Zeinab Ghasemzadeh Kuchi,Pegah Matourypour,Maryam Esmaeili,Masoumeh Zakerimoghadam
Effect of an Empowerment Program on Life Orientation and Optimism in Coronary Artery Disease Patients
Coronary artery disease,empowerment,optimism
Background: Coronary Artery Disease (CAD) complications cause patients to experience a great deal of concerns and challenges that have adverse effects on their mental health. This study aimed to assess the effect of an empowerment program on life orientation and optimism in CAD patients. Materials and Methods: This randomized clinical trial was conducted on 84 CAD patients admitted to post-CCU wards of Tehran Heart Center during 2018–2019 Patients were allocated to intervention and control groups by block randomization method based on inclusion criteria. Demographic and disease characteristics, and optimism and Life Orientation Test-Revised (LOT-R) questionnaires were completed before and eight weeks after intervention. In the intervention group, an empowerment program was implemented. Data were analyzed by independent t-test, paired t-test, and Chi-square test. Results: The results showed that the mean of patients' age in the intervention and control group was Mean [Standard Deviation (SD)] 54.59 (7.93) and 55.92 (7.81) years, respectively. Most patients in both intervention (61.90%) and control (66.70%) groups were male. The majority of patients in the intervention group (92.90%) and the control group (95.20%) were married. There were no significant differences between the two groups in terms of demographic characteristics and disease history before the intervention (p > 0.05). After the intervention, a significant difference was observed in the life orientation and optimism scores between the intervention and control groups (p < 0.001). Conclusions: By stimulating self-awareness, providing knowledge and encouraging patients to control, and manage their disease, the empowerment program changes patients' view of their disease, and increases their optimism and positive life orientation.
Effect of an Empowerment Program on Life Orientation and Optimism in Coronary Artery Disease Patients

Coronary Artery Disease (CAD) complications cause patients to experience a great deal of concerns and challenges that have adverse effects on their mental health. This study aimed to assess the effect of an empowerment program on life orientation and optimism in CAD patients.

This randomized clinical trial was conducted on 84 CAD patients admitted to post-CCU wards of Tehran Heart Center during 2018–2019 Patients were allocated to intervention and control groups by block randomization method based on inclusion criteria. Demographic and disease characteristics, and optimism and Life Orientation Test-Revised (LOT-R) questionnaires were completed before and eight weeks after intervention. In the intervention group, an empowerment program was implemented. Data were analyzed by independent t-test, paired t-test, and Chi-square test.

The results showed that the mean of patients' age in the intervention and control group was Mean [Standard Deviation (SD)] 54.59 (7.93) and 55.92 (7.81) years, respectively. Most patients in both intervention (61.90%) and control (66.70%) groups were male. The majority of patients in the intervention group (92.90%) and the control group (95.20%) were married. There were no significant differences between the two groups in terms of demographic characteristics and disease history before the intervention (p > 0.05). After the intervention, a significant difference was observed in the life orientation and optimism scores between the intervention and control groups (p < 0.001).

By stimulating self-awareness, providing knowledge and encouraging patients to control, and manage their disease, the empowerment program changes patients' view of their disease, and increases their optimism and positive life orientation.

