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[Qualitative Research in Medicine & Healthcare 2017; 1:7006] [page 121]
Introduction
Cardiovascular disease is the leading cause of death
in the United States followed closely by stroke.1,2 In 2010,
the direct and indirect costs of the two together were es-
timated to be over three-hundred billion dollars.2 Car-
diovascular disease and stroke are often caused by too
much buildup of cholesterol in the blood. The excessive
buildup of cholesterol in the blood is called high choles-
terol. Some uncontrollable factors that increase one’s risk
for high cholesterol are heredity, age, and sex; but patients
can reduce their risk by eating a healthy diet, exercising
more, maintaining a healthy weight, not smoking, man-
aging chronic illnesses if present, and taking medication
when prescribed. Nevertheless, 73 million Americans live
with high cholesterol. One out of three has it under control
and less than half are getting any treatment at all in the
form of diet modification, increased physical activity or
the use of medications.3 However, Aggarwal and Mosca4
suggest the failure of patients to change their behavior as
part of a treatment regimen is not due to a lack of knowl-
edge about high cholesterol.
As one form of treatment, statins control the rate of
cholesterol produced in the body while increasing the
liver’s ability to remove excess from the blood.5 These
medications (known by popular brand names like Lipitor
and Crestor) are effective in decreasing morbidity and
mortality rates associated with cardiovascular disease, so
physicians often prescribe them.6 However in the United
States, 40 to 60 percent of patients fail to take them.7 In
addition to never taking a statin, a patient may discontinue
its use against medical advice, take more or less than pre-
scribed, use it with other drugs it negatively interacts, and
disregard recommendations to diet and exercise to main-
tain a healthy weight.8 Poor adherence is common within
3 to 6 months.9 Even the ability to accurately foresee one’s
risk of heart attack within ten years with or without a
statin does not result in the likelihood that a statin will be
taken as perscribed.10 Patients cite muscle pain as the pri-
mary reason for discontinuation, followed by cost and a
perceived lack of efficacy. Those with low household in-
comes, who have experienced some muscle pain while on
statin therapy, and take other medications for cardiovas-
cular disease are at the highest risk for nonadherence.11,12
Patients living in neighborhoods with a high density of
Hispanics, African Americans, or immigrants and females
If my cholesterol is…then I foresee…: patient accounts of uncertainty
Darlene K. Drummond
Institute for Writing and Rhetoric, Dartmouth College, Hanover, NH, USA
ABSTRACT
The author examines the talk of patients with high cholesterol as they discuss their experiences of adding a statin to their treatment
regimen. The primary objective was to understand patients’ expectations of statins, and their beliefs and feelings as they continued or
discontinued use, and to better understand why adherence to a statin regimen is particularly low. While numerous studies report reasons
for nonadherence, few apply theory to provide plausible explanations. Analysis of the focus group data revealed three major themes.
First, patients do not view high cholesterol as serious in light of other major health problems like diabetes and cancer within the house-
hold. Second, patients believe statins are effective in lowering cholesterol but risky. Third, many patients do not understand how high
levels of cholesterol are produced in the body and how statins interrupt that process. Problematic integration theory is used to explain
the uncertainty patients experience when given a diagnosis of high cholesterol, the use of statins to control it, and the quality of infor-
mation received about both cholesterol and statins.
Correspondence: Darlene K. Drummond, Institute for Writing and
Rhetoric, Dartmouth College, 6250 Baker Library, Room 206B,
25 North Main Street, Hanover, NH 03755, USA.
Tel.:+1.603.646.9840 - Fax: +1.603.646.9747.
E-mail: Darlene.K.Drummond@Dartmouth.edu
Key words: medication adherence, high cholesterol, statins, patient
accounts, problematic integration, uncertainty.
Conflict of interest: the author declares no potential conflict of in-
terest.
Acknowledgments: this article is based on data made available to
the author through research conducted at the University of Miami-
Humana Health Services Research Center under the direction of
Vaughn Keller and sponsored by AstraZeneca.
Received for publication: 21 August 2017.
Revision received: 3 October 2017.
Accepted for publication: 3 October 2017.
This work is licensed under a Creative Commons Attribution Non-
Commercial 4.0 License (CC BY-NC 4.0).
