Perceived and objective risk in children of patients with peripheral arterial disease☆☆☆

Article Outline

• Abstract
• Theoretical framework
• Literature review
• Methods
• Results
• Discussion
  • Practice and research implications
• Acknowledgements
• Perceived and objective risk in children of patients with peripheral arterial disease
• References
• Copyright

Abstract 

This study examined perceived and objective health risks, health promotive behavior, risk perception, and knowledge of risk factors for peripheral arterial disease (PAD) in children of patients with PAD. Children of patients who had lower extremity distal arterial reconstructive surgery or amputation for complications of PAD completed an investigator-developed questionnaire. Risk factor and behavioral measures were self-reported. Data were collected by telephone interview. The sample consisted of 15 children of 6 patients. Subjects displayed optimistic bias regarding their risk for developing PAD, with 67% reporting their parent's illness had no impact on their health behaviors. Fifty-three percent felt their comparative risk was “about the same” as same-age, same-sex peers. Risk factor knowledge varied and none mentioned hypertension, age, obesity, or gender; the most commonly cited risk factor was diabetes mellitus. Forty-seven percent of the offspring never smoked, less than half exercised regularly, most were overweight or had class I or class II obesity, and most were unaware of their blood pressure or cholesterol levels. Despite frequent interactions with their affected parent, these children exhibited poor understanding of risk factors and personal risk of developing PAD and most did not participate in health promotive behaviors. Educational efforts by national societies promoting an understanding of modifiable risk factors must be improved. Future studies need to explore interventions designed to improve risk perception and health promotive behaviors. (J Vasc Nurs 2003;21:17-21)

Atherosclerosis affects multiple vascular beds and accounts for approximately 750,000 deaths annually in the United States, primarily as a result of myocardial infarction and stroke. Peripheral arterial disease (PAD), a marker for cardiovascular disease and increased mortality, consists of atherosclerotic disease of the peripheral arteries and the arteries supplying peripheral vessels. PAD affects 10 million people in the United States¹ and is typically considered a disease of the lower extremities. However, arterial diseases of the upper extremities and brain are also considered forms of PAD. Modifiable and nonmodifiable risk factors that contribute to the development of atherosclerotic lesions include age, sex, hypertension, diabetes, elevated low-density lipoprotein and triglycerides, decreased high-density lipoprotein, smoking, obesity, sedentary lifestyle, family history of vascular disease, and genetic factors.² Early intervention in the atherosclerotic process through risk factor modification may slow the process or result in regression of the disease³, ⁴ and is essential to maintaining and promoting health.

Research exploring risk perception in the context of other disease processes and safety issues exists, but studies exploring risk perception and behavioral practices affecting modifiable risk factors in children or siblings of patients with PAD could not be found in the literature. It was hypothesized that because of the visible nature of the disease in their parent, children of patients requiring arterial reconstructive surgery or amputation for PAD would perceive an increased risk of developing PAD themselves and would modify behavior to minimize risk.

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Theoretical framework 

The Health Belief Model (HBM) served as the theoretical framework for this study. It suggests that an individual's behavior depends on the degree to which he or she values a goal and his or her confidence in achieving that goal. It also assumes that health is a goal valued by that individual. Core dimensions of the HBM include perceived susceptibility to a disease process, severity of the disease, benefits of risk-reducing behavior, and barriers to participation in risk reduction. In addition, the HBM suggests that internal or external cues of sufficient magnitude will trigger a decision-making process affecting health behavior.⁵, ⁶

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Literature review 

No studies addressing risk perception and PAD were identified in a literature review using Medline and Cumulative Index to Nursing and Allied Health Literature databases. Studies exploring perception of risk in the context of cardiovascular disease were identified and reviewed.

The concepts of optimistic and pessimistic bias were mentioned frequently in the risk perception literature, with optimism defined as a tendency to adopt a positive view and pessimism associated with a negative outlook.⁷ Further exploration identified unrealistic optimism as a belief that positive events are more likely to occur than they actually are, and negative events as less likely to occur than they actually are. Comparative optimism is described as a perception that positive events are more likely for the self than others and negative events more likely for others than the self.⁸ Risk perception, a central construct in many health behavior theories, is based on an individual's assessment of his own health situation—either realistic, optimistic, or pessimistic. Both optimistic and pessimistic bias have critical implications for illness prevention and disease management.

