Commentary: Listening to the Patients' Perspective

‘‘It was the worst pain I ever feltI. I thought I was a goner’’ [anonymous patient describing his heart attack]. Patients who have had a heart attack commonly describe the event in terms of the threat that they felt at the time and the residual feelings that haunt them even after they recover. Yet, despite the seemingly life-altering experience of a heart attack, many individuals struggle with the self-care practices necessary to maintain health including medication adherence. Poor medication adherence rates are reportedly as high as 60% in some studies. Patient education conducted by nurses routinely includes detailed instruction on medication purpose and dose as well as the importance of taking medications as prescribed to prevent future cardiac events. Although patients affirm at discharge that they will dutifully take medications: ‘‘I don’t want that to happen again,’’ many will discontinue medications within months of hospital discharge or cardiac event. I think we have probably all pondered the question, why do some people change and others do not? Adherence to cardiac medication regimens involves the active collaboration by the patient in a ‘‘mutually acceptable course of behavior to produce a desired preventative or therapeutic result. ’’ Inherent in this definition is the series of decisions patients make in determining whether to take medications regularly and when or if to discontinue a medication entirely. There are many published quantitative studies that document the problem of poor adherence and identify predictors of adherence. Yet, many questions about adherence remain unanswered. The major limitation in using a quantitative approach is that quantitative results answer only a portion of the variance in adherence. For example, according to a recent meta-analysis, only a small portion of the variance identified inmedication adherence is attributed to demographic factors, that is, age, education, and socioeconomic status. In their article, ‘‘Exploring Patients’ Reasons for Discontinuance of Heart Medications,’’ the authors explore the reasons for discontinuation of 2 frequently prescribed cardiac medication types using a qualitative descriptive study design. In these results, we gain a glimpse into what other factors may influence medication adherence. The nature of qualitative inquiry is to understand a phenomenon within its social and cultural contexts. In qualitative research, the emphasis is on understanding, appreciating, and accepting that humans, as inherently complex, are able to shape and create their own experiences. The use of qualitative methods in this study aims to fill the gap of quantitative studies by seeking the individual’s perspective as to why medication was discontinued. The study by Decker et al is guided by the Health Belief Model (HBM), a common psychological model that attempts to explain and predict behaviors. The underlying tenet of the HBM is that health behaviors are determined by personal beliefs or perceptions about a condition (eg, heart attack) and the strategies available to decrease its occurrence (eg, take medications, eat a healthy diet). According to the HBM, an individual’s behavior can be explained or predicted by his/her perceived susceptibility to a particular health condition and the perceived severity of that condition, the individual’s evaluation of potential benefits of taking action that is weighed against perceived barriers involved in the action, and the potency of the cues to action that may be internal and/or external. Therefore, exploring the phenomenon of medication discontinuation among postYmyocardial-infarction patients through the lens of the HBM is an innovative approach. Many patients who experience a heart attack describe the event in emotional terms, as a threat. Furthermore, clinicians use words such as risk, prevent, and protect, suggesting that taking the appropriate action or engaging in a particular behavior can influence the likelihood of a reoccurrence. So, exploring an individual’s perception of susceptibility and threat of a cardiac event as well as barriers and benefits to medication adherence provides insight into why individuals may decide to discontinue cardiac medications. In this study, the authors’ primary use of the HBM was to organize the results of their study. In this way,