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Preparing for change in the secondary prevention of coronary heart disease: a qualitative evaluation of cardiac rehabilitation within a region of Scot

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Journal of Advanced Nursing
Preparing for change in the secondary prevention of coronary heart disease: a qualitative evaluation of cardiac rehabilitation within a region of Scotland
Author(s):

Clark, Alexander M. BA PhD RN; Barbour, Rosaline S. MA PhD; McIntyre, Paul D. BSc ChB MB MSc MD MRCP

Issue:
Volume 39(6), September 2002, p 589–598
Publication Type:
[Issues and innovations in nursing practice]
Publisher:
© 2002 Blackwell Science Ltd.
Institution(s):
Post Doctoral Research Fellow, Division of Sports Medicine, Department of Medicine and Therapeutics, University of Glasgow, Glasgow, UK (Clark)
Senior Lecturer in Primary Care R & D, Department of General Practice, University of Glasgow, Lancaster Crescent, Glasgow, UK (Barbour)
Senior Lecturer, Division of Sports Medicine, Department of Medicine and Therapeutics, University of Glasgow, Glasgow, UK (McIntyre)
Correspondence: Alexander Clark, Level 5 Cardiology, Royal Alexandra Hospital, Corsebar Road, Paisley PA2 9 PN, UK. E-mail: amc48c@udcf.gla.ac.uk
Submitted for publication 11 November 2001
Accepted for publication 30 May 2002
Keywords: Cardiac Health Promotion, quality, organizations, development, services, interface, primary care, change
Abstract

Background: Secondary prevention of Coronary Heart Disease (CHD) is often poorly managed and its benefits attained in only a minority of those with CHD. Guidelines developed in the United Kingdom and North America suggest that in future cardiac rehabilitation programmes should provide services through individualized programmes that cater for a wide range of conditions associated with CHD. This will involve substantial and costly changes to current programmes that are mostly standardized and for postmyocardial infarction patients. Based on change theory, this study examined the dynamics, strengths and weaknesses of an existing programme in a Scottish region which was due to undergo the changes suggested by guidelines.

Aim: To examine the perceived provision of secondary prevention services for CHD from the perspectives of health professionals within one region in the West of Scotland.

Methods: A purposive sample of 14 health professionals (eight primary and six secondary care health professionals) was selected to cover a range of professional roles including both specialists and generalists. Separate focus group discussions (2) were held with primary care and secondary care professionals.

Findings: Whilst the health professionals were enthusiastic about CHD prevention and their involvement, they perceived barriers to the success of the existing service as being complex and multifactorial, including patient, social and service-related factors. Although both groups identified motivation as the most influential personal factor, secondary care staff tended to focus on the importance of patient factors in influencing motivation to change, whereas the primary care staff referred more to the cumulative effects of social and cultural factors. Professionals highlighted weaknesses in the transition between hospital and community-based services with regard to the information flow between primary and secondary care.

Conclusions: Although the study has immediate relevance for the local area, it highlighted issues of more general relevance to cardiac rehabilitation programme development and intersectoral working, such as communications and role perceptions in multi-professional working and the need to adapt services to local socio-economic conditions.



Background

Pharmacological and nonpharmacological interventions can reduce Coronary Heart Disease (CHD) risk and prevent cardiac events (Wood et al. 1998, Kuulasmaa et al. 2000, Sebregts et al. 2000). The management of risk factors for CHD in primary and secondary care sectors throughout Europe remains poor (ASPIRE Steering Group 1996, Campbell et al. 1998, Moher et al. 2000, Euroaspire II Study Group 2001). Interventions that attempt to reduce CHD risk across entire populations have also had limited success (Ebrahim & Davey Smith 1997, Tudor-Smith et al. 1998, Feder et al. 1999, Moher et al. 2001). These disappointing results contrast with the relative success of interventions for those with established CHD or those at high risk of developing CHD. This includes disease-specific interventions for those with angina, heart failure, hypertension or previous myocardial infarction (MI) (Rich et al. 1995, Bradley et al. 1999, Lewin 1999) and programmes of cardiac rehabilitation (Wenger et al. 1995, National Health Services [NHS] Centre for Reviews and Dissemination 1998; Jolliffe et al. 2001).

