ORIGINAL ARTICLE
The effect of a supportive educational intervention developed based on the Orem’s self-care theory on the self-care ability of patients with myocardial infarction: a randomised controlled trial Ali Mohammadpour, Narjes Rahmati Sharghi, Shahla Khosravan, Ali Alami and Majid Akhond
Aims and objectives. The aim of this study was to assess the effect of a supportive educational intervention developed based on the Orem’s self-care theory on the self-care ability of patients with myocardial infarction. Background. Patients with cardiovascular disease suffer from the lack of knowledge about the disease and consequently are not able to fulfil their own self-care needs. Design. This was a randomised controlled trial conducted in 2012. Methods. We recruited a random sample of 66 patients with myocardial infarction who had been recently discharged from coronary care unit. The study setting was two university hospitals located in Khorasan, Iran. Patients were randomly allocated to either the experimental or the control groups. Patients in the experimental group received education, support, and counselling while patients in the control group received no intervention. We employed a demographic questionnaire and the Myocardial Infarction Self-Care Ability Questionnaire for data collection and SPSS version 16.00 for data analysis. Findings. After the study, patients in the experimental group had higher levels of self-care knowledge, motivation and skills compared to the prestudy readings and the control group. Conclusion. The supportive educational intervention developed based on the Orem’s self-care theory can improve nonhospitalised patients’ self-care ability and positively affect public health outcomes. Consequently, using the developed programme for providing follow-up care to nonhospitalised patients is recommended. Relevance to clinical practice. Having the ability to develop caring systems based on the nursing theories is a prerequisite to standard nursing practice. Identifying patients’ educational needs is a fundamental prerequisite to patient education. Our findings revealed that the supportive educational intervention developed based on the Orem’s self-care theory can help health care providers identify and fulfil patients’ self-care needs.
Authors: Ali Mohammadpour, BSN, MSN, PhD in nursing, Associated Professor, Department of Nursing, Social Determinants of Health Research Center, Gonabad University of Medical Sciences, Gonabad, Iran. Narjes Rahmati Sharghi, BSN, Student in Master of Nursing Education, Student Research Committee, Gonabad University of Medical Sciences, Gonabad, Iran; Shahla Khosravan, BSN, MSN, PhD in nursing, Associated Professor, Department of Community and Mental Health Nursing, Faculty of Nursing and Midwifery, Social Determinants of Health Research Centre, Gonabad University of Medical Sciences, Gona-
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, doi: 10.1111/jocn.12775
What does this paper contribute to the wider global clinical community?
• The supportive educational inter-
•
vention developed based on the Orem’s self-care theory can improve patients’ self-care ability. Cardiac patients need self-care support. The supportive educational intervention developed based on the Orem’s self-care theory can help health care professionals identify and fulfil patients’ self-care needs.
bad, Iran; Ali Alami, MD, PhD, Assistant Professor, Department of Health School of Public Health; Social Determinants of Health Research Center, Gonabad University of Medical Sciences, Gonabad, Iran; Majid Akhond, BSN, Student in Master of Intensive Care Nursing, Mashhad University of Medical Sciences, Mashhad, Iran Correspondence: Narjes Rahmati Sharghi, Student in Master of Nursing Education, Student Research Committee, Gonabad University of Medical Sciences, Gonabad, Iran. Telephone: +98 09173000878 E-mail: [email protected]
1
A Mohammadpur et al.
Key words: clinical trial, Orem’s self-care theory, patient education, self-care ability Accepted for publication: 8 December 2014
Introduction Cardiovascular disease (CVD) is the first leading cause of death worldwide (Costa et al. 2012, Thygesen et al. 2012). In our country, Iran, 205 cases per 100,000 people die from CVD yearly (Beyranvand et al. 2011). CVD dramatically affects patients’ lives (Woods et al. 2004). Taherian et al. (2007) reported that patients with CVD experience many problems such as job loss and ineffective role performance (Taherian et al. 2007). Follow-up care and rehabilitation are the main components of standard nursing care provided to patients with CVD (Brunner & Suddarths 2011). However, in Iran, there is no follow-up care available to patients with CVD and hence, most of these patients convalesce at home. Consequently, self-care is a matter of great importance for these patients. Rafieifar et al. (2005) also noted that conventional self-care is the most important approach to primary care (Rafieifar et al. 2005). Despite the great importance of self-care, patients usually receive little, if any, detailed health information from health care providers. In other words, they are provided only with short pieces of general information limited to areas such as medications and permitted level of physical activity. Consequently, patients, particularly during the first six month after hospital discharge, suffer from health misinformation and misconceptions as well as lack of knowledge about the aetiology, risk factors and the management of CVD. The consequences of such unawareness are adverse emotional reactions such as stress and anxiety (Jaarsma et al. 1994). Accordingly, patients with CVD are not able to fulfil their own self-care needs and hence, are frequently re-admitted to hospital to receive primary care services. Frequent hospitalisations place a heavy financial burden on patients and their families and increase the risk of cardiovascular complications, nosocomial infections, as well as emotional and physical health problems (Heydari et al. 2011).
