A STUDY TO ASSESS THE EFFECTIVENESS OF A SELF

INSTRUCTIONAL MODULE ON KNOWLEDGE REGARDING

LIFE STYLE MODIFICATION FOR MAINTAINING HEALTHY
HEART AMONG CARDIAC PATIENTS IN SELECTED
HOSPITAL AT MADURAI”

A DISSERTATION SUBMITTED TO THE

TAMILNADUDR.M.G.R.MEDICAL UNIVERSITY,
CHENNAI, IN PARTIAL FULFILMENT OF THE
REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE IN NURSING.

OCTOBER– 2016
 A STUDY TO ASSESS THE EFFECTIVENESS OF A SELF
INSTRUCTIONAL MODULE ON KNOWLEDGE REGARDING
LIFE STYLE MODIFICATION FOR MAINTAINING HEALTHY
HEART AMONG CARDIAC PATIENTS IN SELECTED
HOSPITAL AT MADURAI.

Mr. MARTIN DANIEL .P

A DISSERTATION SUBMITTED TO THE TAMILNADU

DR.M.G.R. MEDICAL UNIVERSITY, CHENNAI, IN PARTIAL
FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE
OF MASTER OF SCIENCE IN NURSING

OCTOBER – 2016
 CERTIFICATE

This is a bonafide work of Mr.P.Martin Daniel, M.Sc (N) II Year

Student from Sakthi College of Nursing, Dindigul, Tamilnadu, India, submitted

in partial fulfillment for the Degree of Master of Science in Nursing under the

Tamil Nadu Dr.M.G.R Medical University, Chennai.

Signature of the Principal __________________________________

Prof.V.JANAHI DEVI, M.Sc (N).,
Principal
Sakthi College of Nursing,
Oddanchatram,
Dindigul. (DT)

College Seal ___________________________________

 A STUDY TO ASSESS THE EFFETIVENESS OF A SELF
INSTRUTIONAL MODULE ON KNOWLEDGE REGARDING
LIFE STYLE MODIFICATION FOR MAINTAINING
HEALTHY HEART AMONG CARDIAC PATIENTS IN
SELECTED HOSPITAL AT MADURAI.

1. RESEARCH GUIDE:________________________
Prof.V.JANAHI DEVI, M.Sc (N).,
Principal
Sakthi College of Nursing,
Oddanchatram,
Dindigul. (DT)

2. CLINICAL GUIDE:___________________________
Asso.Prof.Mrs.Reena Msc.(Nsg),

Department of Medical Surgical Nursing,

Sakthi College of Nursing,

Oddanhtram,

Dindugal district.

3. MEDICAL EXPERT: _____________________________

Dr.RAMESHBABU KESAVAN M.D.,
Apollo Specialty

Hospital,

Madurai- 625 020

 CERTIFIED BONAFIDE WORK DONE BY

Mr. Martin Daniel.P

SAKTHI COLLEGE OF NURSING,

ODDANCHATRAM, DINDIGUL.

SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR

THE DEGREE OF MASTER OF SCIENCE IN NURSING FROM THE

TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY, CHENNAI.

EXAMINERS

INTERNAL EXTERNAL

1. ______________________ 2._______________________
 ACKNOWLEDGEMENT

“The Lord Bless Thee out of Zion”

