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Experiences of peer support in self-management interventions among people with ischemic heart disease: a systematic review protocol

Enggaard, Helle; Uhrenfeldt, Lisbeth

JBI Database of Systematic Reviews and Implementation Reports: March 2016 - Volume 14 - Issue 3 - p 10–16
doi: 10.11124/JBISRIR-2016-2372

Review question/objective: The objective of this review is to identify, appraise and synthesize the best available evidence regarding people with ischemic heart disease and their experiences with peer support in self-management interventions.

More specifically, the review question is: How do people with ischemic heart disease experience peer support in structured self-management interventions led or co-led by peers?

1Department of Nursing, University College Northern Denmark

2Department of Health Science and Technology, Aalborg University

3Danish Center of Systematic Reviews: an Affiliate Center of the Joanna Briggs Institute, the Center of Clinical Guidelines–Clearing House, Aalborg University, Aalborg, Denmark

Correspondence: Helle Enggaard,

There is no conflict of interest in this project.

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Ischemic heart disease is one of the leading causes of death worldwide, and specifically in the USA, United Kingdom, Australia and Denmark, even though the mortality due to ischemic heart disease is decreasing.1–5 Ischemic heart disease is insufficient blood flow to the heart muscle, caused by narrow coronary arteries or obstructions by a thrombus often due to artherosclerosis.6,7

Ischemic heart disease is within the group of cardiovascular diseases (CVDs), with common risk factors such as tobacco, unhealthy diet, physical inactivity, and psychosocial stress.8 This review focuses on ischemic heart disease because prevention has been proven to be effective. Specifically, more than 50% of the reduction that has been observed in the mortality of patients with ischemic heart disease is related to changes in lifestyle.8 European guidelines on the prevention of CVD highlight that secondary prevention is based on self-care and self-management.8 Self-management is defined as “the individual's ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition. Efficacious self-management encompasses ability to monitor one's condition and to affect the cognitive, behavioral and emotional responses necessary to maintain a satisfactory quality of life. Thus, a dynamic and continuous process of self-regulation is established.”9(p.177) The World Health Organization defines self-care as “the ability of individuals, families and communities to promote health, prevent disease, and maintain health and to cope with illness and disability with or without the support of a health-care provider”.10(p.102) These concepts are similar given that both focus on the individual's ability and approach to handle life and disease. However they are different in that self-care also includes families and communities. This review will focus on the individual's approach to and management of life with ischemic heart disease. Secondary prevention is often delivered in cardiac rehabilitation led by health care professionals,8 but structured peer support interventions led by peers seem to be beneficial in supporting the life of individuals with ischemic heart disease and other chronic conditions.8,11–14

Peer support is defined by Dennis as the provision of “emotional, appraisal and informational support”,15(p.325) which can be provided in various ways, for example, one-to-one sessions and group sessions delivered online, at home, in hospitals or in community settings.15 Furthermore, Dennis distinguishes between three types of people providing peer support: laypeople, peers and paraprofessionals.15 This review considers peer supporters as peers. Peers are described as laypeople selected by the professionals or by self-referral who have similar characteristics as the target population. They receive some training to provide an intervention. This training is structured to introduce the peer to the program objectives and the acquisition of skills necessary to use their experiential knowledge and unique understanding of the target population. Peers possess experiential knowledge that is concrete, pragmatic and derived from personal experience rather than formal training.15,16

A systematic review on the experiences and perceived impact of peer support interventions across multiple chronic diseases showed that peer support can provide informational, emotional and appraisal support that benefits both the peers and the participants.17 This review stated that both parties can experience a development in knowledge about disease and self-management skills, and in their behavior and approach to dealing with life and disease.17 Participants perceive a peer supporter to hold a higher authority and credibility rather than professionals because support from peers is grounded in personal experiences and shared identity.17 This reinforces the fact that peers can provide important support to people with, for example, ischemic heart disease that professionals cannot. That peers benefit from acting as peers has also been found in other studies,18,19 one of which featured peers who were people who had myocardial infarction (MI).19 The fact that peer support is beneficial for both the parties denotes the potential for peer support in secondary prevention, wherein health is improved for both the provider and the receiver of peer support.

The systematic review by Embuldeniya et al.17 also highlighted that sharing experiences reduced the feeling of isolation and loneliness and found that it was central for success in peer support interventions. Yet, these results are threatened if peers and the target population are too different. Participants can experience isolation within the peer support interventions if peers are unfamiliar with their condition, or too different in lifestyle or personalitities. This argues for peer support in disease-specific interventions and, in this review, related to people with ischemic heart disease.