©Copyright D.K. Drummond, 2017
Licensee PAGEPress, Italy
Qualitative Research in Medicine & Healthcare 2017; 1:121-127
doi:10.4081/qrmh.2017.7006
Qualitative Research in Medicine & Healthcare 2017; volume 1:121-127
not males are more likely to be nonadherent.11 Discontin-
uers admit that they fail to regularly monitor their choles-
terol, are not satisfied with their physicians’ explanation
of cholesterol treatment, and feel the need to use the in-
ternet to research statins for themselves.12
Medical researchers are not oblivious to the concerns
of patients and seek to confirm or disconfirm claims of
the adverse effects of statins. A few meta-analyses con-
clude that some adverse effects include muscular toxicity
and/or myopathy,13,14 cataracts,13 raised liver enzymes,14
and diabetes.13,15,16 However, most argue that these effects
are small compared to the beneficial effects of statins on
major cardiovascular events.14,15 The Cholesterol Treat-
ment Trialists’ (CTT) Collaboration17 asserts statins re-
duce the risk of major vascular events irrespective of age,
sex, baseline LDL cholesterol, previous vascular disease
or the presence of other diseases. The continued use of
statins with at least eighty percent or greater adherence
over time is associated with progressively increasing sur-
vival rates.18 Statins are associated also with lower risks
of dementia, cognitive impairment, fractures and pneu-
monia.14 To date, there is no evidence that connects statins
to an increased risk of cognitive decline or to cancer,16,17
to renal disorders, arthritis, depression5 or to adverse ef-
fects on mood, sleep, and physical functioning.19,20
In addition to establishing the lack of adherence to
statin therapy, discerning the reasons for nonadherence,
and investigating the adverse effects of statins, researchers
seek to understand the thought process involved in statin
nonadherence. Chakraborty21 applied the mental models
approach to understand lay perceptions in relation to ex-
isting scientific information on the risk of nonadherence.
He found statin-nonadherent patients negatively perceive
the healthcare system, the Food and Drug Administration,
the drug industry, government, and insurance companies,
and consequentially believe statins are too risky. He con-
cluded that these patients do not trust the information they
receive from major stakeholders in the fight against car-
diovascular disease. Although insightful, these findings
seem incomplete. We still do not understand the patient’s
thought process when a statin is added as part of the treat-
ment plan, or how she or he evaluates its worth and con-
tinued use. We do not fully understand why statin
adherence is low.
To me, distrust signals misgivings, questions, doubts,
suspicions or uncertainties about something or someone.
Problematic integration theory suggests we orient to our
world based not solely on our beliefs but consider what
issues are associated with those beliefs and the evaluative
meanings those associations hold for us.22-24 It proposes
that illness involves the endless experience of the prob-
lematic integration of one’s beliefs or expectations with
one’s desires.25 The theory organizes types of uncertainty
into a coherent framework and asserts that we are often
uncertain about how to integrate a particular belief with
other beliefs.24 My objective was to ascertain the percep-
tions, beliefs, understandings, and uncertainties of patients
about high cholesterol and the use of a statin, and then
discuss those findings using problematic integration the-
ory. A clearer understanding of this thought-process may
assist physicians in devising more effective ways in ad-
dressing high cholesterol with their patients.
Materials and Methods
My study draws upon existing data from a previous in-
vestigation (sponsored by a major drug company) that con-
sisted of focus-group interviews conducted with
high-cholesterol patients and their spouses residing within
20 miles of a focus-group facility in the Southeastern region
of the United States.26 All procedures were approved by an
institutional review board. In that previous investigation, I
served as a focus-group facilitator. Statin adherent and non-
adherent participants were recruited from the claims data-
base of a major health insurance company via telephone
and prepared script. The health insurance company desig-
nated a patient as non-adherent when he or she ceased using
a statin for at least 3 months after a minimum of six months
of therapy. The majority of patients were white, middle-
class, and between the ages of 45-78. A total of thirty-two
patient-spouse dyads were assigned to four primary focus
groups based on the patient’s statin-adherence status. This
resulted in two adherent and two nonadherent groups. After
interviews were conducted with the patient-spouse dyads,
we placed each individual into a patient-only or spouse-
only group for additional interviewing.
