Adult ’ s perception of health care after myocardial infarction

Rev Bras Enferm. 2020;73(5): e20190074 http://dx.doi.org/10.1590/0034-7167-2019-0074 7 of ABSTRACT Objectives: to describe the Adult’s perception of healthcare after Myocardium Infarction. Methods: qualitative descriptive analysis carried out with 12 adults who had myocardial infarction and conducted from February to May 2018. The research design was based on the “Consolidated Criteria for Reporting Qualitative Research”. Data collection was performed through semi-structured questionnaire, interview script and field diary. The interviews were encoded, and their content was analyzed using software support. Results: three classes were obtained: “Fear, (un) certainty and (un) awareness”; “Lifestyle and beliefs of illness” and “Health care search”. Unhealthy lifestyle habits, lack of health prevention / promotion, difficulties in accessing services and lack of knowledge about the disease generated fear and uncertainty about the future. Final Considerations: the perception of acute myocardial infarction is related to the trajectory of illness, lifestyle and the belief that the infarction only affects others. Descriptors: Chronic Disease; Myocardial Infarction; Adult Health; Perception; Community Health Nursing.


INTRODUCTION
The process that culminates in a myocardial infarction (AMI) occurs slowly and silently, as coronary artery disease develops gradually over the years, so people have difficulty identifying and interpreting that there is something "wrong" with their body (1) .
It is possible to characterized infarction as a deficiency in the blood supply to the vessels and arteries of the heart, causing failure in cardiac function and various health complications in people who are affected, especially young adults (2) .
There is no doubt that daily living habits can have profound effects on the likelihood of developing cardiovascular disease. Among the risks described, we can classify them as non-modifiable, such as family history, gender and advanced age; and the modifiable ones being smoking, sedentarism, alcohol intake, obesity and overweight, as well as psychological stress (3) .
When the acute cardiac event occurs, people are frightened and surprised because they were not prepared to fall ill and were often performing their routine activities. After AMI, because they are young and consider themselves healthy, feelings of fear of death, disability and the unknown arise. In this new phase, they need to learn to cope with the dependence caused by the disease and the need for ongoing care (4)(5) .
The illness caused by AMI changes the life of both the affected person and their relatives, by modifying the routine due to the absence of work activities and generating physical limitations on the person who fell ill. At this point, the importance of a structured family network to assist in home care arises (6) .
It can be considered that the search for health care performed by the people who suffered the infarct is related to the way they experience and understand the disease and how much getting sick impacts their life routine (7)(8) .
Health and disease arise from the interaction between the biological and the environment in which the person lives, whether it is the society or the community in which they are inserted. Therefore, the way they come to understand the disease cannot be characterized solely as a biological event, but a process of experiences. In it, for each person, there is an individual meaning about what is "being sick", which is built by their cultural and social values, in a dynamic way, which leads to various questions by the person affected by the cardiac event, in the work with my family and health team to find a cure (9) .
Thus, there is a need to describe how people perceive myocardial infarction and how the cardiac event interferes with their lives.

OBJECTIVES
To describe the Adult's perception of healthcare after Myocardium Infarction.

Ethical aspects
The study was submitted to the Ethics Committee of the state of Paraná, and the recommendations of Resolution 466/2012 of the National Health Council (CNS) were followed, with CAAE No. 82916018.9.0000.0107 and approval opinion 3,178,581. To carry out the study, we obtained the authorization from the Health Department of the city (Secretaria Municipal de Saúde) where the study was conducted. All participants signed the free and informed consent form. After the full transcript of the interview content, a copy was given to the participant for prior reading of the material and confirmation or rectification of some excerpt read. The information collected was kept anonymous, and the participant's name was replaced by an identifying code, using the letters IP (interview / participant) followed by an Arabic number in ascending order (IP_1, IP_2...). The research was conducted at the participant's home, in a private place, without the presence of other people, except in cases where the participant requested it.

Type of study
This is a qualitative descriptive analytical study, derived from a master's thesis. The Consolidated Criteria for Reporting Qualitative Research (COREQ) was used as the basis for the study.

Methodological procedure
The study included 12 adults of both sexes, aged 18 to 65 years, who were affected by AMI, from February to May 2018. The inclusion criteria were having a diagnosis of AMI in medical records, having confirmation by family member or participant, living in the municipality where the research was being carried out, having been attended in an emergency room and transferred to the standard cardiology hospital. For exclusion, the Mini-Mental State Exam (MMSE) was used, the cut point being 13 for illiterate, 18 for low and medium education and 26 for high education. 1 to 4 years are considered as low education level; average schooling, from 4 to 8 incomplete years; and high education, over 8 years (10) .

