The Construct of "Value of Health" as a Predictor of Post-Hospital Compliance in People Affected by TIA

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The Construct of “Value of Health" as a Predictor of Post-Hospital Compliance in People Affected by TIA

Конструкт «цінність здоров'я» як предиктор постгоспітального комплаєнсу в осіб, постраждалих від ТІА

Bondarenko Nikita

Post-Graduate Student of H.S. Kostiuk Institute of Psychology of the National Academy of Educational Sciences of Ukraine, Doctor-Neurologist at the Municipal Non-Profit Enterprise “Kyiv Clinical Hospital No.3”, Kyiv (Ukraine)

Бондаренко Нікіта

аспірант Інституту психології імені Г.С. Костюка НАПН України, лікар-невролог комунального некомерційного підприємства «Київська міська клінічна лікарня №3», м. Київ (Україна)

Abstract

psychological help patient transient ischemic attack

The article is devoted to the specifics of providing clinical and psychological assistance to people who, after a short-term hospitalization (5-7 days), were discharged from the hospital with a diagnosis of “transient ischemic attack" (TIA).

The purpose of the study is to clarify the hierarchy of value meanings in the value system of patients who have undergone a TIA, as well as to study how exactly these values affect their attitude to taking care of their own health and, more importantly, adherence to the post-hospital outpatient self-care regimen.

Research methods and techniques. Based on the main task of the research, the following diagnostic tools were used: the Mini-mult test adapted by V.P. Zaitsev; method of portrait selections by L. Sondi (MPV); questionnaire “Attitude to health" (author R. Berezovska); patient health questionnaire (Patient Health Questionnaire - PHQ-9); J. Rother's method of diagnosing the level of subjective control (adaptation by E.F. Bazhyn, S.A. Golinkin, O.M. Etkinda); quality of life assessment questionnaire (SF-36); universal questionnaire for the quantitative assessment of adherence to treatment (QAA-25) by N.A. Nikolaev and Y.P. Skir- denko.

Results and discussion. The study found that health is the leading terminal value for patients who have undergone a TIA, a happy family life is the second, and independence is the third one. At the same time, on the basis of regression analysis, the assumption about the overwhelming desirability for patients of such forms and methods of treatment, which minimizes their own efforts in order to overcome the disease, is substantiated.

Conclusions. The results show that there are clearly expressed trends, with the help of which it is possible to orient oneself in the probable post-hospital behavior of the patient in relation to his own health, which in a new way raises the question of defining not so much typical, but rather individual ways of psychological approach to the patient's personality, which corresponds to the prospects for the development of personalized medicine.

Key words: transient ischemic attack, values, construct, compliance, regression analysis.

Introduction

Бондаренко Нікіта. Конструкт «цінність здоров'я» як предиктор постгоспітального комплаєнсу в осіб, постраждалих від ТІА.

Стаття присвячена специфіці надання клініко-психологічної допомоги особам, які після короткострокової госпіталізації (5-7 діб) були виписані з лікарні з діагнозом «транзиторна ішемічна атака» (ТІА).

Мета дослідження - з'ясування ієрархії ціннісних смислів у системі цінностей пацієнтів, які перенесли ТІА, а також дослідження того, як саме ці цінності впливають на їхнє ставлення до піклування про власне здоров'я та, що ще важливіше, на прихильність до післягоспітального режиму амбулаторного самодогляду.

Методи та методики дослідження: виходячи з головного завдання дослідження, був застосований такий діагностичний інструментарій: тест Міні-мульт в адаптації В.П. Зайцева; метод портретних виборів Л. Сонді (МПВ); опитувальник «Ставлення до здоров'я» (автор Р. Бере- зовська); анкета здоров'я пацієнта (Patient Health Questionnaire - PHQ- 9); методика діагностики рівня суб'єктивного контролю Дж. Ротера (адаптація Бажина Є.Ф., Голинкін С.А., Еткінда О.М.); опитувальник оцінки якості життя (SF-36); універсальний опитувальник кількісної оцінки прихильності до лікування (КОП-25) Н.А. Ніколаєва та Ю.П. Скирденко.