In the United Kingdom (UK) and North America, prevention of CHD will increasingly come under the remit of cardiac rehabilitation. This is important for nursing, as nurses form the majority of health professionals who staff and co-ordinate these programmes (Thompson & Bowman 1995, Bethell 2000). To meet these changes, guidelines recommend that cardiac rehabilitation programmes should extend longer than the current 12-week norm, include more liaison with community-based services and have greater primary care involvement in the provision of care (Department of Health [DoH] 2000, Scottish Intercollegiate Guidelines Network [SIGN] 2002). Programmes should include a wider range of patients, such as those with angina and heart failure, and also be menu-based. This means that a component (such as one dealing with psychological well-being) is offered based on an individual's needs (Wenger et al. 1995, DoH 2000).

The magnitude of change required to develop existing services to meet these objectives should not be underestimated as they will markedly increase the numbers of those eligible for intervention (Wenger et al. 1995, DoH 2000, The SNAP Working Group for Cardiac Rehabilitation 2001). Additionally, though the majority of cardiac rehabilitation programmes have access to long-term exercise facilities, liaison between secondary and primary care is often poor or nonexistent (Bethell 2000). The content of many programmes also appears to deviate substantially from guidelines that were developed some years ago (Lewin et al. 1998).

Cardiac rehabilitation services have developed markedly from the early programmes set up in the 1980s (Horgan et al. 1992, Thompson & Bowman 1995, Bethell 2000) and this change is likely to be accelerated in future. Yet, beyond identifying groups less likely to be invited or attend (Melville et al. 1999) and surveys of programme content and staffing (Thompson & Bowman 1995, Bethell et al. 2001), there have been little detailed published examinations of the processes involved in the day-to-day provision of cardiac rehabilitation or similar secondary prevention services at the local level (Bradley et al. 1999, Wright et al. 2001). The study of these processes is considered to be an essential part of the evaluation of health care interventions because, amongst other benefits, it can allow providers and policy makers to understand better how outcomes are produced and the strengths and weaknesses of service provision (Patton 1987, Ovretveit 1998, Bradley et al. 1999, Campbell et al. 2000, Clarke 2000). Literature on organizational change suggests that such an examination would be useful in relation to cardiac rehabilitation services because those involved in planning for change can learn from the existing organization as it is from this structure that development must emerge (Carnall 1999, Zikmund 2000). For example, Wright et al. (2001) identified that while practice nurses involved in secondary prevention of CHD were comfortable with this activity and reported being effective in history-taking and advice giving, they felt inadequately prepared to discuss patients' understandings of CHD and medication. This learning therefore involves understanding both success and failure and gaining insight into the:

…dynamics within which we are enmeshed and attempt to transform and introduce changes…(and) yet rarely do we attempt to understand what has happened as part of a preparatory diagnosis of what and how to change an organization (Carnall 1999, p. 11).

This study aimed to examine the provision of secondary prevention from the perspectives of health professionals within a mixed urban/rural region in the West of Scotland. A new, menu-based cardiac rehabilitation service involving both primary care and secondary care health professionals was being proposed for the region (Figure 1). In line with current guidelines, the service will provide a comprehensive menu-based programme of cardiac rehabilitation to a wide range of client groups. At the time of data collection (Spring 2001), a standardized programme of cardiac rehabilitation was provided by the local hospital with additional assistance from primary care services for postmyocardial infarction patients. This programme is typical in format and content of the majority of programmes in the UK (Bethell 2000).



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Figure 1 The current and proposed rehabilitation programme.