Study Scenario and Data Source
The research was conducted in a city located in the western region of the state of Paraná. To list the participants who could be part of the research, the main researcher daily checked the list of hospitalization and transfer of the Medical File Service sector (SAME) of the Emergency Care Units of the municipality. After identifying the possible participants by the diagnostic obtained from the online ambulatory care form, a telephone contact was made and a home visit was scheduled to present the research project, at a place, date and time defined by the participants or their relatives.

Data collection and organization
For data collection, we used a semi-structured form that included the sociodemographic, clinical, and lifestyle habits variables of the participants. There was also an interview script with ten open questions and a field diary, in which aspects of the participant's environment, family interaction, and verbal and nonverbal answers were noted.
The researcher recorded the interviews, with the prior consent of the interviewees and lasted an average of one hour. After transcribing and reading all the interviews, we used as support for content analysis and data encoding the software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ_0.6-alpha3 ® ). The characterization of the participants was presented through tables and analyzed using descriptive statistics with the aid of Microsoft Excel ® 2010. For lexical analysis, IRAMUTEQ_0.6-alpha3 ® was used.

Data Analysis
The content analysis of the statements was performed according to the steps proposed by Creswell (11) , by the following steps: 1) pre-analysis; 2) material exploration or encoding and treatment of results; and 3) interpretation. In the first stage, the interviews were organized and transformed into text units to explore the content by transcribing it and reading the interviews word for word. The field diary was used to complement the information, emphasizing the different phases experienced by people by AMI, chronologically. The reading of the participants' reports aimed to understand them and further fragment and construct the textual corpus for insertion in the IRAMUTEQ_0.6-alpha3 ® qualitative analysis software.
This software provides statistical accuracy, allowing the use of various technical vocabulary analysis resources, in which words are grouped and organized graphically according to their frequency, enabling the construction of a single corpus that gathers the texts interview originals (12) .
Textual statistics or classical lexical analysis, provided by the software, present the number and segments of text, identify word count, average frequency and hapax (words with a frequency of one), investigate vocabulary, reduce words based on their roots (reduced form) and identify active and supplemental forms. Specificities analysis allows the association of texts with variables characterization of the text narrators. (12)(13) . For the construction of the analysis corpus, the texts were recorded in the format "txt" and encoded in Unicode UTF 8 (12) .
In the second stage, exploring or encoding the material, the interviews were described in sequence, and the text was separated into smaller categories of information, allowing an accurate description of the relevant properties of the presented content. The corresponding classes identified were named using the software (11) .
In the third stage, the speech was interpreted and analyzed, expanding the meanings of the codes and themes found beyond the initial representation. The interpretation and understanding of the data were performed based on the research literature.

RESULTS
The transcripts of the interviews allowed a general corpus consisting of 12 texts, separated into 226 text segments (TS) with 81.42% utilization. The first category originated from the subcorpus of classes 1 and 6, with 23 Elementary Context Units (ECUs) and 31 ECUs, corresponding to 12.5% and 16.85%, respectively. The second category was formed by the subcorpus of classes 2 and 3, both with 29 ECUs, equivalent to 15.76%. And the third category corresponds to classes 4 and 5, with 38 and 34 of the ECUs, concentrating 20.65% and 18.48% of the total corpus ECUs, respectively. These classes were organized by similarity into three categories: "Fear, (un) certainty and (un) awareness"; "Lifestyle and beliefs of illness" and "Health care search".
Participants were 4 women and 8 men, aged from 36 to 65 years; having an income higher than 2 minimum wages, married or in a stable union, with less than 3 children. Two participants were not literate. Regarding lifestyle, eight participants, before AMI, consumed alcohol, two smoked and all did not practice physical activities regularly.
Regarding the presence of comorbidities, five had hypertension, one was diabetic, and the others were unaware of any associated pathology, but had a family history of cardiovascular disease. The Brazilian National Health System (SUS -Sistema Único de Saúde) was the first choice in the search for health care, but they migrated to private service to complement care.
In the first category, "Lifestyle and beliefs of illness", it is clear that the participants' lifestyle reflects their family history. Stress and anxiety, related to the modern lifestyle, agitation and, daily rush, were considered as important causes of illness and responsible for the acquirement of unhealthy lifestyle habits. [ In the second category, "(Un) awareness, Fear and (Un) Uncertainty", the statements revealed questions about illness, fear and uncertainties regarding the future, as well as ignorance of the precipitating factors of AMI.
The perception of the disease repercussions demonstrates that the participants did not perform ongoing health care, which is evidenced by aspects such as inadequate lifestyle, lack of adherence to drug treatment, lack of concern with health prevention and promotion, lack of knowledge about the disease and, the changes caused by the infarction in their lives. In the category "Search for health care", it was possible to perceive the barriers the participants encountered during the search for care in the health sector, such as the delay in care, the difficulty in early identification of AMI, the professionals lack of reception and willingness to help.