Результати та обговорення. Дослідженням встановлено, що провідною термінальною цінністю у пацієнтів, що перенесли ТІА, виступає здоров'я, на другому місці - щасливе сімейне життя, на третьому - незалежність. Разом з цим на основі регресійного аналізу обґрунтовано припущення про переважну бажаність для пацієнтів таких форм і способів лікування, які мінімізують докладання власних зусиль з метою подолання хвороби.

Висновки. Результати свідчать, що існують яскраво виражені тенденції, за допомогою яких можна зорієнтуватися в ймовірній післягоспітальній поведінці пацієнта у ставленні до свого власного здоров'я, що по-новому ставить питання про визначення не стільки типових, скільки саме індивідуальних способів психологічного підходу до особистості пацієнта, що й відповідає перспективам розвитку персоналізованої медицини.

Ключові слова: транзиторна ішемічна атака, цінності, конструкт, комплаєнс, регресійний аналіз.

Mental health and cardiovascular disease are closely related. Meanwhile, the latter currently occupy a leading place in the structure of the total mortality of the population of many countries of the world, including Ukraine (Клінічна настанова, 2022: 10). Among them, a special place is occupied by an acute violation of cerebral blood circulation. More than 105,000-110,000 cases of primary or recurrent stroke are registered annually in Ukraine (Гирявець, 2021; Віничук, & Фартушна, 2017). This pathology is one of the main causes of disability in the population of Ukraine. Out of the total number of people recognized as disabled for the first time, 12.5% suffer from cerebrovascular disease (Загуровський та ін., 2020). According to data, 78% of cases of cerebrovascular disease lead to the development of disability and deterioration of the quality of life of patients; 46% of stroke patients die within the first month; among those who survived, about 10% return to work, 53% need outside help, 48% have disabling hemiparesis, and 30% develop psycho-organic syndromes (Черенько та ін., 2011). But there is another important aspect in this problematic for people, which, due to its specificity, has so far, with a few exceptions, remained outside the scope of research attention. It is about the specificity of providing clinical and psychological assistance to people who, after a short-term hospitalization (5-7 days), were discharged from the hospital with a diagnosis of «transient ischemic attack» (TIA), returned to their usual lifestyle, disregarding the recommendations of doctors, and after some time were hospitalized again, but now with a real stroke. They ignore the doctor's recommendations because they are discharged from the hospital with the pleasant thought that they have not been diagnosed with a stroke. Meanwhile, say, in Canada, ischemic strokes and TIAs account for approximately 85-90% of all stroke cases for which patients turn to hospitals (Клінічна настанова, 2022: 10). Such an event is especially dangerous for people of working age, because usually a terrible disease that can threaten them can undermine their personal, professional, and social status, which, in turn, makes the whole situation even more traumatic.

In extremely numerous publications on the problem of stroke in its various forms, both domestic and foreign, there are occasional statements that attention should be paid to both psychosocial and psychological aspects, especially at the stage of rehabilitation of patients who have suffered a stroke (Gennai et al, 2018; Labri et al, 2021; Mendelson, & Prabhakaran, 2021; Ranta et al, 2018 ), what exactly to focus efforts on in cases of TIA, how to build a hierarchy of clinical and psychological work, orient oneself in the degree of adherence to psychoprophylaxis of the patient himself, the main personal radicals and properties, probability and primary importance of psychotherapeutic targets, this question remains open. It is complicated by the fact that, according to WHO, approximately half of all patients with chronic diseases do not follow medical recommendations (Adherence to Long-Term Therapies, 2003). The analysis of the literature shows that researchers choose someone component from clinical and psychological problems - say, anxiety, depressive disorders, aggressiveness of patients, or features of the cognitive sphere prompts researchers to form this or that cohort of subjects. While, rather, it is necessary to find an integral combination of the universal and individual in the psychological and psychosocial characteristics of the patient, taking into account which would contribute to the determination of the optimal strategy for providing psychoprophylaxis in this particular case. All this determined the general idea of our research.