Background Many strategies have been developed for supporting patients with chronic diseases after hospital discharge. The Orem’s self-care deficit theory is one of these strategies (George 2011). It is a simple, easy-to-apply, widely used
2
theory of self-care (Arlene & Marjorie 1996, Mohammadhassani et al. 2010). Olivella-Fernandez et al. (2012) noted that Orem’s theory has made a significant contribution to care provision and knowledge development in nursing. They also reported that this theory could help nurses improve patients’ self-care ability. The main focus of the theory is on individual’s health-maintenance and self-care abilities. According to this theory, most people have the potential for self-care. Similarly, individuals’ self-care knowledge, motivation and skills help them develop their self-care abilities. According to Orem, when self-care needs exceed self-care ability—for example in case of chronic diseases such as CVD—, people experience health deviation and require care. Accordingly, they need to fulfil their selfcare needs either individually or by asking for others’ help (Memarian 2011, Meleis 2012). When using this theory, a nurse assesses clients’ self-care knowledge, motivation and skills and determines their self-care needs. Then, the nurse selects one of the nursing systems proposed by Orem— wholly compensatory system, partially compensatory system or supportive-educative system—to fulfil the clients’ self-care needs (Meleis 2012). The supportive-educative system helps individuals reduce their self-care deficit, improve their self-care ability, and fulfil their universal, developmental and health deviation self-care needs. In this system, a nurse acts mainly as a regulator, educator, supporter and counsellor (Meleisebrahim 2007). Previous studies demonstrated that patient education could improve patients’ self-care ability (Daryabygi & Jalili 2003, Shojaefard et al. 2008, MangolianShahrbabaki et al. 2012). The findings of a review study also revealed that educational interventions could significantly modify selfcare behaviours in patients with heart failure (Barnason et al. 2011). Moreover, many studies have examined and indicated the effectiveness of Orem’s self-care theory in improving patient outcomes (Daryabygi & Jalili 2003, Najafi et al. 2008, Shojaefard et al. 2008, Hamidizadeh et al. 2009, Barnason et al. 2011, MangolianShahrbabaki et al. 2012). However, to the best of our knowledge, none of the previous studies has investigated the effects of the Orem’s self-care theory on all the dimensions of patients’ self-care ability and all kinds of patients’ self-care requisites. Consequently, we conducted this study aiming at examining the effect of a supportive educational intervention developed © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
Original article
based on the Orem’s self-care theory on self-care ability of patients with myocardial infarction.
Methods Design This was a randomised controlled trial conducted in 2012.
Participants The study setting was four coronary care units affiliated to two university hospitals located in Southern Khorasan, Iran. The study population consisted of all patients with myocardial infarction (MI) who had been recently discharged from the study setting. The inclusion criteria were having an age of less than 70 years, having a history of previous hospitalisation, having a definite diagnosis of MI—as established by a cardiologist and documented in patients’ medical records —, and having no history of speech and hearing impairments and physical and mental disabilities. We referred to the medical records units of the study setting and listed the names of all patients with MI who had been discharged during the two years preceding the study. The list included 80 patients meeting the study inclusion criteria. Then, we recruited a random sample of 66 names from the list. Thereafter, we phoned the recruited patients, provided them with information about the aim and process of the study, and invited them to the study. All the invited patients agreed to participate in the study. We used the results of Mehri et al. study (2008) and the following formula for calculating the sample size, þ ðZ1 bÞÞ2 n ¼ 2ððZ1 a=2Þ . Accordingly, with a confidence level ðl1l2Þ=S of 95% and a power of 80%, the sample size was determined to be 31 patients in each group. We employed the coin-tossing method to randomly assign the patients to either the control or the experimental groups. We asked the patients to refer to the study setting to receive the study intervention.