PSALMS 128:5

The Lord Almighty is praised for uttering profusely his blessing and
guidance me throughout my endeavor and sustained me during the hour of
need.
I am substantially thankful to our Chairman Dr.K.Vembanan M.B.B.S.,
M.S., and I express my deep gratitude and heartfelt thanks to our Vice-
Chairman Dr. Gokila Vembanan, M.B.B.S., D.G.O., for their blessing
encouragement and dedication for academic and giving formidable opportunity
to finish my project peacefully.
It is my bounden duty to express my heartiest gratitude to
Prof.V.Janahi Devi, M.sc (N), Principal, Sakthi College of Nursing, for her
constant enthusiastic support warmth inspiration, encouragement and gave
innovative ideas to incorporate in this project.
I express my deep heartfelt thanks to my clinical guide Associate.
Prof.Reena, M.Sc.,(Nsg) Medical Surgical Nursing, for her intelligible suggestions,
immense patience, diligent effort to ensure the best quality, peace of work, her
reassuring plan and a very approachable and inspiring quote, that can never be
forgotten and for her constant encouragement throughout the entire course of
study also to complete the study successfully.
I extend my whole hearted thanks to all Faculty members of Sakthi
College of Nursing for their continuous encouragement, guidance and suggestions
for this study.
I profusely thank all Medical and Nursing Experts who validated the
content and tool, which helped to incorporate their views in this project.
I am thankful to Mrs. Poongodi., (B.A)P.A., M.L.I.Sc., Librarian, Sakthi
College of Nursing and special thanks to Ms.Bhuvaneswari.S, M.Sc., computer
operator Sakthi College of Nursing, Oddanchatram, for their support and which
made it possible to update the content.
I wish to communicate my extraordinary credit to Mr.Mani,M.Sc.,
M.Phil., Biostatistian for his well timed and opportune aid and backing in
statistical analysis and presentation of data.
 I express my special thanks to the Medical Officer of Primary Health
Centre, Dindigul district. who granted me permission to conduct the samples who
participated in the study. Without their cooperation it would not have been possible
to complete my study.
I Extend my sincere thankful to Mr.Sakthivel,M.A,.B.Ed.,A.M.A., Vice
Principal, Sakthi College of Arts & Science and Ms.Sathiya,. M.A.,M.Phil.,
MBA H.O.D of Tamil and English Department Sakthi College of Arts and
science whose editing suggestions and precise sense of language were decisive
towards the completion of this research study.
I also express my warm wholehearted thanks and gratitude to my
Classmates and my lovable Juniors for their constant help throughout the study.
I express my heartful thanks and gratitude to my best friends
M.R.Nirmal kumar Moses, Mr.Franklin ,Ms.Jasmine, Mr.Herald Simon,
and Mr.Renjith Singh for timely help ,prayer, support and guidance throughout
the study.
I Deeply express my heartfelt thanks and gratitude to my Church
Pastors. Pastor. Sam Chellappa and Pastor.Aron their prayers and blessings
too.
I extend my warmest gratitude to my lovable brother’s and sisters kids
Baby.Gracia, Baby Praisia and Master. Perrin Sam who missed my love and
care during the course of the study above all.

Life has blessed me with an lovable care and value oriented my

beloved parents and precious one Mr.S.Pauliah and Mrs.Y.Grace and
lovable sisters Mrs.P.Merlin, Mrs.P.Paulin brother Mr.P.Edwin and my
lovable wife Mrs.M.Nisha and our fabulous new kid for their constant and
continuous support, timely help, prayer and encouragement to complete this
project as a very successive one.

This study drew upon the knowledge and help, experience and expertise
of many persons of good will, tough too numerous to name ,each one of them
is remembered for their individual contributions without which the realization
and presentation of this research would not have been possible. So I shower my
great deal of thanks to those who helped directly and indirectly in this work.
 TABLE OF CONTENTS
CHAPTER CONTENTS PAGE.NO
I INTRODUCTION 1

Need for the study 4

Statement of the problem 9

Objectives 9

Hypothesis 10

Operational definitions 10

Assumptions 11

Limitation 11

Delimitation 12

Project outcome 12

Conceptual framework 13

II REVIEW OF LITERATURE 17

Studies related to incidence of prevalence and Risk 20

factors.
Studies related to life style Modification programme. 25

Studies related to Diet, Habits &Stress. 28

III METHODOLOGY 39

Research approach 39

Research design 39

Variables under the study 41

Setting of the study 41

Population 42
Sample 42

Sampling technique 42

Criteria for sample selection 42

Development and Description of the Tool 49

 Validity and Reliability of the tool 45

Pilot Study 47
Description of the intervention 49

Plan for data analysis 50

Human rights protection: 50

IV DATA ANALYSIS AND INTERPRETATION 51

V DISCUSSION 94
VI SUMMARY AND RECOMMENDATIONS 98

Summary 98

Conclusion 103

Implications 104
Limitations 106

VII REFERENCES 108

Book reference 108

Journal reference 112

Net reference 112

VIII APPENDICES
 LIST OF TABLES

TABLE.NO TITLE PAGE.NO

1 Frequency and distribution demographic variables of 52

cardiac patients
Frequency and percentage distributions of demographic
2 63
variables of patients
Distributions of respondents according to their
3 75
knowledge levels.
4 Aspect wise pre interventional knowledge score 77

No of respondents of post interventional knowledge

5 80
score
6. Aspect wise post test interventional knowledge score 82

7. Comparison between pre-test and post- test knowledge 85

Comparison between pre and post test knowledge score

8 Comparison of mean, sd, and mean percentage for the 87
knowledge variable in the pre and post test.
Comparison of mean, sd, and mean percentage for the
9 88
knowledge variable in the pre and post test.

Improvement of mean score of knowledge variables

10 89
between pre and post test.