Ischemic Heart Disease is a chronic disease with high mortality late all over the world.[1] World Health Organization reports that 17 million people die of Cardiovascular Diseases (CVDs) every year.[2] Coronary Artery Disease (CAD) is the most common type of cardiovascular disease.[3] For better disease control and a healthier lifestyle, it is essential to empower patients.[4] Empowerment refers to the process, in which people earn control over the factors and decisions that shape their lives.[5] It also helps patients to improve their health.[6] Optimism and life orientation are variables associated with mental health.[78] Positive life orientation is a predictor of health and participation in positive and health-oriented behaviors.[9] Life orientation provides an opportunity for people to develop life skills for solving problems, making decisions and informed choices, taking action to achieve success in life, and increasing their quality of life.[10] Optimism refers to two concepts; the first concept is to remain hopeful and second is to believe that, “we are living in the best possible world”.[11] Optimism is correlated with the improvement in cardiovascular health outcomes,[12] and is associated with a lower CAD incidents and mortality.[13] Patient empowerment is correlated with optimism. Empowerment starts by giving information and education to patients and ends with the active participation of patients in making decisions about their disease process.[14] Most studies have been conducted on patient empowerment in chronic diseases like diabetes, asthma, kidney disease, etc[15161718] and less in patients with CAD[19] In the present study, patients with CAD constitute all study population because studies show that these patients, due to the chronic and progressive nature of their disease, are exposed to multiple problems and recurrence of the disease. Heart disease, as one of the debilitating diseases, is considered to have an adverse effect on patients' self-care, self-efficacy, and quality of life. Therefore, there is a need for interventions to increase the self-care and self-efficacy of these patients, so that they can participate in their treatment process. In the studies conducted in this field, the relationship between empowerment programs, life awareness, and optimism has not been examined. They have also some shortcomings and limitations, such as low sample size,[1920] which make it difficult to trust their findings despite being significant, so it is necessary to conduct a study in this field with a stronger methodology. Due to the chronic and progressive nature of coronary heart disease, patients with this disease are exposed to multiple problems and recurrence of the disease. Heart disease accompanies patients throughout life and is considered one of the most debilitating diseases. On the other hand, the diverse educational and care need cause these patients to have difficulty meeting their health needs and overcoming the complications of their disease. Lack of knowledge and awareness reduces motivation and self-confidence and ultimately creates a feeling of weakness and inability in patients, which will have an adverse effect on self-care and preventive decisions made by them. The role of nurses is to persuade, support, and encourage patients. Nurses are the closest member of the medical team to patients and play a key role in supporting and encouraging patients to solve their problems and increase their self-reliance, self-esteem, and ability to deal with the disease and have a positive attitude toward it.[21] This study aimed to investigate the effect of empowerment programs on optimism and life orientation in patients with coronary heart disease.