The study
Methods

Qualitative research methods are well suited to examining the complexities associated with the provision of services (Bradley et al. 1999, Zikmund 2000) and results can lead to the refinement of services by providing an evidence-base for change that is responsive to localities (Bradley et al. 1999, Carnall 1999). In our study, the health professionals involved in providing the existing CHD prevention programme were judged to be those whose perspectives on day-to-day provision and organization would be most useful to study. Patients' perspectives of this service were also examined and are detailed in another report.

Data collection

Focus groups were selected as our method since they provide researchers with access to meetings similar to those likely to feature during interdisciplinary working. By drawing professionals from the same sector together to discuss a common topic, the groups facilitated the generation of collaborative accounts (Zikmund 2000, Webb & Kevern 2001). Focus groups also encouraged dialogue between individuals with different roles and remits and allowed those with similar roles to compare and debate their ideas (Kitzinger & Barbour 1999).

Sampling

As the purpose was not to recruit a representative sample, but rather to explore the diversity of roles and remits, a purposive sample (Kuzel 1992, Mays & Pope 1995) was selected to cover a range of professional roles, and to include both specialists and generalists. The composition of the focus groups reflected the extent of involvement of different professional groups. Thus, as a greater number of health visitors were known to be involved in providing secondary care (around 30), we sought to involve a larger number of health visitors. Telephone calls to all eligible professionals in the area were made and individuals' willingness and availability ascertained. While all were keen to take part, availability was more limited. A sample of 14 individuals from various professional groups was identified as being available during the same period. Each of these professionals was telephoned again and they agreed to take part at the agreed time.

Process

Two focus groups were convened and the sessions were held in a local hospital. Separate groups were held with primary care and secondary health care professionals. A schedule for the groups had been developed by two of the researchers based on existing literature (Figure 2). As is usually the case in focus group research, this served as a topic guide, providing some focus for discussion whilst allowing participants to raise issues salient to them (Barbour & Featherstone 2000).



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Figure 2 Items in focus group schedule for health professionals.

Groups were run by a moderator and co-moderator and tape recorded with participants' permission. Each participant also completed a short form that allowed their discipline to be identified. Full ethical approval for the study was secured from the local ethics committee and all participants were aware that they could withdraw at any point.

Data analysis

After the groups were completed, the data were transcribed onto a word processor and analysed separately by two of the researchers. Common themes were identified and any disparities between the groups were noted, in accordance with the constant comparative method (Green 1998). Attention was also devoted to interactions between participants (Kitzinger 1994, Webb & Kevern 2001) as they produced joint accounts of prevention. To preserve the integrity of these accounts, extensive quotations of the discussions are provided below (Kitzinger & Barbour 1999, Webb & Kevern 2001). After the transcripts were coded independently by the two main researchers (AC and RB), they compared themes and categories ascribed and debated their interpretations. This, in turn, fed into the process of refining categories to develop an agreed coding framework, which was then used to code both transcripts (Ritchie & Spencer 1994, Barbour & Featherstone 2000).

Findings
Health professionals' roles in secondary prevention

The secondary care group (comprising a cardiologist, one cardiac rehabilitation nurse, one care co-ordinator, one dietician, one Coronary Care Unit nurse and one cardiology nurse) provided the first point of contact for individuals after their CHD event in hospital and deliver the hospital-based components of the prevention programme. The interactions that occurred amongst this group suggested that they were enthusiastic about the secondary prevention of CHD. However, their discussions also dwelt on the limitations they perceived in fulfilling this role. In this group, the professionals seen as having secondary prevention as their primary role, unsurprisingly, were those directly involved in the cardiac rehabilitation programme, i.e. rehabilitation nurses, physiotherapists and dieticians. The cardiac rehabilitation service was viewed as the primary source of patient liaison, information and education around a variety of needs and purposes.

