INTRODUCTION:

Essentially a pump, the heart is a muscle made up of four chambers separated by valves and divided into two valves. Each half contains one chamber and first half is called an atrium and the other half is called a ventricle. The atria collect blood, and the ventricles contract to push blood out of the heart. The right half of the heart pumps deoxygenated blood (blood that has a low amount of oxygen) to the lungs where blood cells can obtain more oxygen. Then, the newly oxygenated blood travels from the lungs into the left atrium and the left ventricle. The left ventricle pumps the newly oxygen-rich blood to the organs and tissues of the body. This oxygen provides your body with energy and is essential to keep your body healthy¹.

The coronary arteries are at risk for narrowing as cholesterol deposits, called plaques, build up inside the artery. If the arteries narrow enough, blood supply to the heart muscle may be compromised (slowed down), and this slowing of blood flow to the heart causes pain, or angina.²

Cardiovascular diseases are at present the leading causes of death in the developed countries. Ischemic heart disease is the cause of 25 – 30% of deaths in most industrialized countries³.

The resulting ischemia (restriction in blood supply) and oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium).⁴

Living a healthier life can not only extend your life, it can also improve the quality. Feeling physically better and having control over your own life can greatly increase your mental health as well. Although there are some aspects of physical and mental health that are beyond an individual's control, there are many things that people can do to improve their quality of life.⁵

Modifications of lifestyle are often critically important to adequately control existing hypertension. The elevated blood pressure of patients who are gaining weight, performing little physical activity, smoking and drinking alcohol in excess may be impossible to control despite progressively increasing doses of multiple medications. Thus leads to myocardial infarction.⁶

Modification of lifestyle are even more important to a much larger population of patients, those who are genetically predisposed to develop hypertension if exposed to adverse environmental factors. As a consequence of the rapid growth of these environmental factors including obesity, physical inactivity, stress, excessive alcohol consumption, and too much dietary sodium plus too little dietary potassium the incidence of hypertension continues to increase. Obviously, everyone would benefit from the prevention of hypertension, a far more effective way to reduce the personal and societal burdens of cardiovascular disease than the treatment of the established disease.⁷

Heart is one of the body's most important organs. The heart is roughly cone-shaped hollow muscular organ. It is about 10cm long and is about the size of the owner’s fist. It weighs about 225g in women and is heavier in men (about 310g). The heart lies in the thoracic cavity in the mediastinum between the lungs.⁸

BACKGROUND OF THE STUDY:

An acute myocardial infarction or heart attack occurs when a portion of the cardiac muscle is deprived of an adequate supply of arterial blood (ischemia) with its oxygen and nutrients, long enough so that tissue in that area dies (undergoes necrosis).⁹

Cardiovascular disease is still the leading cause of death in Australia (43·8%) (National Heart Foundation). Coronary heart disease (acute myocardial infarction) accounted for 24·5% of all causes of death in Australia (National Heart Foundation). Despite the debilitating effects of this condition on the individual, family and society, a few studies have investigated the needs of families with a critically ill member. In a review of the literature, found only eight studies concerned with the needs of families. These studies revealed widespread symptoms of distress. A recent study of 37 families during the recovery of the father’s first Myocardial Infarction found that 7 weeks after the MI event family routines were disrupted, household chores suspended, social activities given up and the needs of children neglected or met by others.¹⁰

Patients suffering myocardial infarction (MI) are usually admitted to coronary care units/intensive care units and are cared for by many health professionals, the majority of whom have undertaken advanced clinical courses of study. The emphasis of these courses, however, is often on the medical aspects of care, such as physiology, pharmacology and the biophysical responses of patients to medical treatment. Limited attention has been given to emotional issues associated with critical care psychological support. This highlights a possible lack of understanding by health professionals of the importance of psychosocial implications of cardiac conditions which affect the patient, and their families.¹⁰

Cardiac education and cardiac rehabilitation aims to improve patients’ long-term survival and recovery, post myocardial infarction (MI), through education on risk factor management. Risk factors are those, which when present in an individual, place him at a higher risk of developing ischemic heart disease. These include smoking, hypertension, elevated serum cholesterol, obesity, diabetes and lack of exercise. Patients are commonly taught about management of these areas through written and verbal information regarding anatomy and physiology, lifestyle, medications, exercise, and diet advice.¹¹

Most of the people through the world die from the consequences of cardio vascular disease. Myocardial infarction is more common in middle age group people. The ‘needs-based’ approach has been advocated as a means of educating cardiac patients rather than imparting information based in the preferences of administration, or implementing mass programmers designed for general use with little regard of individual requirements, This approach attempts to identify and meet the needs of the individual.¹²

NEED FOR THE STUDY:

Lifestyle modifications including smoking cessation, weight control, and exercise are among the most difficult risk-reduction strategies to implement. Patients with coronary and other vascular disease who understand the rationale behind recommended lifestyle changes and recognize the potential benefits that can result are more likely to cooperate with physicians in implementing treatment. Setting goals, outlining methods for achieving these goals, and monitoring the patient's progress are also critical to the success of lifestyle modification strategies.¹³

World health Organization reported that coronary artery disease is a worldwide disease. Cardio vascular disease causes twelve million deaths throughout the world each year. American Heart Association estimated that, worldwide approximately 6.3 million deaths occurred due to Myocardial Infarction. Myocardial Infection the leading cause of death in industrialized western world, accounting 40.6% all deaths. Also stated that, the causes of 25-30% of death in industrialized countries are due to Myocardial Infarction.¹⁴

American Heart Association reported that, cardio vascular disease is the currently leading cause of death for Americans, each year kills approximately one third of the 1.5 million persons in U. S. A. The incidences of Myocardial Infarction were in 30% in 1997, 34% were in 2000. 46% were in 2004.¹⁵

Myocardial Infarction has been labeled as the single largest killer disease of the world. Forty million persons in India estimated to suffering from MI. The hospital prevalence of Myocardial Infarctionin India was reported to be 6%-23%, while community prevalence was reported to be 6.5% and 4.8% in urban men and Women and 2.3% and 1.7% in rural men and Women respectively.¹⁶

PROBLEM STATEMENT:

To assess the effectiveness of self-instructional module (SIM) on knowledge regarding life style modification among Myocardial Infarction patients admitted in selected hospital in Vidharbha region.

OBJECTIVES OF STUDY:

· To assess the knowledge regarding life style modification among myocardial infarction patients.

· To evaluate the effectiveness of self-instructional module on knowledge regarding life style modification among myocardial infarction patients.

· To associate post-test knowledge regarding life style modification among myocardial infarction patients with selected demographic variables.

HYPOTHESIS:

H1- There is a significant increase in the knowledge regarding life style modification about myocardial infarction.

H0- There is no significant increase in the knowledge regarding life style modification about myocardial infarction.

LIMITATION:

· The findings of the study are limited to the selected samples only.

· Only acute myocardial infarction patients were included in this study.

· Sample size is too limited.

ETHICAL CONSIDERATION:

· Permission taken from the ethical committee.

· Information must be handled in such a way that confidentiality & anonymity are maintained.

· Information may not be used or released outside the terms of the agreement.

· Subjects must be protected from all types of harm.

THEORETICAL FRAMEWORK:

A conceptual framework or model is made up of concepts, which are the mental images of the phenomenon. These concepts are linked together to express the relationship between them. A model is used to denote the symbolic representation of the concepts. Kings process of concept, development to one of the synthesis and reformulation using inductive and deductive processes, critical thinking, empirical observation as well as extensive reviews of the nursing and other literature. Imogene king’s goal attainment theory is based on the personal and interpersonal system including interaction, perception, communication, transaction, stress, growth and development, time and space.

The investigator adopted king’s goal attainment theory as a basis for conceptual frame work, which is aimed to develop self-instructional module on life style modification to find out these effectiveness and assessing the patients’ knowledge before and after the provision of self-instructional module.

