Atrial fibrillation (AF) is an epidemic (Chugh et al., 2014) that accounts for 15% to 20% of the 795,000 strokes occurring annually in the United States (Benjamin et al., 2018). Advanced age is the dominant contributing factor to AF-related stroke (Benjamin et al., 2018; Kirchhof et al., 2016). Thus, the incidence of AF-related stroke will rise with the aging population (Benjamin et al., 2018; Hannon et al., 2014). Greater functional deficits and higher acute and long-term care costs are associated with AF-related strokes compared to non-AF strokes (Alkhouli, Alqahtani, Aljohani, Alvi, & Holmes, 2018; Hannon et al., 2014). Thus, AF-related strokes place strain on health care resources and quality of life; yet they are highly preventable by detecting AF (Kirchhof et al., 2016). Early detection of AF is crucial because episodes of ≤24 hours, if untreated, increase the risk of stroke five-fold (Healey et al., 2012). Timely treatment reduces AF-related stroke risk by 68% (Kirchhof et al., 2016).
Proponents of screening for AF contend that there is opportunity to prevent stroke if AF is detected early and anticoagulant treatment is begun (Freedman et al., 2017; Mairesse et al., 2017). Availability of mobile electrocardiogram (ECG) devices that detect AF within seconds has spurred screening initiatives to identify undiagnosed AF (Chan, 2018; Chan & Choy, 2017; Lowres et al., 2015; Quinn et al., 2018; Steinhubl et al., 2018; Svennberg et al., 2015). Screening for AF has potential as a strategy for early detection, but detection is limited to the time of screening. Engaging persons at risk for AF to self-monitor by pulse checks and seek prompt evaluation for an irregular pulse is promoted by the Arrhythmia Alliance (2017) and has potential to detect AF that may occur after screening (Mairesse et al., 2017). However, in persons at risk for developing AF, knowledge deficits that exist about AF, how to recognize it, and how to respond to signs and symptoms of AF hinder treatment-seeking (McCabe, Rhudy, Chamberlain, & DeVon, 2016; McCabe, Rhudy, & DeVon, 2015).
Educational interventions to promote treatment-seeking for signs and symptoms of AF have been reported but not adopted on a widespread basis. Education sessions, lasting approximately 10 minutes, conducted in clinics by Virtanen et al. (2014) and Benito et al. (2015) focused on pulse palpation, recognition of an irregular pulse, and instruction to report an irregular pulse to a health care provider. Virtanen et al. (2014) reported that of 205 participants, 177 (86%) were competent in pulse palpation, and at 1 month, 82% completed their pulse diary. After 1 month, 21% of participants noted and reported an irregular pulse. Benito et al. (2015) reported that over a 2-year period in a sample of 463 participants instructed in pulse palpation, new AF was detected in 8 (1.7%) participants compared to 1 (0.2%) participant (p = 0.02) in the control group, which did not receive instruction. McCabe, Vickers Douglas, et al. (2017) described a program where participants received 30 minutes of education focused on improving knowledge of AF symptoms, modifying incorrect beliefs and attitudes about AF, increasing confidence to recognize and respond to signs and symptoms of AF, and adopting daily pulse palpation. Two months after education, 95% of participants logged 88% of possible daily pulse checks, of which none were irregular.
Munschauer, Sohocki, Smith Carrow, and Priore (2004) conducted a community-based study where nurses presented a slide show (content not described), played audio recordings of an irregular pulse, provided pulse palpation education, and instructed participants to notify their physician of an irregular pulse. When interviewed 30 to 60 days after the session, 89% of 1,839 participants remembered that an irregular pulse is a risk for stroke and 70% had checked their pulse. Of 174 participants who discovered an irregular pulse, 32% notified their physician.
In summary, previous studies suggest that patients can learn to palpate a pulse to check for irregularity, adopt the practice at least in the short term, and report an irregular pulse. The advent of AF screening programs provides an opportunity to offer AF awareness education to large numbers of individuals at risk for developing AF. Yet, evidence is lacking about how AF awareness education delivered during an AF screening event influences cognitive outcomes, such as knowledge, beliefs, and attitudes concerning self-confidence that may drive behavioral outcomes of self-monitoring and treatment-seeking for signs and symptoms of AF.
The purpose of the current study was to evaluate cognitive learning outcomes of an AF awareness educational intervention offered to older adults during a community-based AF screening event. Study aims were to determine if Knowledge, Attitudes, Beliefs about Atrial Fibrillation Self-Monitoring and Treatment-Seeking (KABAF-SMTS) survey scores for (a) knowledge of AF symptoms, (b) beliefs about AF and self-monitoring for AF signs and symptoms, and (c) self-confidence attitudes for monitoring for and reporting signs and symptoms of AF differed from baseline to 2 weeks following AF awareness education.