The professionals' perceptions of their roles were illustrated further when they discussed the dimensions of prevention that they considered most important. Significantly, this produced a range of responses that focused on subtly different aspects of prevention. The cardiologist considered drug therapy and exercise to be most important because of the weight of evidence supporting the benefits of interventions in these areas, while nurses who worked in hospital wards believed that behavioural change was the most important element. By contrast, the cardiac rehabilitation nurse and dietician felt that imparting information about the range of risk factors and ensuring that patients had an accurate understanding of their CHD were most important. These discussions reflected the core activities that each individual saw as being central to their own role and also that of their respective profession, as opposed to any perceived shared aims of prevention and the cardiac rehabilitation programme.

Ward-based nursing staff who attended the focus group session worked in those areas most likely to receive patients with CHD. They did not, however, view themselves as providing prevention for CHD, arguing that they did not have sufficient time for this:

Staff Nurse 1: We used to do the cardiac rehabilitation as well as everything else. We used to sit down and think ‘Right, that was part of our things’– we would go and sit down and have a chat with patients…before there was even a cardiac rehabilitation sister, it was part of your job remit. …

Cardiologist: Is there still a role for you being involved?

Staff Nurse 2: I would have to say ‘Not really’ because…unless there is something specific crops up, it is referred on. There is definitely not the time; there is not the time…

Staff Nurse 1: Staffing levels are, to me, a major issues at the moment and not just related to secondary prevention. It has a knock on effect in all areas. We hardly have enough time to do the most basic of care. Maybe it's wrong to see secondary prevention as an enhancement but when you have to feed people, wash people, administer drugs to them, it's something…(Secondary Care Focus Group)

Neither of these senior staff nurses (who collectively had 24 years of experience working in their units) saw themselves or nurses on their wards as providing rehabilitation or prevention. They each reported primarily playing a role in referring patients to the rehabilitation service. However, other aspects of their accounts belied this, providing indications that ward nurses actually supplemented the rehabilitation service in a range of important ways:

Staff Nurse 1: A lot of our input is to do with referral, we would refer definite infarcts to rehabilitation staff…Cardiac rehabilitation and physiotherapy staff are definitely here on a daily basis, we make written and verbal referrals. We also deal with accurately documenting and loading information about the patients, the risk factors are highlighted by the doctors' clerk-in and we might ask patients questions ourselves about that. We deal with specific queries they may have with visits from cardiac rehabilitation staff and their families. We also have input into drug administration, assessing how patients are tolerating their medications, liaising with the clinical pharmacist who comes up to the ward and we speak to him and he speaks to the patients about their medications…We have to be aware at meal times that the patients are eating an appropriate diet – try to steer them clear of obvious pitfalls there…Other things, just again, making sure that the information is there, chasing things up, things like cholesterol results to see if they are available. (Secondary Care Focus Group)

Although they did not view cardiac rehabilitation as integral to their roles, the ward nurses recorded, validated and clarified much of the information that made rehabilitation possible and supplemented the formal cardiac rehabilitation service where necessary through interactions with patients that focused on patients' questions, risk factors and medication concordance.

Primary care health professionals

This group comprised four health visitors from different practices, two General Practitioners from different practices, one liaison nurse and one practice nurse. The health visitors viewed themselves as bearing most responsibility for meeting patients' information needs. In this way they saw themselves as extending the specific role of the rehabilitation team, taking responsibility for education about CHD and secondary prevention including activities such as relaxation. Although the medical practitioners in this group recognized the range of behavioural risk factors that are important in CHD prevention they were particularly involved in pharmacological management. The practice nurse was involved mostly in ensuring that all patients received the appropriate service and were collecting the medications that had been prescribed for them, and in providing health promotion opportunistically.

The primary care group also discussed at length the importance of providing consistent health education and health care practices across all ages and sectors. All professionals present shared this concern.

Barriers to effective prevention
Individuals' beliefs and motivation

Both groups saw individuals' beliefs about the most common CHD risk factors (diet, exercise and smoking) and their motivation to change these as having a large impact on behavioural change. The secondary care group placed particular emphasis on individual factors in determining behavioural change. They tended to conceptualize people as rational decision-makers who process information about risk before deciding on the appropriate behaviour:

Rehabilitation Nurse: Because the clever folk, they weigh up the risks and they think ‘Well, if I do this, I do that, I can maybe do this’…they are the ones who sit with a pen and paper and try to work it out.