Association of level of knowledge on patients with

11 90
demographic variables
 LIST OF FIGURES

FIGURES TITLE PAGE.NO

1 Conceptual frame work 16

2 Schematic representation of research design. 40
Frequency and percentage distribution of age of cardiac
3 55
patients.
Frequency and percentage distribution of gender of the
4 56
cardiac patients
Frequency and percentage distribution of educational
5 57
status of cardiac patients
Frequency and percentage distribution of occupational
6 58
status of cardiac patients
7 Frequency and Percentage distribution of religion 59
Frequency and percentage distribution of marital status
8 60
of cardiac patients
9 Frequency and percentage distribution type of family 61
Frequency and percentage distribution of monthly family
10 62
income of cardiac patients
Frequency and percentage distribution of illness of
11 66
cardiac patients
Frequency and percentage distribution of type of diet
12 67
cardiac patients
Frequency and percentage distribution of type of cardiac
13 68
patients
Frequency and percentage distribution of type of habitat
14 69
of cardiac patients
Frequency and percentage distribution of medical
15 70
diagnosis cardiac patients
Frequency and percentage distribution of number of
16 71
admissions in one yearof cardiac patients
Frequency and percentage distribution of type of
17 72
exposure to media of cardiac patients.
 Frequency and percentage distribution of patients visits
18 73
for follow-up of cardiac patients
Frequency and percentage distribution of awareness
19 74
about life style modification among cardiac patients
Frequency and Percentage and distributions of
20 76
respondents according to their knowledge levels.
Frequency Aspect wise pre interventional knowledge
21 79
score
No of respondents of post interventional knowledge
22 81
score
23 Aspect wise post test interventional knowledge 84
Comparisons between pre-test and post- test knowledge
24 86
score
 LIST OF APPENDICES

PAGE. NO
APPENDIX TITLE
Letter Seeking Permission to conduct the Study
I i
Letter Seeking Permission for Content Validity
II ii
Certificate for content validity
III iii
List of experts
IV iv
Certificate for Tamil Editing
V v
Certificate for English Editing
VI vi
Statement in English
VII
Section A - Demographic variable proforma
ix
Statement in Tamil
xiii
Section B Demographic variable proforma

Score key
xxxvii
Check list
xxxviii
Self-Instructional module in English

Self-Instructional module in Tamil

Photographs
IX xli
 CHAPTER-I

INTRODUCTION
 INTRODUCTION

“To ensure good health eat lightly, breathe deeply live moderately, cultivate

cheerfully and maintain interest in life”-Unknown

Everyone should lead a conscious life style that prevents diseases as,

individual life style is central to the development of chronic diseases. Living healthy

life style means taking responsibility for own health and well-being, it is the best step

forward in our destiny and the advancement of human kind. Among the diseases CAD

has become an epidemic and chronic increasing number of deaths among the younger

age group affecting the productivity of economy.

“Health is defined as a state of complete physical, mental and social well-being, not

merely the absence of disease or infirmity”. This definition of health highlights the

importance of understanding health and disease burden within the personal, social and

cultural context specific to the patient those who all are affected by CVD

A healthy lifestyle is a combination of healthy eating and regular exercise.

Healthy balanced diet combined with regular physical activity helps to keep the heart

healthy, as well as helping the body keep fit, maintain optimum body weight, improve

energy utilization, and prevent the early on set of long term cardiac complications.

There is need to educate people and arose awareness of the importance of

taking health in their hands.

CAD is an insidious progressive disease that results in narrowing or complete

occlusion of coronary artery causing disruption of blood supply to the myocardium.

1
Permanent disruption of blood flow causes myocardial dysfunction, including sudden

death.

CVD is diseases that are associated with atherosclerosis. These diseases occur

more frequently in people who smoke, who have high blood pressure, who have high

blood cholesterol (especially high LDL), who are overweight, who do not exercise,

and/or who have diabetes.

India has the highest burden of acute coronary syndromes in the world.

Several factors appear likely to have contributed to the acceleration of Coronary

artery disease epidemic in India. In the recent times these are demographic transition

to an older population as a result of increasing life expectancy, confluence of both

conventional risk factors like hypertension, diabetes, hypercholestroleaemia, smoking

etc owe their origin to growing urbanization and western “acculturation” amongst

Indians and Non-conventional risk factors like hyperinsulinemia, insulin resistance,

lipoprotein-A are determined genes. The gravity of this situation is emphasized by a

recent projection from the WHO and the Indian council of medical research (ICMR)

which predicts that India will be the MI capital of the world 2020.

