Cognitive and emotional reactions to pictorial-based risk communication on subclinical atherosclerosis: a qualitative study within the VIPVIZA trial

Figures & data

Figure 1. Graphical elements of the result letter, sent to participants in the intervention group after the ultrasound examination of carotid arteries, including information on plaque and intima media thickness.

Table 1. Illustration of the analysing process moving from text to sub-theme.

Text	Condensed meaning unit	Code	Sub-category	Category	Sub-theme
Well, the thing is that it becomes a warning bell. Yes, well, you have to grab hold of things and not just throw away that piece of paper and think ‘Whatever!’ but instead try to improve things. Yes, I think it has been good.	Good to get a warning bell and try to grab hold of things and improve them	A strong warning bell	Shocking news	A wake-up call	Problem-focused coping
I was very tense and hoped, I really hoped for an improved result. But I was worried though that it would not be that way, so the relief was just enormous when I found out that ‘yes, it is in fact improved’.	The relief was enormous when I saw that it was improved	Relieved to find out	Relived to learn about my result	Joy and relief	Encouragement driven process

Notes: The complex nature of the research questions, focusing on cognitive and emotional reactions and their interaction, was one of the reasons why qualitative content analysis was considered an appropriate choice of method. This, in particular, due to how the text in the initial phase is shortened into condensed meaning units, which allows for careful assessment of manifest as well as latent content [1]. In this initial phase, where one should stay close to the original text and shorten the material while still striving to preserve the core meaning, the method was useful for discovering nuances and distinguishing between cognitive and emotional processes. The meaning units were condensed, coded and grouped into subcategories and categories. The analysis continued by going back and forth between codes and subcategories, a process of turning and re-evaluating with the aim of reaching understanding of the participants stories and value codes and categories against the purpose of the study [15].

Table 2. Description of the informants regarding demographic data and atherosclerosis at baseline.

	Men	Women
	(n = 7)	(n = 6)
Age (years)
50	2	0
60	5	6
Education
Basic or middle	5	4
High (university)	2	2
Place of residence
City	5	2
Rural coastland	0	1
Rural inland	2	3
Plaque status
No plaque	5	4
Plaque	2	2
IMT colour code
Green	2	1
Yellow	1	2
Orange	2	1
Red	2	2
Nurse phone call
Yes	6	4
No	1	2

Table 3. Overview of results in terms of main theme, sub-themes, categories and sub-categories.

	Cognitive and emotional reactions in strong interplay for orchestration of health-related behavioural change
Main theme Sub-themes	Problem-focused coping		Encouragement-driven process
Division of categories in chronological order	Intervention	Reaction	Action
Categories Sub-categories	A source of knowledge Get to know A clear message A source of support The follow-up call: clarifying,  reassuring and health  promoting Reinforcing messages Recurring feedback Generation of social support	Joy and relief Happy about my result Positively surprised by improved result Relieved to learn about my result A wake-up call Shocking news Unpleasant and disturbing message For me, bad health was remote Empowered and seeing opportunities rather than threats Felt no worries about the result Optimistic about my possibilities for health behaviours I know I can do it (self-efficacy) Habits matter (response efficacy)	Making the decision I realised I have to do something about my health I want to stay in good health Ready for change I have prior experience of disease (own or others) Retirement is a new chapter in life with new opportunities Staying aware, active and self-evaluating After finding out my result, I changed my way of living I have an awareness of health behaviours and CVD Healthy habits are enjoyable and makes me feel well I guess I could have done more for my health Goals and motivators keep me going

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