Utilizing a semi-structured interview format, partici-
pants were asked about their reactions to a high-choles-
terol diagnosis, treatment plans, and how these issues
impacted their relationships. The sessions were video-
taped and professionally transcribed. I analyzed the tran-
scriptions utilizing McCracken’s27 five-step guideline for
qualitative analysis and Owen’s28 framework of identify-
ing key terms. First, I sorted responses addressing a high-
cholesterol diagnosis, statins, and adherence. Then
examined the transcripts within and across focus groups
based on adherence status to identify any logical relation-
ships and contradictions. Third, I re-read the transcripts
to confirm or disconfirm emerging reasons for adherence
or nonadherence within specific contexts. Then I reviewed
themes to determine connections between and across var-
ious contexts. Finally in using McCracken’s27 guidelines,
I examined the resulting themes within a framework of
published research on statin adherence and problematic
integration theory. In addition, I looked for the repetition
of key words that were significant in describing a certain
experience or feeling; examined meanings threaded
throughout the text, and identified important words or
phrases displayed through the use of vocal inflection, vol-
ume, or emphasis.28 Three major themes emerged. First,
patients do not view HC as serious in light of other major
health problems within the household. Second, patients
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Article
believe statins are effective in lowering cholesterol but
risky. Third, many patients do not understand the disease
process and how statins interrupt that process.
Results
High cholesterol is not serious
Whether adherent or not, patients believe the best way
to manage high cholesterol is with a combination of
healthy eating, exercising and taking a statin. However,
as indicated in the following comments, they do not view
a diagnosis of high cholesterol as significant especially if
genetic or in comparison to other health problems that
exist within the household. (Note. AF=adherent female,
AM=adherent male, NF=nonadherent female, NM=non-
adherent male).
AF1: It’s not like you have cancer or something.
AM1: That’s true. My father died at 87. He smoked
3 packs of Camel a day and died from lung cancer.
AF2: I don’t think about my cholesterol at all! Who
thinks about cholesterol when you are going to be op-
erated on and be in a brace?
NF: Does cholesterol have symptoms? I don’t
know of any! [Laughing]
NF: My mom’s first five siblings died of Parkin-
son’s. That’s what I’m worried about!
NM: It’s not a priority item. It’s not something that
I think is going to affect me immediately, or that is
going to create a problem that can’t be taken care of.
NF: Families have lived with it through genera-
tions. That’s part of their body make up and it may not
be a concern although doctors are focused in on that.
Most of the patients and their spouses have multiple
health problems. Therefore for them, a diagnosis of high
cholesterol fits into a complex hierarchy of health issues
in which immediate pain and perceived vulnerability are
the criteria governing how serious an illness is judged.
Cancer, diabetes, other chronic illnesses, and trauma are
often viewed as much more important than a high-choles-
terol diagnosis. These illnesses have visible symptoms
and consequences, unlike high cholesterol. Some patients
view cholesterol simply as a natural component of body
functioning. They do not connect directly or indirectly the
deaths of any loved ones to a diagnosis of high choles-
terol. They have witnessed others live with it for years and
do not view or speak of high cholesterol as a precursor to
cardiovascular disease or stroke. It is believed to be in-
consequential.
Statins are safe but risky
In the transcripts, patients talk about statins available
on the market, side effects, prescription plans and cost.
They acknowledge they are blessed to have health insur-
ance that keeps costs down. Adherent patients expressed
concerns about side-effects, and with the support of their
physicians, some switched to another medication. They
interpreted the results of blood tests indicating lowered
cholesterol levels as evidence of the positive effect of
statins. However, some thought they would eventually
learn something unfavorable about statins. Notice in the
following exchange how these patients seem aware of the
importance of a healthy diet, but are also cognizant of how
difficult it is to maintain one. They see taking a statin as
the quickest and easiest solution to the problem, although
they have lingering thoughts in the back of their minds of
the possibility of receiving bad news about the negative
effects of statin use based on current mediated reports of
other drugs. Regardless, statin-adherent patients are will-
ing to take the risk. (Note. M=male, and F=female).
M1: I think a lot of times we take these medications
thinking we can eat anything because my cholesterol’s
going to start coming down.
M2: Practically speaking, I’m not always going to
eat right. I’m happy that I’m losing weight and maybe
in ten years I could be down to the weight that I’m
supposed to be. It doesn’t bother me at all to say that
in ten years I’m going to be taking the same pills, be-
cause for me it’s genetic anyway. It’s a small price to
pay. It doesn’t hurt, so I take the pill.
F: It’s definitely the easier way out than discipline.
M3: It’s out of my mind unless I see something in
the media that makes me think, “Maybe this stuff is
going to turn out to be bad news one day like Viox.”
I’ll be thinking “God, I took that stuff for years no
wonder I’m screwed up!”