The purpose of the article

Patients who have suffered a TIA face not only physical limitations, but also psychological aspects related to their health and lifestyle. Therefore, it is important to understand the hierarchy of value meanings in the value system of patients who have undergone a TIA, as well as to study how exactly these values influence their attitude to taking care of their own health and, more importantly, to adherence to the post-hospital ambulatory self-care regime, which includes taking medications, following a certain lifestyle, following and fulfilling the doctor's recommendations, etc. Understanding these aspects will allow a more focused approach to the issue of helping patients on their way to recovery, as well as preventing the occurrence of a threatening condition (stroke, to put it simply) in the future.

Research methods and techniques

This study was carried out within the framework of a broader topic - the study of the features of clinical and psychological support for stroke prevention in patients of working age after transient ischemic attack and non-validating strokes. Based on the main task of the research, the following diagnostic tools were used:

- Mini-mult test adapted by V.P. Zaitsev;

- L. Sondi's portrait selection method (MPS);

- Questionnaire “Attitude to health” (author R. Berezovska);

- Patient Health Questionnaire (PHQ-9);

- J. Rother's method of the level control (adaptation by E.F. Bazhin, S.A. Golinkin, O.M. Etkind);

- Quality of life assessment questionnaire (SF-36);

- Universal questionnaire for quantitative assessment of adherence to treatment (QAA-25) by N.A. Nikolaev and Y.P. Skirdenko.

The research was conducted on the basis of neurology departments of communal non-profit enterprises of the executive body of the Kyiv City Council (Kyiv City State Administration): «Kyiv City Clinical Hospital No. 3», «Kyiv City Clinical Hospital No. 4», «Olexandrivska Clinical Hospital», as well as on the basis of a private “DolinSky Medical Center”, Brovary). The study was conducted with confidentiality and voluntary participation in the period from October 2021 to January 2024. 106 patients participated in the study, however, at the stage of initial processing of diagnostic materials, 24 sets of diagnostics were removed from the total volume as unsuitable for further analysis due to various reasons (refusal, partial completion of tasks, etc., because giving answers to 7 diagnostic methods is not an easy task for patients of the neurological department The author takes this opportunity to express his deep gratitude to the master's students, interns, colleagues and heads of the specified departments and institutions for their selfless help and the opportunity to conduct diagnostic examinations and collect data. We would like to express our special thanks to Veronika Mazur, Alina Rahuba, Svitlana Fedko, Natalia Kucherovska, Svyatoslav Masovych. I express my personal gratitude and respect to Alla Mykolaivna Cherkez, Larisa Oleksan- drivna Vakulenko, and Victoria Yuriivna Krylova, without whose generous support this research could hardly have taken place.

So, the final sample of subjects consisted of 82 patients aged 34 to 63 years, 29 of which were female and 53 were male, after a transient ischemic attack and non-disabling strokes. The average age of the patients was 51 years. Detailed descriptive statistics by age parameter are given in table 1.

Table 1Descriptive statistics according to the age of the subjects

In this article, special attention is paid to the empirical material collected using R. Berezovska's Health Attitude Questionnaire and the Quantitative Assessment of Adherence to Treatment Questionnaire (KOP-25).

Results and their discussion

There are summarized quantitative results below according to the criteria of patients' attitude to their own health, where: cognitive level implies a measure of a person's awareness or competence in the field of health, understanding of the main risk factors, etc.; the behavioral level assesses the degree of compliance of the patient's actions with the idea of a healthy lifestyle; the emotional level describes the level of anxiety, calmness or satisfaction in relation to one's own health; value-motivational level indicates the high importance of health in the individual hierarchy of values (especially terminal values), the degree of formation of motivation to preserve and strengthen health.

Table 2Quantitative results according to the scales of the Questionnaire «Attitude to health» by R. Berezovska

According to the quantitative results shown in Table 2, the dominant component of the attitude to health is the value-motivational one. Since the technique involves not only quantitative, but also qualitative interpretation, this component indicates: the place of health in the individual hierarchy of values; possible reasons for the lack of taking enough care of your health (subjective and objective). Let's consider it in more detail.

