1. BACKGROUND:

Cardiovascular disease is among the most important causes of death in the world. It is also expected to become the first cause of death and disability in the world by 2030. Every year more than 23.6 million people die from cardiovascular diseases (1)This disease accounts for 46% of deaths in Iran, which is one third of all deaths in this country, and half of these deaths are due to myocardial infarction (2). Myocardial infarction is one of the most common diagnoses in patients with cardiovascular disease (3). Myocardial infarction is a wide spared disease and causes a number of complications, such as: congestive heart failure, cardiogenic shock, and acute pulmonary edema (4). It leads to significant disability and reduction of efficiency and imposes a huge care and therapeutic costs to the patients and their family (5). Teaching families is the main responsibility of nurses which, with the change of health system approach to health-centered and realization of families’ role in the health of patients as well as family-centered education, has been approved (6). Nursing knowledge about cardiovascular disease has changed in recent years as helping patients to fell independent and in control of the situation is not always useful (7). Active presence of families however, has been proven to be effective in creating motivation in patients to follow the treatment plan (8).

The proper observance of treatment plans such as medications (9), a regular exercise program (10) and proper nutrition (11) play an important role in the prevention of myocardial infarction and management of its complications. Therefore, patients need education for self-care and changing of their health behavior (12)With provision of education and proper health care, it would be possible to improve health, adhere to treatment, return to the level of performance prior to the disease, prevent disease exacerbation and help the patient and family to cope with changes in health status (13). The level of awareness and understanding of many patients about causes of their disease, treatments, health care and ways of adherence to regimen, is often very low which, in turn, indicates inattention of the healthcare teams to the beliefs of patients and providing them with detailed recommendations (14). After the acute phase of the disease, the patients are discharged from the hospital and observance of recommended treatment regimen occurs outside the medical system and at home (15). Therefore, interventions such as educating patients and their families to improve adherence to treatment regimen has a special position (5). Family-centered education is one of the main concepts of nursing, since a person's illness cases every family member to enter in the course of the disease (16). Today, the focus of nursing is on self-care and empowerment of patients and their families which is also the main purpose of nursing. The ultimate goal of a nurse and the treatment team is to help patients achieve ability to perform daily activities and family, with its multi-dimensional role, is the key to achieve the goal. Family participation facilitates provision of health care through joint planning by nurses, family members and patients, with a focus on all aspects of patient’s health (17). Therefore, family participation is recommended in all medical care and nursing programs as it creates; positive attitude, reduce anxiety and improve patient’s health (18). There are several ways for education. The traditional methods of education cannot be accountable for the changes and rapid development of information and meeting the educational needs of patients with chronic diseases (19). Computerized education is a basic tool for content teaching that, the teacher can use to demonstrate sample matters in form of multimedia software with audio, video and graphics in order to teach students and involve their visual and auditory sense in learning (20) Teaching by multimedia software is one of the new educational methods which, with the rapid advances of communication technology, affects all aspects of human life. Studies, regarding computerized education in patients with heart diseases (21), pregnant women (22), adolescents (23) and hem dialysis patients (24), reported positive results such as; increase awareness and adherence to the treatment regimen.

Considering the above-mentioned information and given that the researcher found no study on the impact of family-centered education on clinical outcomes of patients with myocardial infarction

2. OBJECTIVES:

This study aimed to determine the effect of family-centered education through multimedia software on the clinical outcomes of patients after acute myocardial infarction.

Patients and Methods:

The above study is a clinical trial of quasi-experimental type in two groups which aims to determine the impact of family-centered multimedia education on the clinical outcomes of patients with acute myocardial infarction between Octobers to March 2014.The eligible samples were divided, based on random allocation by using the table of random numbers, into two intervention and control groups In a CCU ward. The criteria to enter the study were; to be patients with 30 to 70 years of age; experiencing acute myocardial infarction for the first time which has been confirmed by a doctor, not to be in critical and emergency condition during the study, patient and family member should not be suffering from speech problems, deafness and blindness, to have access to a computer or to someone who could help them to use it, and have received no modern education about the treatment regimen.

