Effects of Educational Intervention on Lifestyle Among

 Iranian Heart Journal; 2019; 20 (4)

Lifestyle modification in cardiac Patients

Khodabandehlooie et al

Original Article
Lifestyle Modification in Cardiac Patients

Khodabandehlooie et al

Effects of Educational Intervention on Lifestyle Among Iranian

Patients After Coronary Angioplasty: A Randomized Controlled Trial

Sara Khodabandehlooie1, MS; Fatameh Estebsari2*, PhD; Camelia Rohani2, PhD; Elham Shaarbaf Eidgahi3, PhD

ABSTRACT

Background: Cardiovascular disease risk factors are associated with lifestyle, and patients undergoing coronary angioplasty require a great deal of training on modifying their lifestyle. The aim of this study was to survey the effects of educational intervention on lifestyle among Iranian patients after coronary angioplasty in Tehran in 2017.

Methods: This research was a randomized clinical trial with 2 groups of control (n = 29) and intervention (n = 28). The patients’ lifestyle was evaluated by using a healthy lifestyle questionnaire at baseline and then at 1 month and 3 months after an educational intervention. The data were analyzed using SPSS, version 20.

Results: The mean age of the intervention and control groups was 62.54 ± 4.23 and 60.52 ± 5.37 years old, respectively. The Mann–Whitney U and Friedman tests showed that the scores of healthy lifestyle, healthy nutrition, and exercise and physical activity significantly improved in the intervention group in comparison with the control group at 1 month and 3 months after the educational program (P < 0.001). The Friedman test showed a significant increase in the score of avoiding tobacco and alcoholic beverages, health responsibility, health-based purchase, and healthy lifestyle in both groups at 1 month and 3 months after the educational program (P < 0.05). The results revealed that the score of stress management in both groups did not increase significantly during the survey.

Conclusions: In the present study, our educational program had a considerable effect on modifying lifestyle among the Iranian patients after coronary angioplasty. Psychological support programs for managing the stress of these patients are suggested. (Iranian Heart Journal 2019; 20(4): 38-45)

KEYWORDS: Lifestyle, Coronary disease, Angioplasty, Nurses, Iran

1 Department of Community health nursing t, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran. 2 Department of Community Health Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran. 3 Department of Biostatistics, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Science, Tehran, IR Iran.

*Corresponding Author: Fatameh Estebsari, PhD Email: [email protected]

Tel: 09122992798

Received: February 7, 2019

Accepted: May 15, 2019

Cardiovascular diseases (CVDs) are the leading cause of morbidity and mortality. 1 About 54% of deaths from
noncommunicable diseases in the Eastern

Mediterranean Region are due to CVDs, 2 and
there is a concern at the alarming increase of cardiovascular risk factors in Iran. 3 In Iran, the
incidence of coronary artery disease and

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Lifestyle Modification in Cardiac Patients
coronary angioplasty is on an upward trend due to the industrialization of cities, air pollution, demographic changes, aging, 4 low physical activity, unhealthy diet, and mental stress. 5,6 Patients undergoing coronary angioplasty require a great deal of training in modifying their lifestyle. 6 A healthy lifestyle can reduce the risk of CVDs, 7 and most CVDs can be prevented by modifying behavioral risk factors. 1 Considering the high contribution of prevention in reducing mortality from CVDs, nurses—as the sole provider of multiple prevention programs—can play key roles in decreasing the risk of these diseases and promoting a healthy lifestyle. 8-11 In Iran, a limited number of studies have examined the impact of educational intervention on cardiac patients’ lifestyle. 12 The current study was conducted to evaluate the efficacy of an educational program on lifestyle among Iranian patients after coronary angioplasty.
METHODS
This randomized clinical trial study (code: IRCT2017070334867N) was conducted at the cardiology clinic of a specialized hospital in Tehran in 2017. By using a systematic randomization method, the study samples in the intervention and control groups were selected from among 200 patients who had met the criteria for inclusion in the study. The allocation of the patients to the 2 study groups was done via a simple randomized sampling method. The age of the study patients was between 35 and 70 years old, they underwent angioplasty for the first time 1 week before joining the study, they did not have a history of open-heart surgery, they had no other diseases such as cancer, they had an ejection fraction > 30%, and they were not at high risk when performing exercise. In addition, the study patients were able to read, write, and answer the questions in the questionnaire. Patients were excluded if they failed to fill out the questionnaire