Peer support interventions are applied to support the everyday life of people with ischemic heart disease.16,20–22 One study showed that structured co-led peer support intervention for people with post-MI and coronary artery by-pass surgery (CABG) promoted active participation in cardiac rehabilitation.23 Another study by Carroll compared the effect of peer advisor and advanced practice nurses’ interventions with standard care after MI. This study did not show any significant differences in effect, but participants expressed satisfaction with the peer advisor intervention.24 It is, however, not known what experiences led to this satisfaction.

Hildingh and Friedlund25,26 found that people who participated in a peer support intervention after experiencing MI, percutaneous coronary intervention or CABG exercised more regularly, smoked less and had a bigger network and higher level of support from non-family members than the comparison group. The trend that peer support can increase the level of physical activity for people with MI is also found elsewhere.27 Still, it is not known how participants experienced these peer-led activities or what level of impact they perceived to have received in peer support regarding these changes.

A study on peer support before and after CABG showed a trend toward a decrease in anxiety, higher self-reported activity level, and a higher expectation to self-efficacy post-CABG.28 Nevertheless, it is not known what aspect of the peer support intervention led to these positive effects.

A peer support intervention to enhance self-management has been studied qualitatively in the context of heart disease, where peers who had an MI supported similar people after they had completed cardiac rehabilitation.29 This study showed that participants experienced peer support differently to cardiac rehabilitation. They positively highlighted the sharing of experiences in peer support as well as motivation and techniques to translate advice and knowledge into behavior changes and techniques to cope with the psychological consequences of living with MI.29

As shown, existing research demonstrates the potential for peer support interventions for people with ischemic heart disease to support their daily living with the disease. However, little is known about how these people experience peer support. Therefore, it is appropriate to identify evidence concerning this. The findings of this review might assist those developing and implementing peer support interventions for people with ischemic heart disease.

A preliminary search of the JBI Database of Systematic Reviews and Implementation Reports, CINAHL, PubMed, Google Scholar and Trip Database revealed that there are no available systematic reviews or protocols on this topic.

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Inclusion criteria

Types of participants

This review will consider studies that include people diagnosed with ischemic heart disease who are participating in or have participated in a peer support intervention.

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Phenomena of interest

This review will consider studies based on experiences of structured peer support in self-management interventions, led or co-led by peers, that support individuals in daily living with ischemic heart disease.

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This review will consider studies conducted in any setting.

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Types of studies

This review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.

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Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English, Danish, Norwegian, Swedish and German will be considered for inclusion in this review (managed by the authors). Databases will be searched from their inception as different research topics are addressed in different time periods in different continents.30 The literature search will be carried out under the guidance of a research librarian.

The databases to be searched will include:

PubMed, CINAHL, Scopus, Academic Search Premier and PsycINFO.

The search for unpublished studies will include:

Google Scholar, Mednar and ProQuest.

Initial keywords to be used will be:

Myocardial ischemia, coronary disease, Ischemic heart disease, coronary heart disease, coronary artery disease, cardiac ischemic, atherosclerotic heart disease, peer counseling, peer group, peers, peer support workers, peer support group, lay health worker, lay people, laymen, volunteers, voluntary worker, group discussion, self care, self-efficacy, self efficacy, self-care, self-regulation, self-management, empowerment.

Homepages to be searched:

The homepages represent professional organizations with special interest in peer support or cardiac diseases. They are searched to identify missing references or innovative projects on the topic of this review.

Peers for progress:

Danish Heart Association:

American Heart association:

British Heart Foundation:

Australian Heart Foundation:

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Assessment of methodological quality

Articles selected for retrieval will be assessed by two independent reviewers for methodological validity before inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

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Data extraction

Data will be extracted from the articles included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The extracted data will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives. If the data is missing or clarification is required, efforts will be made to contact the authors.

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Data synthesis

Qualitative research findings will, wherever possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (level 1 findings) rated according to their quality, and categorizing these findings on the basis of similarity in meaning (level 2 findings). These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings (level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.

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The authors would like to thank Line Jensen (MA) for proofreading.

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Appendix I: Appraisal instruments

QARI appraisal instrument



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Appendix II: Data extraction instruments

QARI data extraction instrument





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