If the patients experienced Psychological crises or were staying in the hospital for a long term due to the complications of the psychological disease, or for reasons other than a heart problem required hospitalization or emergency intervention, they were excluded from the study. The research samples were selected based on Zolfaghari et al study (8) and a sample size formula

(1/96= z¹- ،0/5=p₁_،0/5= q₁_،0/8= p₂، 0/2=q₂، 0/84= z₁-β)

With Inclusion of loss, at the significance level of 0.05 and test power of80 percent, and assuming that the patients’ full adherence to the regimen was at least 25 percent different in the two groups, so the difference was considered statistically significant. The samples in each group consisted of 30 patients. This means that, there were 30 patients in the patient-centered group and 30 patients in family-centered (patient education together with active members of the family) group.

3.1 The Intervention:

Incontrol groupPatient-centered group received education through multimedia software (video, audio, images, animation) in three sessions for every other day. Each session lasted 30-45 minutes. At the end of each session, 10-15 minutes were devoted to answering the patient and family questions about educational content or use of the software. At the end of the third session, the educational CD was given to patients and family members to be used by them at home as they needed. In intervention group,the family-centered group (patient and active family member) was trained by multimedia software similar to the patient-centered group. Three months after the intervention, with coordination with the doctors and during their regular visits to clinic, the relevant list was completed.

Data were collected with the researcher-made checklist and a questionnaire. The questionnaire included demographic information and information relating to the disease. The check list was used for recording; laboratory information (CHOL, HDL, LDL, TG, and FBS), Vital signs (systolic blood pressure, diastolic blood pressure and pulse pressure), body mass index, frequency of chest pain, and ejection fraction of the patients.

3.2 Study Instrument:

Researcher-made checklist and questionnaire were instruments in the study which include;

· General and health-related demographic:

General demographic of the samples included: age, sex, education, occupation, marital status, and health-related characteristic included: a history of smoking, alcohol drinking, family history of cardiovascular disease, exercise and underlying diseases.

· Body Mass Index (BMI):

To determine body mass index, a precision electronic scale of BSR101To (made in Germany), was used to measure the height and weight of the samples. Patients stood on the scale with minimal clothing and no shoes. Their heads were quite upright and faced forward. After that, the researcher sets the stadiometer and recorded the height and weight of the patients and body mass index was calculated by dividing weight (kg) by the square of height (m).

· Laboratory results:

To determine the Laboratory amount of (HDL, LDL, FBS, Chol and TG), after 12 hours of fasting, 5 cc of venous blood was taken from the Antecubital vein of the sample’s hand that did not receive serum, and the blood was sent to the laboratory.

· Blood Pressure:

A heart monitoring device with Datex-ohmeda brand and GIMM compact model (made in Finland) was used to measure blood pressures of the patients. Control blood pressure of the patients was measured by non-invasive method. Patients were at semi-sitting position while the sphygmomanometer cuff was fastened to the right arm and Pulse pressure was calculated from the differences between systolic and diastolic pressure.

· Echocardiography:

In order to determine ejection fraction, Echocardiography was carried out by a physician before and three months after intervention using ultra mark device at 2.5 MHz probe.

· Chest Pain:

To determine the frequency of chest pain, the patients were provided with a check list that they could mark the symptoms in case they were detected

To determine the scientific validity of the researcher-made questionnaires and checklist, content validity method was used. Data collection instrument was prepared after reviewing; books, new and relevant scientific papers, similar research and views of supervisors and advisors and then, they were given to 10 members of the school board of Arak University of Medical Sciences for content validity. After collecting their views, corrective views and suggestions of the professors were applied with the researcher agreed Reliability of the questionnaires. Then checklist was estimated with the Pearson correlation coefficient of r = 0.89.

3.3 Ethical Considration:

The study protocol and its ethical considerations were approved by the nursing and midwifery care research center(grant NO. 93-162-7, Ethical approval code: 20-19-18-17-13-12-5-3-2-1).after receiving permission from the ethics committee of Medical Sciences university of Arak, consulting the samples and obtaining informed consent from them for participation in the study and taking of the blood sample.

Data Analyses:

Data were analyzed using SPSS version 16. General and health-related characteristics of patients were presented in; real number, percentages, means and standard deviations. The difference among Echocardiography, blood pressure (systolic, diastolic, pulse-pressure), laboratory results, and BMI, were analyzed using T-test. Frequency of chest pain was also analyzed using Chi-square test.