The six major concepts of the phenomenon are described as follows:

1. Perception:

In this study the nurse researcher’s perception is that the patients does not have adequate knowledge regarding the risk factors of myocardial infarction and they were unaware about the modification of life style that can avoid further attack of myocardial infarction.

Improving patient’s knowledge life style modification.

Motivate patients to update the knowledge regarding life style modification.

2. Judgment:

The investigator judged to develop self-instructional moduleregarding life style modification.

3. Action:

Refers to mental or physical activity to achieve the goal with the individual perceive. The patient educator’s action is to plan for self-instructional moduleregarding life style modification.

4. Reaction:

In this study investigators and patients’ reaction are setting mutual goal and plan for assessing effectiveness of self-instructional module.

5. Interaction:

It refers to verbal and nonverbal communication of individual and the environment and between two or more individual. In this study investigator interacts with the patient by giving pre-test questionnaires and by giving self-instructional moduleto them.

6. Transaction:

It depends upon the attainment of a goal. In this stage the investigator reassesses the knowledge regarding life style modification and assesses the effectiveness of self-instructional module.

7. Feedback:

There is an increase in level of knowledge life style modification.

REVIEW OF LITERATE:

The review of literature is defined as a broad, comprehensive in depth, systematic and critical review of scholarly publication, unpublished print material, audiovisual material, and personal communication¹⁷

A research literature review is the written summary of the state of evidence of research problem. The major steps in preparing a written research review include formulating a question, devising a research strategy, concluding a search, retrieving relevant sources and abstracting encoding information, critiquing studies, analyzing the aggregated Information and preparing a written synthesis.¹⁸

The purpose of review of literature is to generate research question to identify what is known and not known about a topic to identify a conceptual of theoretical tradition with in the bodies of literature and to describe method of inquiry used in earlier work including their success and short comings.¹⁹

Sources of literature review are primary and secondary. A primary source research review is the original description of the study prepares by the researcher who conducted it. A secondary source is a description of the study by person unconnected with it. Literature review should be based on primary source material.²⁰

The literature review is presented in this chapter under the following headings:

1. Literature related to myocardial infarction.

2. Literature related to life style modification.

3. Literature related to knowledge regarding myocardial infarction.

4. Literature related to the effectiveness of Self-instructional module (SIM).

1. Literature related to myocardial infarction:

A study conducted cardiovascular disease refers to me of a number of conditions that damage the heart or the arteries that carry blood to and from the heart. If the coronary arteries become diseased or blocked, a myocardial infarction occurs.²¹

A study conducted on major risk factors for MI which cannot be changed, are hereditary, sex and age. The major risk factors for MI that can be changed and smoking, high blood pressure, high cholesterol, physical in activities, diabetes, obesity and stress.²²

A study conducted on “Risk assessment and stratification following high-risk MI”, which revealed that, diabetes is a major risk factors for the development of atherosclerotic disease and 20% - 30% of patients presenting with an acute myocardial infarction who had previous diagnosis of diabetes.²³

A study conducted on “The effect of atherosclerosis on the vasomotor response of coronary arteries disease” which revealed that, the role of personality stress and depression have been associated with increased risk for MI. The mental stress induces silent myocardial ischemia and coronary vasoconstriction.²⁴

A study conducted on “Effects of inpatient rehabilitation on cardiovascular risk factor in patients with coronary heart disease” which revealed that, among 2441 patients 24% of patients had high arterial blood pressure, 39% of patients were smokers, 60% of patients with high cholesterol level, 14 % of patients with elevated glucose level above 140mg/dl and 18% of patients were obese.²⁵

Over the past 40 years, the prevalence of heart disease in urban India has increased by a factor 8-10% among person at 35 to 65 years of age group and also it is estimated that because of MI more than 40% of deaths would occur in 2020. (park.2002)²⁶

A study conduct on, “Medical treatment and secondary prevention of coronary heart disease”, which revealed that, among 3850 individuals 86% of individuals had modifiable risk factors: 27% were cigarette smokers, 68% had a body mass index of 25 plus, 40% had hypertension, 29% had hyper cholesterolameia and 19% had hyperglycaemia.²⁷

2. Literature related to life style modification:

A descriptive study was conducted to establish a comprehensive multi-disciplinary cardiac prevention and rehabilitation programme for patients with coronary artery disease in order to achieve life style modification risk factor control and optimal use of proven cardio rotactive medication. Results showed that of 537 patients, 9.2% were non-smokers, mean BMI was 27.2kg/m2, 76% achieved their BP target, and 87% achieved target fasting total cholesterol. The study concluded that a multi-disciplinary cardiac prevention programme can achieve and sustain effective secondary prevention.²⁸

In a randomized controlled study trial over 24 months, to evaluate the effectiveness of an individually tailored multifactor lifestyle intervention in primary care for individuals at high risk for cardiovascular disease 1050 adults with existing cardiovascular disease or multiple risk factors were studied. The results of the study showed that the cardiovascular risk score decreased by 28% in intervention group and body weight decreased by 3.7%; total cholesterol decreased by 10.8% while time engaged in exercise by 39%. The study concluded that cardiovascular risk level of high-risk individuals decreased in both intervention and control group. Primary case prevention should be targeted to high-risk persons.²⁹

A cross sectional study was done in Jordan to evaluate stress level, sources of stress and examine the significance of socio demographics and health characteristics in predicting stress in myocardial infarction patients in the early discharge period. Data was collected from 84 myocardial infarction patients, aged 20-70 years, 2-16 weeks after discharge through structured interview technique. Results revealed that most patients experienced a moderate level of stress, with 20% reporting high stress levels. The most significant predictors of stress were age, gender, income, frequency of chest pain episodes and physician’s recommendations to quit smoking. The findings suggest that in the early discharge period myocardial infarction patients worry about their social role, interpersonal relations and personal health, which can exacerbate symptoms and complicate their future care.³⁰

An interview study was done to explore the self-regulation process in women and men 5 months after a first time myocardial infarction. 11 women and 10 men were interviewed. Results revealed that fatigue and other health problems kept them from taking part in activities as they had done before the heart attack. Reorienting the active self from myocardial infarction was restricted by illness perception and coping.³¹

A cross sectional study was done to identify factors associated with behaviour modification among CAD patients in Northern Taiwan. 156 patients were interviewed and asked to complete a structured questionnaire in cardiovascular clinics at 3 medical centres. Results revealed that total 38% of variance of modifying behaviours was explained by self-efficacy, actual risk factors, and work status and health beliefs. Self-efficacy was the strongest predictor and age and type a personality were the 2^nd leading cardiovascular risk factors for the participants. Most participants could perform modifying behaviours such as taking medications, eating an appropriate diet and following specific lifestyle recommendations.³²

A descriptive study on medical treatment and secondary prevention of coronary heart disease revealed that among 3850 individuals 86 percentage of individuals had modifiable risk factors; 27 percentage were cigarette smokers, 68 percentage had a body mass index of 25 plus, 40 percentage had hypertension, 29 percentage had hyper cholestrolemia and 19 percentage had hyperglycemia³³

An experimental study was conducted to assess the effects of exercise and lifestyle modification activities and cardio-vascular patients outcome. The sample size was 120. The study revealed that the knowledge regarding exercise and nutritional intervention in patients with coronary artery disease had documented decreases morbidity and mortality, decreased symptoms, decreased depression.³⁴

A descriptive study was conducted to assess the effects on cardio respiratory fitness and progression of coronary atherosclerotic lesion. The sample size was 90. This study revealed that physical activity roughly doubles the risk of coronary artery disease. Higher levels of physical fitness and leisure time physical activity are associated with lower rates of all cause of mortality, independent of other risk factors.³⁵

A study was conducted to assess the feasibility of the health related lifestyle self management intervention as a strategy to decrease cardio-vascular risk follwing Acute Coronary Syndrome. The sample size was 125. It resulted with the findings supporting the feasibilityof implementing the health related lifestyle self management intervention for risk factor modification in patients with acute coronary syndrome.³⁶