The authors conducted a single arm pre/posttest clinical trial (access https://clinicaltrials.gov/ct2/show/NCT03440762) that was part of a study to evaluate the feasibility and outcomes of a community-based AF screening and education program. The authors' institution was funded by the Heart Rhythm Society to screen at least 250 adults at risk for AF. The results presented are from data collected from participants who took part in the education portion of the program and completed an objective measure of learning outcomes.
The current study was approved by the Mayo Clinic Institutional Review Board. Written informed consent was obtained.
Sample and Setting
Participants age ≥18 years were recruited from independent living apartments, community centers serving older adults, and a casino within 60 miles of an academic medical center located in the Midwest United States. Participants were required to have at least two of the following self-reported conditions: female, age ≥75, obesity, obstructive sleep apnea, diabetes, hypertension, or peripheral vascular disease. Exclusions were previous diagnosis of AF, inability to communicate in English, and cognitive impairment enough to hinder ability to provide informed consent. Of the 250 individuals who participated in the AF screening activity, as participants' time obligations permitted, the authors recruited 83 participants sequentially to complete the KABAF-SMTS survey until the target sample size plus over sampling for dropout was reached. A sample size of 70 provided 80% power to detect a medium (0.5) effect within a 95% confidence interval (CI). There were no statistically significant differences in clinical or demographic characteristics between the 83 participants who completed the KABAF-SMTS survey and those who did not.
The educational intervention was facilitated by one single cardiovascular advanced practice RN (APRN) (P.J.M.) with advanced training in patient education. The goals were to (a) increase participants' knowledge of AF symptoms, (b) develop beliefs that would sensitize them to their risk for developing AF and seriousness of AF, and (c) develop an attitude of confidence to self-monitor for signs and symptoms of AF and seek treatment. The education approach was modified from McCabe, Vickers Douglas, et al. (2017). Compared to McCabe, Vickers Douglas, et al. (2017), the intervention was shortened to approximately 10 minutes to accommodate participant flow in the screening environment. A shorter animation was presented, and a handout was used instead of a flip chart.
The education was presented immediately following AF screening in an area separate from enrollment and screening activities. To begin, participants were asked what topics were important for their learning and offered learning resources that included viewing an animation about AF (American Heart Association, 2017) and a two-page handout (Heart Rhythm Society, 2016) that contained a description of AF, AF contribution to stroke and heart failure, risks for developing AF, symptoms of AF, and introductory information about treatment. Participants had the opportunity to talk with the APRN, who reinforced and expanded on the content in the animation and handout. The APRN followed a semi-structured outline to ensure that essential components were reviewed, discussed the use of pulse palpation to recognize an irregular pulse, and instructed participants who wanted to learn the technique. Because the discussion with the APRN was individualized, the duration of the education session varied among participants but was typically 10 minutes.
The KABAF-SMTS survey was used to measure knowledge, attitudes concerning self-confidence, and beliefs about AF and self-monitoring and treatment-seeking prior to and 2 weeks after the education session (Table 1). Item development for the KABAFSMTS survey was informed by previous studies (McCabe, Barton, et al., 2017; McCabe et al., 2016; McCabe et al., 2015), such as the Health Belief Model (Rosenstock, Strecher, & Becker, 1988) and self-efficacy (Bandura, 1994) theory. Items were reviewed for content validity (content validity index, 0.91) by four health psychologists, two cardiovascular APRNs, and two nurse scientists. Cognitive interviews were conducted with 25 patient volunteers to assess for interpretation of items, clarity, and time required for administration. Self-reported clinical and demographic data to describe the sample (Table 2) were recorded in an electronic database.
Features of the Knowledge, Attitudes, and Beliefs about Atrial Fibrillation Self-Monitoring and Treatment-Seeking Survey
Demographic and Clinical Characteristics of the Sample (N = 83)
Screening and education events were advertised in advance in local newspapers, newsletters, posters, and brochures placed at the sites. The authors conducted events at walk-in opportunities at four community centers serving older adults, six independent living apartments, and one casino. Individuals were screened for eligibility and an institutionally approved brochure was used to inform individuals about the study.
The authors conducted mock data collection sessions with volunteer participants to train study coordinators. Interrater reliability among three study coordinators was ≥0.90. After enrollment, participants were interviewed to obtain clinical, demographic, and KABAF-SMTS survey data. Participants were screened for AF using a handheld ECG recorder and then participated in the education session. Approximately 2 weeks after the education session, participants were interviewed by telephone to collect KABAF-SMTS survey data.