Instruments The study instrument consisted of a demographic questionnaire and the MI Self-Care Ability Questionnaire. The demographic questionnaire consisted of questions regarding patients’ age, gender, educational status, weight, height, history of previous MI, family history of MI, and systolic and diastolic blood pressures. To assess the patients’ universal, developmental and health deviation self-care requisites as well as their self-care © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
Effect of supportive educational self-care MI
ability, we developed the 47-item MI Self-Care Ability Questionnaire (MISCAQ). The MISCAQ consisted of three dimensions including self-care knowledge (13 items), selfcare motivation (12 items) and self-care skills (22 items). The MISCAQ items included patients’ self-care knowledge, motivation, and skills in areas such as the symptoms of MI, cardiac drugs and their side effects, healthy diet for patients with MI, permitted level of sexual activity and heart disease risk factors (such as obesity, hypertension, and emotional and mental stress). The MISCAQ consisted of both multiple-choice and Likert-type questions. The possible ranges for the scores of the knowledge, motivation and skills dimensions of MISCAQ were 0–52, 0–48, and 0–88, respectively. The items of MISCAQ were generated based on an extensive literature review and the researchers’ clinical and teaching experiences. Moreover, we invited nine nurse educators, four cardiac care nurses and two cardiologists to confirm the content validity of the questionnaire. We included their comments in the final version of the MISCAQ. The reliability of the MISCAQ was assessed using the test–retest method. Accordingly, we asked 20 patients with MI to respond to the questionnaire. Two weeks later, we asked the patients to complete the questionnaire for the second time. The inter-class correlation coefficient between test and retest readings was 0758.
Intervention Initially, we performed a pretest to assess the patients’ selfcare ability and to identify their educational needs in terms of MI self-care. Then, based on the identified educational needs, we provided the patients in the experimental group with information regarding the functions of cardiovascular system, aetiology and risk factors for MI, management of MI risk factors, and the importance of adherence to treatment and dietary regimens. Educations were provided in three 45-minute sessions. Moreover, during the first 45 days after the educations, we made frequent phone calls to the patients in the experimental group and provided them with the required counselling services in terms of MI self-care. The patients were also able to make phone calls to or visit the researchers to receive further education. On the other hand, the patients in the control group received no intervention. Finally, we performed a post-test to re-assess the patients’ self-care ability.
Data analysis We employed the Statistical Package for Social Sciences version 16.0 (SPSS version 16.0; SPSS Inc., Chicago, IL, USA)
3
A Mohammadpur et al.
characteristics. The results of the independent-samples t and the Fisher’s exact tests revealed that before the intervention, there was no statistically significant difference between the study groups in terms of characteristics such as age, gender, education, body mass index, mean arterial blood pressure, number of MIs, and family history of MI (Table 1). On the other hand, the results of the paired-samples t-test showed that in the control group, the levels of self-care knowledge, motivation and skills did not change significantly after the intervention (p-value >005; Table 2). However, the results of this test revealed that in the experimental group, the levels of self-care knowledge, motivation and skills increased significantly after the intervention (p-value 005; Table 2). However, the results of this test revealed that the postintervention selfcare knowledge, motivation and skills in the experimental group were significantly higher than the control group (p-value ≤00001; Table 2).
to analyze the study data. We described the study data using indices such as mean and standard deviation. Moreover, we employed the independent- and paired-samples t-tests to compare the study groups in terms of self-care ability. The level of significance was set at below 005.
Ethical considerations A university-affiliated Ethics Committee and the Clinical Trials Appraisal Center affiliated to the Iranian Ministry of Health approved the study. We explained the aim and the process of the study to the participants and ensured them that both participation in and withdrawal from the study were voluntary. We also guaranteed the confidentiality of the study participants’ information. Finally, we obtained a verbal informed consent from each participant.