A randomized and quasi experimental study was conducted to determine the effect of brief structured intervention on risk factor modification in patients with coronary heart disease. Seventeen trails involving a total of 4725 participants were included in the final review. Three trials compared the effect of brief structured interventions on diet modification, seven on smoking cessation and seven on multiple risk factors. The results showed that there is suggestive but inconclusive evidence from the trials of a benefit in the use of brief interventions for risk factor medication in patients with coronary heart disease.³⁷

A cross sectional study was conducted to assess the knowledge of modifiable risk factors of heart disease among patients with acute myocardial infarction among 720 subjects. Results showed that the mean age was 54 years and mere 42% had good level of knowledge. They concluded that the lack of good level of knowledge modifiable risk factor for heart disease among subjects admitted with acute myocardial infarction. There is an urgent need for aggressive and targeted educational strategies in that population.³⁸

A study was conducted in South Asia on behavioral pattern, life style and socio economic status in elderly normolipidemicacute myocardial infarct subjects: a case control study. The current study was focused on impact of behavioral aspects, life style and physical activity influence on CAD. Lipid profile and behavior aspects and life style were determined in the 165 normolipidemic acute myocardial infarct patients and compared with 165 age / sex matched controls. The result showed that lipid profiles were higher in case of patients than with controls, apart from HDL-c levels (p<.001), which were significantly lower in patients (p<.001). Patients had higher serum cholesterol and blood pressure compared to controls in each behavioral assessment parameters. Physical activity was found to be lower in patients compared to controls. Hyperactive irrelevant thinkers and highly ambitious subjects had higher cholesterol level and blood pressure in each category. Mostly the middle socioeconomic class was affected (71%) by AMI. This study finding indicated a high prevalence of various behavioral risk factors among the myocardial infarcts patients. Remedial measures are needed to minimize future morbidity burden and thereby minimizing medical expenses. In regard to the risk factor of smoking, strict public policy in restricting the behavior and cigarette distribution may be considered.³⁹

A study was conducted in Hamilton (ON) on changes in diet and exercise can make a big difference within six months of ACS. The study shows that benefits of improving diet, exercising more and quitting smoking are additive and can reduce a patients risk within 6 months, if the patient sticks with it.The study included 18809 patients from 41 countries enrolled in the OASIS (organization to assess strategies in acute ischemic syndrome) randomized clinical trial. Patients reported their adherence to diet, physical activity, smoking cessation advised at 30 days. MI, stroke, cardiovascular death and all-cause mortality were recorded out to 6 months. About one third of patients in the study continued to smoke, 30% did not adhere to either the diet or exercise recommendations, 30% adhere to both diet and exercise advice for at least 30 days. By contrast, over 96% of subjects continued to take anti platelet drugs, 79%stayed on statins and about 72% maintained on ACE inhibitors. Quitting smoking cut risk of MI by almost half compared with persistent smoking (odds ratio0.57; 95% CI). Diet and exercise adherence also reduced the risk of MI by nearly half compared with non-adherence(odds ratio: 0.52; 95%CI). On the other hand, patients who continued to smoke and did not adhere to diet and exercise regimens were 3.8 times more likely to suffer MI, stroke or death within 6 months than nonsmokers who modified diet and exercise.⁴⁰

A study was conducted in California on cardiac event rate in a life style modification program for patients with coronary artery diseases. Patients with CAD enrolled in a two year program of exercise training, dietary counseling, stress management and therapeutics education.134 patients enrolled in the program, of this 77 completed the program and 57 failed to do so. Those who completed the program improved their effort tolerance and reached recommended goals for serum lipids and blood pressure levels. The cumulative event rate(cardiac death, MI, stroke) over 10 years in the patients who completed the program was 1.5%. The corresponding event rate in patients who dropped out was 18%. This study suggest that patients who completed a 2 year life style modification program appears to have a favorable prognosis over a expanded period of time.⁴¹

A study was conducted on can life style changes reverse coronary heart disease? The life style heart trial. In a prospective randomized controlled trial to determine whether, comprehensive life style changes affect coronary atherosclerosis after one year, 28 patients were assigned to an experimental group (low fat vegetarian diet, stopping smoking, stress management training, and moderate training) and 20 to a casual care control group. 195 coronary artery lesions were analyzed by quantitative coronary angiography. The average percentage diameter stenosis regressed from 40.0% to 37.8 % in the experimental group, yet progressed from 42.7% to 46.1% in the control group. When only lesions greater than 50% stenosed were analyzed, the average percentage diameter stenosis regressed from 61.1% to 55.8% in the experimental group and progressed from 61.7% to 64.4 % in the control group. Overall, 82% of experimental group patients had an average change towards regression. Study suggest that, comprehensive life style changes may be able to bring about, regression of even severe coronary atherosclerosis after only year, without use of lipid lowering agents.⁴²

A study conducted in Stockholm on diet, life style changes may prevent MI in women based on a Swedish study finding indicated women who have a healthy diet and life style are less likely to suffer myocardial infarction than other women. A population –based prospective study of 24, 444 post-menopausal women who were free from cancer, cardiovascular diseases, and diabetes, at the base line to examine the benefit of combining healthy dietary and life style behaviors in the prevention of MI. Women were classified into quintiles depending on their healthy dietary pattern score, defined by consumption of vegetables fish, whole grain fruits and legumes. Multivariate analysis adjusted for socio demographic and cardiovascular risk factors revealed that women in the lowest quintile of healthy dietary pattern scores had a 71% of increased risk for MI compared with those in the highest quintile (p=0.004). In the final analysis, the combination of a healthy dietary pattern, moderate alcohol consumption, not smoking, being physically active and having low abdominal adiposity was associated with a 92 % reduced risk for MI, compared with women without these healthy dietary and lifestyle behaviors. The researchers noted that the combined benefit of diet, lifestyle and healthy body weight prevented 77% of MI in the study population. The study results that important step can be taken to significantly reduce the risk of coronary artery diseases.⁴³

A study was conducted in Ireland on life style changes following myocardial infarction: patient perspective. The diagnosis of myocardial infarction has a major implication for individuals, in terms of health and social gain, health related quality of life and living and adapting to chronic illness. The diagnosis required life style changes such as changes to diet, smoking habit, physical activity and stress management. The aim of the descriptive qualitative study was to explore patient perspective of making lifestyle changes following MI. Study finding shows that, four themes emerged: life style warning signs, taking responsibility for life style changes, particularly in relation to smoking cessation, and stress management, The study suggest the need for the development of primary care services and cardiac life style modification program to support patients.⁴⁴

A study was conducted in Norway on positive psychological and life style changes after myocardial infarction- a follow up study after 2-4 years. An interview study of 84 males recruited from a post infarction anticoagulant trial reveals a number of positive changes regarding life style and factors related to quality of life 3 -5 months after the index infarction. In the present study, the investigator investigated the extent to which such changes persist after 2-4 years. 74 of 75 survivors responded to a postal questionnaire. The answers concerning the total life situation, as compared with the last month before the myocardial infarction as follows (response after 3-5 months in brackets): improved 29% (33%), unchanged 47% (47%), and deteriorated 24% (20%). There were still appreciable positive changes at follow up regarding smoking, physical activity, alcohol consumption and stress at work. Similar changes or a slight reduction were observed in a previously reported positive scoring of factors related to quality of life. Positive changes in psychosocial and life style factors are seen shortly after MI generally seem to persist after 2-4 years.⁴⁵

A study was conducted in USA ‘A case management system for coronary risk factor modification after acute myocardial infarction” to evaluate the efficacy of physician directed, nurse – managed, home based case management system for coronary risk factor modification, randomized clinical trial in which patients received a special intervention or usual medical care during the first year after acute myocardial infarction. In the hospital specially trained nurses initiated interventions for smoking cessation, exercise training, and diet drug therapy for hyper lipidemia. All medically eligible patients received exercise training, all smokers received the smoking cessation intervention and all patients received dietary counseling and if needed lipid lowering drug therapy. The result shows that in the special intervention and usual care group, cot nine confirmed smoking cessation rates were 70% and 53%, plasma LDL cholesterol were 2.77% and 3.41%and the functional capacities were 9.3% and 8.4% respectively. This study concludes that in a large health maintenance organization, a case management system was considerably more effective than usual medical care for modification of coronary risk factors after MI.⁴⁶