Twelve studies were reviewed that investigated perceived and objective risk and the behaviors associated with cardiovascular disease.⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰ All studies examining risk perception found participants optimistically biased regarding their risk for developing cardiovascular disease.⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁵, ¹⁷ Only 1 of these studies examined perceived and objective risk in siblings of patients with cardiovascular disease, and no studies were located that examined these concepts in children. Becker and Levine¹³ studied risk perception, knowledge, and lifestyle behaviors in 80 biological siblings of patients who were admitted with premature coronary artery disease. The sibling group, interviewed within 2 weeks of patient discharge, had a significantly higher perception of risk than the group interviewed at 4 months after patient discharge. However, 67% of these siblings perceived their risk as the same or lower than same-age, same-sex peers in the general population. Knowledge of risk factors, age, education, the hospitalized patient's diagnosis, or number of prior cardiac events in the family did not significantly affect risk perception. Researchers also noted no statistically significant differences in smoking, body weight, exercise, salt or fat intake, or self-reported stress levels at the 4-month post-discharge interview. They also reported that a significant number still smoked, were inactive, had high levels of stress, and consumed foods high in salt and fat. Sibling-cited reasons for their risk perception were psychological factors, physical body type, and behavioral factors. Only 4 of the 12 cardiovascular research studies reported a positive association between family history and increased risk perception¹¹, ¹⁴, ¹⁵, ¹⁸ and, surprisingly, 1 study noted that a personal history of myocardial infarction did not increase risk perception.¹⁵ The effect of demographics such as age, gender, level of education, income, and nationality on risk perception resulted in diverse research findings among studies. These findings from the cardiovascular literature may have important implications for the PAD population, as the underlying process for both diseases is atherosclerosis and the risk factor management is the same.

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Methods 

This exploratory cross-sectional pilot study used a structured nonexperimental descriptive design and was based on the hypothesis that the visible nature of PAD complications and surgical interventions would influence children of these patients to perceive an increased risk and practice health promotive behaviors to minimize risk. Specific questions addressed by the study are listed in Table I.

Table I. STUDY QUESTIONS

PAD, Peripheral arterial disease.

This research project was approved by the College of Nursing University of Massachusetts Dartmouth Human Subjects Review Committee.

Patients who had lower extremity distal arterial reconstructive surgery or amputation for complications of PAD were randomly selected from a surgical case list generated by 2 vascular surgeons. Patients were eligible to participate if at least 30 days had passed since their last surgical procedure and they had living biological offspring. Children were eligible to participate if they were at least 21 years of age and biological offspring.

The patient was not the focus of this research but provided access to study subjects. Patients were contacted by phone by the investigator. After describing the study and obtaining telephone consent, eligible patients were mailed an informational packet including a letter of introduction and consent form, a letter of introduction to their children, and an adult child consent form with a self-addressed stamped envelope. Patients were asked to sign and return a consent to participate and deliver a letter introducing the study to each of their adult children along with a consent to participate. If willing to participate, each adult child was asked to return the signed consent form along with his or her phone number and best time for the investigator to be in contact.

Eight patients who met eligibility criteria for this study agreed to participate, and a total of 33 children were eligible for participation.

A data collection tool was developed, as none of the instruments identified during the literature review were appropriate for this study.¹³, ²¹, ²², ²³ This questionnaire consisted of open-ended and closed-ended questions and included children's demographics, pre-existing medical conditions, current medications, perceived risk assessment, knowledge assessment of cardiovascular risk factors, atherosclerosis lifestyle risk assessment, and presence of symptoms pertinent to cerebrovascular, cardiovascular, and peripheral vascular disease. This questionnaire was not evaluated for reliability or validity.

Adult children were contacted and data collection was begun when signed consent forms were received by the investigator. Data collection was done by telephone interview and was completed during October and November 2000.

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Results 

Sixteen offspring (48%) of 6 patients agreed to participate. One child subsequently did not participate because of a death in the family, leaving a total of 15 subjects. Ages ranged from 38 to 58 years (mean 45.6 years), with 6 males and 9 females, all of whom considered themselves Caucasian. Education levels for the sample ranged from 12 to 24 years (mean 15.5 years) and 80% were married. No offspring had been treated for PAD and 47% denied any medical problems.

