cardioversion, aimed at improving QoL and invasive symptoms (fatigue, palpitations, dyspnoea) do not consistently improve patient reported QoL. Patients with AF also experience high levels of depression and anxiety. The Common-Sense Model (CSM), which examines patients' self-regulatory beliefs about their illness and treatment, and coping responses, may provide insight into why AF patients experience poor QoL, high anxiety and depression. The CSM is widely supported in research examining chronic illness but has not been addressed in detail in the context of AF patients. The way patients view and understand their illness and treatment (illness and treatment beliefs) have previously be shown to predict health-related outcomes such as QoL in cardiovascular conditions. This PhD aims to examine whether illness and treatment beliefs and coping responses predict QoL, anxiety and depression, over 12 months in AF patients. In addition, the thesis examines the role of procedural treatment type and treatment success (defined as freedom from AF and sustained sinus rhythm at three months) in QoL at 12 months follow-up. Methods: A mixed-methods design was used whereby qualitative methods informed quantitative methods. Patients with a diagnosis of persistent AF due to undergo procedural treatment (catheter ablation, cardioversion or atrioventricular node ablation) were recruited from cardiology clinics and online. In the qualitative component, patients who had undergone or were due to undergo procedural treatments completed semi-structured interviews about their experiences of AF. These interviews informed the modification of an AF-specific version of the Revised Illness Perception Questionnaire (IPQ-R; Moss-Morris et al., 2002) used in the quantitative component of the thesis. In addition a set of questionnaires was given to persistent AF patients to complete (including the Beliefs about Medicines Questionnaire (BMQ; Horne, Weinman, & Hankins, 1999), Generalised Anxiety Disorder Questionnaire-7 (Spitzer et al., 2006), Patient Health Questionnaire-8 (Kroenke & Spitzer, 2002), Cognitive and Behavioural Response to Symptoms Questionnaire (Skerrett & Moss-Morris, 2006), Atrial Fibrillation Effect on Quality of Life Questionnaire (Spertus et al., 2010) and the EQ5D-5L (EuroQol Group, 2009). These questionnaires were completed at baseline (prior to procedural treatments), and 3, 6 and 12 months after procedural treatment. The thesis consists of four key areas of study: 1. Qualitative study (N=30): The study examined the illness and treatment beliefs, coping behaviours and QoL of persistent AF patients. Inductive thematic analysis with elements of grounded theory were used to identify core themes. This study is published in the British Journal of Health Psychology. 2. Modification of the IPQ-R (N=198): The initial qualitative study and further deductive analysis informed the modification of the Revised Illness Perception Questionnaire, to be specific to patients with persistent AF. Exploratory and confirmatory factor analysis was conducted, followed by validity and reliability analyses for the modified questionnaire. This study is published in Psychology and Health. 3. Baseline study (N=144): This study examined clusters of illness representations in AF patients. Cluster analyses and hierarchical regressions were conducted to examine whether cluster membership was a key predictor of QoL, anxiety and depression. This paper is under peer review at the International Journal of Behavioral Medicine. An addendum is included in this chapter to examine clusters of cognitive and behavioural responses to symptoms. Hierarchical regressions were used to examine whether cluster membership was a key predictor of QoL, anxiety and depression. 4. Longitudinal study (N=155): Multilevel modelling was used to examine the predictive relationship between treatment type (catheter ablation/cardioversion) and treatment success/failure, baseline illness representation cluster, baseline cognitive and behavioural responses cluster, and other clinical and demographic variables, with QoL, depression and anxiety over 12 months. Results: 1. Qualitative study: Inductive analysis identified an overarching theme relating to perceived lack of knowledge and understanding of AF, attempts to gain control of symptoms, and negative emotional reactions to failed control attempts. Three subordinate themes were also identified relating to i) unpredictability and uncertainty of AF and symptoms, ii) coping with symptoms through (a) avoidance, (b) all-or-nothing and (c) slowing down behaviours; and iii) concerns and expectations of treatment. 2. Modification of the IPQ-R: Key modifications included addition of a triggers of AF scale, examining patients' beliefs about the triggers of their AF. This included emotional triggers (such as stress), health behaviour triggers (such as smoking and other cardiovascular conditions), and over-exertion triggers (such as over-work or exercise). The treatment control component was also modified to relate to AF-specific procedural and pharmacological treatments. Three new items related to personal control were added. The modified questionnaire (AF-IPQ-R) evidenced good validity and reliability. 3. Baseline study: Illness representation clusters were significantly associated with QoL, anxiety and depression: Cluster 1, 'high coherence of AF and treatment control', experienced significantly greater QoL, lower depression and anxiety, than patients in cluster 2, 'negative illness and emotional representations and high personal control. The addendum also outlined two clusters relating to cognitive and behavioural responses to symptoms. These included, cluster 1: 'unhelpful cognitive and behavioural responses, with greater fear avoidance, beliefs that symptoms are a sign of damage, symptom focussing and behavioural avoidance', and cluster 2: 'lower engagement in unhelpful cognitive and behavioural responses to symptoms'. Patients in cluster 1 experienced significantly poorer QoL and greater levels of anxiety and depression, compared to patients in cluster 2. 4. Longitudinal study: Final model results indicated that treatment success (but not treatment type) consistently predicted QoL (in all measures) at 12 months. Treatment success did not predict depression or anxiety at 12 months. Baseline cognitive and behavioural responses to symptoms cluster and illness representation cluster predicted QoL (EQ5D) at 12 months. Cognitive and behavioural responses to symptoms cluster also predicted QoL (EQ5D) and depression at 12 months. Conclusion: The results suggest that illness representations contribute to variations in QoL, anxiety and depression in AF patients at baseline (pre-treatment). Patients can be grouped into clusters of illness representations and cognitive and behavioural responses to symptoms. In relation to the longitudinal findings, treatment success predicted greater QoL at 12 months than patients who had failed treatments. However, treatment success but did not predict anxiety or depression at 12 months. Treatment type did not significantly predict QoL, anxiety or depression. The relationship between treatment success and QoL was not moderated by treatment type. Clusters of illness representations and cognitive and behavioural responses to symptoms predicted QoL (EQ5D) and depression at 12 months. Patients in illness representation cluster 1 and cognitive and behavioural responses cluster 2, experienced significantly greater QoL and lower depression. Further research should examine ways to improve QoL and reduce anxiety and depression. This may be achieved using illness-perception based interventions, self-management strategies and integrated cognitive behavioural methods tailored to AF patients.
Supervisor: Moss-Morris, Rona ; Hughes, Lyndsay Dawn ; O'Neill, Mark Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available