3. Literature related to knowledge regarding myocardial infarction:

A population based case control study was conducted to evaluate the modification effects of sex in the association between life style and acute myocardial infarction in Porto, Portugal. Trained interviewers collected information using a standard structured questionnaire. Associations were estimated using unconditional logistic regression the effect modification by sex was evaluated in the regression models, testing interaction terms between lifestyles and sex. The study sample included Portuguese Caucasian adults, aged > or =18 years. Cases were patients consecutively admitted with incident acute myocardial infarctions during and controls were a representative sample of non-institutionalized inhabitants of Porto with no evidence of previous clinical or silent infarction. The study results showed that cigarette smoking was positively associated with acute myocardial infarction in both men and women (smokers >15 cigarettes/d v. never smokers: OR = 9.11, 95% CI 4.83, 17.20 for women; OR = 3.92, 95% CI 2.75, 5.58 for men; interaction term P value = 0.001). A significant protective effect of moderate alcohol intake on acute myocardial infractions occurrence was found in women (0.1-15.0 g/d v. non-drinkers: OR = 0.48, 95% CI 0.31, 0.74), but not in men. Fruit and vegetable intake, vitamin and mineral supplement use and leisure-time physical activity practice were found to decrease acute myocardial infarction risk, with similar effects between sexes. So the study concluded that a strong positive association between smoking and acute myocardial infarction was found in women. Also, a protective effect of moderate alcohol intake was only found among females. Fruit and vegetable intake, vitamin and mineral supplement use and leisure-time physical activity practice were found to decrease acute myocardial infarction risk in both sexes.⁴⁷

A case-control study was conducted with an objective to elicit risk factors for myocardial infarction among Southern Indians and to find out its association with body mass index in Chennai. The study included patients with myocardial infarction matched against healthy control subjects was carried out in a tertiary care teaching hospital. Standard methods were followed to elicit risk factors and body mass index. Chi-square and Fishers exact test for categorical versus categorical, to show relationship with risk factors were analyzed. The study results showed that a total of 949 patients (male (M) = 692 and postmenopausal female (F) = 257) and 611 age and sex matched healthy controls were included. In our study, body mass index was below 23 in 48.2% of patients and below 21 in 22.5%. The risk of developing myocardial infarction was significantly more in males (odds ratio (OR) = 3.3, 95% confidence interval (C.I.) = 2.69-4.13), among females with post-menopausal duration of more than or equal to 3 years (OR = 9.27, 95% C.I. = 6.36-13.50) and in those with body mass index less than 23 with one or other risk factors (P = 0.002, OR = 1.38, 95% C.I. = 1.13-1.70).So the study concluded health education on life style modification and programs to diagnose and control diabetes and hypertension have to be initiated at community level in order to reduce the occurrence.⁴⁸

A descriptive study was conducted to assess the level of knowledge regarding modifiable risk factors of myocardial infarctions among 50 Coronary heart disease patients at Chennai. The result showed that 82% had inadequate knowledge, 12% had moderately adequate and 6% had adequate knowledge regarding modifiable risk factors of myocardial infarction. The study concluded that there is an immense need of educational programmers in related fields.⁴⁹

A study was conducted to assess the level of knowledge of cardiovascular risk factors and recommended life style changes in patients rehabilitated after an acute coronary syndrome with a simple size of 31 patients. The result showed that after rehabilitation programme the subjects had significant improvement regarding knowledge on recommended lifestyle changes and cardiovascular risk factors. The study was concluded that the patients after acute coronary syndrome have poor knowledge of cardiovascular risk factors and recommended life style modifications. The level of knowledge improves after short term, stationery cardiac rehabilitation.⁵²

A cross sectional study was conducted to assess the knowledge of modifiable risk factors of heart disease among patients with acute myocardial infarction among 720 subjects. Results showed that the mean age was 54 years and mere 42% had good level of knowledge. They concluded the study that the lack of good level of knowledge of modifiable risk factors for heart disease among subjects admitted with acute myocardial infarction. There is an urgent need for aggressive and targeted educational strategies in that population.⁵³

A cross sectional study was conducted to assess the knowledge of modifiable risk factors of coronary atherosclerotic heart disease in New Delhi among 217 patients. The result showed that 41% of them had good knowledge. 68%, 72%, 73% and 57% of population identified smoking obesity, hypertension and high cholesterol correctively, respectively. They concluded that an Indian population in a hospital setting shows a lack of knowledge pertaining to modifiable risk factors of coronary atherosclerotic heart disease. Educational interventions can be effectively targeted and implemented as primary and secondary prevention strategies to reduce the burden of coronary atherosclerotic heart disease in India.⁵⁴

A descriptive study was conducted to assess the level of knowledge regarding modifiable risk factors of myocardial infarctions among 50 Coronary heart disease patients in Chennai. The result showed that 82% had inadequate knowledge, 12% had moderately adequate and 6% had adequate knowledge regarding modifiable risk factors of myocardial infarction. The study concluded that there is an immense need of educational programs in related fields.⁵⁵

4. Literature related to the effectiveness of Self-instructional module (SIM):

A study was conducted on “To assess the effectiveness of Self Instructional Module regarding quality of life among patients following CABG surgeries in the elderly”. A total number of 63 patients with 65 years of age group, both males and females were selected by convenience sampling technique. A detailed questionnaire was used to collect data about quality of life and improvement in lifestyle after CABG surgery. The study result showed that a high proportion of the patients experienced improvement (that is 45 patients) in life style modifications, while a substantial number (that is 15 patients) had exacerbations in cognitive function, lack of confidence and dependence. The study concluded that an important step is needed to improve the quality of life, might be through the institution of a structured multidisciplinary rehabilitation program, also the life style modification with focus on emotional support.⁵⁰

A study was conducted to assess the effectiveness of Self Instructional Module on patient knowledge and compliance of Quality of Life among 30 patients who had underwent valve replacement surgery and 18 patients who had had coronary artery bypass surgery were included in this study. Among them 25 patients were taught by masters-prepared clinical specialists and 23 by nurses with less than master’s preparation. Measurements of knowledge and compliance were obtained preoperatively. The study revealed that the patients who had received teaching from masters-prepared nurses had significantly higher test scores at discharge than the teaching received by nurses with less than master’s degree. So there is an effectiveness of teaching programme by the nurses with masters in degree regarding Quality of life after valve replacement surgery.⁵¹

An experimental study was conducted to evaluate a self instructional education module with audit and feed back, designed to increase the skills of General Practitioner in diagnosing melanocyte lesion and in skin cancer. The sample size was sixteen General Practitioner. The overall diagnostic accuracy of malignant lesions was 63.2%during baseline and 64.5% posteducation. Significant improvements were seen posteducation in the proportion of melanocytic lesions confirmed as malignant 6.1% baseline and 13.5% posteducation, The study concluded with the findings that General Practitioners with less experience benifited most from the programme, indicating that tailoring of programmes to individual skills and years of practice might bebenificial.⁵⁶

A study was conducted to evaluate the effectiveness of a self instructional module in increasing nurses knowledge of Genetics. Sample size was 262 registered nurses. The study has shown a significant increase of 20.8 percentage in participants mean knowledge score on the post-test as compared with pre-test. The study concluded with self instructional module for registered nurses was effective in increasing knowledge of basic human genetic concepts and risk assessment.⁵⁷

A study was carried out to determine the learning needs of Staff Nurses regarding care of children receiving Oxygen Therapy; finding association between learning needs and selected variables; determining validity of self-instructional module, on "care of child receiving Oxygen Therapy", and evaluating the effectiveness of the self-instructional module or SIM. The total sample of the study was 30 Staff Nurses, of 6 months experience in Paediatric Ward. The findings of the study showed high learning need status in most of the areas and the Staff Nurses also expressed the desirable need for learning in detail. It was found that age, total years of experience, experience in Paediatric Ward and married, with or without children were independent of their learning need. SIM was effective in terms of gain in knowledge score as well as acceptability and utility scores of Staff Nurses.⁵⁸

RESEARCH METHODOLOGY:

Research methodology defines what the activity of research is, how to proceed, how to measure progress, and what constitutes success. The methodological decision paves crucial implications for validity and credibility of the study findings. Methodology of research indicates the general pattern for organizing the procedure for the empirical study together with the method of obtaining valid and reliable data for an investigation. ¹⁷

This chapter deals with the methodology adopted for assessing the knowledge regarding life style modification. It includes the description of the research approach, research design, identification of the target and accessible population, setting of the study, sample and sampling technique, development of data collection tools, reliability and validity of the tool and questionnaire, procedure for data collection and the plan for data analysis.