DISCUSSION
The participants' reports showed their perceptions about AMI, through which it was possible to highlight the lack of interest characterized by negligence regarding health care, lack of selfcare and, the perspective that the disease only affects the other.
This perception may be linked to the fact that AMI suddenly sets in and determines difficult and painful changes in the health status of people who did not expect to get sick or have their lives changed due to illness. Besides, the acute infarction generates feelings of uncertainty about the future, doubts, and fears regarding the treatment and severity of the disease, and also the therapeutic procedures. They lead the affected person to reflect on the possibility of leaving their relatives without support, as well as on their finitude (5) .
Ignorance regarding the process of illness interferes with adherence to treatment, as it is influenced by beliefs and myths experienced by people throughout their lives and can generate demotivation to control the disease, inability to relate the behavior with the management of adverse situations and low expectation in the result of treatment (14) .
People's attitudes represent the way they think and how they feel about the disease, based on life experience, which influences their way of acting or behaving in the face of certain situations. The worldview acquired throughout life impacts on decision making and it is represented in the different behaviors people present in their illness (15) .
The cardiac event triggers a stressful effect on the patients and their family, as it generates fear that the affected person will have a new occurrence. After AMI, in most cases, a caregiver appears within the family network for monitoring and controlling the patients' life so that they do not get sick again because the family believes that the resistance to treatment is the cause of the disease (16) .
Regarding lifestyle and beliefs of illness, participants recognized that unhealthy habits, especially regarding diet, stress and, anxiety, contributed to the occurrence of AMI. The illness understanding relates to the patients' beliefs regarding why it occurs. In most cases, they relate it to food, family heritage and, problems with the environment, people and society (17) .
The participants' reports show the difficulty in the primary identification of cardiac events through the denial of the signs and symptoms severity. This result corroborates a study conducted in Istanbul, Turkey, with 93 patients who suffered infarction. This study made possible to realize that 81.7% stated that if they were aware or understood that signs and symptoms indicated heart problems, they would have sought pre-hospital care earlier. Furthermore, 33.3% of patients did not consider their complaints serious and expected them to recover; a total of 45.2% did not attribute the symptoms to cardiac causes (18) .
Another study developed in Sweden, with 21 infarcted men, also found that the delay in seeking specialized medical care was associated with misinterpretation of symptoms, illusion of invulnerability, a belief that symptoms would disappear or attempt to relieve or treat symptoms before seeking specialized care (19) .
These studies presented similarities with the present study, in which participants reported difficulties in identifying the cardiac event, resistance in seeking health services at the first moment, denial of severity, fear of loss of control and independence due to illness, tolerance to pain and hope that symptoms would disappear.
After the cardiac event, people perceive that their way of living has been modified, they often present limitations in relation to daily activities and in order to avoid a new episode of infarction or develop other heart disease, they try to modify their lifestyle (20) .
Knowledge regarding risk factors for the development of coronary heart disease has a close relationship with the way in which people deal with life, disease and health. A qualitative study conducted with 31 people in a family health unit, after being affected by an AMI, observed that, in relation to the knowledge of the disease, its definition and risk factors for the development of the AMI episode, 15% could explain the disease, and 74% of the people interviewed reported only 1 to 2 causes as risk factors. Regarding lifestyle, 58% did not modify their lifestyle. The study noticed that people still have little information about the disease and its prevention, a fact that contributes to the difficulty in adherence to healthy lifestyle habits (21) .
Lifestyle can remain for decades in a family and can lead to the development of the same diseases of that family nucleus because eating habits are elaborated in childhood and can perpetuate generation to generation (17) . A study conducted in southern Taiwan observed the association between the overweight of parents, diabetes, hypertension and pediatric adiposity in the development of cardiometabolic risk factors among adolescents. The study found that a healthy lifestyle based on the family is important for the prevention of risk factors such as obesity and hyperlipidemia, as shared environments through generations influence the eating habits acquired and reproduced in adulthood (22) .
For the treatment of cardiovascular diseases, it is necessary that affected people understand the factors that influence the emergence and development of the diseases, so that they become aware of the importance of a healthy lifestyle to prevent related complications (23) .
