Five years after a coronary angiography, this research examined the respective associations between incidents of CVD, risk factors, unhealthy behaviours, and socioeconomic inequality and life satisfaction (LS) among INCCI patients in Luxembourg.
Patients suffering from angina pectoris in the previous 5 years had lower LS than patients with myocardial infarction and/or bypass surgery. A previous study found the same results; LS related to angina was probably principally responsible for this association [3]. Previous work suggests that angina is a predictor of future cardiovascular events, but other investigations of psychological factors and coronary heart disease find that conventional risk factors explain little of the observed association [19]. Of course, having a chronic illness or a disability is associated with reduced LS, and the effect is larger if this disability limits daily activities. Those findings accord with the conclusion of the last report of Eurofound, which observed that the most important predictor of LS is health [7].
Another finding consistent with recent research [3] was the relationship between CVRF and LS. Patients who were not physically active and suffered from obesity, diabetes and hypercholesterolemia were more likely to have low LS. Among the initial population of our study, the investigation observed that awareness of hypercholesterolemia was more often declared as a CVRF than diabetes [13]. What can we conclude in regard to the theoretical perspective cited in the introduction. Two profiles of patients were linked with lowest LS: those who were ‘inclined abstainers’ and had an intention to modify their behaviours, but could not do it, and those who were ‘disinclined abstainers’ and had no intention to change because they were not concerned about continuing the behaviour. A recent research study among Luxembourgish people showed that more time spent sitting, viewing television, and using a computer during a day off might be unfavourably associated with ideal cardiovascular health [20]. Being sedentary is the main behavioural risk factor of all major non-communicable diseases, i.e. CVD, if appropriate action is not taken; deaths due to CVD are projected to rise further [21].
However, patients who stopped smoking also had the lowest LS. They included ‘disinclined actors’, patients who must adjust their lifestyles, 5 years after a coronary angiography, and adopt a behaviour that is perceived by them as unpleasant. The first hypothesis may be that the patients do not have a real ambition to stop smoking, ambivalence would exist between their intention and the behaviour, which they continued [22]. Additionally, patients whose attitudes were more aligned with social norms, such as stopping smoking, were more likely to accept the benefits of preventive behaviours [23]. The distance between the difficulties of making a modification and the ability to change behaviour would probably link with their low LS. Knowledge of the emotional impact of preventive behaviours such as physical exercise may be useful for policy interventions aimed at improving the health and daily life of patients [2]. The second hypothesis is in accord with recent research [24] which demonstrated that smoking reduction, sustained for at least 12 weeks, was not associated with a change in mental health, suggesting that reducing smoking was no better or worse for mental health than continuing smoking.
Among other interesting findings, the LS of INCCI patients (7.3/10; 69 years) was higher than in Luxembourgish patients (7.1/10; 65.5 years) living at home, two years after a stroke [25], and lower than the national LS indicator in Luxembourg (in 2013, 7.8), which was higher than that in the European Quality of Life Survey, 2012 (7.1 for EU-27) [7]. Relationships between socioeconomic conditions and LS are recognised. Our study revealed associations of gender, marital status and income with LS. Gender may include both social role and biological aspects. We observed that patients who are women and have a low to middle income had lower LS. The fact that the LS was lower in female than in male patients calls for further research on symptoms, and potential risk factors such as health-related behaviours, nutrition, leisure, etc. Our finding is not consistent with those of the European LS survey, which reported small gender difference in various countries. However, the study patients who lived in a couple were more satisfied, and slightly more satisfied than single people in various groups. We have no definitive explanation for these findings, but some relationships are well documented, for the whole population, in the recent report of the European Quality of Life Survey. People aged 25 or more who live with a partner have better LS than single people. This indicates that the emotional and social aspects of living in partnership are important to well-being [7]; in our sample, three out of four patients live in couples and their spouse or partner is probably the family caregiver.
An OECD working paper used the Gallup World Poll data to explore the determinants of well-being and examine the drivers of measures of affect (positive and negative states), as well as the determinants of LS that are more prevalent in the existing literature [26]. It reported that, overall, items relating to health status, personal security, and freedom to choose what to do with one’s life appear to have a larger impact on affect balance when compared to LS, while economic factors such as income and unemployment have a more limited impact [26]. Like patients living at home 2 years after stroke [25], we can postulate that the impact of socioeconomic factors would be greater for the study patients 5 years after their coronary angiography already facing disadvantages in lifestyle, and that the effect of health-related behaviours will be greater when they confront social disadvantages.
Cardiovascular disease affects health in combination with social, psychological and material factors [10, 13]. Contextualising our findings poses a challenge for a number of reasons, in particular the economic situation (as regards Luxembourg’s gross domestic product per inhabitant), and the fact that Luxembourg is one of the smallest European countries (502,500 inhabitants, area 2600 km2) and distances between the population and the health system are short. Care facilities are therefore geographically accessible to the whole population. The sociodemographic characteristics of the study patients (2/3 had an income of more than 36,000€) suggest that social and medical support focussed on community professional-oriented services is easily available. Location and income influence domiciliary care delivery: distribution of resources at local levels; financial constraints; and the application of eligibility criteria in providing medical and community services [11].
This study has numerous strengths
The strengths reside in the population sample; the small size of the country made it possible to organize data collection at a national level. Our participation rate of 35.5 % is similar to 32.2 % in a previous study, also in Luxembourg [17]. This rate is a low estimate. Indeed, patients were contacted by mail and it was expected that relatives of deceased patients would inform us by return mail. We can assume that relatives of deceased patients were less motivated to respond than living patients, for this reason it is likely that the number of deceased patients is substantially higher and that the response rate is underestimated. Conducting a study 5 years after coronary angiography creates an opportunity to obtain valuable information. In this chronic phase, patients and their families may well have reorganised their daily lives and adapted to their new preventive behaviours. Such a study protocol remains rare because it is very expensive, and difficult to organise. Some patients died, now lived in institutions, had changed their residence (for example to live with a son or daughter), or failed to respond.
Some limitations concern the stronger finding for angina
For the authors of a recent study [3], one explanation involves a reporting bias. Angina is often established through self-reports of chest pain. Individuals with favourable views of their lives may be more likely to report favourable views of their health and have higher pain tolerance. All self-reported instances of angina were confirmed clinically in the present investigation, but the extent of its classification due to undiagnosed angina was probably dependent on self-report, which introduces a potential reporting bias according to one’s psychological outlook.