The above techniques are used to structure this study and to gather and analyze information in a systematic fashion. This chapter deals with research design, setting of the study, population, sample, criteria of sample selection, sampling technique, sample size, tools and scoring, tool preparation and feasibility of the study, pilot study, validity and reliability method of data collection and statistical analysis and also emphasises on particular methodology adopted by the investigator to conduct the study.¹⁹

RESEARCH APPROACH:

Descriptive evaluative approach is used in this study. This approach was selected because the aim of this research study was to evaluate the effectiveness of self-instructional module in improving the knowledge of patients regarding life style modification. With this approach it would be possible to describe the knowledge of patients regarding life style modification.

The interventional approach would help the investigator to evaluate the effect of the intervention that is “self-instructional module” on the variable that is knowledge of the patients.

RESEARCH DESIGN:

Research design is an overall plan how to obtain answer to the question being studied and how to handle some of the difficulties encountered during research process and also enhances for the specification of the study to be used in the research process. The research design helps the researcher in the selection of the subject, manipulation of the experimental variables, procedure of data collection and the type of statistical analysis to be used to interpret the data. ¹⁸

In the present study Quasi experimental one group pretest posttest research design was used. A pretest was administered by means of structural questionnaire depicted as 0₁and then self-instructional module given depicted as X.A post test was conducted using the same structured questionnaire depicted as 0₂. The study design is depicted as

Table No-1: Quasi experimental one group pretest posttest design

PRE TEST	INTERVENTION	POST TEST
Day 1	Day 1	Day 7
0₁	x	0₂

SETTING OF THE STUDY:

Setting is the physical location and condition in which data collection takes place. This study is conducted in selected hospitals of Vidarbha region.

The investigator found the setting appropriate to conduct the study because adequate numbers of patients were available who could take for the study and also hospital authorities were cooperative and gave permission to conduct the study.

Names of hospitals are

1. Acharya Vinoba Bhave Rural Hospital, 1198 beds, Sawangi (Meghe), Wardha.

2. Avanti Institute of Cardiology Pvt.Ltd.Nagpur

POPULATION:

A population is the entire aggregation of cases in which a research is interested.¹⁷

In this study the population was all the Myocardial infarction patients. Population is distinguishing as target and accessible population.

Target population:

The target population is aggregate of cases about which the researcher would like to generalize.¹⁷

In this study the target population was the myocardial infarction patients admitted in hospital in Vidarbha region

Accessible population:

The aggregate of cases that conform to eligibility criteria and that are accessible as subjects for a study.¹⁷

The accessible population for this study was myocardial infarction patients admitted in the selected hospital in Wardha and Nagpur.

VARIABLES:

Independent variable:

An independent variable is a stimulus or activity that is manipulated by researcher to create an effect on the dependent variable. It is also called an intervention or experimental variable.¹⁷

The independent variable in this study is self- instructional module on life style modification.

Dependent variable:

“It is response, behavior or outcome that the researcher wants to predict or explain changes in the dependent variable are presumed to be caused by the independent variable”.¹⁷

The dependent variable in this study is knowledge of patients.

SAMPLE:

Sample is a sub set of population elements. An element is the most basic unit, about which information is collected. In nursing research elements are usually human. In this study samples were patients who were fulfilling the inclusion and exclusion criteria.¹⁷

Samples are taken from Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha, and Avanti Institute of Cardiology Pvt. Ltd, Nagpur.

SAMPLE SIZE:

In this study sample size was 60 patients.

SAMPLING TECHNIQUE:

Sampling refers to the process of selecting the portion of the population to represent the entire population.¹⁷

The sampling technique used in the study was non probability convenient sampling. According to Polit and Hungler convenient sampling entails the selection of most readily available individuals as subject in the study, it represents typical conditions and researchers knowledge about his population and its elements can be used to hand pick cases.

The investigator preferred to choose this sampling technique because of the constraint of time and in order to complete the data collection within the stipulated time.

CRITERIA FOR SAMPLE SELECTION:

Inclusion criteria:

Patients who were:

· Willing to participate in the study.

· Available during data collection.

· Able to read and understand Hindi & Marathi.

Exclusion criteria:

· Patients who had attended the similar programme.

· Patients, who were medical person like, doctor, nurse.

TOOLPREPARATION:

A tool is an instrument or equipment used for collection of data.

Development of the tool:

The investigator developed the tool after updating his theoretical knowledge regarding life style modification, the investigators own experience, theoretical knowledge and guidance from the experts along with the review of literature helped in developing the tool necessary for the study.

Structured questionnaire consists of two sections

Section I consists of demographic variables of the students to be participated in the study e.g. Age, gender, education, occupation and religion.

Section II consists of 30 questions on knowledge regarding life style modification.

Scoring

· Score 1 was given for correct answer

· Score 0 was given for wrong answer

· Knowledge was graded from poor knowledge to excellent knowledge based on scores

Table No-2; scoring procedure on knowledge regarding life style modification.

Sl. No.	Level of knowledge Score	Score Range	Percentage range (%)
1.	Poor	0-7	0-25
2.	Average	8-15	26-50
3.	Good	16-22	51-75
4.	Excellent	23-30	76-100

DEVELOPMENT OF MODULE ON LIFE STYLE MODIFICATION:

The self-instructional module was developed for patients. The steps adopted in the development of the self-instructional module were:

· Through review of relevant published literature and websites on various aspects of life style modification, modifiable risk factors.

· Preparation of the first draft of the self-instructional module.

· Content validation of the self-instructional module.

· Preparation of the final draft of the self-instructional module.

The areas covered in the self-instructional module were:

1. General knowledge on myocardial infarction.

2. Risk factors of myocardial infarction.

3. Define life style modification.

4. Management of modifiable risk factors.

PREPARATIONOF THE FINAL DRAFT OF THE SELF INSTRUCTIONAL MODULE

The final draft of the self-instructional module was prepared considering the suggestions given by the experts.

· Introduction

· Definition of myocardial infarction.

· Risk factors of myocardial infarction.

· Define life style modification.

· Management of all modifiable risk factors.

· Conclusion

A cover page with appropriate title and illustration was prepared

Validity:

“Validity refers to degree of which an instrument measures what it is supposed to measure.”¹⁷

In order to obtain content validity, the tool was given to 12 experts who included one from Department of Statistics, one each from Department of Marathi and English, Department of Medicine and nine from Department of Medical Surgical Nursing. After receiving opinions from the experts and consultation from the guide some modifications were done in framing the item and same were incorporated in to the tool.

Reliability:

Reliability of the tool is a major criterion for assessing the quality and accuracy. It is the degree of consistency with which it measures the attribute. Reliability analysis was done by Guttmann Split Half Coefficient, and was 0.86

Feasibility of the study:

Tool was tested on 06 samples that were eligible for the study and the investigator found that tool was feasible. These samples were excluded from the main study.