Analyses were performed using IBM SPSS Statistics for Windows version 25.0. Continuous data are reported as means, standard deviation, and 95% CI. Categorical data are reported as frequencies and percentages. Paired t tests were used to compare the mean differences between preand post-education KABAF-SMTS survey scores. Post priori, the authors analyzed data to determine if any differences in mean change scores existed by age dichotomized as the younger group (≤74 years) and the older group (>74 years) or sex by independent t tests, and education categorized as group 1 (high school or less), group 2 (some college or vocational training), and group 3 (bachelor's or graduate degree) by analysis of variance. The level of significance was set at p < 0.05 (two-sided).
Demographic and Clinical Characteristics of the Sample
The sample was predominately White (98%) and female (77%), with a mean age of 74.9 (SD = 8.56 years) and a median age of 74 years (Table 2). Approximately all participants (99%) were 58 or older. Using the Congestive Heart Failure, Hypertension, Age, Diabetes, and Stroke/TIA-Vascular disease (CHA2DS2-Vasc) scoring system to estimate AF-related risk for stroke and indication for anticoagulation (counting points for: congestive heart failure , hypertension , age ≥65 , female , age ≥75 , diabetes , stroke history , and vascular disease ), the median score was 3.0; 79 (95%) participants had a CHA2DS2-Vasc score of ≥2. Thus, anticoagulation may have been indicated for 95% of participants if AF was discovered (Kirchhof et al., 2016).
Although participants had the option to decline any educational resource offered, all participants chose to view the animation, receive the handout, and talk with the APRN. Results reflect exposure to all three educational resources. Two-week follow-up data from the KABAF-SMTS survey were available for 73 participants. Table 3 displays a comparison between baseline and 2-week KABAF-SMTS total and subscale scores and effect sizes. Scores for the knowledge of symptoms increased significantly as did the scores for threat, benefits, barriers, and confidence.
Comparison of KABAF-SMTS Survey Mean Scores Between Baseline and 2 Weeks After Education
To further explore symptom knowledge, the authors separated the knowledge of symptoms items into knowledge of AF-related symptoms and symptoms not usually related to AF (e.g., wheezing, indigestion, arm numbness). Although there was improvement in knowledge of AF symptoms (mean difference = 0.873 [SD = 1.99], 95% CI [0.403, 1.32]; t = 3.7; p = < 0.001), there was no significant improvement in knowledge related to symptoms not usually related to AF. There was no significant difference between baseline and 2-week risk mean change scores or differences for mean change scores by age, sex, or education level for any subscale of the KABAF-SMTS.
The authors believe the current study is the first published investigation of cognitive learning outcomes of AF awareness education delivered to older adults during a community screening for AF. Goals of the intervention were met in terms of increasing knowledge of AF symptoms and increasing awareness of the seriousness of AF and promoting beliefs and attitudes conducive to self-monitoring for AF and treatment-seeking.
Although knowledge deficits about AF and its consequences in those diagnosed with AF have been documented (Desteghe et al., 2016; Hendriks, Crijns, Tieleman, & Vrijhoef, 2013; Thryosee, Stromberg, Brandes, & Hendriks, 2018), published reports about AF awareness in persons at risk for developing AF are rare. Participants of qualitative studies reported that before diagnosis of AF they had no knowledge of the condition, did not realize they were at risk for developing AF, and did not recognize their symptoms as those of AF (McCabe et al., 2015; Thryosee et al., 2018). In the current study, mean AF symptoms scores at baseline (6.03 [SD = 2.0]) and after the education session (6.89 [SD = 1.7]) reflected that participants were able to identify most symptoms common to AF but were not able to differentiate symptoms not typically associated with AF.
Knowledge of symptom scores (8.44 [SD = 2.7]) in the current study were slightly higher than those of a previous study (7.76 [SD = 3.0]) (McCabe, Barton, et al., 2017) whose participants also attributed non-AF symptoms to AF.
There were no significant changes in participants' perception of risk for developing AF. At baseline, the mean risk score of 13.37 (SD = 2.14) reflects an accurate risk perception; 70% of participants were aware that their chronic conditions put them at risk. A finding of no change is not surprising because participants may have recognized their risk and enrolled because of it. By reading about enrollment criteria, participants may have gained an understanding of their risks before they answered risk items on the survey.