Results In total, 66 patients—33 patients in each group—participated in the study. Table 1 shows the study participants’ Table 1 Patients’ characteristics Variables
Cont. group
Age (years) BMI Education MAP (mmHg) Gender (M/F) n Number of MI (1/2
The effect of a supportive educational intervention developed based on the Orem’s self-care theory on the self-care ability of patients with myocardial infarction: a randomised controlled trial Ali Mohammadpour, Narjes Rahmati Sharghi, Shahla Khosravan, Ali Alami and Majid Akhond
Aims and objectives. The aim of this study was to assess the effect of a supportive educational intervention developed based on the Orem’s self-care theory on the self-care ability of patients with myocardial infarction. Background. Patients with cardiovascular disease suffer from the lack of knowledge about the disease and consequently are not able to fulfil their own self-care needs. Design. This was a randomised controlled trial conducted in 2012. Methods. We recruited a random sample of 66 patients with myocardial infarction who had been recently discharged from coronary care unit. The study setting was two university hospitals located in Khorasan, Iran. Patients were randomly allocated to either the experimental or the control groups. Patients in the experimental group received education, support, and counselling while patients in the control group received no intervention. We employed a demographic questionnaire and the Myocardial Infarction Self-Care Ability Questionnaire for data collection and SPSS version 16.00 for data analysis. Findings. After the study, patients in the experimental group had higher levels of self-care knowledge, motivation and skills compared to the prestudy readings and the control group. Conclusion. The supportive educational intervention developed based on the Orem’s self-care theory can improve nonhospitalised patients’ self-care ability and positively affect public health outcomes. Consequently, using the developed programme for providing follow-up care to nonhospitalised patients is recommended. Relevance to clinical practice. Having the ability to develop caring systems based on the nursing theories is a prerequisite to standard nursing practice. Identifying patients’ educational needs is a fundamental prerequisite to patient education. Our findings revealed that the supportive educational intervention developed based on the Orem’s self-care theory can help health care providers identify and fulfil patients’ self-care needs.
Authors: Ali Mohammadpour, BSN, MSN, PhD in nursing, Associated Professor, Department of Nursing, Social Determinants of Health Research Center, Gonabad University of Medical Sciences, Gonabad, Iran. Narjes Rahmati Sharghi, BSN, Student in Master of Nursing Education, Student Research Committee, Gonabad University of Medical Sciences, Gonabad, Iran; Shahla Khosravan, BSN, MSN, PhD in nursing, Associated Professor, Department of Community and Mental Health Nursing, Faculty of Nursing and Midwifery, Social Determinants of Health Research Centre, Gonabad University of Medical Sciences, Gona-
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, doi: 10.1111/jocn.12775
What does this paper contribute to the wider global clinical community?
• The supportive educational inter-
•
vention developed based on the Orem’s self-care theory can improve patients’ self-care ability. Cardiac patients need self-care support. The supportive educational intervention developed based on the Orem’s self-care theory can help health care professionals identify and fulfil patients’ self-care needs.
bad, Iran; Ali Alami, MD, PhD, Assistant Professor, Department of Health School of Public Health; Social Determinants of Health Research Center, Gonabad University of Medical Sciences, Gonabad, Iran; Majid Akhond, BSN, Student in Master of Intensive Care Nursing, Mashhad University of Medical Sciences, Mashhad, Iran Correspondence: Narjes Rahmati Sharghi, Student in Master of Nursing Education, Student Research Committee, Gonabad University of Medical Sciences, Gonabad, Iran. Telephone: +98 09173000878 E-mail: [email protected]
1
A Mohammadpur et al.
Key words: clinical trial, Orem’s self-care theory, patient education, self-care ability Accepted for publication: 8 December 2014
Introduction Cardiovascular disease (CVD) is the first leading cause of death worldwide (Costa et al. 2012, Thygesen et al. 2012). In our country, Iran, 205 cases per 100,000 people die from CVD yearly (Beyranvand et al. 2011). CVD dramatically affects patients’ lives (Woods et al. 2004). Taherian et al. (2007) reported that patients with CVD experience many problems such as job loss and ineffective role performance (Taherian et al. 2007). Follow-up care and rehabilitation are the main components of standard nursing care provided to patients with CVD (Brunner & Suddarths 2011). However, in Iran, there is no follow-up care available to patients with CVD and hence, most of these patients convalesce at home. Consequently, self-care is a matter of great importance for these patients. Rafieifar et al. (2005) also noted that conventional self-care is the most important approach to primary care (Rafieifar et al. 2005). Despite the great importance of self-care, patients usually receive little, if any, detailed health information from health care providers. In other words, they are provided only with short pieces of general information limited to areas such as medications and permitted level of physical activity. Consequently, patients, particularly during the first six month after hospital discharge, suffer from health misinformation and misconceptions as well as lack of knowledge about the aetiology, risk factors and the management of CVD. The consequences of such unawareness are adverse emotional reactions such as stress and anxiety (Jaarsma et al. 1994). Accordingly, patients with CVD are not able to fulfil their own self-care needs and hence, are frequently re-admitted to hospital to receive primary care services. Frequent hospitalisations place a heavy financial burden on patients and their families and increase the risk of cardiovascular complications, nosocomial infections, as well as emotional and physical health problems (Heydari et al. 2011).