4. RESULTS:

60 patients with acute myocardial infarction (30 patients in each group) participated in this study. The Age of the patients in patient-centered group and family-centered group was 96/6±52/60 and 78/8±23/61, respectively, and based on independent t-test there was no statistically significant difference between the two groups. Further, based on chi-square test, the two groups were homogeneous in terms of; sex, marital status, education level, underlying disease, history of smoking, alcohol drinking, and exercise, there was also no statistically significant difference between them.

Before the intervention, the average body mass index in the family- centered and patient-centered groups were 54/1 ± 96/21 and 48/1 ± 14/22 respectively, which according to independent t-test, the two groups were not significantly different. However, three months after the intervention, the average body mass index in the family-centered and patient-centered groups were 06/1±75/19 and 06/1±56/21 respectively, that showed a significant statistical difference between the two groups (P=0<000.1). Furthermore, according to echocardiography, the average ejection fraction of patients before the intervention were 83/46±7/62 and 86/5±68/45 in family-centered and patient-centered groups respectively that showed, a significant statistical difference between the two groups. Mean±SD of laboratory values (Chol, TG, HDL, LDL and FBS¹), systolic blood pressure, diastolic blood pressure and pulse pressure before and after the intervention in both groups are shown in table 1. The frequency of chest pain in both groups is shown in table2.

DISCUSSION:

The research results showed that, education of (nutrition, and appropriate pharmaceutical and exercise program) improves clinical outcomes (levels of blood lipids, blood sugar, body mass index, ejection fraction, the frequency of chest pain) in patients suffering from myocardial infarction. But the effect of education on family-centered group was significantly higher than patient-centered group. Several studies have been conducted in this regard. Hosseini et al (2013) in a study of the relationship between nutrition knowledge and physical activity level and the level of total cholesterol, HDL, LDL in men with myocardial infarction concluded that, proper nutrition and a regular exercise program can reduce LDL and total cholesterol which are risk factors for cardiovascular disease. As the result of the study shows, a proper education program can reduce the risk of cardiovascular disease, including myocardial infarction (25). The results of several studies also confirmed the positive impact of education on; reducing the incidence of chest pain (26), Better use of cardiac output and an increase in the level of performance (27), and faster restoration of ECG changes to normal(28). However, in this study, in addition to patient education, family education was also carried out which had a more positive impact on the improvement of the clinical implications of patients. The present study is similar to the study of Zolfaghari et al (2015) in which, they compared the efficacy of family-centered and patient-centered education on hem dialysis complications. They concluded that, family-centered education (compared to patient-centered education) is more effective in reducing the complications of hem dialysis and improving clinical implications of patients (8) with the difference that, the present research was conducted to study the effect of family-centered education in patients with acute myocardial infarction which proved to be effective. Also, Sanaei et al in their study concluded that, family-centered empowerment model increases family participation in patient adherence to treatment regimen¹ and an increase in self-efficacy and self-esteem of patients (29). In a study by Chien et al (2006), the impact of patient and family-centered education on patients hospitalized in CCU was investigated. They concluded that people who, along with their families receive education for post- hospitalization health care, enjoy a higher level of knowledge and awareness compared to patients who had been trained alone (30). In the present study, despite the similarity of the content and education methods in both groups, patients who participated in education sessions with their families had better clinical outcomes compared to patients who were trained alone. Therefore, it seems that education with participation of familiesis one of the measures that can provide a proper ground for improving the clinical status of patients. A study carried out by Aggarwal et al. (2010) also showed that, active family participation and support are one of the most important factors in following the regimen programs for cardiovascular patients after released from hospitals (31). Therefore, involvement of families in patient education, especially chronic patients, such as cardiovascular patients who need comfort and appropriate psychological conditions can have a positive impact on improving patients’ observance of regimen programs and the clinical outcomes accordingly. The results of a study carried out by Zarkhah et al (2011) on the effect of family-centered intervention on dietary patterns in patients suffering from a heart attack, are also similar to the results of the present study. They concluded that, the family-centered education (compared to patient-centered education) is more effective in modifying the dietary patterns (32). The only difference is that, in this study computerized education was carried out in the field of medicine, nutrition and sports and its impact on clinical outcomes of patients was examined. The study carried out by Asgari et al (2015) on the impact of patient-centered and family-centered education methods on the attitude and adherence of patients to regimen programs and fluid restrictions in hem dialysis patients (in 2 and 4 weeks) showed that, although the attitudes of patients and their adherence to regimen programs was better improved in the family- centered group during the second week. But in the fourth week, there was no significant difference between the two groups (6). As the results of the study shows, short term education alone, does not lead to continuous adherence to the therapeutic program and patients and their families need to follow different procedures to obtain continuous adherence to the therapeutic program. As the study carried out by Mosavifaret al (2011) showed, follow up programs through telephone and through short messaging leads to improvement of adherence to diabetes therapeutic program in three areas of medicine, exercise, and food (33). Therefore, patient education and follow-ups after they are discharged from hospital, plays an important role in improving the clinical outcomes of patients. And according to studies cited above, from the presence of the patient’s family, the follow-up procedures are also necessary. Therefore, with regard to the above-mentioned issues and results of this study, it seems that, nursing education using modern teaching methods with an emphasis on active participation of patients and families in this process can improve the clinical outcomes of patients. The limitations of this study include different psychological characteristics, motivations and personal differences that affected the patient's adherence to therapeutic program. Attempts were made to reduce them through full explanation of the importance of information insertion and assuring the participants about the confidentiality of information and the creation of proper conditions for answering the questions. Further, there was a possibility for non-cooperation of the samples three months after they are released, which was controlled by obtaining patients and families phone numbers, and through cooperation of the physicians in arranging new appointments. During the study, it was possible for both (the control and the intervention) groups to receive information from any other source (radio, television, family, etc) other than education, which was beyond the control of researchers.It should be noted that, despite extensive searches by the researcher, no study on the impact of family-centered education through multimedia software on the clinical outcomes of patients after acute myocardial infarction was found.

