Abstract
Background
This study was conducted with descriptive design to determine the level of knowledge and quality of life of individuals suffering from coronary artery disease.
Methods
The study was conducted with 236 patients who applied to the cardiology outpatient clinic of a training and research hospital between November 2021 and April 2022. The data of the study were collected by personal information form, coronary artery disease education questionnaire-II and cardiac health profile scale.
Results
The patients’ total mean score for the coronary artery disease education questionnaire-II was 25.71±12.49. According to the total score obtained from the coronary artery disease education questionnaire-II, it was determined that 49.2% of the patients had an “insufficient” knowledge level, 44.5% “Poor”, and 5.9% “Acceptable”. Knowledge level of only one patient was good. In the chest pain classification of the cardiac health profile scale, the chest pain level of 28.4% of the patients was the “class II”. Total mean score of the patients for the cardiac health profile scale was 679.88±245.89.
Discussion
It was found that the level of knowledge of the participants about coronary artery disease was insufficient and their level of quality of life was moderate. It is recommended to organize education programs based on the education, culture, perception of health, spoken language in order to elevate their knowledge level and thus their level of quality of life.
Introduction
Coronary artery disease (CAD) is a common condition characterised by reduced or interrupted blood flow in the coronary arteries feeding the myocardium. One of the most common causes of CAD is atherosclerosis and it clinically manifests as stable angina pectoris, unstable angina pectoris, and myocardial infarction (MI).
According to the World Health Organisation (WHO), there were 55.4 million deaths worldwide in 2019, with ischemic heart diseases accounting for 16% of these deaths. In Turkey, 36.8% of deaths in 2019 are known to be caused by circulatory system diseases. The 26-year data from the Turkish Adult Risk Factors (HDRCiTa) study on Heart Disease indicate that CAD is responsible for 42% of all deaths in Turkey.
Nurses assume significant roles in the prevention and treatment of cardiovascular diseases, being one of primary global health problems. Interventions aimed at patients without symptoms and signs of the disease are effective to prevent the disease, and interventions that arrest the disease progression and promote recovery after the condition develops are effective to treat the disease. , For the prevention of cardiovascular diseases, nurses also have important responsibilities such as raising awareness in the community, educating individuals, bringing healthy lifestyle behaviours (smoking and alcohol cessation, healthy diet, exercise, spiritual development, stress management), keeping blood pressure under control, monitoring lipid values, controlling weight, controlling diabetes (if any) and maintaining patient compliance with treatment. ,
When managing coronary artery disease, the nurse aims to enhance the quality of life of the patient, family and community in physical, psychological and social dimensions. It is important that effective management of the disease leads to better outcomes in nurse-patient collaboration. , Coronary artery disease brings several restrictions to the individual’s life and negatively affects the individual’s health both physically, psychologically and with respect to adaptation to the environment. Effective patient education can reduce these negative effects, promote patient compliance with the disease, improve healthy living behaviours and reduce risk factors. However, patient education contributes to an improvement in physical functions, alleviation of depressive symptoms, an enhancement in treatment compliance and an enhancement in the level of quality of life. ,
Patient education is the basic step of quality life and health care. Patient education aims to achieve behavioural change in the patient. , Patient education is defined as the process of improving the health-related skills of patients and their relatives, providing information, and assimilating and turning them into their behaviours. Patient education enhances the quality of patient care and allows the patient to be involved in patient education in collaboration with family members to achieve success in patient education. It is known that patient education delivered by nurses leads to a fall in blood pressure and cholesterol levels, changes in eating habits, more physical activities, better knowledge of their disease and an improvement in management strategies in individuals with coronary artery disease. , The education delivered to patients by nurses intends to enhance the quality of life and reduce symptoms. ,
The factors such as physical restrictions, reduced independence, hopelessness, impaired sleep quality, sexual problems, difficulties in working life, and psychosocial and economic challenges affect the quality of life of patients with CAD. When patients have difficulty in or are dependent on carrying out their activities of daily living and self-care, their quality of life gets impaired. , The determination of the patient’s quality of life enables the patient to adopt healthy lifestyle behaviours, raise awareness about the disease and increase compliance with treatment by organising training programmes to address the patient’s problems.
There are limited number of studies in the literature that assessed disease knowledge and quality of life of patients with CAD. The studies that assessed the level of quality of life and disease knowledge of patients with CAD separately reported that their level of quality of life as well as their level of disease knowledge were low. , It is necessary to assess patients’ level of knowledge and quality of life in order to manage the disease and reduce complications. , Also, every year approximately 20 thousand people apply to the cardiology outpatient clinic of Şanlıurfa Training and Research Hospital, where the study was conducted. Based on this information, the low level of knowledge about CAD, the high rate of hospital admission and the low level of knowledge of patients admitted to the hospital suggest that the level of knowledge and quality of life in patients diagnosed with CAD may also be low. This descriptive study was therefore conducted to determine the level of knowledge about the disease and quality of life among patients with CAD in Şanlıurfa province.