At baseline, 21% of participants reported agreement with the statement “Getting AFib [AF] would not be a serious problem for me,” but at 2 weeks only 5.5% agreed with the statement. The association of AF and stroke, the fact that asymptomatic AF carries as much threat as symptomatic AF, and the incidence of AF in individuals without other cardiac disease was emphasized in the education session. The education session may have created greater appreciation of the seriousness of AF and understanding that one cannot rely on symptoms to judge the seriousness of AF.
McCabe, Barton, et al. (2017) reported that 37% of participants at risk for AF did not realize that AF could occur in the absence of preexisting heart disease, and 25% did not know that asymptomatic AF or AF with symptoms that are not bothersome, carries the same risk for complications as symptomatic AF. Lane, Ponsford, Shelley, Sirpal, and Lip (2006) documented poor understanding of the link between AF and stroke even in persons diagnosed with AF. These findings point to the importance of educational efforts such as those used by advocacy groups to increase awareness of the consequences of untreated AF (Arrhythmia Alliance, 2017).
At baseline, participants in the current study endorsed benefits of early recognition of AF and seeking treatment, but beliefs were strengthened after the education session. The intervention may have reinforced participants' beliefs and influenced them to change responses from agree at baseline to strongly agree at 2 weeks. These results are consistent with those from a previous study (McCabe, Barton, et al., 2017).
The barrier items score at baseline reflects that older adults in the current study did not perceive strong barriers to monitoring themselves for signs (e.g., irregular pulse) and symptoms of AF or seeking evaluation. Nevertheless, perception of barriers was lessened to a greater degree after the intervention. This finding is notable because clinicians may underestimate the willingness of older adults to self-monitor for signs and symptoms of AF.
The largest change in scores from baseline to 2 weeks was observed in the self-confidence scale. Participants reported increased confidence in their ability to recognize signs and symptoms of AF, monitor their pulse, and know when to contact their provider for signs and symptoms of AF. The self-efficacy theory proposes that confidence to undertake self-monitoring and treatment-seeking is critical to enacting those activities (Bandura, 1994).
Thus, the brief intervention used in the current study that helped participants gain knowledge about symptoms of AF, learn how to monitor for an irregular pulse, and when to seek evaluation, may have contributed to participants' self-confidence. Results showing improved confidence to recognize AF and knowing when to seek treatment for AF support findings of a previous study (McCabe, Barton, et al., 2017) and suggest that the educational intervention shows promise as a strategy for promoting early treatment-seeking for signs and symptoms of AF.
Few studies have examined differences among demographic characteristics and knowledge, attitudes, and beliefs about AF in those at risk for developing AF. Results were consistent with those of a previous study in which no differences were found for attitudes and beliefs about AF for age, sex, or educational attainment (McCabe, Barton, et al., 2017). The finding that there was no difference in scores related to educational attainment is notable because it reflects the suitability of this intervention for older adults from a range of educational levels.
The current study is the first to document outcomes of knowledge and beliefs about attitudes of confidence for self-monitoring and treatment-seeking for signs and symptoms of AF in participants who are at risk and who received AF awareness education within a community-based AF screening event.
Thus, the authors suggest implications for practice with caution. Findings that participants perceived few burdens to pulse checking reflect an openness of patients to self-monitoring, which health care providers can capitalize on to engage patients in pulse checking for irregularity. Attitudes concerning confidence to monitor for and report signs and symptoms of AF increased markedly after delivering education that included encouragement to report, minimizing barriers, and role playing for reporting. This finding suggests that health care providers can promote self-confidence in reporting by encouraging the importance of self-monitoring and by coaching patients on how to communicate their observations.
Findings are limited by lack of ethnic and racial diversity in the sample and recruitment of participants only from Midwestern communities. The sample may represent participants who are more motivated to learn and engage in preventive activities than the general population of persons at risk for developing AF. Although participants' educational levels varied, 78% reported education beyond high school. Most participants (96%) had access to a primary care provider; this relationship may have influenced their interest in engaging in self-monitoring and having the confidence to seek treatment.
It is possible that participants in the current study who made the effort to attend the screening event may have been sensitized to the benefits of self-monitoring to prevent adverse outcomes and perceive fewer barriers in doing so. Between the intervention and the 2-week KABAF-SMTS survey data collection, participants' knowledge, attitudes, and beliefs could have been influenced by factors other than the intervention that were outside the control of the investigators. Measurement of knowledge, attitudes, and beliefs 2 weeks after the intervention does not allow evaluation of how those outcomes would be sustained long term.
However, in a previous study, knowledge, attitudes, and beliefs remained stable from the 1-month postintervention measurement to the 2-month measurement (McCabe, Barton, et al., 2017). Acquiring knowledge of AF symptoms and confidence to recognize and seek evaluation for AF signs and symptoms does not necessarily translate to enactment of seeking evaluation. However, knowledge and confidence provide a foundation from which individuals make the decisions to act (Bandura, 1994).