Staff Nurse 1: It's the person's attitude, not talking about social background…

Cardiologist: But I think what (Rehabilitation Nurse) is saying is that we have got to continue to give them information and attack them at the right stage of behaviour change, and we might not be successful but I think we are incredibly successful at stopping people smoking.

Staff Nurse 2: One doctor goes in and asks them if they want to see their grandchildren grow up. (Secondary Care Focus Group)

Notably, members of both focus groups dichotomised patients into those who were motivated and those whom it was difficult to motivate. Overall, individuals who were more motivated were seen as being better able to make long-term behavioural changes. The secondary care group viewed motivated people as being more likely to attend cardiac rehabilitation and to continue exercising after the 12-week in-hospital cardiac rehabilitation programme. The primary care group saw the motivated as being more likely to take medication and respond positively to general health promotion. This suggests that professionals are employing a definition of motivation that reflects their perceptions of their own roles.

Service-related factors

While acknowledging that individual circumstances were important with regard to behavioural change, participants in both groups also recognized that service-related factors adversely affected the effectiveness of secondary prevention. Both primary and secondary care groups identified that individuals from more deprived areas were less likely to be able to afford the travel costs to attend the rehabilitation programme and any community-based exercise sessions as the result of long distances and relatively poor public transport facilities.

Although a patients' transition from hospital to the community had been identified by both groups as crucial to the success of services, this was also the point when communication between primary and secondary care was held to be weakest:

Coordinator Nurse: The health visitors will go and actually visit people at home in the first two week or so (after MI). The pattern gets a bit more sketchy with regards to who is seen and when…there is a general feeling that they (community nurses) are not always receiving their referrals…they normally pick up referrals from their own GP and perhaps even using the GP's home visit books…it's not reliable…The health visitors feel they don't have enough information or perhaps social history. (Secondary Care Focus Group)

The extent and quality of liaison between primary and secondary care services was also identified as being important by the primary care group, who discussed this issue in terms of ‘communication’ between those involved in providing primary and secondary care. The flow of information between sectors was seen as being inconsistent and unpredictable, with the primary care professionals being unsure either that they were receiving sufficient information on patients or that information about all eligible patients was being provided. The primary care team also identified that, although some members of the team may have sufficient information about an individual patient, this would not necessarily be disseminated effectively between professionals. For example, a health visitor might fail to pass on relevant information to a general practitioner, or vice versa.

The influence of social and cultural factors

In addition to prevention being influenced by individual circumstances and service-related factors, participants also referred to the effect of social and cultural factors. In the primary care group, poverty and the culture associated with deprived areas were identified as important. Here discussion clearly progressed from a focus on relevant individual attributes to a detailed consideration of the social and cultural factors that impacted on patients' motivation and readiness to implement professionals' advice:

Practice Nurse: The motivated ones are not a problem because they will come back for their appointments and take their medications at the same time everyday. It's the ones who maybe have lots of other things going on in their lives and it is not a priority for them…

Health Visitor 3: I find people that live on their own have difficulty adjusting to the change and complying with medications, it could be for other reasons. They have not so much going on in their mind…

General Practitioner 1: I think people who come from socially deprived backgrounds, I think is it very difficult for these people to, well there are many problems and it can be difficult to motivate and financially difficult. (Primary Care Focus Group)

The primary care health professionals also believed that people had difficulties in implementing advice on healthy behaviours due to a range of factors associated with poverty. In this lengthy extract, the dynamics of the focus group foster a discussion regarding the complexities of behavioural change in a socially deprived environment:

Health Visitor 2: I wouldn't say there is not a good local shop but the majority of people I visit don't have cars. Although it's not that far away…

Practice Nurse: But it is if you have a lot of shopping.