Subjects rated their health as very good (33%), good (60%), and fair (7%). Five (33%) of the children reported at least daily and 4 (27%) reported at least weekly visits with their affected parent. Ten children (67%) reported their parent's illness had no impact on their health behavior. Children who responded that their parent's illness affected their health behavior tended to be older than those not affected by their parent's health (47 years vs 44.9 years) and tended to be more educated (17.4 years vs 14.5 years). Children cited factors influencing their health behavior regarding atherosclerosis risk factors, which are listed in Table II.

Table II. FACTORS INFLUENCING CHILDREN'S HEALTH BEHAVIOR

Three (20%) responded that they didn't pay attention to their health or to behaviors affecting their health.

Children were asked 5 questions to determine if they perceived an increased risk for developing PAD. When asked “How concerned are you about developing circulation problems,” 4 (27%) responded “not concerned,” 5 (33%) said “mildly concerned,” 4 (27%) answered “moderately concerned,” and 2 (13%) responded “very concerned.” Children were asked what they thought the likelihood was of circulation problems developing in the next 5 to 10 years and the majority, 10 (67%), responded “not likely,” whereas 1 (7%) responded “very likely.” When asked about the likelihood of having circulation problems develop in their lifetime, 8 (53%) of the sample felt it was “somewhat likely,” 3 (20%) responded “likely,” and 4 (27%) said “very likely.”

Comparative risk was evaluated when children were asked to evaluate their risk for developing circulation problems compared with same-age, same-sex peers. Eight (53%) responded that their comparative risk was “about the same,” 6 (40%) responded “greater,” and 1 (7%) responded “much greater.” When children were asked for the rationale behind their comparative risk judgment, responses, which are listed in Table III, ranged from “heredity” to influences of personal actions.

Table III. CHILDREN'S RATIONALE FOR COMPARATIVE RISK

Risk factor knowledge was assessed by an open-ended question, and responses are listed in Table IV.

Table IV. CHILDREN'S RESPONSES FOR RISK FACTORS THOUGHT TO CAUSE CIRCULATION PROBLEMS

No children mentioned hypertension, obesity, age, or gender as risk factors for having circulation problems develop. Of the children who mentioned diabetes mellitus as risk factor, 6 mentioned it first and 2 mentioned it second when listing risk factors.

Children's responses to atherosclerosis risk factor questions revealed that 7 (46%) never smoked, 4 (27%) had quit smoking at the time of the study, and 4 (27%) continue to smoke. More females never smoked, more males continue to smoke, and there was no difference in education or age between these groups. Six children (40%) did not exercise on a regular basis. Children exercising at least 3 times per week tended to be female and more educated than those who didn't exercise (mean 17.4 years vs mean 14.3 years), and age was similar between the groups. Most participants were unaware of their blood pressure (60%) and cholesterol levels (53%). Children who didn't know their blood pressure tended to be less educated (15.4 years vs 16.2 years) and tended to be older (46.6 years vs 44.2 years) than those who knew their blood pressure, and no difference was noted between genders. Those who didn't know their cholesterol level tended to be male, had less education (14.9 years vs 18 years), and tended to be older (47.5 years vs 42.7 years) than those who did. Analysis of body mass index (BMI) revealed 1 child as underweight with a BMI of < 18.5 kg/m², 3 had a normal BMI of 18.5 to 24.9 kg/m²; however, 5 (33%) were overweight with a BMI of 25 to 29.9 kg/m², 5 (33%) had class I obesity with a BMI of 30 to 34.9 kg/m², and 1 (7%) had class II obesity with a BMI of more than 35 kg/m². There were no differences in gender, education, or age among these groups.

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Discussion 

The data from this study demonstrated that children of patients with PAD displayed optimistic bias regarding their risk of developing PAD. Most participants (87%) were not “very concerned” about developing PAD in spite of frequent interactions with their affected parent and the suspected strong cue of the visual complications of this disease in their affected parent. This finding is concerning but not unexpected considering findings from the reviewed literature.