An Indian multicenter study that analyzed data from 4081 subjects reported

that Acute Coronary Syndromes occurred at mean age of 56.6±12 yrs in men and

61.8±10 yrs in females.

In India incidence of Coronary Heart Disease is more in metropolitan cities.

Because of high mental stress and less physical work, the incidence of Coronary Heart

Disease is more prevalent in high socio-economic groups. Considering the different

studies conducted in urban and rural population in India an average figure of 25/1000

2
population in the age group of 40 years and above appears the more common age

group.

Every year approximately 1.5 million American have heart attack. Myocardial

Infarction is the leading cause, an estimated 5,00,000 deaths occur each year. About

2,40,000 women die of Myocardial Infarction. Approximately 2,50,000 people die of

before they reach the hospital. Studies indicate that half of all heart attack victims

wait more than 2 hrs before getting help.

People with ancestry in the countries of India n sub-continents (south-Asian)

comparing more than one fifth of the global population are highly susceptible to

CVD.

It is documented that in India 50l% of deaths occurring due to Coronary Heart

Disease are preventable. Adopting a healthy lifestyle can prevent the disease of heart

and arteries. Nurses as health professionals can play an important role in creating

awareness among public about heart diseases and their prevention

The WHO has drawn the attention of the facts Coronary Heart disease is our

Modern ‘Epidemic’ that it is a disease that affects proper not an unavailable attribute

of aging, males are affected more than females. Coronary heart disease (CHD) is still

most frequent single cause of death among men under 65 years. The Coronary Heart

Disease(CHD) is due to atherosclerotic changes, cigarette smoking cholesterol content

diet, lack of exercise and uncontrolled hypertension cause these changes.

CAD striking at the younger age was seen in an another study dine at

Tirupathi prevalence of CAD and coronary risk factors were seen in age group of

3
42.50±9.41(male), 38.89±11.22(females) , with overall incidence of 12.63 in the

sampled population.

Cardiovascular Disease incidence rises in a perceptible and surprisingly

predictable fashion with the increasing rates of risk factors and change in behavior

patterns implying the urgent need for preventive strategies at the Mass across the

country.

Increasing rates of obesity has lead on to higher rates of type II diabetes

mellitus and cardiovascular diseases. Abdominal obesity is an important risk factor

for cardiovascular diseases and the prevalence is high in South Asians. An increase in

waste-hip-ratio has been noted to be an important predictor of stroke and

cardiovascular disease.

Obesity is now a true epidemic and public health crisis that both clinicians and

patients must face. Normal body weight is defined as a Body Mass Index (BMI).

Body Mass Index is a measure of body fat based on height and weight that applies to

both adult men and women. It is calculated as weight in kilograms divided by the

height in meters squared

NEED FOR THE STUDY

The heart is one of the few truly vital organs. Some people may focus their

attention on their heart beat and the worry when it skips a beat, other people fear the

changes a disease will make on their daily lives and whether they will survive. As

pointed out in Roy’s Adaptation Self Concept Model, need states may arise from

somatic sensation.

4
 Cardiovascular disease is becoming a chronic, major health problem and

an epidemic in India; has the highest burden of acute coronary syndromes in the

world.

The estimated prevalence of CAD in India is currently about 3% in rural

areas and 8% to 10% in urban zones. The CHD rate in India is expected to rise in

parallel with the increase in life expectancy secondary to increases in per capita

income and declining infant mortality rate (IMR). The average life expectancy has

increased from 41 years in 1951 to 61 years in 1991 and is projected to reach 72 years

by 2030, which could lead to large increases in CHD prevalence. CAD is becoming

chronic causing increasing number of deaths among the younger age group affecting

the productivity of economy.

In a study “Knowledge if modifiable risk factors of Coronary Atherosclerotic

Heart Disease (CASHD) among a sample in India”, reported that several factors have

contributed to the acceleration of Coronary artery disease epidemic in India, in the

recent times these are demographic transition to an older population as a result of

increasing life expectancy, confluence of both conventional risk factors like

hypertension, diabetes, hypercholestroleaemia, smoking etc owe their origin to

growing urbanization and western “acculturation” amongst Indians and Non-

conventional risk factors like hyperinsulinemia, insulin resistance, lipoprotein-A are

determined genes. The gravity of this situation is emphasized by a recent projection

from the WHO and the Indian council of medical research (ICMR) which predicts

that India will be the MI capital of the world 2020.