Knowing the family history is important for the development of actions aimed at preventing and/or delaying the onset of cardiovascular diseases, especially in young adults (24) .
Lifestyle-related risk factors, such as eating habits, tobacco and alcohol use, and physical inactivity, are also associated with psychosocial factors, a result of modern life that has intensified stress and consequently generated anxiety and depression. This leads people to develop unhealthy habits that directly affect their health and may trigger heart attack (25)(26) .
A study conducted in Brazil observed that patients with symptoms of AMI did not immediately seek health services because they had difficulty understanding the initial signs and symptoms. This interfered with the immediate search for professional healthcare (27)(28) , which this research also observed in the participants' statements.
The delayed recognition of the cardiac event and, consequently, the late search for the health system are the result of the difficulty of patients with AMI in identifying the signs and symptoms related to this episode. Therefore, this interferes with the prognosis, which could be better if they could understand earlier the signs and symptoms presented as an urgency (29) .
In addition to the participants having delayed demand for health services, we noticed that when they sought it, they had difficulties to be attended, which was mainly due to the lack of early recognition of AMI signs and symptoms by health professionals, difficulty of reception, denial of care and overcrowding of prehospital care units.
The delay in seeking prehospital care is an important obstacle to the proper management of AMI (30) . When the search for emergency services occurs, people often face overcrowding, the physical structure scrapping, poor and ineffective care, difficulty in early recognition of AMI by professionals, reception difficulties and denial of care (7,31) .
A study conducted in Bahia, in two benchmark hospitals in cardiology, with 100 users who had myocardial infarction, observed that, regarding the conduct of health professionals, 82% had the expected care, that is, they were treated and admitted or admitted and transferred to other services, and 18% did not have the expected care, due to the lack of structure of institutions and the difficulty of clinical management by health professionals regarding infarction (32) .
This research observed problems in the provision and organization of care to people affected by AMI, a fact that corroborates the lack of public health structure, evidenced by the low supply of clinical and surgical beds in the cardiology specialty, insufficient response from emergency services. This happens because, although these services aim to provide fast care and counter-reference to other sectors of the health network, there are difficulties in the work process, such as overloading the care of spontaneous demand disconnected from basic health units, health teams dislocated, disjointed work process, scrapping of physical structures, and difficulties in reference and counter-reference (33) .
It is noteworthy that people's perceptions about the disease have multiple factors, which permeate the physiological, and determine the adherence or not to treatment, such as family habits, life history, and experiences in the search for the health system, which interfere with the way people seek health services.
Thus, professionals must be aware of the patients' needs and develop practical and effective actions for the treatment -whether in the physiological and therapeutic aspects or regarding the limitations and frustrations caused by the illness -through active listening and welcoming, valuing people's core. Studies that evaluate people's perceptions should be carried out in environments outside the health services, so that they can discuss their real perceptions.

Study limitations
The limitation of this study is that it was performed only in Emergency Care Units and exclusively with people who use public health services. For the search performed in the Emergency Care Units, according to the age group chosen for the research, the number of participants was reduced due to losses related to the complication of the clinical picture, resulting in a sample of 12 participants.

Contributions to the nursing, health, or public policy fields
The results of this study contribute to a different perspective on the care of adults who suffered infarction. A perception that is not limited to physiological aspects, but that considers care more broadly, like active listening and appreciation of information passed on by people when seeking health services.

FINAL CONSIDERATIONS
Research participants, through their testimonies, perceive AMI as a consequence of their lifestyle and beliefs of illness, which are related to lifestyle habits, especially eating habits, considered as the main factor for the development of the infarction, so that it becomes the goal of change, because, by modifying it, they would not get sick again.
In the acuity period, we noticed that the search for health care was hindered by ignorance of signs and symptoms, as well as barriers to care access. After AMI, participants reported fear of a new episode, which made them rethink their life and finitude, about the need to take care of their health and to acquire healthier habits, as well as to adhere to drug treatment correct form.
We suggest expanding this research by investigating the comprehension of how health professionals approach people with AMI.