Health Visitor 4: They don't know how to prepare fresh food and actually the dieticians are not often aware, they are saying about the nice stew pack you can cook with quite cheaply but if you don't know what to do with it, that is a huge problem. I have to teach mothers how to peel an apple!

General Practitioner 2: And there is not wanting to be different, you know. It is (seen as) posh to go and buy salad, so it's a huge attitudinal thing and nobody cooks.

Health visitor 4: There is an awful lot of processed food like takeaway Chinese meals. It is a big problem.

Practice Nurse: And not everyone has the cooking facilities that you assume they do. I had a man and I asked him what he ate…Chinese and Indian food and fish and chips. and I said, ‘But when do you cook?’ and he said, ‘I don't have anything to cook on!

Health Visitor 3: And takeaway food is so accessible these days.

General Practitioner 2: Or actually help them go around the supermarket, there is actually a basic thing, in how do you actually go and pick that packet of rice off the shelf. If you have never done that. I know I only buy the same two or three things, you don't really change you habits. To go to a different part of the supermarket and pick something off the shelf is quite scary.

General Practitioner 1: I suppose could you maybe lay on buses twice a week to the supermarket, but then I suppose the local shops would go out of business.

Health Visitor 2: They had been provided but there were problems with vandalism. (Primary Care Focus Group)

The health professionals in this group recognized a range of interrelated practical, environmental, social and cultural factors that limited the possible effectiveness of secondary prevention. They also allude to contested expertise, with members of the primary care team being presented as having greater knowledge than had others of the actualities of patients' everyday lives.

Discussion

This study offered an approach that could be adopted by those evaluating and/or developing intersector interventions elsewhere or developing consensus guidelines, as has been carried out in the development of management protocols (Fardy & Jeffs 1994). In the context of current policy and guidelines, the insights offered by this type of evaluation should be of particular use to those planning for or currently developing cardiac rehabilitation services.

Tackling practical barriers to attendance

While retaining a focus on local factors, the research identified patterns that have been noted elsewhere. The primary and secondary care health professionals identified that access to cardiac rehabilitation was often poor, an observation that accords with previous work (Ades et al. 1992, McGee & Horgan 1992, Pell et al. 1996, Thomas et al. 1996, Cooper et al. 1999, Halm et al. 1999, Melville et al. 1999, Barbour et al. 2001, King et al. 2001). Prompt reimbursement of travel costs and more localized or home-based programmes may ensure more equal access to services (Bowman et al. 1998, Ades et al. 2000, Collins et al. 2001). While relevant to the local area, this aim will also be of prime importance to cardiac rehabilitation programmes in England and Wales, as recent policy directs those providing health care services to ensure that age does not act as a direct or indirect barrier to services (DoH 2001).

Improving communication amongst service providers

The service that we studied adopted a process-based approach to service delivery (Martin 1998); that is, the organization of the service was divided according to the different components and stages of rehabilitation. This method of organization impaired the perceived quality and consistency of information exchange between sectors. Although the transition between hospital and community was seen as a particularly crucial period in influencing patient outcomes, it was here that information flow was perceived to be poorest. Communication difficulties also arose regarding information flow from primary care about the range of community services available to patients.

Communication difficulties are not uncommon across health care disciplines and sectors (Podesta & Watt 1996, Schroder et al. 1999, Cox 2000, Gandhi et al. 2000, Tanielian et al. 2000, Kvamme et al. 2001). Larger organizations tend to have more formalized procedures to deal effectively with the high volume of information associated with their larger size (Daft 1995). Such formalization will be important for those providing cardiac rehabilitation services, given the increase in the volume of information flowing between sectors that is likely to occur as eligibility criteria for programmes widen and community-based services develop. In the region we researched, a more formalized system of information flow should improve the consistency of information flow between sectors (Kvamme et al. 2001).