5
 Tremendous loss of productive working years due to premature CVD deaths,

and estimated 9.2 million productive working years of life were lost in Indian in 2000,

and with an expected increase to 17.9 million years in 2030. Survival in these great

numbers should prompt the health care systems to re-evaluate its role in facilitating

optimal care of patients with CVD. Education measures need to be reinforced and

clients need to be informed of their propensity to develop premature CAD and its

adverse consequences.

The dramatic decline in the morbidity and mortality caused by Coronary Heart

Disease in some countries has been substantial substained and real. This notable

public health achievement is due to change in the lifestyle; eg-dietary patterns,

altering mass sedentary phenomenon and encouraging physical activity,

stopping/reducing smoking, moderation in alcohol and salt consumption, avoiding

undue stress and practicing proper relation, yoga, meditation and other measures like

control of Hypertension, diabetes and serum lipids. A number of known major

precursors of this diseases are modifiable lifestyles to promote the risk factor must be

identified.

On the occasion of World Health Day, 7th April 1992, the theme of which was

“Heart beat – the Rhythm of heart”, Dr.Hiroshi Nakajima said in his message that

disease of the heart and arteries account for an estimated 12 million (1.2 crores)

annually worldwide.

According to WHO, some 3,70,000 new cases of Rheumatic fever and

1,50,000 recurrence take place each year, which leads to 3,00,000 new cases of

Rheumatic Heart Disease.

6
 Since the investigator found from their clinical experience, there are more

number of cases with cardiac illness. The main cause of these cardiac illness are

excessive intake of fatty and oily foods, increases plasma lipids and cholesterol level,

excessive intake of non-vegetarian diet, over weight, smoking, alcoholism, lack of

physical exercise, genetic factors, stress etc. these patients lack knowledge regarding

their illness, though there are various studies conducted on cardiac patients.

Coronary Heart Disease (CHD) is a multifactorial disease and the exact cause

still remains the mytery despite some lingering uncertainalities and incomplete

knowledge we have enough information to act effectively. CHD can be prevented by

identifying known risk factors and modifying them and by changing lifestyles

patterns. We must prevent entrenchment of the enthusiasm of prevention minded

physicians. Medical practices now attempts to modify lifestyle of coronary candidates

to improve their change of avoid heart attacks.

Efforts shall be made to identify traditional health related behavour which

shall be encourages, e.g.,the traditional low-sodium ‘salt diet’ the general message to

the community at large will aim at preventing the unhealthy behavior pattern and

spread of risk factors in the hospital and community.

Recognition of hypercholesterolemia as a risk factor in Coronary Heart

Disease (CHD) has lead to development of drugs that reduce cholesterol levels. These

drugs that reduce cholesterol level. These drugs have been used in well controlled

studies of patients with high cholesterol levels caused primarily by evaluated level of

low-density lipoprotein (LDL). The results of these trials indicate the Coronary Heart

Disease (CHD) mortality is reduced when hyper cholesterol emic patients are treated

with moderate doses of hypolipidamic drugs.

7
 Clearly an all out increase in efforts to implement clinically and cost-effective

risk reduction strategies and improve the quality of life in patients with /at high risk of

Coronary Heart Disease (CHD).

To conclude our country is witnessing remarkable advances in the

management of Coronary Heart Disease (CHD) but there is paucity of efforts towards

mass education, detection of disease, early intervention and follow-up to fore still

them. As a keen interest and inspiration gained by previous studies, I would like to

conduct the study to assess patients for making them to adopt and improve a healthy

behavior towards life style modification aspects for maintaining healthy heart. This

study also helps the cardiac patients to prevent complication

8
STATEMENT OF THE PROBLEM:

“A study to assess the effectiveness of a Self Instructional Module on

knowledge regarding Life Style Modification for maintaining healthy heart among

cardiac patients in selected hospital at Madurai”.

OBJECTIVES

1. To assess the level of knowledge regarding the life style modification for

maintaining healthy heart among cardiac patients.

2. To develop and administer Self Instructional Module regarding the life style

modification like, dietary modification & weight loss, Regular physical activity

& stress management, and changing or modifying bad habits for maintaining

healthy heart among cardiac patients.

3. To evaluate the effectiveness of the Self Instructional Module regarding the life

style modification for maintaining healthy heart among cardiac patients.

4. To compare the pre-test and post-test knowledge score after the Self Instructional

Module.

5. To find the association between knowledge regarding the life style modification

for maintaining healthy heart among cardiac patients with selected demographic

characteristics.

6. To find out the association between the mean differences of gain in knowledge

regarding the lifestyle modification program

9
HYPOTHESIS

 H1 – The mean post test knowledge score regarding the life style modification

for maintaining healthy heart among cardiac patients will be significantly higher than

the pre-test knowledge score.