Both adherent and nonadherent patients alike do not be-
lieve the healthcare system and science will ever have a
comprehensible explanation for high cholesterol or a defin-
itive answer about the most effective way to treat it. If ad-
herent, patients hold on to the hope that they are doing the
right thing by taking a statin, and if nonadherent, patients
are comfortable questioning the motives of corporations as
illustrated in the following. (Note: AM=adherent male,
NM=nonadherent male, and NF=nonadherent female).
AM: If I’m still taking the medicine I’m hoping it’s
not going to be a problem. I think cholesterol might
be a big hoax from the medical industry. Plenty of peo-
ple live to be old with HC. If I find out it’s a hoax I’m
going to be really mad!
NM: Companies are selling these pills and they’re
making a fortune. They want everybody on it.
NF: Yes, it’s just business. It’s about the medical
association getting us to buy drugs.
A few nonadherent patients chose to concentrate on
diet and exercise and did not take a statin especially if this
was their first chronic disease medication. Others took an
and if stance. These nonadherent patients declared that
they would use a statin only under the following condi-
tions: i) their high cholesterol was proven to be genetic
and ii) maintenance of a healthy diet did not work. As one
man stated:
[Qualitative Research in Medicine & Healthcare 2017; 1:7006] [page 123]
Article
If my cholesterol is caused by genetics, then I fore-
see myself in ten years taking whatever the new or the
prescribed medication to control cholesterol. If, in ten
years, medical science says, “We’re on the same path.
We do believe the same things we believed ten years
ago.” And if it isn’t my diet. And if I decide to really
do something about my diet, where as I become – this
is it, I’m going to try and stay within a completely
healthy diet, and if it doesn’t change, I absolutely fore-
see in ten years me taking Lipitor.
In addition to simply choosing not to take a statin,
many patients connected their nonadherence directly to
the negative side effects they experienced when taking
one. These nonadherent patients suffered muscle aches
and in some instances excruciating pain when using a
statin. Some worked with their doctor to find another
statin that did not cause any pain. Alternatively, doctors
successfully reduced the dosage of the undesirable statin
for some patients, while other patients were instructed to
take in addition to the undesirable statin, another choles-
terol-lowering drug, ezetimibe (Zetia) to address adverse
effects. A few took matters into their own hands and re-
duced the dosage of the offending drug before consulting
a doctor. The angst of finding the right statin without side
effects is clear in the following exchange. (Note.
NM=nonadherent male, and NF=nonadherent female).
NM: Yes, I’ve tried Crestor and Zocor, every one
of them. With every one I’ve had some muscle distress.
Some worse than others. There is a percentage of the
population they say that cannot take this medication
because you are one of the two percent that has this
thing, and I’m probably part of that two percent. But
maybe I’m not. So then what do you do?
NF: I thought, “Well, I don’t want liver disease.”
And my mother had died of liver disease, so I was re-
ally unhappy with my doctor. I really didn’t want to
take it but he insisted that I take it. I took what he gave
me and cut it in half, and took that. I think doctors
overmedicate, so I self-adjusted. It really did not agree
with me. Subsequently, I was switched to another one.
I was on Zocor and switched to Lipitor, and I did feel
better.
In sum, both adherent and nonadherent patients ques-
tion the ability and desire of the healthcare system and
science to find a cure for high cholesterol. Patients living
with high cholesterol believe statins work but question
whether or not the benefits outweigh the risks. Many are
nonadherent during a drug switching process due to mus-
cle-pain side effects. A few nonadherent patients do not
want to take a statin at all while other nonadherent patients
take an and if stance where a decision to take a statin is
based on i) discovering their high cholesterol is genetic
and ii) whether they have the ability to sustain lifestyle
changes involving diet. Statin-adherent patients view a
statin as the quickest and easiest solution in comparison
to lifestyle modification requiring a change in diet.
Ignorance is bliss
Patients do not understand the biochemistry at work
with cholesterol lowering drugs or the influence of cho-
lesterol on the formation of plaque. The relationship be-
tween high cholesterol, heart attacks and stroke are rarely
mentioned. In other words, there is a serious gap in the
understanding of the disease process at work and how
statins interfere with that disease process, as follows.
(Note. F=female, and M=male).
F: I was more concerned about my liver than cho-
lesterol. Maybe because I’m not too informed about
cholesterol. I don’t know.
M: I have the same question she had, like really I
don’t know the seriousness of cholesterol. Nobody ever
explained it to me. I really don’t know the symptoms
either. I figured I’d take the pills for six months and
be alright.
