Immigrants with heart failure- A descriptive comparative study of symptoms, self care, social support, care and treatment

Abstract

Background: The current demographic profile in Sweden demonstrates blended ethnicities and cultures evolving through mass migration and resettlement. While it is acknowledged that cultural background affects, illness experience, participation in the care or self-management of illness, little is presently known about the treatment patterns, symptoms, health care seeking and health outcomes among immigrants with heart failure (HF) in Sweden or other Scandinavian countries – despite the fact that worsening of chronic heart failure is the most common cause of hospitalisation in patients over 65 years of age. Aim: This comparative, explorative thesis describes immigrants with HF regarding symptoms, self-care, social support, care and treatment, physical limitation and emotional state, as well as health outcomes, e.g., readmissions and mortality, in comparison to Swedes. Method: The thesis has a descriptive and comparative design. The first study is an interview study exploring symptom recognition and health care strategies related to worsening of HF. The second and third studies of the thesis are retrospective record audits of patient records describing care and treatment of immigrant and Swedish patients with HF in a medical ward and at a nurse-led HF clinic. The fourth study is a descriptive study with group comparisons of changes from baseline to four month follow up, in symptoms, functional limitations, emotional status, social support and self-care measures over a four month period, from baseline to four-month follow-up. The study setting was a university hospital serving a large and diverse immigrant population. Results: A majority of the immigrant and Swedish patients sought health care for symptoms and signs, such as breathing difficulties, fatigue and swelling. In addition, equal numbers of patients in both groups were aware of their reluctance to seek care when symptoms and signs occurred, and gave diverse explanations for delays. However, twice as many immigrants as Swedes were unaware of the underlying reason for their illness and its connection with HF (I). Reviewed patient records revealed no significant differences between the groups regarding symptoms, diagnostic investigations, medical treatment, hospital stay and health outcomes, such as readmissions and mortality. Furthermore, records from both patient groups showed that functional status using the New York Heart Association classification was infrequently assessed and that documentation of provided HF information was lacking. The only significant between-group differences were that more immigrants were referred to the nurse-led HF clinic for a follow-up visit at discharge (II); fewer routine clinical parameters were assessed in immigrants; and fewer immigrants were scheduled for follow-up visits (III). No differences were seen between immigrants and Swedes regarding 4-month changes in symptoms and signs, physical functioning, social support, emotional status, or in health care seeking in response to certain symptoms. However, adherence to prescribed medications was significantly higher among immigrants, whereas significantly fewer immigrants reported that they had access to emotional support if needed (IV). Conclusion and implication: Although immigrant and Swedish patients with chronic heart failure were provided largely the same care and treatment, fewer immigrants were able to relate their symptoms to their condition when seeking acute care. Immigrants also reported higher adherence to prescribed medication and were more often referred to the nurse-led HF clinic by physicians at discharge from hospital, possibly with the expectation that the patients would receive more individualised care and follow up. Information about how and if patient education and counselling had been carried out was rarely documented in the patient records. More precise and comprehensive notations of the patients’ own perceptions of their care may enhance the quality of this documentation. Patient records should also document performed assessments and interventions, which may improve communication between caregivers in different health care settings and consequently improve the efficiency of future care plans.