Findings showed that after MI, participants faced unknown and unexpected conditions and hence, their main concern was encountering unfamiliar conditions. Consequently, they used some strategies to manage this main concern. The main categories of the study were encountering unfamiliar conditions, aggravation of conditions, fighting between awareness and preference, taking problematic arbitrary measures, consulting lay people, and threat to life (Table 2).
1. Main concern: Encountering unfamiliar conditions
Participants reported that severe chest pain at the time of MI caused them high levels of anxiety and stress and gave them a sense of inevitable imminent death. They noted that they had never experienced such symptoms and highlighted that such lack of experience caused them great concern. In this step, participants encountered some symptoms that they had never experienced before. These symptoms included severe chest pain radiating to the shoulder, arm, and back, a sense of suffocation, nausea, and vomiting. Even patients with previous history of MI reported that the symptoms of their current MI were considerably different in type or severity from the symptoms of their previous MI. The two subcategories of the main concern of participants were incorrect interpretation of symptoms and uncertainty about the best measures due to ambiguities about symptoms.
1.1. Incorrect interpretation of symptoms
None of the participating patients had considered themselves at risk for MI. Therefore, they had incorrectly interpreted symptoms such as shoulder or abdominal pain, nausea, and vomiting and attributed them to problems other than MI.
I stooped with my hand on my chest. I had severe nausea and vomiting for two days and hence, I thought it was a stomach problem. I did not think that it was a heart problem until the doctor told me (P. 3).
1.2. Uncertainty about the best measures due to ambiguities in symptoms
Inappropriate understanding about symptoms and their incorrect interpretation made participating patients neither take any appropriate measure nor seek medical help until the aggravation of their symptoms or development of obvious cardiac symptoms.
I only had pain in the left side of my face and a radiating pain to my left hand. However, my symptoms were not the symptoms of MI and I thought that there would be no serious problem. I never thought that I was experiencing an MI (P. 14).
2. Context
Context refers to a set of conditions that are part of a given situation and give meaning to it. Some contextual factors can aggravate the conditions of patients with MI and negatively affect their MI self-management. These factors are not directly related to the course of MI; rather, they are personal, environmental, or social factors that can influence all patients with MI. The subcategories of these factors were loneliness at the time of MI, affliction by underlying diseases, occurrence of symptoms at inappropriate time, and referring to non-specialty centers.
2.1. Loneliness at the time of MI
In most cases, MI was associated with severe and debilitating pain and patients needed others’ help to save their lives. However, some patients reported that they were alone at the time of MI and hence, experienced severe pain and strain until the arrival of help.
My pain was very severe. Nonetheless, I had to drive to the healthcare center because I was alone and was in a remote area that nobody could help me. You know, my garden was at the end of the village and people were not in their gardens at that time because that time was not the harvest time (P. 4).
2.2. Affliction by underlying diseases
Affliction by underlying diseases such as diabetes mellitus had caused patients not to experience the symptoms of MI as severe as other patients. Disabilities associated with underlying diseases had also affected prehospital self-management of MI among some participants.
I have lost my toes due to diabetes mellitus and hence, have balance disturbances and frequently experience fall. I couldn’t do anything when my pains increased. My wife and son were with me (P. 6).
2.3. Occurrence of symptoms at inappropriate time
The symptoms of MI are unpredictable and may occur at any time. Some participants had experienced MI symptoms at midnight or holidays, i.e., when healthcare services were not easily accessible and hence they had been unable to make sound decisions and effectively manage their symptoms.
Primary healthcare centers are closed at the afternoon. There is only one ambulance in our area that may transfer you to hospital if your conditions are severe. At the afternoon, you should personally refer to the hospital or call the emergency medical service. The emergency medical service staff usually arrive after twenty minutes because their station is far from us (P. 4).
2.4. Referring to non-specialty centers
The early onset of MI treatment is critically important to treatment outcomes and hence, patients need to refer just to specialty centers to immediately receive advanced MI management services from experienced staff. Nonetheless, some participants reported that they had referred to the office of general physicians or to non-specialty healthcare centers with limited equipment for MI management. This made them spend long time on receiving the right diagnosis of MI and receiving MI-specific treatments.