Many patients with high cholesterol do not know their
numbers or keep good records as we see in the comments
of F below.
M: What’s HDL in cholesterol?
F: I don’t know.
M: How high is your HDL?
F: I don’t know. I can’t remember. They’re written
down somewhere. It’s not the kind of thing you know
unless it’s bad.
This lack of understanding leads to an overreliance on
statins and a mindset that seems to value dietary change
but does not result in behavior change. Instead, patients
resort to blaming their physicians for not providing them
with information or answers to their questions, as in the
following:
F1: It would be nice to have a paper diet or some-
thing.
F2: I wish that they had sent me to a nutritionist.
F3: I have never been recommended to a nutrition-
ist by any doctor ever.
M1: I’ve had three heart attacks – one in 1986, in
1990, and in 2005. My cholesterol had been around
300. I’ve used Mevacor, Lipitor and now I’m on Vy-
torin. They all brought my numbers down and I’ve had
no side effects, but the doctors never gave me a nutri-
tional system.
M2: I discussed sending me to a nutritionist with
my doctor and he poo pooed it! So now I’ve had eight
bypasses.
F2: They had ice cream on the hospital tray after
my bypass surgery and justified it!
Nevertheless, some patients wanted to know more
about cholesterol. When a more knowledgeable person in
the group spoke, people paid attention. Several acknowl-
edged that simply engaging in the focus group process en-
couraged them to seek out more information and in some
cases, consider changing their behavior. The following is
an example of the types of explanations of cholesterol
shared:
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Article
F: Clots stop your arteries. Image a greasy buildup
like in a hose. You turn on the faucet and have the water
go through the hose. Well, suppose there is an obstruc-
tion in the hose. The water may flow through or not with
the force that you want it to. Well, that’s going to happen
with cholesterol. It’s like a greasy or fat buildup inside
the vein. It clogs up the vein, and then there’s problems
with blood flowing through and it’s scary, because it
can easily cause a heart attack or stroke.
In sum, ignorance may be bliss. Many living with high
cholesterol do not understand what it is, how it effects the
body, how it causes or is an agent in the development of
other chronic illnesses. They do not understand the role
of a statin beyond its ability to lower cholesterol. As long
as one feels good and does not experience negative side
effects of a statin, the conclusion is that things are okay.
If things are not going well, then the fault lies with physi-
cians who fail to provide the specific information needed
to affect change.
What if, either-or, both-and, according to whom?
High-cholesterol patients live with uncertainty. Uncer-
tainty is apparent in their communication with one another
indicating the substance of their cognitive and emotional
processing. Their talk serves to construct, illuminate, con-
fuse, confront, and alter probabilistic and evaluative ori-
entations as a productive endeavor through which they
come to understand their experiences as problematic.22
One type of uncertainty that patients experience, has
to do with the complexity at the core of the illness itself.25
Some patients do not understand what high cholesterol is
and how it effects the body. Most have an expectation that
illnesses have symptoms, and therefore cannot take a
high-cholesterol diagnosis seriously in comparison to
other illnesses experienced within the household with vis-
ible symptoms. Families tend to prioritize the treatment
of illnesses based on the degree of pain experienced and
evidence of physical deterioration that interferes with
quality of life.29-31 Sells et al.30 label this behavior a virtual
cascade of crises (p. 95). For these high-cholesterol pa-
tients, the nonexistence of symptoms is positively associ-
ated with the evaluation of high cholesterol as nothing to
be truly concerned.
The probabilistic orientation experienced by high-cho-
lesterol patients as a certainty that high cholesterol is not
serious is further complicated by another type of uncer-
tainty. This type of uncertainty relates to the nature of
one’s judgment about the likelihood of particular out-
comes.24,25 Evaluative orientations address whether or not
an object or outcome is good or bad.22 In this case, the ob-
ject of focus is the statin prescribed. First, the patient de-
termines the likelihood that he or she is at risk of
experiencing some negative outcome like a stroke due to
a diagnosis of high cholesterol. If at risk, then one must
decide to take a statin to lower one’s cholesterol level or
engage in lifestyle modification through diet and exercise.