Khodabandehlooie et al
completely or if they failed to participate in the educational sessions. The following formula determined the sample size (with a 30% probability of dropping) in the intervention and control groups to be 30 individuals in each group: 13,14
This study was done on 60 patients. During the study, 3 subjects were dropped from the analysis and 57 subjects were assessed in 2 groups of intervention (n = 28) and control (n = 29).
Measures A demographic characteristics questionnaire was used to evaluate the patients’ age, gender, marital status, educational level, occupation, and monthly income adequacy. The patients’ lifestyle was appraised using the Healthy Lifestyle Questionnaire, which is designed for Iranian cardiovascular patients and is based on HPLP II. 15 The questionnaire comprised 44 items in 6 subscales of diet (12 items), stress management (7 items), avoiding smoking and alcoholic beverages (6 items), exercise and physical activity (7 items), health responsibility (8 items), and health-based purchase (4 items). The items were calculated on a 4-choice spectrum (never = 1, low = 2, usually = 3, and always = 4). The score of each subscale was categorized into 5 categories in the form of 5 equal parts (very low=1, low=2, average=3, high=4, and very high=5).
Validity and Reliability Maleki et al 15 reported that their literature review and content evaluation confirmed the content validity of the healthy lifestyle questionnaire and factor analysis supported the construct validity. Additionally, the alpha coefficient of internal consistency for the total scale was 0.914. In the present study, the validity and reliability of this questionnaire were confirmed. The validity of this questionnaire for relevance,
39

 Iranian Heart Journal; 2019; 20 (4)

 Iranian Heart Journal; 2019; 20 (4)

Lifestyle modification in cardiac Patients

Khodabandehlooie et al

clarity, and fluidity was assessed by cardiovascular experts, and the results were 0.96, 0.91, and 0.93 respectively. The content validity ratio (CVR) of the questionnaire was evaluated as acceptable (CVR = 0.6). Further, the reliability of the questionnaire was determined through the use of Cronbach’s alpha to measure the internal consistency (alpha = 0.88) and test-retest was used to appraisal stability (r = 0.92).
Educational Intervention Program The educational program lasted for 3 months, starting with 6 sessions in a month. This program consisted of intense health educational and behavior change activities—including lectures, discussions, and practical skills training. Healthy lifestyle areas—including diet and nutrition, exercise, physical activity and weight loss, stress management, and smoking cessation—were taught in these sessions. The training materials were slideshows, pamphlets, and booklets which were taken from the

National Heart, Lung, and Blood Institute; National Health Service; and American Heart Association sites.
Statistical Analysis The data collected were analyzed using SPSS, version 20. The Kolmogorov–Smirnov, independent t, χ2, Fisher exact, nonparametric Mann–Whitney U, and Friedman tests were used. A P value <0.05 was assigned as the criterion of statistical significance.
Ethical Considerations This research was conducted after receiving an ethical code (SBMU.PHNM.1395.699.IR) from the Nursing and Midwifery School. The participants were reassured that their responses to the questionnaire would be kept confidential and anonymous and that they could quit the study at any time with no penalty. Additionally, informed consent was obtained from the entire study population.

Assessed for eligibility (n=255)
Excluded (n=55) Not meeting inclusion criteria (n=43) Declined to participate (n=12) Other reasons (n= 0)
Systematically randomized (N=200)

Randomized (n=60)

ALLOCATION

Allocated to intervention (n=30)

Allocated to intervention (n=30)

ENROLLMEN F O L L OTW - U P

Lost to follow-up (not referring to clinic) (n=2)

Lost to follow-up (filling questionnaires incompletely) (n=1)

ENROLLMEN A N A LTY S I S

Analyzed (n=28) Excluded from analysis
(give reasons) (n=0)

Analyzed (n=29) Excluded from analysis
(give reasons) (n=0)

ENROLLMEN T
40

Figure 1. CONSORT flowchart of the participants

 Iranian Heart Journal; 2019; 20 (4)

Lifestyle Modification in Cardiac Patients

Khodabandehlooie et al

RESULTS
The t-test and the χ2 test revealed that the intervention and control groups did not differ significantly in terms of key demographics at the start of the study. The mean age of the patients was 62.54 ± 4.23 years in the

intervention group and 60.52 ± 5.37 years old in the control group. In both groups, there was a preponderance of men, about 80% of the patients were married, most patients had high school diplomas, and the monthly income of 50% of the patients was less than their living expenses (Table 1).