Figure 1. The place of health in the individual hierarchy of terminal values of research participants (according to the «Attitude to Health» method by R. Berezovska)

It is well known that terminal values are a kind of guidelines and priorities that a person strives to achieve, that is, what a person considers to be the most important and essential in his life. The results of the conducted research showed that health is the leading terminal value in patients who have undergone a TIA, happy family life is on the second place, and the third place is taken by independence.

It is quite predictable that health itself occupies a central place in the system of terminal values of the studied patients who are being treated in a hospital, because it is fair to assume that a painful condition is capable of bringing with it a number of other problems, such as deterioration of the quality of life, narrowing of the circle of social connections, problems of self-realization, deterioration of the material condition, and, of course, wellbeing. Therefore, for this category of subjects, the preservation of health is the highest priority and the key to achieving other goals.

Accordingly, it becomes quite clear why the value of independence is the next in the hierarchy of patients' values. It is clear that good health can contribute to a person's independence and self-reliance. Being healthy allows you to participate more actively in various areas of life, including work, social interaction, etc. Conversely, poor health can become an obstacle to independence and require support from other people.

The third value in the hierarchy is probably related to the latter - the value of a happy family life. We can assume that this value category is considered by patients as a support in a difficult situation, in particular in a situation of illness. In addition, the quality of family relationships and family support can significantly affect an individual's physical and, importantly, psychological well-being.

Similarly, the leading instrumental values were determined, the hierarchical distribution of which is shown in Figure 2.

As we can see from the results, the leading instrumental values are diligence/perseverance, health, and abilities. It is in them that patients see the means of realizing their goals and ideals.

It is noteworthy that hard work/perseverance represents the leading instrumental value, as the primordial universal way of achieving a goal. The next in the hierarchy is health, which, obviously, for the studied cohort is an important means of maintaining work capacity, productivity and general well-being. After all, as it was shown above, in a situation of illness, an individual may experience difficulties in realizing his potential and achieving his desired goals. Abilities are the third key component in the system of instrumental values of the studied sample. A person can use his individual abilities and talents as a tool to achieve success, both in professional and personal life.

Figure 2. The place of health in the individual hierarchy of instrumental values of research participants (according to the «Attitude to health» method by R. Berezovska).

So, for people who have survived a TIA, health seems to become an overriding aspect in the hierarchy of values. This is due to a temporary but significant deterioration of the physical condition and, moreover, awareness of the threat of more serious consequences, such as a stroke. We can assume that after a TIA, patients show greater motivation to change their lifestyle, take care of their health, and follow the recommendations of doctors to ensure long-term physical well-being and prevent relapses.

From the point of view of common sense, the described results seem quite predictable for hospital patients undergoing treatment and rehabilitation after TIA. But at the same time, these results served for us only as a guide for the further - main - stage of the research, the purpose of which is to determine the place of the value of health in the system of value orientations of patients. In accordance with this task, a correlation analysis of the system of terminal values was carried out, and then, according to a similar procedure, of instrumental values. Correlation analysis was carried out using the non-parametric test of C. Spearman.

Table 3The results of the correlation analysis of the value-motivational aspect of the attitude to health and terminal and instrumental values

Note 1:** - correlation is significant at 0.01; * - correlation is significant at 0.05

As can be seen from Table 3, the value-motivational component is significantly moderately correlated with a happy family life (0.521) and independence (0.551), a moderate correlation is recorded with health variables (0.403) and recognition of others (0.401), a low correlation with material well-being (0.335), having true friends (0.320) and interesting work (career) (0.244).

Among the variables represented by instrumental values, a moderate direct correlation was noted with abilities (0.490) and perseverance (hardworking) (0.467), a low one with a good education (0.362), material wealth (0.327), luck (luck) (0.308) and health (0.229).

Thus, it can be seen that despite the dominance of the value of health in the quantitative distribution of values, which was discussed above, at this stage of the research we observe a significant, but rather low connection of this construct with the value-motivational component that determines the attitude to health and to illness. The next task follows from this, namely: finding the real place of the construct «health as a value» in the system of value meanings of an individual who has undergone a TIA, rather than a labeled one.