This study is part of a larger research,[22] a randomized clinical trial (IRCT201607254443N22), conducted on 84 CAD patients in post-CCU wards of Tehran Heart Center during 2018-19. Based on the results of Bustanji et al.[23] study and taking into account 95 confidence interval, 80% test power, and 20% sample drop, the required number of samples for each group was determined to be 42 patients, using the following formula. The adequacy of the sample size was re-evaluated based on the primary information in this study. A total of 84 patients with coronary heart disease admitted to a teaching hospital of Tehran University of Medical Sciences were selected by convenience sampling and assigned to the study groups by block randomization method. The subjects were selected from the patients admitted to post-CCU wards based on the inclusion criteria. The inclusion criteria were being 18–65 years old, having reading and writing literacy, having a confirmed diagnosis of CAD by a specialist, having the ability to communicate, being able to get out of bed, having no known psychological disorders, not attending similar empowerment programs, being hospitalized for CAD for the first time, and having stable conditions (vital signs within normal range without dyspnea or chest pain). The exclusion criteria consisted of entering the acute phase of the disease (experiencing unstable hemodynamic means disturbance in blood pressure, pulse rate, arrhythmia, and hypoxia), death of the patient, not attending one of the workshop sessions, being discharged before the end of the workshop, and not taking part in the telephone follow-ups. After explaining the study objectives, written informed consent was obtained from the participants. Then, patients were assigned to control and intervention groups by Block Balanced Randomization (BBR). The randomization sequence was obtained from the website: (http://www.randomization.com/), and the number of subjects per block was determined to be four. Letter A was assigned to the control group and letter B to the intervention group, and eventually, randomization sequence was applied for 21 blocks. Next, block-containing cards were put into standard envelopes to achieve allocation concealment. Based on eligible hospitalized subjects, one envelope was randomly taken by the researcher using envelop shuffling method, and ultimately random allocation of subjects was determined. Details are given in [Figure 1] (consort diagram). The data collection tools included a demographic characteristics and disease history questionnaire, and the Life Orientation Test-Revised (LOT-R) questionnaire for measuring both life orientation and optimism. First, both groups completed the demographic and disease history, and LOT-R questionnaires. The LOT-R questionnaire consists of 10 questions based on the Likert scale, ranging from 0 (strongly disagree) to 4 (strongly agree). The scoring is done in two stages: In the first stage, the questions 3, 7 and 9 are scored in reverse (so that the scores are 0 = 4, 1 = 3, 2 = 2, 3 = 1 and 4 = 0). In the second stage, to calculate the total score, the scores of questions 1, 3, 4, 7, 9, and 10 are summed up (questions 2, 5, 6, and 8 are only filling questions and their scores are not counted). The minimum and maximum scores are 0 and 40, respectively, with a higher scores indicating a higher level of optimism. This questionnaire was designed and standardized for the first time by Scheier et al. (1999).[24] Another study determined the validity and reliability of this questionnaire by Cronbach's alpha of 0.71. Since this tool has never been used in Iran, it was first translated into Persian and the ambiguities and inaccuracies in the text were corrected. The translation was done with the Back Translation technique. It should be noted that no item was deleted or modified at this stage. Then a pilot study was performed on patients with coronary heart disease, who were similar to the target group of this study but were not part of the study. The validity of the tool was evaluated after translation, using the face and content validity index by a panel of experts. Face validity was confirmed by checking the grammar, wording, appearance, and punctuality. The Content Validity Index (CVI) was calculated to be (0.8), which is acceptable. The internal consistency of the tool was also measured by Cronbach's alpha coefficient (0.7) in a sample size of 30 patients, which was acceptable. The empowerment programs begin with providing information and education to patients, and end with achieving patient participation in decision-making about the disease process. These programs are used to develop five main skills problem solving, decision-making, using resources, forming a therapeutic relationship between caregiver and patient, and activity planning. The empowerment program was delivered over three workshop sessions with the presence of 5 to 7 eligible patients on three consecutive days. Each session lasted between 60 to 90 min was adjusted according to patient's preference. After patients' discharge, patients in the empowerment group became members of the Telegram social network for further training on risk control and disease recurrence prevention. The group discussion and intervention continued over the phone for eight weeks with contents, including a review of information provided, ongoing evaluation of achieving objectives, giving advice on modifying performance, encouraging patients to apply heart attack-prevention methods, change of lifestyle, and answering patients' questions. Telephone contact was made by the researcher once a week between 10 am and 8 pm depending on patients' preference, and lasted at least ten minutes according to patients' needs. By the end of the intervention, the LOT-R questionnaire was completed again by both groups. The Magic Empowerment Program (MEP) contains five stages motivating patient self-awareness, assessing causes of problems, setting goals, developing a personal self-care plans, and assessing goal achievement.[17] In this study, the educational content of this program (first stage) was modified for CAD patients and finalized by 10 nursing faculty members. Details of each stage are given in Table 1. The program was implemented by the main researcher (first author). The LOT-R questionnaire was used in this study to gather information in both groups before and after the intervention. Data were analyzed by SPSS (version 16; SPSS Inc., Chicago, Illinois), using descriptive and analytical tests (independent and paired t-tests).

The present study was approved by the ethics committee of Tehran University of Medical Sciences (Grant No. IR.TUMS.FNM.REC.1396.2691) All participants participated voluntarily in the study and signed informed consent to do that.