Pilot study:

“A pilot study is a miniature run of the main study.” The pilot study was conducted in Wardha from 14^thAug. to20^thAug. 2012 as per laid down criteria 6 samples were selected from Pawade Nursing Home, Wardha for pilot study from non-probability convenient sampling technique.

On the first day of the study, pretest was conducted on knowledge regarding adverse effects of antipsychotic drugs. Questionnaire was administered, each sample required mean time of 30 min. to complete the structured questionnaire. After the pretest self-instructional module was carried on life style modification. The post test was conducted with same questionnaire on the 7^th day.

The findings of the pilot study were analyzed. The pilot study helped the investigator to visualize practical problems that could be encountered while conducting the main study. It also gave an insight into the actual process of data collection and analysis. The samples who were included in the pilot study were excluded in the main study.

Method of data collection:

The data gathering process began from 17^th Sept. to 13^th Oct. 2012. The investigator visited to selected hospitals of Vidarbha region in advance and obtained the necessary permission from the concerned authorities. The investigator introduced himself and informed them about the nature of the study so as to ensure better cooperation during the data collection.

The investigator approached the myocardial infarction patients admitted in selected hospital of Vidarbha region and explained the purposes of the study and explained how it will be beneficial for them. He enquired their willingness to participate in the study, the investigator made a group of such patients, made them comfortable and oriented them to the study and administered questionnaire to them, instructed them not to interact with each other, doubts were clarified. Once the questionnaire completed, investigator collected them back, each sample required mean time of 30 min. to complete the structured questionnaire. After the pretest self-instructional module was given.

Post test was administered with the same questionnaire on the 7^th day. The collection of data was performed within the stipulated time. After the data gathering process the investigator thanked all the study samples as well as the authorities for their cooperation.

ANALYSIS AND INTERPRETATION:

This chapter deals with the analysis and interpretation of data collected from 60 subjects from selected area of Vidarbha region. The present study was taken up to assess the effectiveness of Self-Instructional Module on knowledge regarding life style modification among myocardial infarction patients admitted in selected hospital in Vidarbha region. A structured questionnaire was used for data collection. The analysis was done with the help of inferential and descriptive statistics

The objectives of the study were:

1. To assess the knowledge regarding life style modification among myocardial infarction patients.

2. To evaluate the effectiveness of Self-Instructional Module on knowledge regarding life style modification among myocardial infarction patients.

3. To associate the knowledge regarding life style modification among myocardial infarction patient with selected demographic variables.

Observations are arranged in following sections

· Section –I: Distribution of subjects with regards demographic variables

· Section-II: Assessment of knowledge regarding life style modification among myocardial infarction patients.

· Section-III: Evaluation of effectiveness of self instructional module on knowledge regarding life style modification among care myocardial infarction patients.

· Section-1V:Association of knowledge score in relation to demographic variables

Table No- 5: Distribution of subjects with regards demographic variables n =60

Demographic Variables	Frequency	Percentage (%)
Age(yrs.)
35-45	23	38.4
46-55	15	25
56-65	17	28.3
Above 65 yrs.	05	8.3
Total	60	100
Gender
Male	32	53.3
Female	28	46.7
Total	60	100
Educational Status
Primary	6	10
Secondary	25	41.7
Graduation	25	41.7
Post-graduation	4	6.6
Total	60	100
Occupation
Farmer	16	26.7
Government service	23	38.3
Business	10	16.7
Other	11	18.3
Total	60	100
Religion
Hindu	32	53.3
Muslim	11	18.3
Christian	03	5
Others	14	23.4
Total	60	100

SECTION I:

DISTRIBUTION OF SUBJECTS WITH REGARD OF DEMOGRAPHIC VARIABLES:

This section deals with percentagewise distribution of subjects according to their demographic variables. Convenient sample of 60 subjects were drawn from the study population, myocardial infarction patients admitted in selected hospital of Vidarbha region. The data was obtained to describe the sample characteristics including age, gender, educational status, occupation, religion and information about life style modification.

· The above table regarding distribution of subjects according to their age shows that 38.4% subjects were of age group of 35-45 years, 28.3% of 56-65 years, 25% of 46-55years and only 8.3% of above 65years.

· Distribution of subjects according to their gender shows that 55.3% were male and 46.7% were female.

· Distribution of subjects according to their educational status shows that the secondary and graduates were 41.7% each: 10% were having primary education and only 6.6% of subjects were post graduates.

· Distribution of subjects according to their occupation shows that the majorities 38.3% of subjects were doing the government job, 26.7% were framers, 18.3% of other, and only 16.7% of subjects were doing business.

· Distribution of subjects according to their religion shows that the majority 53.3% of subjects belonged to Hindu, 18.3% was Muslim, 5% were Christian religion and 23.4% were other religion.

Figure No-3: Distribution of myocardial infarction patients according to their age (yrs.).

Figure No-4: Distribution of myocardial infarction patients according to their gender

Figure No-5: Distribution of myocardial infarction patients according to their educational status

Figure No-6: Distribution of myocardial infarction patients according to their type of occupation

Figure No-7: Distribution of myocardial infarction patients according to their religion

SECTION-II:

ASSESSMENT OF KNOWLEDGE REGARDING LIFE STYLE MODIFICATION AMONG MYOCARDIAL INFARCTION PATIENTS

This section deals with the assessment of knowledge regarding life style modification among myocardial infarction patients. The level of knowledge is divided under following headings poor, average, good, and excellent.

Table No- 6: General assessments with pre test n = 60

Level of knowledge score	Score range	Percentage Range (%)	Pretest score
Level of knowledge score	Score range	Percentage Range (%)	Frequency	Percentage (%)
Poor	1-7	0-25	20	33.3
Average	8-15	26-50	38	63.4
Good	16-22	51-75	02	3.3
Excellent	23-30	76-100	00	00.0
Minimum score	04
Maximum score	22
Mean score	540/60= 09

The above table shows that in pre test scores, 63.4% of subjects were having average knowledge, 33.3% having poor knowledge and 3.3% subjects having good knowledge. Minimum score was 04; maximum score of pre test was 22 and mean score was 09.

Table No- 7: General assessments with post test n = 60

Level of knowledge score	Score range	Percentage Range (%)	Post test score
Level of knowledge score	Score range	Percentage Range (%)	Frequency	Percentage (%)
Poor	1-7	0-25	0	0.00
Average	8-15	26-50	0	0.00
Good	16-22	51-75	37	61.67
Excellent	23-30	76-100	23	38.33
Minimum scores	16
Maximum scores	28
Mean scores	1307/60 = 21.7

The above table shows that in post test scores 61.67% of subjects were having good knowledge, and 38.33% having excellent knowledge. Minimum score was 16; maximum score of pre test was 28 and mean score was 21.7.

SECTION III:

EVALUATION OF EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE REGARDING LIFE STYLE MODIFICATION AMONG MYOCARDIAL INFARCTION PATIENTS

This section deals with evaluation of effectiveness of self instructional module on Knowledge regarding life style modification among myocardial infarction patients. The hypotheses is tested statistically with area wise distribution of pretest and post test mean and standard deviation and mean score percentage.The levels of knowledge during the pretest and post test are compared to prove the effectiveness of self instructional module. Significance of difference at 5% level of significant is tested with paired ‘t’ test and tabulated ‘t’ value is compared with the calculated ‘t’ value. Also the calculated ‘p’ values are compared with acceptable ‘p’ value i.e.0.05.

The above table shows that in pre test scores, 63.4% of subjects were having average knowledge, 33.3% having poor knowledge and 3.3% subjects were having good knowledge. Minimum score was 04; maximum score of pre test was 22 and mean score was 09, but in post test scores 61.67% of subjects were having good knowledge, and 38.33% subjects having excellent knowledge. Minimum score was 16; maximum score of post test was 28 and mean score was 21.7.