Table 1: Comparison of Mean± SD^aof laboratory values (Chol, TG, HDL, LDL, FBS^b) and systolic blood pressure, diastolic blood pressure and pulse pressure before and after the intervention in both patient-centered and family-centered groups.

After the intervention				Before the intervention		Time Variable
Patient-centered		Family-centered		Patient-centered	Family-centered
Mean± SD				Mean± SD
147.50±25		154.33±31.6		247.47±68/18	202.17±48.12	FBS
P=0.03 t=0.928 df=58				P=0.149 t=1.464 df=58		Result
237.43±27.43		197.33±33.11		263.40±65.01	209.47±43.51	Chol
P=0.0001 t=5.104 df=58				P=0.928 t=3.772 df=58		Result
42.3±7.01		50.8±8.45		35.56±5.1	35.33±6.03	HDL
P=0.0001 t=4.21 df=58				P=0.872 t=0.161 df=58		Result
147.27±16.62		120.57±10.04		137.37±19.72	139.80±36.82	LDL
P=0.0001 t=7.530 df=58				P=0.690 t=0.09 df=58		Result
219.90±23.42		192.27±22.9		220.07±27.69	209.98±22.43	TG
P=0.0001 t=4.704 df=58				P=0.122 t=1.568 df=58		Result
119.60±8.62			114.53±10.71	137.17±20.83	140.50±17.79	BPs^c
P=0.048 t=0/149 df=58				P=0.528 t=0.635 df=58		Result
82.83±8.97	75.50±9.94			92.66±15.07	92.16±14.21	BPd^d
P=0.004 t=2.99 df=58				P=0.895 t=0.132 df=58		Result
35/5±5/27	39.33±3.40			44.50±9.59	48±9.05	PP^e
P=0.016 t=4.41 df=58				P=0.152 t=1.45 df=58		Result

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Received on 04.05.2017 Modified on 08.10.2017

Asian J. Nursing Education and Research. 2018; 8(2): 189-195.

DOI: 10.5958/2349-2996.2018.00039.3

Frequency	Family-centered	Patient-centered	Result
Frequency	N(%)	N(%)	Result
0	6(20)	2(6.7)	96/X²squer =17 P=0/014
1	9(30)	2(6.7)
2	5(16.7)	2(6.7)
3	5(16.7)	4(13.3)
4	2(6.7)	9(30)
5	0	3(10)
6	2(6.7)	5(16.7)
7	1(3.3)	2(6.7)