 H2 – There will be significant association between the mean pre-test

knowledge score regarding the life style modification for maintaining healthy heart

among the cardiac patients and their selected demographic variables.

OPERATIONAL DEFINITION

Assess:

It refers to evaluation of desired or intended outcome of the study.

(OR)
Measurement of knowledge of the cardiac patients.

Effectiveness:

Refers to a significant increase in the level of knowledge of the clients with

Coronary artery disease regarding life style modification to maintain heart health,

which is measured from: pre-test, Self Instructional Module and comparing the mean

scores with the post-test scores.

Self Instructional Module:

It refers to the learning material prepared in Tamil and English language, by

the researcher to provide information.

Knowledge:

It refers to correct responses from the participants regarding lifestyle

modifications for maintaining healthy heart which will be measured by structured

interview schedule & knowledge score.

10
Life style Modification:

It means the type of actions, which can be changed and undertaken to remain

in the best possible conditions in their limits of Heart function.

Healthy heart:

It refers to strategies to be followed by individuals to lead healthy life style in

order to maintain and promote heart health.

Cardiac patients:

It refers to an individual who is diagnosed with coronary artery disease such

as, Angina pectoris and Myocardial infarction.

Coronary artery disease:

CAD is an insidious progressive disease that results in narrowing or complete

occlusion of coronary artery causing disruption of blood supply to the myocardium.

ASSUMPTIONS

1. The clients who are suffering from cardiac diseases have a basic knowledge

about Life style Modification Program.

2. The clients as adults will express their knowledge about Life Style

Modification.

LIMITATIONS

1. The study is limited to the cardiac wards or ICUs or the selected hospitals.

2. Patients who are admitted to cardiac wards or ICUs with cardiac problem.

3. Assessment is limited only to the patients who are having myocardial

infarction, angina pectoris.

11
DELIMITATIONS

1. This study is delimited to the patients with the CAD who are not willing to

participate in the study.

2. Cardiac patients who all are not able to read & write English and Tamil.

PROJECTED OUTCOMES:

The projected outcome of the study includes,

 The effectiveness of self Instructional Module will bring knowledge

regarding healthy Heart.

 The effectiveness of self Instructional Module will help to prevent the

cardiac failures.

 It helps to improve their condition in day today life.

12
 CONCEPTUAL FRAMEWORK OF THE STUDY

Concept is defined as a complex mental formulation of an object, property or

an event that is derived from the individual’s perception and experience.

Conceptualization is the process of forming ideas, which are utilized and

forms conceptual frame work for development of research design. It helps the

researcher to know what data need to be collected and gives direction to an entire

research process.

Theories and conceptual models are the primary means of providing a

conceptual context for a study. The aim of the study was to assess the Self

Instructional Module on knowledge of cardiac patients regarding Life Style

Modification.

Conceptual models can deal with interrelated concepts or abstracts that are

assembled together in some rationale, scheme by virtue of their relevance to common

theme.

The conceptual model selected for this study is based on “Penders health

promotion model”. This study designed to assess the knowledge regarding Life Style

Modification for cardiac patients. The health promotion model proposed by Nola

Pender was designed to be a complementary counterpart to model of health

protection. Health promotion is directed at increasing a client level well being. The

model focused on following three areas.

13
 1. Individual characteristics and experiences

2. Behavior specific cognition and affect

3. Behavior outcome

Individual characteristics:

In this study individual characteristics refers to the demographic variables of

the patients with CVD consisting of patients age, sex, occupation, education, religion,

monthly income, type of family, type of diet, duration of illness and medical

diagnosis.

Behavior specific cognition and affect:

In this study it refers to the existing knowledge regarding Life Style

Modification for cardiac patients. Investigator used structured questionnaire to assess

the knowledge on patients regarding Life Style Modification by using interview

schedule the investigator identified the levels of knowledge as inadequate, moderate

and adequate based on the findings.

To all patients Self Instructional Module on Life Style Modification was

administered.

Behavioral outcome:

It helps to identify and assess outcomes intended and unintended short term and

long term, both to help investigator and keep focused on achieving important out

comes and ultimately to help the broader group of users cause the efforts of success in

meeting in targeted needs.

In the present study behavioral outcome refers to the comparison of pre-test and

post-test knowledge scores of patients regarding Life Style Modification.

14
Improvement of knowledge of patients regarding Life Style Modification is done by

statistical computation, in this study effectiveness of Self Instructional Module needs

reinforcement by the health sector to promote adequate knowledge of patients

regarding Life Style Modification.