Background Many strategies have been developed for supporting patients with chronic diseases after hospital discharge. The Orem’s self-care deficit theory is one of these strategies (George 2011). It is a simple, easy-to-apply, widely used
2
theory of self-care (Arlene & Marjorie 1996, Mohammadhassani et al. 2010). Olivella-Fernandez et al. (2012) noted that Orem’s theory has made a significant contribution to care provision and knowledge development in nursing. They also reported that this theory could help nurses improve patients’ self-care ability. The main focus of the theory is on individual’s health-maintenance and self-care abilities. According to this theory, most people have the potential for self-care. Similarly, individuals’ self-care knowledge, motivation and skills help them develop their self-care abilities. According to Orem, when self-care needs exceed self-care ability—for example in case of chronic diseases such as CVD—, people experience health deviation and require care. Accordingly, they need to fulfil their selfcare needs either individually or by asking for others’ help (Memarian 2011, Meleis 2012). When using this theory, a nurse assesses clients’ self-care knowledge, motivation and skills and determines their self-care needs. Then, the nurse selects one of the nursing systems proposed by Orem— wholly compensatory system, partially compensatory system or supportive-educative system—to fulfil the clients’ self-care needs (Meleis 2012). The supportive-educative system helps individuals reduce their self-care deficit, improve their self-care ability, and fulfil their universal, developmental and health deviation self-care needs. In this system, a nurse acts mainly as a regulator, educator, supporter and counsellor (Meleisebrahim 2007). Previous studies demonstrated that patient education could improve patients’ self-care ability (Daryabygi & Jalili 2003, Shojaefard et al. 2008, MangolianShahrbabaki et al. 2012). The findings of a review study also revealed that educational interventions could significantly modify selfcare behaviours in patients with heart failure (Barnason et al. 2011). Moreover, many studies have examined and indicated the effectiveness of Orem’s self-care theory in improving patient outcomes (Daryabygi & Jalili 2003, Najafi et al. 2008, Shojaefard et al. 2008, Hamidizadeh et al. 2009, Barnason et al. 2011, MangolianShahrbabaki et al. 2012). However, to the best of our knowledge, none of the previous studies has investigated the effects of the Orem’s self-care theory on all the dimensions of patients’ self-care ability and all kinds of patients’ self-care requisites. Consequently, we conducted this study aiming at examining the effect of a supportive educational intervention developed © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
Original article
based on the Orem’s self-care theory on self-care ability of patients with myocardial infarction.
Methods Design This was a randomised controlled trial conducted in 2012.
Participants The study setting was four coronary care units affiliated to two university hospitals located in Southern Khorasan, Iran. The study population consisted of all patients with myocardial infarction (MI) who had been recently discharged from the study setting. The inclusion criteria were having an age of less than 70 years, having a history of previous hospitalisation, having a definite diagnosis of MI—as established by a cardiologist and documented in patients’ medical records —, and having no history of speech and hearing impairments and physical and mental disabilities. We referred to the medical records units of the study setting and listed the names of all patients with MI who had been discharged during the two years preceding the study. The list included 80 patients meeting the study inclusion criteria. Then, we recruited a random sample of 66 names from the list. Thereafter, we phoned the recruited patients, provided them with information about the aim and process of the study, and invited them to the study. All the invited patients agreed to participate in the study. We used the results of Mehri et al. study (2008) and the following formula for calculating the sample size, þ ðZ1 bÞÞ2 n ¼ 2ððZ1 a=2Þ . Accordingly, with a confidence level ðl1l2Þ=S of 95% and a power of 80%, the sample size was determined to be 31 patients in each group. We employed the coin-tossing method to randomly assign the patients to either the control or the experimental groups. We asked the patients to refer to the study setting to receive the study intervention.