Table 1. Demographic characteristics of the research samples in the intervention and control groups

Demographic characteristic

Gender Marriage
Education Monthly income

male female single married divorced widowed elementary middle school high school university less than costs equal to costs more than costs

Intervention

Group

N

%

15

53.6

13

46.4

0

0

23

82.14

5

17.58

0

0

6

21.4

10

35.7

11

39.3

1

3.6

14

50

10

35.7

4

13.3

Control

Group

N

%

18

62.1

11

37.9

0

0

24

82.75

3

10.34

2

6.89

3

10.3

8

27.6

14

48.3

4

13.8

17

58.6

7

24.1

5

17.2

P value 0.516 0.612
0.339 0.633

The mean and the standard deviation of the healthy lifestyles scores of the patients in the intervention and control groups, at baseline and then at 1 month and 3 months after the educational intervention, are shown in Table 2. The Mann–Whitney U test demonstrated a significant rise in the scores of healthy nutrition, exercise and physical activity, and healthy lifestyle (total) in the intervention group in comparison with the control group at 1 month and 3 months after the educational intervention (P < 0.001). The nonparametric alternative to the one-way ANOVA with repeated measures, the Friedman test revealed that the scores of healthy nutrition and exercise and physical activity in the intervention group significantly increased at 1

month after the educational program and remained high after 3 months (P = 0.001). Moreover, the Friedman test showed that at 1 month and 3 months after the educational program, there was a significant increase in the scores of avoiding tobacco and alcoholic beverages, health responsibility, health-based purchase, and healthy lifestyle in both groups (P < 0.05). The Mann–Whitney U and Friedman tests showed that there was no significant difference in the stress management score between the intervention and control groups, and the score of this subscale in both groups did not increase significantly at 1 month and 3 months after the educational program (Table 2).

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Lifestyle modification in cardiac Patients

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Table 2. Healthy lifestyle and its subscales in the patients at baseline and then at 1 month and 3 months after the educational program in the intervention and control groups

Healthy Lifestyle and its Subscales

Group

Baseline Mean ± SD

One Month Afterward
Mean ± SD

Three Months Afterward
Mean ± SD

Healthy nutrition
Stress management Avoiding tobacco and alcoholic beverages Exercise and physical activity
Health responsibility
Health-based purchase
Healthy lifestyle (total)

Intervention Control Intervention Control Intervention Control Intervention Control Intervention Control Intervention Control Intervention Control

3.11±0.31 3.28±0.45 2.71±0.60 2.83±0.46 4.50±0.63 4.79±0.49 1.75±0.64 1.83±0.65 3.11±0.68 3.21±0.62 3.86±1.07 3.76±0.95 3.11±0.41 3.21±0.55

3.71±0.46** 3.41±0.50 2.86±0.45 2.93±0.53 4.68±0.54 4.83±0.46 2.21±0.73** 1.79±0.67 3.57±0.57 3.62±0.56 4.18±1.15 3.90±1.07 3.68±0.47** 3.41±0.50

3.71±0.46** 3.41±0.62 2.82±0.44 2.93±0.53 4.68±0.54 4.79±0.49 2.21±0.73** 1.72±0.64 3.57±0.57 3.66±0.61 4.14±1.14 3.90±1.07 3.71±0.46** 3.41±0.50

⁎ Significance: P < 0.05 in the Friedman test. ⁎⁎ Significance: P < 0.05 in the Mann–Whitney U test

P value
>0.001* 0.135 0.156 0.097 0.016* 0.028* >0.001* 0.368 >0.001* >0.001* >0.001* 0.018* >0.001* 0.011*