First, they took me to the primary healthcare center of our village, where there was an inexperienced doctor who couldn’t do anything for a serious problem like a heart problem. He only administered some pills to reduce my pain. However, the burning sensation in my chest was coming to my neck. His pills did not work and he said that I had to go to the city. Then, they took me here by ambulance (P. 1).
3. Strategies
Strategies refer to participants’ actions/interactions for the management of their main concern. Participating patients had taken some strategies for the self-management of their symptoms. However, their strategies were ineffective. These strategies were fighting between awareness and preference, taking problematic arbitrary measures, and consulting lay people.
3.1. Fighting between awareness and preference
With the onset of MI symptoms, patients had felt unpleasant feelings but had not paid careful attention to their symptoms. Even patients with previous history of heart problems had not attributed their symptoms to heart problems. Despite their awareness of symptoms, they had preferred to deny the existence of any heart problem and avoid attributing their symptoms to serious problems such as MI. The subcategories of this category were ignoring symptoms, concealing symptoms, continuing activities, and waiting for spontaneous recovery.
3.1.1. Ignoring symptoms: Ignoring symptoms was one of the most prevalent strategies of participants. They highlighted that they had ignored their symptoms and had taken no measure if their symptoms were not severe or their pains were in areas other than the chest.
We were working in the farm land in the village. I was pushing a wheelbarrow that contained woods. Suddenly, I felt that my breath was becoming short and felt a sense of suffocation. I left the wheelbarrow and waited. I disregarded it t and told myself it would disappear spontaneously (P. 4).
3.1.2. Concealing symptoms: Participants had also concealed and downplayed their severe pains in order not to disturb their family members’ peace. This had caused them to avoid taking any serious measure to manage their symptoms.
Sometimes, my wife noticed that I had chest pain, but I pretended that I had no serious problem. I knew that my wife had great fear over these things and hence, I didn’t tell her anything about my recent severe pain and just told her that there was nothing wrong with me (P.13).
3.1.3. Continuing activities: Some participants reported that performing heavy activities had caused them MI symptoms. Nonetheless, they noted that they were inattentive to their activity-induced chest pain and continued their activities. They preferred to finish their activities before taking any measure for their chest pain. This had aggravated their symptoms.
I was driving that my pain started. I disregarded it and decided to drive to home. I told myself that I would do something for the pain after arriving home. The pain was intolerable when I arrived home (P.10).
3.1.4. Waiting for spontaneous recovery: Some participants had endured their pain hoping that it would spontaneously disappear. They had waited for spontaneous disappearance of their symptoms while their symptoms had progressively increased, leading to delay in medical help seeking.
I endured my pain for two hours and told myself that it was not a significant problem. However, when we arrived at hospital, they said why we came to hospital so late and highlighted that MI-related pain should not be endured for more than two hours (P. 10).
3.2. Taking problematic arbitrary measures
One of the main strategies of participants for the self-management of MI symptoms was taking problematic arbitrary measures. In this step, participants had intentionally taken arbitrary measures to reduce their symptoms. However, their measures not only had not reduced their symptoms, but also had aggravated their symptoms and had led to delay in medical help seeking in most cases. The subcategories of this category were reusing previously prescribed medications, taking traditional measures, and referring to doctor alone.
3.2.1. Reusing previously prescribed medications: Some participants with previous history of heart problems had reused their previous medications to manage their symptoms. They had attributed their symptoms to heart problems and attempted to manage their symptoms by reusing their previous medications.
When my pain started, I used my hypertension and heart medications; but they were not beneficial. I felt no reduction in my pain and no change in my conditions (P. 4).
3.2.2. Taking traditional measures: Some participants had used traditional products such as herbal essences or teas to enhance their cardiac function, improve their calmness, and reduce their pain. However, none of these measures were effective in significantly reducing their symptoms.
My husband brought me a glass of rosewater and sugar because rosewater has sedative effects. He also sprinkled some rosewater on my face. But, my pain did not change (P. 13).