15
 INDIVIDUAL BEHAVIOUR SPECIFIC BEHAVIOR OUT
CHARACTERSTICS COGNITION
AND EXPERIENCES
COME

Adequate
Adequate Knowled
knowled
DEMOGRAPHIC

DATA
To assess the
Age knowledge Self Instructional
Sex regardin life
Module to improve
the knowledge
Religion style PRE
TEST
regarding Life Style POST
Education modification Modification for TEST

Occupation with
Marital Status structured
Type of family questionnaire
Dietary pattern Inadequate
knowledge Inadequate
knowledge

Fig. 1 MODIFIED HEALTH PROMOTION MODEL NOLA J. PENDER

16
 CHAPTER-II

REVIEW OF LITERATURE
 CHAPTER-II

REVIEW OF LITERATURE

Literature review is a key in the research process, the task of reviewing

involves the identification, selection of critical analysis and reporting of existing

information on topic of interest. The main goal literature review is to develop a strong

base to carry out research and non-research scholarly activities in education and to

improve knowledge upper respiratory tract infection among the mothers of toddler.

Literature review can serve the number of important functions in the research process

and they also play critical role for nurse seeking to develop evidence based practical.

A review of related literature gives an insight of various aspects related to

the study. It enables to study various problems encountered during the course of study

and helps in directing ways to increase the effectiveness of data analysis and

interpretation.

The investigator to elicit factual information about lifestyle of cardiac patients

did an extensive review of literature. The related literature is organized and presented

under the following headings:- Literature related to:

 Knowledge and incidence of coronary artery disease

 Knowledge and risk factor of coronary artery disease

A) Diet

B) Habits

C) Stress

D) Exercise

17
 The purpose of study is to assess the knowledge of selected cardiac

patients regarding lifestyle modifications which include mainly

 Diet (Cholesterol & salt content)

 Activities of daily living

 Weight reduction

 Nature of work, rest and sleep

 Smoking, alcoholism and sexual activities

 Stress

 Prevention of complications

 Benefits

The review of related literature gives an insight of various aspects related

to study. It enables to study various problems encountered during the course of study

and helps by directing ways to increase the effectiveness of data analysis and

interpretation. The related literature review is alone from Published Journals,

Unpublished thesis and Magazine, Books and News Papers.

Knowledge and Incidence of Coronary Artery Disease

Bainey R et al (2009) reviewed the evidence supporting the increased risk of south

Asians living in North America with CAD. The collective evidence suggests that

other risk factors beside the conventional may be involved in the increased

susceptibility of south Asians to CAD. In addition to upward trend in cardiovascular

mortality the prevalence of AD among south Asian between the age of 35 and 64

years has increased to about 10%. Targeting all the risk factors as an early stage might

prevent CAD progression and there by improve outcome in the high risk population.

It is mentioned in the review that eight factors are causally linked i.e., tobacco

consumption, elevated LDL, High BP, elevated glucose, physical inactivity, obesity

18
and diet and six factors are associates i.e., socioeconomic status, prothrombotic

factors, markers of inflammation, elevated homocystine, elevated lipoprotein (a) and

psychological factors. Interventions to promote healthy weight control should be

pertinent to and well-received by school-going youth in India. Healthy weight control

practices need to be explicitly encouraged and unhealthy practices reduced.

Xavier.D et al (2008) conducted a prospective registry study (CREATE) in India to

document the characteristics, treatment and outcomes of patients with acute coronary

syndromes, the recorded range of clinical outcomes and all cause mortality at 30 days

found that mean age of patient was 57.5 and patients were form lower middle class

(52%),and poor (19.6%), diabetes 23.7%, hypertension 42.2% and 40.2% were

smokers indicating the higher rate of coronary artery diseases in Indians attributable

to life style changes. The study concluded that most of the patients are poor, less

likely to get evidence – based treatments, and greater 30 – day mortality; reduction in

delays in access to hospital and provision of affordable treatments could reduce

morbidity.

Ramraj et al (2008) conducted a review on Indian poverty and cardiovascular

disease. The estimated prevalence of CAD in India is currently about 3% in rural

areas and 8% to 10% in urban zones. Lack of public awareness and perception among

policy makers that CAD is largely problem of the urban rich is a thereat to tackle the

epidemic in India. The review concludes that cost-effective interventions to reduce

risk of CAD will help in reducing the looming threat of an escalating epidemic of

CVD.