DISCUSSION
A healthy lifestyle is recognized as a major contributor to the prevention and control of CVDs. 16 In the current study, we implemented a healthy lifestyle education program for Iranian patients with coronary artery disease. The results revealed that this program caused favorable changes in the healthy nutrition, exercise and physical activity, and healthy lifestyle of the intervention group after the 1month period and these changes persisted at 3 months’ follow-up. In terms of healthy nutrition, the consumption of imbalanced diets with high energy, sugar, and salt contents and low-nutrient density has played a critical role in the development of CVD risk factors among Iranians. 17 Educational programs strengthen the motivation of patients and help them adhere to the recommended healthy diet. We found that after the educational program, there was a significant increase in the mean score of healthy nutrition in the intervention group. This finding is in line with the results of many studies assessing the

efficiency of educational interventions on lifestyle among cardiac patients. 18-20 In patients with coronary artery disease, exercise improves endothelial function, halts the progression of coronary stenosis, and reduces cardiovascular event rates. 21 Many studies have shown that educational programs are an effective strategy to increase the physical activity of cardiac patients. 19,20,22 The results of the present study also showed a significant increase (26.3%) in the score of exercise and physical activity in the intervention group after the program. Our results indicated that after the educational program, there was a favorable change in the scores of avoiding tobacco and alcoholic beverages, health responsibility, health-based purchase, and healthy lifestyle in both groups. This rise in the scores in the control group may have been due to the patients’ responses to the physical and emotional symptoms after angioplasty. 23 Many researchers have found that patients adjust their habits as a reaction to common symptoms after angioplasty such as loss of autonomy, self-confidence, uncertainty and worry about the future, depression, and

42

Lifestyle Modification in Cardiac Patients
anxiety. 24 An investigation conducted on 4535 coronary patients revealed that the patients were more likely to adopt healthy behaviors. In addition, increasing the score of avoiding tobacco and alcoholic beverages in the control group might have been due to the brief advice from their doctor to stop smoking. Perk et al 25 showed that a brief recommendation to stop smoking could significantly help patients quit smoking. Our results revealed that there was no significant difference in the score of stress m0anagement between the intervention and control groups and that the score of this subscale in both groups did not increase significantly over the 3 months. A systematic review on the treatment of anxiety in patients with coronary heart disease showed that stress was a secondary outcome. 26 Dehdari et al, 27 in their study on stress among Iranian patients after percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery, reported that the PCI patients had higher stress and anxiety score than did the surgical patients because of uncertainties surrounding the PCI procedure. They also noted that more than 70% of their PCI patients had anxiety at 12 months’ follow-up. In the present study, the monthly income of most of the patients was lower than their living expenses, which can engender financial stress. Financial stress can increase the stress level of patients and divert energy from focusing on health and a healthy lifestyle. As can be seen in Table 2, the scores of healthy nutrition, stress management, avoidance of tobacco and alcoholic beverages, exercise and physical activity, health responsibility, and health-based purchase in the intervention group were upgraded to 3.71, 2.82, 4.68, 2.18, 3.17, and 4.14, respectively. Since the scores were ranged from “very low = 1” to “very high = 5”, the scores of exercise and physical activity and stress management were low. To mitigate these problems among patients undergoing PCI, aside from educational interventions, we recommend

Khodabandehlooie et al
that nursing models and rehabilitation programs be taken into consideration. 28-30
CONCLUSIONS
The results of the current study indicated that lifestyle education had a positive effect on lifestyle among Iranian patients after coronary angioplasty. Psychological support programs aimed at managing stress among these patients are suggested.
Limitations Because of the time limit, this research was conducted only in 3 months. A thorough evaluation of the effects of the lifestyle education programs requires much longer follow-up periods because behavioral changes tend to occur at different times.
Conflict of Interest No conflict of interest was declared by the authors.
Acknowledgments We express our thanks to the Research and Technology Chancellorship at Shahid Beheshti University of Medical Sciences. Our special gratitude goes to the authorities of Bahman Hospital and the staff of the Cardiology Clinic for their assistance. Needless to say, this investigation would not have been possible had it not been for the collaboration of the patients.
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