This table shows the pre test and post test knowledge scores of the life style modification. Mean, standard deviations and mean percentage values were compared and paired ‘t’ test was applied at 5% level of significance. The tabulated ‘t’ value for n-1, i.e.59 degrees of freedom was 2.00. The calculated values were 27.69 respectively for knowledge regarding life style modification. The calculated ‘t’ values are much higher than the tabulated values at 5% level of significance which is statistically acceptable level of significance. In addition the calculated ‘p’ values for all the areas of knowledge regarding life style modification are 0.000 which is ideal for any population. Hence it is statistically interpreted that the self instructional module regarding different aspects of life style modification was effective. So thus the H₁ is accepted.

Figure No-8: Assessment of level of knowledge with pretest and posttest

Figure No-9: Significance of difference between knowledge score in pre and posttest in myocardial infarction patients in relation to knowledge of life style modification.

SECTION IV:

ASSOCIATION OF KNOWLEDGE SCORE IN RELATION TO DEMOGRAPHIC VARIABLES

This section deals with the association of post test knowledge scores with selected demographic variables of the study participants. One way ANOVA and unpaired ‘t’ test were used for within group comparisons categorically. Variables having more than two categories, one way ANOVA was used and for variables having two categories unpaired ‘t’ test was used.

Table No- 10; Association on knowledge of life style modification with age of Study participants. n=60

Age (yrs)	Frequency	Mean ±S.D	F-value	p-value
35-45	23	22.17±2.24	0.604	0.615 NS, p>0.05
46-55	15	21.4±2.22
56-65	17	21.47±2.37
Above 65	05	22.4±1.94

This table shows the association of post test knowledge scores with the age of study participants. The tabulated ‘F’ value for the association with the age of the participant was 3.34 which was higher than the calculated ‘F’ = 0.604 at 5% level of significant and 59 degrees of freedom. Also the calculated ‘p’ = 0.615 was much higher than the acceptable level of significance i.e. ‘p’ = 0.05. Hence it is interpreted that age of the study participants was not associated with the post test knowledge scores.

Table No-11: Association on knowledge of life style modification with gender of study participants. n=60

Gender

Frequency

Mean ±S.D

t-value

p-value

Male

21.90±2.19

0.51

0.61

NS, p>0.05

Female

21.60±2.34

This table shows the association of post test knowledge scores with the gender of study participants. The tabulated‘t’ value was 2.00 which was higher than the calculated ‘t’ 0.51 at 5% levels of significant and 59 degrees of freedom. Also the calculated ‘p’ = 0.61 was much higher than the acceptable level of significance i.e. ‘p’ = 0.05. Hence it is interpreted that gender of the study participants was not associated with the posttest knowledge scores.

Table No-12: Association on knowledge of life style modification with education of study participants n=60

Education	Frequency	Mean ±S.D	F-value	p-value
Primary	6	21.5±2.58	0.306	0.82 S, p<0.05
Secondary	25	21.44±2.51
Graduation	25	22±1.60
Post-graduation	4	22±3.16

This table shows the association of post test knowledge scores with the education of study participants. The tabulated ‘F’ value for the association with educational status was 3.34 which was less than the calculated ‘F’ = 0.306 at 5% level of significance and for 59 degree of freedom. Also the calculated ‘p’ = 0.82 was much less than the acceptable level of significance i.e. ‘p’ = 0.05. This indicates that there was statistically significant association of post test knowledge scores with educational status of the study participants. This association is attributed to majority of study participants belonging to higher secondary educational status.

Table No- 13: Association on knowledge of life style modification with occupation of study participants n=60

Occupation	Frequency	Mean ±S.D	F-value	p-value
Farmer	16	20.68±2.08	2.35	0.082 NS, p>0.05
Government	23	21.86±2.61
Business	10	22.8±1.68
Other	11	22.27±1.34

This table shows the association of post test knowledge scores with the family of study participants. The tabulated ‘F’ value for the association with types of family was 3.34 which was higher than the calculated ‘F’ = 2.35 at 5% level of significance and for 59 degrees of freedom. Also the calculated ‘p’ = 0.082 was much higher than the acceptable level of significance i.e. ‘p’ = 0.05. Hence it is interpreted that family of the study participants was not associated with the posttest knowledge scores

Table No-14: Association on knowledge of life style modification with religion of study participants n=60

Religion	Frequency	Mean ±S.D	F-value	p-value
Hindu	32	21.57±2.21	.467	0.70 NS, p>0.05
Muslim	11	21.90±2.98
Christian	3	23±2
Others	14	22.07±1.68

This table shows the association of post test knowledge scores with the religion of study participants. The tabulated ‘F’ value for the association with religion was 3.34 which was higher than the calculated ‘F’ = 0.46 at 5% level of significance and for 59 degrees of freedom. Also the calculated ‘p’ = 0.70 was much higher than the acceptable level of significance i.e. ‘p’ = 0.05. Hence it is interpreted that religion of the study participants is not associated with the posttest knowledge scores.

SUMMARY, FINDINGS, CONCLUSION, IMPLIMENTATION AND RECOMMENDATIONS

The following are the major findings of the study.

Section –I

Demographic Variables:

· Distribution of subjects according to their gender shows that 55.3% were male and 46.7% were female.

· Distribution of subjects according to their educational status shows that the 41.7% of the subjects were secondary and graduates each; 10% having primary education and only 6.6% of subjects were post graduates.

· Distribution of subjects according to their occupation shows that the majority 38.3% of subjects doing the government job, 26.7% were famer, 18.3% only 16.7% of subjects doing the business and 18.3% of other.

· Distribution of subjects according to their religion shows that the majority 53.3% of subjects belonged to Hindu, 18.3% to Muslim 5% of subjects to Christian and remaining 23.4% to other religions.

Section-II:

Assessment of knowledge regarding life style modification among myocardial infarction patients:

The findings show that in pretest scores, 63.4% of subjects were having average knowledge, 33.3% having poor knowledge and 3.3% subjects having good knowledge. Minimum score was 04; maximum score of pretest was 22 and mean score was 09.In Post test scores 61.67% of subjects were having good knowledge, and 38.33% having excellent knowledge. Minimum score was 16; maximum score of posttest was 28 and mean score was 21.7.

Section-III:

Evaluation of effectiveness of self instructional module on knowledge regarding life style modification among myocardial infarction patients

The finding show that the tabulated ‘t’ value for n-1, i.e.59 degrees of freedom was 2.00. The calculated values were 27.69 respectively for knowledge regarding life style modification. The calculated ‘t’ values are much higher than the tabulated values at 5% level of significance which is statistically acceptable level of significance. In addition the calculated ‘p’ values for all the areas of knowledge regarding life style modification are 0.000 which is ideal for any population. Hence it is statistically interpreted that the self- instructional module regarding different aspects of life style modification was effective. So thus the H₁ is accepted.

Section- IV

Association of knowledge score in relation to demographic variables

There is no significant association between age, gender, educational status, occupation and religion.

DISCUSSION:

The findings of the study were discussed with reference to the objectives stated in chapter I and with the findings of the other studies in this section. The present study under taken was “To assess the effectiveness of Self Instructional Module (SIM) on knowledge regarding lifestyle modification among myocardial infarction patients admitted in selected hospital in Vidarbha region”.

OBJECTIVES OF THE STUDY:

1. To assess the knowledge regarding life style modification among myocardial infarction patients.

2. To evaluate the effectiveness of self-instructional module on knowledge regarding life style modification among myocardial infarction patients.

3. To associate post-test knowledge regarding life style modification among myocardial infarction patients with selected demographic variables.