The mean and Standard Deviation (SD) of the samples' age in the intervention and control groups was 54.59 (7.93) and 55.92 (7.81), respectively. Most patients in both intervention (61.90%) and control (66.70%) groups were male. The majority of patients in the intervention (92.90%) and control (95.20%) groups were married. Most patients in the intervention group had primary education (33.30%)and a high school diploma in the control group (28.60%). The income of most patients in the intervention (47.60%)and control (38.10%) groups was somewhat sufficient. The majority of patients in the intervention (78.60%) and control (57.10%) groups were living with their spouses and children. Also, most patients in the intervention (100%) and control (97.60%) groups had health insurance. According to the findings, there was no significant difference between the two groups in terms of demographic characteristics and disease history before the intervention and the two groups were homogeneous (p < 0.05), [Table 2]. According to Table 3, there was no significant difference between the two groups in terms of the mean and standard deviation of optimism and life orientation scores before the intervention, so this score was 15.30 (3.65) in the control group and 15.21 (3.24) in Intervention group, so the two groups were homogeneous (p = 0.900). However, after the intervention, a significant difference was observed between the two groups in terms of the mean and standard deviation of these two variables (p < 0.001). The scores of optimism and life orientation differed significantly before and after the intervention in the intervention group (F = 40, p < 0.001), while no significant difference was observed in the control group in this regard (F = 41, p = 0.05).

The purpose of this study was to investigate the effect of an empowerment program on life orientation and optimism in patients with coronary heart disease. The findings showed that the empowerment program increased life orientation and optimism in the intervention group compared to the control group. In this study, after the intervention, a significant difference was observed between the two groups in terms of the mean and standard deviation of two variables (p < 0.001), so that the scores of optimism and life orientation differed significantly before and after the intervention in the intervention group (p < 0.001). Similar findings in the study of Shepperd et al.[25] (1996) showed that at the end of a cardiac rehabilitation program, increased optimism in patients represented a lower risk of CAD, and also played an important and unique role in the recovery of high-risk cardiac patients, leading to a reduction in their level of saturated fat in the diet, body fat and global risk of coronary heart disease. Also, Habibović et al.[26] (2018) showed that high levels of optimism are associated with a reduction in anxiety and depression, and also there is a significant relationship between optimism and physical/mental health, as increased optimism improves physical and mental health. Boehm, (2013) in her prospective study emphasizes that optimism protects a person against disease and slows disease progression.[27] Various studies with different methodologies show that optimism is an important issue in patients, and by improving optimism we can enhance other related variables. Empowerment and rehabilitation programs can improve patient optimism. No study with results opposite our findings was found. The findings of various studies show that optimism has a positive effect on the physical and mental health of cardiac patients. The effect of optimism is more detectable in the physical dimensions, such as laboratory indexes and general health status in various studies. These effects can be due to the connection between body and soul, and their mutual impact on each other. The scores of life orientation differed significantly before and after the intervention in the intervention group (p < 0.001). Aghaei (2013) reported in his research that if we increase the level of life awareness, a higher level of general health will be achieved.[19] As Carbon (2017),[28] and Rezaei (2015),[29] express, optimism, and positive life awareness lead to physical and mental well-being. Souri (2014),[8] introduces optimism as an internal and predictive source that is correlated with positive health behaviors and ensures the physical and mental health of individuals. The relationship between other variables, such as health dimensions, was not measured in the present study, as done in another study.[21] The present study could not assess the other factors and variables affecting the psychosocial health of the subjects due to the time restriction, so future studies are recommended to examine more variables. The limitation of this study was that some patients in this study had been ordered to remain in bed by their physician due to the constant need for cardiac monitoring or bleeding from the catheter site, so they were unable to move or sit during the sessions. To overcome this issue, the researcher organized group meetings in the rooms of these patients. Considering the results of the present study, we suggest future studies to evaluate and review the factors affecting patients' risk perception and accuracy of risk perception (difference between perceived risk and real risk) and also to compare patients' social interactions before and after the program implementation.

By stimulating self-awareness, providing knowledge, and encouraging patients to acquire the ability to control and manage their disease, the empowerment program changes the patients' view of their disease and increases their optimism and positive life orientation, which leads to a decrease in negative emotions. Given the mutual relationship between mental and physical health, patients in this study witnessed a reduction in disease progression and reoccurrence, and cardiovascular events, and also experienced an improvement in their general health.

Tehran University of Medical Sciences, Iran

Nothing to declare.