3.2.3. Referring to doctor alone: Some patients with MI had experienced fear over their symptoms and had found themselves unable to cope with their pain. Therefore, they had decided to seek medical help alone at any cost through walking or driving long distances. This had aggravated their symptoms and put others at risk.
My chest pain became very severe and I had severe dizziness as if my head was not in my control. There was no one with me. I drove car and reached hospital with great difficulty (P. 8).
3.3. Consulting lay people
Some participants had been with their family members or friends at the time of MI and hence, had consulted them. However, some recommendations of their family members or friends had negatively affected their MI management. The subcategories of this category were inaccurate recommendations and inappropriate patient transferring.
3.3.1. Inaccurate recommendations: Based on their own presumptions and without any professional knowledge, some family members or friends of patients had recommended patients to use some medications. Although they had provided their recommendations to reduce patients’ symptoms, the ineffectiveness of their recommendations had led to symptom aggravation.
My mother’s pain did not reduce whatever we did; rather, it progressively aggravated. We didn’t know what to do. We gave her ibuprofen which was ineffective. Her breathing was also becoming very difficult (P. 12).
3.3.2. Inappropriate patient transferring: Aggravation of chest pain and patients’ request for help had required their family members or friends to transfer them to healthcare centers. However, they had limited knowledge about accurate patient transfer and transferred patients to healthcare centers with private vehicles. During such inappropriate patient transfer, some family members or friends even required patients to walk or climb stairs.
When my father’s pain increased, my brother and I took him to the car and put him on the back seat and transferred him to a physician’s office. In the office, there were some stairs. Climbing the stairs caused my father great discomfort (P.17).
4. Outcomes: threat to life
Participants reported that their strategies for MI self-management caused delay in medical help seeking, aggravated their symptoms, and hence, threatened their lives. They noted that they had eventually felt that their death was imminent and inevitable and felt compelled to seek medical help. The subcategories of this category were symptom aggravation and close encounter with death.
4.1. Symptom aggravation
Participants highlighted that the postponement of medical help seeking seriously aggravated their symptoms beyond their imagination.
Pressure and pain in my chest became so severe as if a person was hitting my chest with a hammer. I felt short of breath (P. 7).
4.2. Close encounter with death
Most participants reported that the prolongation of the process of MI self-management encountered them with the sense of imminent death. Even patients with previous history of chest pain described their pain as lethal.
This time was different from previous times. I hadn’t experienced so severe pain before. I had severe pain in my back and arm as if one person was pulling my arm bones. I had severe pain in my jaw and in the back of my ear. What a severe pain it was! I felt I was dying (P. 3).
Storyline
Patients with MI experience different symptoms. These symptoms are completely new and unknown to those with no previous history of heart problems and hence, they incorrectly interpret them and attribute them to disorders other than heart problems. Patients with previous history of heart problems may also experience symptoms that are different from their previous symptoms in type or severity and hence, experience confusion in symptom management. Increasing chest pain and dyspnea help patients think about affliction by heart problems. Nonetheless, some patients may still ignore their symptoms due to conditions such as loneliness, affliction by underlying diseases, or inappropriate time of symptom onset. Some of them may also prioritize the rest of their activities over symptom management or may even conceal their symptoms from their family members in order not to disturb their peace. Most patients tolerate their symptoms hoping for their spontaneous disappearance.
Ignorance of symptoms and inappropriate strategies for their management aggravate them and give patients a sense of approaching imminent death and hence, require them to take measures to escape death. Examples of these measures are reusing previously prescribed medications and taking traditional medicine products. However, none of these measures are effective and therefore, patients decide to seek medical help. Patients who are alone attempt to refer to healthcare centers alone which in turn aggravates their symptoms, while patients who experience symptoms in the presence of family members or friends ask their help. However, family members or friends may have limited knowledge about accurate symptom management and patient transfer and hence, may provide inaccurate recommendations and inappropriately transfer them to healthcare centers. These strategies can also aggravate patients’ conditions. The eventual outcomes of this process are threat to patient life and close encounter with death. This process is the process of taking problematic arbitrary measures.