Research questions
What is the level of knowledge of patients with coronary artery disease?
What is the level of quality of life of patients with coronary artery disease?
Is there any correlation between these patients’ level of knowledge about the disease and their level of quality of life?
Materials and methods
Aim
This study was conducted with descriptive design to determine the level of knowledge about the disease and level of quality of life among patients with coronary artery disease in Şanlıurfa province.
Design
This study was conducted as a cross-sectional survey with coronary artery disease in Türkiye.
Sample/participants
The population of the study consisted of patients who were referred to the Cardiology outpatient clinic of Şanlıurfa Training and Research Hospital and were diagnosed with CAD. The sample consisted of a total of 236 patients who applied to the hospital between November 2021 and April 2022 and met the inclusion criteria. The sample size was calculated as 236 patients based on a total of 5359 patients who applied to the Cardiology outpatient clinic due to the diagnosis of CAD between January 2021 and June 2021 at the confidence interval of 80%, margin of error of 5% and significance level of p<0.05. The whole sample (100%) was reached.
Patients who were 18 years of age or older, were diagnosed with CAD for at least six months, knew their diagnosis and could verbally express it, had no communication problems, had no known psychiatric disease, and agreed to participate were included in the study.The study exclusion Criteria also was patients who suffered from severe chronic diseases (Alzheimer’s disease, dementia, stage IV COPD, CVO), cognitive disorientation, and severe complications (atrial fibrillation, ventricular tachycardia), and voluntarily withdrew from the study.
Dependent variables were The total and subscale mean scores of the Cardiac Health Profile (Turkish version) and its subscales and the total and subscale mean scores of the Coronary Artery Disease Education Questionnaire-2 in the study. Independent variables were The socio-demographic and disease-related characteristics of the patients.
Data collection
The data were obtained using a personal information form, the coronary artery disease education questionnaire-2 and the cardiac health profile (Turkish version). The data were collected through face-to-face interview method for roughly 30 minutes.
Personal information form
The researcher prepared this form with two parts based on the literature review. , The first part contains information on the patient’s socio-demographic characteristics (age, gender, marital status, education level, income level, social security) and the second part contains on the patient’s medical condition (diagnosis, duration of diagnosis, presence of another chronic disease, family history of cardiovascular disease, presence of previous surgical intervention, education about the disease, medical staff who trained the patient, smoking and alcohol consumption, and dietary and exercise details).
Coronary artery disease education questionnaire-2 (CADE-QII)
Ghisi et al., developed the coronary artery disease education questionnaire-2 in 2009 to raise awareness about the importance of patient education — one of the key components of the cardiac rehabilitation programme in patients with coronary artery disease — and to identify and assess the level of patient’s knowledge on the disease. Ghisi et al., revised the questionnaire in 2015. The Cronbach’s alpha value of the scale was found to be 0.91. Akbulut and Bayrak Kahraman conducted its Turkish validity and reliability study in 2018. It has a total of 31 items and five subscales (medical condition, risk factors, nutrition, exercise, and psychosocial risk. The questionnaire is rated on a scoring system. Each response in the items indicates a level of knowledge. The items are rated as “Full knowledge: 3 points, “Inadequate knowledge: 1 point’’, “Incorrect knowledge: 0 point’’ and “Insufficient knowledge: 0 point’’. The questionnaire includes multiple-choice questions. Each question has four possible responses. Only one of the options is correct. The assessment of the Coronary Artery Disease Education Questionnaire-2 is based on the total score obtained from the questionnaire as well as the total score obtained from each subscale. The lowest and highest scores of the subscales are 0 and 21 points in the medical condition subscale, 0 and 15 points in the subscale of risk factors, 0 and 21 points in the exercise subscale, 0 and 21 points in the nutrition subscale, and 0 and 15 points in the psychosocial risk subscale, respectively. The maximum score of the overall questionnaire is 93. The knowledge levels of the patients are assessed to be “Excellent” between 93-83 points, “Good” between 82-65 points, “Acceptable” between 64-47 points, “Poor” between 46-29 points, and “Inadequate” between 28 points and below. A high score indicates a high level of knowledge about coronary artery disease. In this study, the Cronbach’s alpha coefficient of the questionnaire was found to be 0.827.