This is an either-or not a both-and situation. Specific
causes reasoned as crucial precedents to certain outcomes
are at the heart of risk assessment.32 Therefore, if the out-
come of taking a statin results in lowing cholesterol then
one must have had high cholesterol and in some cases that
high cholesterol was caused by genetics. If no side effects
are experienced then there is no perceived need for
lifestyle changes. However, if taking a statin causes ex-
cruciating muscle pain that is not resolvable through
switching or dosage modification, then a statin may be as-
sessed as too risky and the focus becomes the less desir-
able alternative of lifestyle modification. Improved
cholesterol numbers satisfy the expectations of the patient
while simultaneously fulfilling one’s desire to continue
with one’s current lifestyle. Patients are creating cognitive
maps based on a variety of cause-and-effect beliefs and
their evaluations of links between beliefs.
Concerns about the accuracy, sufficiency, reliability
and validity of information also lead to uncertainty.22,24,25
Individuals selectively evaluate, bracket, integrate, and
compare information from a variety of sources.32 For these
high-cholesterol patients key sources of information in-
clude the media, one’s physician, one another and key
stakeholders in the healthcare system. Media in the form
of direct-to-consumer advertising promotes over-diagno-
sis of high cholesterol and over-treatment for those who
the use of a statin presents more risks than benefits.33
These advertisements portray statins as miracle drugs in
lowering cholesterol while simultaneously casting doubt
on the efficacy of lifestyle changes as sustainable. As a
result, patients tend to view diet and exercise as less im-
portant.21,33,34 Such mixed messaging conflict with com-
mon wisdom resulting in uncertainty and questions about
the reliability of mediated messages.
As previously noted, Aggarwal and Mosca4 suggest
that nonadherence is not due to a lack of knowledge about
high cholesterol. I argue however, that these patients do
not understand the relationship between high cholesterol
and its comorbidities and feel it is the responsibility of
physicians to make sure they do. Because physicians fail
to provide sufficient information, patients believe it is not
important to know the specifics of high cholesterol. This
belief is positively associated with the belief that high
cholesterol is not serious anyway. This probabilistic ori-
entation experienced as certainty is then challenged by
knowledge acquired through learning more about high
cholesterol and statins from listening to other patients re-
sulting in a quandary of how to evaluate and organize in-
coming messages.24 Additionally, many high-cholesterol
patients, as in other studies21,33 believe insurance compa-
nies are greedy and profit driven; and that the healthcare
system is ineffective. Such distrust of the government,
drug industry and science increases perceptions of risk as-
sociated with statin adherence. Questions then arise about
the credibility of these sources and whether one should
view as valid any information from them.
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Article
Conclusions
My findings support those of other studies9,10,12 that
the side effect of muscle pain from the use of statins is a
major reason for nonadherence. However, Aggarwal and
Mosca’s4 assertion that a lack of knowledge about high
cholesterol is not linked to statin-nonadherence was not
supported. Unlike the conclusions drawn in previous
works4,9,10,12 my findings suggest that the major problem
for the high-cholesterol patient is the probabilistic orien-
tation that high cholesterol is not serious. This initial be-
lief held by patients complicates the formation and
maintenance of other positive probabilistic and evaluative
orientations toward believing that sustained behavior
modification consisting of eating healthier, increasing
physical activity, and taking a statin consistently over time
are worth the effort. As a result, high cholesterol patients
live with uncertainty that is not necessarily experienced
as bad. At times, they may actively seek to reduce or man-
age it, but are not likely to see it resolved through more
information. They are more likely to use what Babrow24
refers to as piecemeal coping strategies (p. 563) through
reappraisal and accepting things as they are, or by refram-
ing as an opportunity for self-exploration. These findings
suggest that physicians may have the greatest impact on
high-cholesterol patients’ understanding and beliefs at ini-
tial diagnosis. More attention should be given to sharing
information about its link to cardiovascular disease, stroke
and other comorbidities to foreground its threat. Patients
must see high cholesterol as serious as they view cancer.
This study should be viewed in light of a few limita-
tions. Findings reflect primarily the experiences of White
middle-class women with health insurance. Personality
factors such as introversion, extroversion, degree of opti-
mism or pessimism, were not taken into consideration. In
addition, demographic factors such as, level of education,
religion, race, and gender were not considered.
In future studies exploring statin adherence and non-
adherence in the context of living with high cholesterol,
researchers should consider the aforementioned person-
ality and demographic factors. We must identify the
rhetorical strategies used by physicians with patients who
do view a diagnosis of high cholesterol seriously. What is
the structure and specific content of these persuasive mes-
sages? Discourse analyses of actual sessions in which
physician diagnose high cholesterol may be the most en-
lightening. How did patients process these messages?
One-on-one in-depth interviews with patients should pro-
vide even more insight into relevant thought processes.
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