The authors evaluated the cognitive learning outcomes of a brief AF awareness educational intervention offered during a community-based AF screening event. Two weeks after participating in the education session, older adults' knowledge about AF symptoms improved, beliefs about the seriousness of AF and benefits of self-monitoring for AF signs and symptoms were strengthened, perceptions of barriers to self-monitoring were diminished, and confidence for recognizing AF and seeking evaluation was increased.
These findings represent the first known report of cognitive learning outcomes associated with education delivered during an AF screening event and document the benefit of offering AF awareness education to those who participate in AF screening. Further research is needed to determine if similar results can be achieved in more diverse samples and settings where AF screening is conducted. The current initial study provides a foundation for future studies that need to be conducted to evaluate both cognitive and behavioral outcomes, such as treatment-seeking for symptoms or signs of AF (e.g., irregular pulse) and detection of AF. Although such studies require long-term follow up and considerable commitment from participants and research teams, those investigations would elucidate the benefit of AF awareness education.
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Features of the Knowledge, Attitudes, and Beliefs about Atrial Fibrillation Self-Monitoring and Treatment-Seeking Survey
|Item Grouping||Number of Items||Item Example||Response||Range||α|
|Symptom knowledge||14||Shortness of breath, racing heartbeat||1 = correct||0 to 14||0.72|
|Risk belief||5||My health conditions increase my chances of getting AFib.||1 = strongly disagree to 4 = strongly agree||5 to 20||0.62|
|Seriousness/severity (threat) beliefs||4||Untreated AFib can lead to serious medical problems.||1 = strongly disagree to 4 = strongly agree||4 to 16||0.71|
|Benefits beliefs||5||Checking my pulse every day is a small thing to do if it would help to get treatment for AFib before serious health problems occur.||1 = strongly disagree to 4 = strongly agree||5 to 20||0.85|
|Barriers beliefs||5||I don't have time to check my pulse every day (reverse code).||1 = strongly disagree to 4 = strongly agree||5 to 20||0.76|
I am sure that I can learn to feel my pulse for an irregular heartbeat.
I am sure that I can report an irregular pulse to my provider.
|Visual Analog Scale: 0 = not at all sure to 10 = very sure||0 to 70||0.86|
Demographic and Clinical Characteristics of the Sample (N = 83)
|Age (years) (mean, SD) (median [IQR]; range)||74.9 (8.56) 74 (13); 47 to 93|
|Female (n, %)||64 (77)|
|Non-Hispanic White (n, %)||81 (98)|
|Educational attainment (n, %)|
| Less than high school||2 (2)|
| High school||16 (19)|
| Some college or vocational||38 (46)|
| Bachelor's degree||18 (22)|
| Graduate degree||10 (12)|
|Comorbidities (n, %)|
| Hypertension||62 (75)|
| Obesity||41 (49)|
| Obstructive sleep apnea||25 (30)|
| Diabetes||22 (27)|
| Coronary artery disease||8 (10)|
| Previous stroke||7 (8)|
| Tobacco use||6 (7)|
Comparison of KABAF-SMTS Survey Mean Scores Between Baseline and 2 Weeks After Education
|KABAF-SMTS Item||Mean (SD)||95% CI||t||p Value||Cohen's d|
|Total instrument||110.65 (17.75)||120.65 (17.48)||10 (15.7)||19 to 160||[6.32, 13.69]||5.41||<0.001||0.6|
|Symptom knowledge||8.44 (2.76)||9.54 (2.16)||1.1 (3.35)||0 to 14||[0.309, 1.89]||2.77||0.007||0.3|
|Risk||13.37 (2.14)||13.4 (2.31)||0.027 (2.05)||5 to 20||[−0.452, 0.507]||0.114||0.910||—|
|Threat||11.84 (1.8)||12.47 (1.7)||0.616 (1.7)||4 to 16||[0.221, 1.01]||3.10||0.003||0.4|
|Benefits||16 (2.28)||16.68 (1.93)||0.685 (2.13)||5 to 20||[0.187, 1.18]||2.75||<0.001||0.3|
|Barriers||14.55 (2.3)||15.3 (2.04)||0.753 (2.02)||5 to 20||[0.282, 1.22]||3.18||0.002||0.4|
|Confidence||46.29 (13.83)||53.69 (13.36)||7.4 (13.6)||0 to 70||[4.21, 10.6]||4.62||<0.001||0.5|