Cardiac health profile (CHP- Turkish version)
Peter Währborg developed the cardiac health profile in 1996 to determine the level of quality of life of patients with cardiovascular disease. Duğan and Bektaş conducted its Turkish validity and reliability in 2021. CHP consists of three parts: The first part assesses the level of angina pectoris. The second part of the scale contains 16 items and 4 subscales. The subscales are cognitive function (1, 2, 3, and 4), emotional characteristics (5, 6, 7, and 8), social characteristics (9, 10, 11, and 12) and physical characteristics (13, 14, 15, and 16). The third part consists of two questions related to treatment intervention (17, 18). The profile is rated on a visual analogue scale and the total scale score is calculated out of 100. A low total score indicates good health conditions. The Cronbach’s alpha coefficient was found to be 0.85 for the overall cardiac health profile and between 0.62-0.76 for the subscales. , In this study, the Cronbach’s alpha coefficient of the scale was found to be 0.927.
Preliminary application of data collection forms
The pilot study was conducted on 30 individuals diagnosed with CAD who applied to the Cardiology outpatient clinic of Şanlıurfa Training and Research Hospital between November 8, 2021, and November 19, 2021, met the inclusion criteria and were voluntary to participate in the study. No revisions were made to the questions in the personal information form after the pilot study since none of the questions were incomprehensible or needed to be updated.
Ethical considerations
To conduct of the study, approval from the Clinical Trials Ethics Committee of a university (session dated 18/10/2021 and numbered HRU/21.18.22), permission from the related provincial directorate of health (session dated 03/11/2021 and numbered 77121), and consent from the participants were obtained. The study was conducted in accordance with the principles of the Declaration of Helsinki (2013) based on ethical principles.
Data analysis
A Statistical Package for Social Sciences (SPSS) for Windows 22.0 software was used to analyse the data. The data were analysed using number, percentage, median, mean and standard deviation as descriptive statistics. Kolmogorov Smirnov test of normality was used to determine whether or not the data were normally distributed. The data were analysed with the student t-test, Pearson’s correlation, and ANOVA test when the data were normally distributed and the Mann-Whitney U test, Spearman correlation and Kruskal Wallis test when the data were not normally distributed. The significance value of the data was accepted as p<0.05.
Results
Table 1 shows the distribution of the participants based on their socio-demographic characteristics.
| Characteristics | Groups | x̄±SD | Min-max |
|---|---|---|---|
| Age | 59.00±11.42 | 28-88 | |
| N | % | ||
| Gender | Male Female | 147 89 | 62.3 37.7 |
| Marital statu | Married Single | 229 7 | 97.0 3.0 |
| Education statu | Illiterate Literate Primary School High school and above | 103 67 48 18 | 43.6 28.4 20.3 7.7 |
| Employment statu | Not employed Employed | 148 88 | 62.7 37.3 |
| Social security | Yes No | 208 28 | 88.1 11.9 |
| Income statu | Poor Intermediate Good | 138 86 12 | 58.5 36.4 5.1 |
| Total | 236 | %100 |
The mean year of CAD diagnosis was found to be 4.60±3.97 (min: 1 year, max: 24 years). Table 2 shows the distribution of the patients in terms of their disease characteristics.
| Characteristics | Groups | N | % |
|---|---|---|---|
| Hospitalization for CAD | Yes No | 159 77 | 67.4 32.6 |
| Hospitalization duration form CAD (n=159) * | 1 2 3 and above | 116 27 16 | 73.0 17.0 10.0 |
| Family history of cardiovascular disease | Stable angina pectoris Myocardial infarction Unstable angina pectoris | 111 74 51 | 47.0 31.4 21.6 |
| Family history of CAD | Yes No | 146 90 | 61.9 38.1 |
| Education about the disease | Yes No | 173 63 | 73.3 26.7 |
| Smoking | Uses Quit Not use | 89 85 62 | 37.7 36.0 26.3 |
| Exercise statu | No Yes | 167 69 | 70.8 29.2 |
| Frequency of exercise (n=69) ⁎⁎ | Every day 1-2 day a week 3-4 day a week Irreguler/sometimes | 8 31 14 16 | 11.6 45.0 20.3 23.1 |
| Duration of exercise | Less than 30 minutes 30-45 minutes | 35 34 | 50.7 49.3 |
| Diet statu | Yes No | 154 82 | 65.3 34.7 |
| Diet compliance (n=82) ⁎⁎⁎ | Good Intermediate Poor | 34 39 9 | 41.5 47.5 11.0 |
| Medication compliance | Good Intermediate Poor | 148 51 37 | 62.7 21.6 15.7 |
⁎ This parameter was calculated over 159 patients since 77 participants were not hospitalised due to coronary artery disease.