Instruments The study instrument consisted of a demographic questionnaire and the MI Self-Care Ability Questionnaire. The demographic questionnaire consisted of questions regarding patients’ age, gender, educational status, weight, height, history of previous MI, family history of MI, and systolic and diastolic blood pressures. To assess the patients’ universal, developmental and health deviation self-care requisites as well as their self-care © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
Effect of supportive educational self-care MI
ability, we developed the 47-item MI Self-Care Ability Questionnaire (MISCAQ). The MISCAQ consisted of three dimensions including self-care knowledge (13 items), selfcare motivation (12 items) and self-care skills (22 items). The MISCAQ items included patients’ self-care knowledge, motivation, and skills in areas such as the symptoms of MI, cardiac drugs and their side effects, healthy diet for patients with MI, permitted level of sexual activity and heart disease risk factors (such as obesity, hypertension, and emotional and mental stress). The MISCAQ consisted of both multiple-choice and Likert-type questions. The possible ranges for the scores of the knowledge, motivation and skills dimensions of MISCAQ were 0–52, 0–48, and 0–88, respectively. The items of MISCAQ were generated based on an extensive literature review and the researchers’ clinical and teaching experiences. Moreover, we invited nine nurse educators, four cardiac care nurses and two cardiologists to confirm the content validity of the questionnaire. We included their comments in the final version of the MISCAQ. The reliability of the MISCAQ was assessed using the test–retest method. Accordingly, we asked 20 patients with MI to respond to the questionnaire. Two weeks later, we asked the patients to complete the questionnaire for the second time. The inter-class correlation coefficient between test and retest readings was 0758.
Intervention Initially, we performed a pretest to assess the patients’ selfcare ability and to identify their educational needs in terms of MI self-care. Then, based on the identified educational needs, we provided the patients in the experimental group with information regarding the functions of cardiovascular system, aetiology and risk factors for MI, management of MI risk factors, and the importance of adherence to treatment and dietary regimens. Educations were provided in three 45-minute sessions. Moreover, during the first 45 days after the educations, we made frequent phone calls to the patients in the experimental group and provided them with the required counselling services in terms of MI self-care. The patients were also able to make phone calls to or visit the researchers to receive further education. On the other hand, the patients in the control group received no intervention. Finally, we performed a post-test to re-assess the patients’ self-care ability.
Data analysis We employed the Statistical Package for Social Sciences version 16.0 (SPSS version 16.0; SPSS Inc., Chicago, IL, USA)
3
A Mohammadpur et al.
characteristics. The results of the independent-samples t and the Fisher’s exact tests revealed that before the intervention, there was no statistically significant difference between the study groups in terms of characteristics such as age, gender, education, body mass index, mean arterial blood pressure, number of MIs, and family history of MI (Table 1). On the other hand, the results of the paired-samples t-test showed that in the control group, the levels of self-care knowledge, motivation and skills did not change significantly after the intervention (p-value >005; Table 2). However, the results of this test revealed that in the experimental group, the levels of self-care knowledge, motivation and skills increased significantly after the intervention (p-value 005; Table 2). However, the results of this test revealed that the postintervention selfcare knowledge, motivation and skills in the experimental group were significantly higher than the control group (p-value ≤00001; Table 2).
to analyze the study data. We described the study data using indices such as mean and standard deviation. Moreover, we employed the independent- and paired-samples t-tests to compare the study groups in terms of self-care ability. The level of significance was set at below 005.
Ethical considerations A university-affiliated Ethics Committee and the Clinical Trials Appraisal Center affiliated to the Iranian Ministry of Health approved the study. We explained the aim and the process of the study to the participants and ensured them that both participation in and withdrawal from the study were voluntary. We also guaranteed the confidentiality of the study participants’ information. Finally, we obtained a verbal informed consent from each participant.
Results In total, 66 patients—33 patients in each group—participated in the study. Table 1 shows the study participants’ Table 1 Patients’ characteristics Variables
Cont. group
Age (years) BMI Education MAP (mmHg) Gender (M/F) n Number of MI (1/2
