"Elders in our study tend to view their work as a lifelong endeavour, and there is an ethic of stoicism with an attitude of , I can wait it out or not go to the hospital", said Alex Clark, lead researcher on the study and a professor in the Faculty of Nursing at the University of Alberta in Edmonton, Canada.

The ongoing study is supported by the Alberta Centre on Aging. Research assistant Nicole Freydberg interviewed 30 patients 65 to 85 years old (70 per cent of them male), 24 unpaid caregivers including spouses and other family members, and 22 health professionals in rural communities in Alberta. Focus groups were also conducted with home care nurses in the health region. During the interviews, patients were encouraged to retrace their illness experience, explore what their heart conditions meant to them, and identify both barriers and facilitators to managing chronic illness in a rural setting.

During this process, more than half of the patients recalled times when they had waited days for heart-related symptoms to subside, or gotten used to the discomfort and delayed seeking medical care until symptoms were severe.

"During our discussions, rural elders expressed a pride in their ability to avoid care-seeking for seemingly minor ailments," Freydberg said. "Many did not want to burden what they viewed as an already stressed health care system. However, many of their symptoms became difficult to control successfully at home."

Because the patients often associated the causes of their heart conditions with a lifetime of hard labour and stressful work conditions, usually farm and manual labour--they felt they had little control over the progression of their illness. Patients often spoke of how they've learned to live with", ignore or don't think about their heart conditions.

"What this means is, there is a risk of seeking help at too late a juncture," said Clark. "But 24 hours can make the difference between successfully controlling heart failure symptoms and having to be hospitalized for a lengthy time," he noted.

The researchers were encouraged that most of the patients and their caregivers were interested in learning more about their illness, and requested information on how better to manage medications, diet, exercise, symptoms and related quality of life issues. Many of them wanted to see their rural community form support groups for chronic illness and management.

Heart failure is the most common reason for hospitalization of seniors in Canada. In addition rural patients are more likely to be hospitalized than their urban counterparts, and due to differences in prescribing, are less likely to get the drugs they need at the right dosages, Clark said.

Preliminary results of the study suggest that support for the rural patients should stress the importance of recognizing symptoms and seeking help earlier from health care professionals, and should harness the strong work ethic evident in the rural population.

The researchers also recommend that rural and urban health care regions continue to find ways to improve rural access to specialist health professionals in heart care, such as physicians, nurses and pharmacists.

ualberta