For this purpose, a regression analysis was applied, with the help of which predictors of the value-motivational component of the attitude to health were determined in a sample of people who had undergone a TIA. The procedure was carried out in two stages, as part of the first, terminal values acted as predictors, and in the second - instrumental values.

In table 4 the results of the regression analysis are given, according to which we can predict the level of expression of the value-motivational component of the attitude to health (according to the methodology of R. Berezovska) depending on the level of expression of individual values, including health.

Table 4 Regression models for predicting the indicator of the expressiveness of the value-semantic component of the attitude to health based on the expressiveness of the leading terminal values

a. Predictors: (Constant), Health

b. Predictors: (Constant), Health, Happy family life

c. Predictors: (Constant), Health, Happy family life, Independence (freedom)

Despite the fact that the dependent and independent variables describe a largely similar phenomenology, the predictors included in the third model describe only 35% of the variance, which indicates their significance in the expression of the valuemeaning aspect of the attitude to health, but a certain indirectness of their impact.

Table 5Regression models for predicting the indicator of the expressiveness of the value-semantic component of the attitude tohealth based on the expressiveness of the leading instrumental values

As one can see, the third model describes a rather small percentage of variance (20%), which means: the expected dependent variable expressing the value-meaning component of the attitude to health is weakly explained by such variables as “health”, “abilities” and “ persistence”.

The ultimate goal of this survey is to assess the interdependence of values that determine the attitude of patients who have undergone TIA to health and their adherence to treatment.

The above data presents us with the task of general orientation in the peculiarities of adherence to the treatment of patients of the studied cohort. The detailed distribution by high, medium and low levels of adherence is shown in table 6.

Based on the obtained data, we can state that the most pronounced component of adherence to treatment among the subjects is adherence to therapy (high - 36.6%, average - 34.1, low - 29.3), and the least desirable is adherence to changing the method life (high - 14.6, average - 39.0, low - 46.3). Thus, it is possible to make an assumption about the overwhelming desirability for patients of such forms and methods of treatment that minimize their own efforts to overcome the disease.

Table 6 Distribution of patients according to the degree of adherenceto treatment according to the KOP-25 Methodology

Based on the assumption that the integral indicator of adherence to treatment is determined by the values that outline the attitude to health, we note that the result of the correlation analysis of the indicators proved the existence of a direct moderate relationship between the integral indicator of adherence to treatment and the value of recognition by others (r= 0.328; p=0.00). The latter, in turn, correlates with the presence of true friends (0.206; p=0.03) and a happy family life (0.235; p=0.03).

Table 7The results of the correlation analysis of the integral indicator of adherence to treatment and individual value categories

Conclusions

As we can see, despite the fact that the descriptive quantitative analysis at the initial stage of the study showed the leading role of the value of health as a construct of consciousness, social values are the key in the issue of adherence to treatment.

Indeed, in practice, the closest environment can play a key role in supporting the patient in the treatment process. Involvement, emotional support can act as a powerful motivator for adherence to treatment. Moreover, the very feeling of responsibility towards loved ones can motivate the patient to follow the doctor's recommendations and adhere to the treatment regimen. At the same time, we report to ourselves that our research, in the way it is presented in this article, does not reflect such important indicators of the sample as its socio-demographic indicators. In our main study, we definitely take into account a number of these important data.

Taking into account the psychological aspect of the obtained results, we note that the results of the study presented in the article allow us to quite clearly formulate a well-defined conclusion regarding the totality of patients affected by TIA, from the standpoint of understanding how exactly their behavior is determined in the post-hospital period.

These results indicate that there are clearly expressed trends, which can be used to guide the patient's likely post-hospital behavior in relation to his own health. And these are: a) the reluctance of educated and relatively well-off individuals to make their own efforts towards self-management in order to improve their own health; b) discrepancy between the declaration of health as a value (with the fact that the construct “health” is part of the system of value meanings) and the actual power of motivation to ensure this value; c) the importance of psychosocial factors (from the presence of true friends to the importance of family relationships and a sense of personal freedom), which in a new way raises the question of defining not so much typical, but rather individual methods of psychological approach to the patient's personality, which corresponds to the prospects for the development of personalized medicine.

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