A descriptive study on medical treatment and secondary prevention of coronary heart disease revealed that among 3850 individuals 86 percent of individuals had modifiable risk factors; 27 percentage were cigarette smokers, 68 percentage had a body mass index of 25 plus, 40 percentage had hypertension, 29 percentage had hyper cholestrolemia and 19 percent had hyperglycemia.⁵⁹

A study was conducted to assess the feasibility of the health related lifestyle self management intervention as a strategy to decrease cardio-vascular risk follwing Acute Coronary Syndrome. The sample size was 125. It resulted with the findings support the feasibilityof implementing the health related lifestyle self management intervention for risk factor modification in patients with acute coronary syndrome.⁶¹

A study conducted to evaluate the effectiveness of a self instructional module in increasing nurses knowledge of Genetics. Sample size was 262 registered nurses. The study has shown a significant increase of 20.8 percentage in participants mean knowledge score on the post-test as compared with pre-test. The study concluded that self-instructional module for registered nurses was effective in increasing knowledge of basic human genetic concepts and risk assessment.⁶²

A population based case control study was conducted to evaluate the modification effects of sex in the association between life style and acute myocardial infarction in Porto, Portugal. Trained interviewers collected information using a standard structured questionnaire. Associations were estimated using unconditional logistic regression the effect modification by sex was evaluated in the regression models, testing interaction terms between lifestyles and sex. The study sample included Portuguese Caucasian adults, aged > or =18 years. Cases were patients consecutively admitted with an incident acute myocardial infarctions and controls were a representative sample of non-institutionalized inhabitants of Porto with no evidence of previous clinical or silent infarction.The study results showed that cigarette smoking was positively associated with acute myocardial infarction in both men and women (smokers >15 cigarettes/d v. never smokers: OR=9.11, 95% CI 4.83, 17.20 for women; OR=3.92, 95% CI 2.75, 5.58 for men; interaction term P value=0.001). A significant protective effect of moderate alcohol intake on acute myocardial infractions occurrence was found in women (0.1-15.0 g/d v. non-drinkers: OR=0.48, 95% CI 0.31, 0.74), but not in men. Fruit and vegetable intake, vitamin and mineral supplement use and leisure-time physical activity practice were found to decrease acute myocardial infarction risk, with similar effects between sexes. So the study concluded that a strong positive association between smoking and acute myocardial infarction was found in women. Also, a protective effect of moderate alcohol intake was only found among females. Fruit and vegetable intake, vitamin and mineral supplement use and leisure-time physical activity practice were found to decrease acute myocardial infarction risk in both sexes^.63

CONCLUSION:

After the detailed analysis, this study leads to the following conclusion:

The patients do not have 100% knowledge regarding life style modification. There was a significant increase in the knowledge of subjects after the introduction of self- instructional module. To find the effectiveness of self- instructional module student’t’ test was applied and t value was calculated, post test score was significantly higher at 0.05 levels than that of pretest score. Thus it was concluded that SIM on life style modification was found effective as a teaching strategy.

Demographic variables did not show a major role in influencing the pretest and posttest knowledge score among myocardial infarction patients.

Hence based on the above cited findings, it was concluded undoubtedly that the written prepared material by the investigator in the form of SIM helped the patients to improve their knowledge on life style modification.

IMPLICATION OF THE STUDY:

The findings of this study have implications for nursing practice, nursing education, nursing administration and nursing research.

Nursing Services:

· When professional liability is recognized, it defines the parameters of the profession and the standard of professional conduct. Nurses should therefore enhance their professional knowledge.

· The role of nurses has expanded rapidly within past ten years to include expertise specialization, autonomy and accountability. The patient is considered the consumer of nursing and health care.

· The finding will help the nursing personnel to estimate the effectiveness of self-instructional module.

· The self instructional module can be used for imparting knowledge regarding life style modification to health team members.

· It can be used as a guide and can serve as reinforcement to the health education given by the teachers to the nurses.

· This study will help the nurses for coordination with health care service to health care professionals.

· It will also help the nurse to keep up date knowledge regarding life style modification.

· The study finding will help the nursing personnel to understand about the necessity of providing service education programme.

Nursing Education:

· Health care personnel should be given an opportunity to update their knowledge periodically.

· The educators need to remember that more emphasis is to be given for knowledge regarding life style modification.

· Educators will help students, colleagues, and junior staff to be trained in using self-instructional module regarding life style modification.

· In the nursing curriculum now a day much emphasis is given on comprehensive care.So the study will help the teachers to educate the students and the staff nurses for increasing the knowledge about life style modification

· The Self instructional module could help educator to use it as a tool for teaching.

Nursing Administration:

Findings of the study can be used by the Nursing Administrator in creating policies and plans for providing education to the staff nurses and patients. It will help the nursing administrators to plan and organize and in giving continuing education to nurses and to others for applying and updating the knowledge regarding life style modification.

Nursing Research:

· The findings of the study have added to the existing body of the knowledge regarding life style modification.

· Other researchers may utilize the suggestions and recommendations for conducting further study.

· The tool and technique used has added to the body of knowledge and can be used for further references.

· A large scale study can be done for application to standardize the self-instructional module.

· The findings can be utilized for conducting research on the effectiveness of self-instructional module.

PERSONAL EXPERIENCE:

The entire study gave an enriching experience to the investigator. It helped her to develop her skill in critical thinking and analysis and realize the importance of effective communication with respondents. The entire study was varied and rich learning experience which enabled the investigator to develop her skill in dealing with different personalities. The concept clarity about research as a whole increased. At every stage, the investigator received guidance and support from her guide. This boosted confidence to go ahead and carry out the planned activities and the co-operation from study subject was remarkable. The research was a great learning opportunity for the investigator.

RECOMMENDATIONS:

On the basis of the findings of the study, it is recommended that the following studies can be conducted.

1. A similar study may be conducted on a larger population for generalization of findings.

2. Studies may be conducted to evaluate the effectiveness of self-instructional module versus other methods of teaching on knowledge regarding life style modification.

3. A study may be conducted to assess the existing knowledge regarding life style modification.

4. A study may be conducted to assess the existing knowledge and practice regarding life style modification.

5. A structured teaching programme may be used in the hospitals, so that the entire nurses can participate in improving the knowledge regarding life style modification.

6. Instead of self-instructional module, planned teaching can be used.

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2. Robert Beaglehole, et al. (2004) (PDF). The World Health Report 2004 – Changing History. World Health Organization.. ISBN 92-4-156265-X. http://www.who.int/entity/whr/2004/en/report04_en.pdf. Page no: 120–124.

3. Thygesen K, Alpert JS, White HD (October 2007). "Universal definition of myocardial infarction". Eur. Heart J. 28 (20): 2525–38. doi:10.1093/eurheartj/ehm355. PMID 17951287

4. Little RA, Frayn KN, Randall PE, et al. (1986). "Plasma catecholamines in the acute phase of the response to myocardial infarction". Arch Emerg Med 3 (1): 20–7. PMC 1285314. PMID 3524599

5. Lamas GA, Escolar E, Faxon DP; Examining treatment of ST-elevation myocardial infarction: the importance of J Cardiovasc Pharmacol Ther. 2010 Mar;15(1):6-16. Epub 2010 Jan 8. [abstract]

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Received on 31.05.2017 Modified on 28.07.2017

Asian J. Nursing Education and Research. 2018; 8(2): 247-267.

DOI: 10.5958/2349-2996.2018.00050.2

SL. NO	AREA OF KNOWLEDGE	KNOWLEDGE	SKILL	ATTITUDE	TOTAL
1	General questions on myocardial infarction	1, 3, 5, 7,	2, 6,	4,	7
2	Risk factors of myocardial infarction	8, 9, 10, 11, 13, 14, 15, 16,		12,	9
3	Lifestyle modifications for myocardial infarction	18, 20, 21, 22, 24, 26, 27, 29, 30,	19, 23, 28,	17, 25,	14
	TOTAL	21	5	4	30
	PERCENTAGE	70%	16.67%	13.33%	100%

Level of knowledge score	Score range	Percentage Range (%)	Pretest score		Posttest score
			Frequency	Percentage (%)	Frequency	Percentage (%)
Poor	1-7	0-25	20	3.33	0	0.00
Average	8-15	26-50	38	63.4	0	0.00
Good	16-22	51-75	02	3.33	37	61.67
Excellent	23-30	76-100	0	0.00	23	38.33
Minimum scores			09		16
Maximum scores			20		28
Mean scores			540/60=09		1307/60=21.7