Fifty-three percent of children felt their risk of developing PAD was “about the same” as same-age, same-sex peers. Cited reasons included fate and personal actions. This finding is similar to that of Becker and Levine¹³ who noted 67% of siblings of patients with acute myocardial infarctions perceived their risk of developing heart disease as identical to same-age, same-sex peers. This also supports the finding of Weinstein,²⁴ in which participants were optimistic about their own risk when compared with peers. Children's behaviors also tended to increase or decrease risk perception, depending on the behavior, and is a finding similar to previous research.¹³, ¹⁸, ²⁴

Sixty-seven percent of the children in this study reported their parent's illness had no impact on their health behavior. This is consistent with the findings of several studies that found family history did not influence perception of risk in study participants.¹⁰, ¹³, ¹⁸, ²⁴ Children who reported heredity as influencing comparative risk judgment (40%) reported an increased lifetime risk perception and comparative risk, suggesting that some of these individuals, although not cognizant of the impact of their parent's illness, are more aware of their family history and its potential influence on health when comparing themselves to others. Forty percent of children responded that their parent's illness had affected their health behaviors and cited exercising more, being more health conscious, and eating a healthier diet. This group tended to be older and more educated than children not affected by their parent's health. This may be reflective of these individuals' awareness of their proximity to the age at which onset of health problems becomes more frequent.

Knowledge of risk factors for PAD varied among children. It is important to note that most children (67%) reported diabetes mellitus as a risk factor for PAD, and all cited it either first or second when listing risk factors.

This study had several important limitations that limit the extent to which findings can be generalized. The sample size was small, all participants in this study were Caucasian, and all had at least 12 years of education. The study also relied on self-reports for risk factor measurements, which may be less reliable than actual measurements. Tested questionnaires were not used in this study because of their time requirement and the desire to obtain data by telephone interview.

Practice and research implications 

This research has important implications for health care providers. If at-risk individuals do not perceive their increased risk, then the potential for behavior change is minimal. Increasing public awareness of atherosclerosis risk factors while providing screening and counseling on the management of modifiable risk factors should be a primary focus of health care providers. Societies dedicated to addressing atherosclerotic diseases must collaborate and educate the public about all atherosclerotic diseases. The challenge is in how to tailor the message to reach children of patients with atherosclerotic diseases early to impact health promotive efforts effectively and prevent disease.

Based on the results of this study and others, health care providers should not assume that individuals accurately perceive their risk. Providers must not only evaluate actual risk for disease, but must also explore the patient's perception of risk and the basis of that perception. It is also essential for providers to determine the patient's desire to engage in health-promotive behavior, perceived value of behavior change, perceived barriers, and the patient's perception of their ability to sustain behavior change. Providing individuals with specific behaviors, the necessary tools, and psychological support is critical to encouraging sustained health promotive lifestyle changes.

This pilot study only begins to explore perception of risk and health-related behaviors in children of patients with PAD. More research is needed to explore this concept in a larger, more diverse sample and to examine interventions aimed at changing risk perception and improving health promotive behaviors.

This study has increased our understanding of children of patients with PAD. Most notably, children were optimistically biased when determining their personal and comparative risk for developing PAD. Armed with this information, health care providers can tailor interventions to this challenging population.

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Acknowledgements 

A special thank you to Eileen S. O'Neill, RN, PhD, my thesis advisor, and to Nancy Dluhy, RN, PhD, my second reader, professors at University of Massachusetts Dartmouth.

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Perceived and objective risk in children of patients with peripheral arterial disease 

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• Nursing Continuing Education Answer/Enrollment Form JOURNAL OF VASCULAR NURSING

OBJECTIVES:

1. Which is a modifiable risk factor?

2. The Health Behavior Model (HBM) states that behavior is based on the degree to which the individual values a goal and the ______ in achieving that goal.

3. Core dimensions of the HBM include the following EXCEPT:

4. The HBM model suggests that the decision-making process affecting health behavior is triggered by:

5. Responses to “risk factor knowledge” resulted in the children's identification of which risk factor?

6. Providers should approach patients in all of the following easy EXCEPT:

7. This study discovered that children of patients with PAD:

Refer to tables for questions 8-10:

8. The most frequent factor influencing their own health behavior identified by children of PAD patients was:

9. The most frequent risk factor affecting circulation problems identified by children was:

10. Which of the following was listed as the LEAST identified risk factor by children of PAD patients?

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