⁎⁎ This parameter was calculated over 69 patients since 167 participants did not exercise.
⁎⁎⁎ This parameter was calculated over 82 patients since 154 participants were not on a diet.
It was determined that 48.3% of the patients had another chronic disease accompanying CAD, 70.3% underwent cardiovascular surgery, and 91% of the patients who underwent cardiovascular surgery underwent a coronary angioplasty-stent procedure. Hypertension and diabetes mellitus was found in 35.5% and 25.4% of patients with CAD, respectively.
The mean (median) scores of patients in the subscales of the coronary artery disease education questionnaire-2 were 7.57±3.55 in the medical condition subscale (8), 3.68±3.15 in the subscale of risk factors (3), 4.47±3.42 in the subscale of exercise (3), 7.77±4.88 in the subscale of nutrition (8), 2.20±2.73 in the psychosocial risk subscale (1), and the total score was 25.71±12.49 (26). The patients obtained the highest mean score from the nutrition subscale, followed by the medical condition, risk factors, exercise and psychosocial risk subscales.
The patients’ CADE-QII total score indicated that 49.2% of them had “Inadequate” level of knowledge, 44.5% had “Poor” level of knowledge, and 5.9% had “Acceptable” level of knowledge. Only one patient had a good level of knowledge. There was no patient with an excellent level of knowledge.
Part 1 of the CHP includes data on the classification of patients’ chest pain. Accordingly, 28.4% of the patients had “class II” chest pain and 27.5% had “class I” chest pain.
In Part 2, the CHP total mean score of the patients was 679.66±245.89 and their mean scores of the subscales were 173.9±75.91 for cognitive function, 168.6±75.85 for emotional characteristics, 151.6±79.22 for social characteristics, and 185.4±66.57 for physical characteristics.
Part 3 includes the patients’ adherence to the treatment and evaluation. The mean score of the patient’s adherence to the treatment and evaluation was 56.65±38.57.
Table 3 compares the socio-demographic and disease characteristics of the patients with the score medians of the CADE-Q II and its subscales.
| Characteristics | Medical Condition | Risk Factors | Exercise | Nutrition | Psychosocial Risk | Total Score | |
|---|---|---|---|---|---|---|---|
| Median | Median | Median | Median | Median | Median | ||
| Gender | |||||||
| Male Female | 9.00 7.00 | 4.00 2.00 | 4.00 3.00 | 9.00 7.00 | 1.00 0.00 | 29.00 21.00 | |
| MWU P | 8522.500 <0.001 | 7730.000 .018 | 8179.000 0.01 | 7845.500 .010 | 7696.500 .018 | 8451.000 <0.001 | |
| Education statu | |||||||
| Illitarete ᵃ Literate ᵇ Primary School c High School and above ᵈ | 6.00 9.00 9.00 11.00 | 2.00 4.00 3.00 7.00 | 2.00 3.00 4.50 8.00 | 7.00 9.00 9.50 13.00 | 0.00 1.00 3.00 4.00 | 20.00 26.00 30.00 41.00 | |
| KW P | 47.957 <0.001 a<b,c,d | 25.429 <0.001 d>a,b,c | 38.862 <0.001 a<b,c,d | 23.092 <0.001 a<b,c,d | 34.869 <0.001 a<c,d; b<d | 51.579 <0.001 a<b,c,d; b<d; c<d | |
| Employment statu | |||||||
| Employed Nor employed | 9.00 7.00 | 4.00 3.00 | 5.50 3.00 | 10.00 7.50 | 3.00 0.00 | 31.50 22.00 | |
| MWU P | 4923.000 .002 | 5389.000 .026 | 3979.000 <0.001 | 4482.000 <0.001 | 4130.000 <0.001 | 3878.000 <0.001 | |
| Income statu | |||||||
| Poor ᵃ Intermadiate ᵇ Good ᶜ | 7.00 9.00 10.50 | 3.00 4.50 3.50 | 3.00 6.00 5.00 | 8.00 9.00 13.00 | 0.00 2.00 4.00 | 21.50 31.00 37.50 | |
| KW P | 11.346 .003 a<b | 12.763 .002 a<b | 37.734 <0.001 a<b,c | 8.621 .013 a<b,c | 26.179 <0.001 a<b,c | 27.359 <0.001 a<b,c | |
| Previous Hospitalization Status | |||||||
| Yes No | 8.00 7.00 | 4.00 2.00 | 3.00 4.00 | 8.00 10.00 | 1.00 1.00 | 26.00 25.00 | |
| MWU P | 6733.000 .212 | 7589.500 .003 | 6116.500 .992 | 5212.500 .064 | 6129.500 .987 | 6500.00 .515 | |
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