For example, the design and agreement of care pathways for different client groups should ensure that patients are treated more consistently and in accordance with current guidelines. As regards referrals, designated professionals in secondary care should provide information to designated members of the primary care team and vice versa. Greater standardization and systematization should be developed in the type of information to be provided across sectors and to whom this information should subsequently be sent within sectors. An agreed data set and cross-sector computer system has been set up to support this communication.

Improving the performance of the organization: importance of a shared vision

As well as informing the development of services and barriers faced in providing existing services, the focus groups allowed examination of how different members of the health care team interpreted their own roles within the organization. The process model of organization can lead to compartmentalization, with individuals tending to focus on only part of the overall organization, thereby diluting the ‘clarity of purpose’ within it (Martin 1998). Health professionals' involvement in distinct and separate teams can lead to a lack of clarity regarding the broader objectives and priorities of a strategy for CHD prevention (Bradley et al. 1999). In the area we researched, disparities existed between the groups about the importance accorded to different factors in determining an individual's capacity to change, the priorities of the service and health professionals' roles in secondary prevention.

The effects of this compartmentalization were evident in the ward nurses, who viewed themselves as not being involved in preventative services. This view, while being understandable (Naidoo & Wills 2000), is incongruent with policy and nursing curriculars that emphasize the centrality of the health-promoting role to nurses' work (UKCC 1986, World Health Organization 1991, Naidoo & Wills 2000).

Health professionals' values can also influence their decision-making (Gray 1997). In both focus groups, an individual's motivation to change was viewed as being an important factor that influenced the effectiveness of services. However, the primary care group appealed more frequently to a range of social and cultural factors in accounting for differences in individuals' capacity to change behaviours and thereby influence risk factors. The secondary care group focused on the primacy of individual attributes, such as motivation and knowledge, in determining behaviour. The relative importance of individual characteristics and social or cultural factors in determining behaviour has been debated widely in discussions about the roles of agency and structure (Nettleton 1995). In relation to health promotion, a view centred on agency implies that individuals are rational beings who weigh up in a logical manner the costs and benefits of alternative behaviours (Lupton 1995, Petersen & Lupton 1996). In this view, CHD prevention is based on a cognitive approach that focuses on modifying individuals' beliefs and attitudes to lifestyle change (Farrant & Russell 1986, Lupton 1995). Implicit in this stance are assumptions that such behaviours are amenable to change and that, if aware of the risks, individuals will change. However, as Lupton (1995, p. 57) notes:

…the overwhelming concern with the individual fails to account for the complexity of the socio-cultural world in which subjectivity is constructed and reconstructed.

While recognizing the epidemiological reality that some behaviours are associated with death and increased CHD risk, this view suggests that a disproportionate emphasis is placed on individual risk factors, while the importance of social factors (such as cultural beliefs, social networks, poverty, housing, employment, income inequalities, gender, global and racial inequalities) is relatively neglected (Farrant & Russell 1986).

The disparities that we have identified above as existing between the groups reflect a lack of shared vision and involvement that often occurs within organizations (Martin 1998). To improve this vision and ensure that all individuals feel involved in the service, the development of the future programme should involve on-going consultation with all the professionals involved in its design and implementation. A shared, overarching goal (or set of goals) to guide all activities within the programme should be agreed. This should form a basis for all interventions across health care sectors and disciplines. Additionally, attention should be devoted to ensuring that the programme is developed and delivered with a shared and appropriate view of behavioural change and human functioning.

This study was designed to examine service provision from the perspectives of health professionals in a specific locality. It was not intended to produce generalisable findings. However to the extent that the same constellation of professional roles, remits and service organization is likely to feature in other settings throughout the UK and North America, we argue that the findings may be transferable. This may especially be the case with communication between service providers, different interpretations of roles, and the need to recognise and adopt to particular total socio-economic conditions (Hamberg et al. 1994).

Acknowledgements

We would like to thank the health professionals who took part so willingly in the study and Ms. Cheryl Martin at the University of Glasgow for her assistance with the focus groups.

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Keywords: Cardiac Health Promotion; quality; organizations; development; services; interface; primary care; change


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