19
Abinav et al (2006) reviewed on the burden of cardiovascular disease in Indian

Subcontinent, found that in 2003; the prevalence of CHD in India was estimated to be

3-4% in rural areas and 8-10% in urban areas with total of 29.8 million was affected

according to population based cross sectional surveys. The study recommends that

Life style structured programs to promote healthy dietary patterns and physical

activity must be developed to combat the deleterious effects of urbanization. In

addition, cultural norms that hinder the adoption of healthy lifestyles should be

appreciated so that novel approaches to encourage healthy lifestyles can be developed

and implemented in a culturally sensitive manner.

Rajeev Gupta et, al (2002) this study aimed to determine the prevalence of certain

socio-economic factors and biological coronary risk factors in urban communities and

to compare the findings found in the Hindus and Muslims. They employed a cross-

sectional survey design and stratified random sampling technique consisting of 1364

males and 776 females. Among Males there were 685 Hindus and 91 Muslims. The

study concluded with results as the prevalence of Coronary Heart Disease (CHD) is

significantly more in Hindu males as compared to that of Muslims and is associated

with a greater prevalence of Diabetes and Hypertension.

Knowledge and Risk Factors of Coronary Artery Disease

Omar Saeed, Vineet Gupta et al (2009) conducted cross sectional study at (AIIMS)

Delhi to assess knowledge of modifiable risk factors of Coronary Atherosclerotic

heart disease (CASHD) among a sample in India. Participants (n=217) was given

standardized questionnaires to assess their knowledge. The risk factor specially

included were smoking, hypertension, elevated cholesterol levels, diabetes mellitus

and obesity. Identifying 3 or less risk factors was regarded as a poor knowledge level,

20
whereas identifying 4 or more risk factors was regarded as a good knowledge level.

The mean age of participants was 35, of which 82% were males. Overall, a majority

of participants lacked the predefined food level of knowledge pertaining to modifiable

risk factors of CASHD. Specifically, only 41.1% of the participants had a “good

level” of knowledge versus 58.6% showing a “Poor knowledge”. The study suggests

that public awareness of risk factors for CASHD is essential. Educational

interventions are needed to make the Indian public aware of modifiable risk factors

for CASHD and specifically should target individuals who do not exercise, currently

smoke, and have less formal education to be optimally effective as a preventive

measure.

Engeibrech et al (dec 2008) studied the effect of structured and unstructured cardiac

teaching on knowledge of myocardial infarction patients, convenience two group

(n=30). A before-and-after experimental design was used. Pretest and Posttest scores

on the Coronary Heart Disease Teaching Evaluation Form (CHDTEF) were utilized to

determine the significance. The patients in the control group received a non-structured

teaching done by staff nurses, physicians, and other health professionals. The

experimental group received a structured teaching program provided by the

investigator through the process of that included educational needs assessment,

contracting with the patients about teaching and learning objectives; providing

information 9booklets, audio-visual aids, didactic interaction; obtaining feed back;

correcting any errors, gaps in knowledge and repeating information was needed; and

evaluating progress. The structured program consisted of five 20-minute teaching

sessions implemented over five consecutive days at the patient’s bedside in the CCU

and the Progressive Coronary Unit (PUC). All teaching sessions were completed

within 24 to 48 hours prior to the admission of posttest. The findings revealed a

21
statistically significant higher degree of knowledge for the patients who received a

structured, individualized cardiac teaching program. The study suggests Clinical

Implication: a planned, systemic, objective-oriented and individualized presentation

should be provided to all MI patients.

Perkins-Porras L et, al (2006) conducted an interview and questionnaire study of

171 acute coronary syndrome patients assessed within 5 days of admission at three

hospitals in the London area. The most common attributions were to stress, smoking,

high blood pressure, chance or bad luck, and heredity. Attributions were strongly

associated with risk factors: 90% of smokers attributed heart disease to smoking,

compared with 0% never smokers; 90.4% of hypertensive’s attributed heart disease to

high blood pressure, 72.2% of patients with a positive family history to heredity, 85%

of obese patients to being overweight, and 49% of sedentary patients to lack of

exercise. Finally attributions to stress were related both to current mood and reports of

recent life stress. There were few sex differences, but higher socio-economic status

patients were more likely to attribute heart disease to heredity and genetic factors.

Patil SS et, al (2004) conducted a prospective case-control study to determine the

risk factors for acute myocardial infarction in a rural population of central India. The

sample size is 111 consecutive patients with a first episode of acute myocardial

infarction and 222 age- and sex-matched controls. This study compared the

demographics, anthropometric measures, lipids, blood glucose, smoking and other

lifestyle factors among cases and controls to identify the risk factors independently

associated with acute myocardial infarction. Elevated fasting blood glucose, abnormal

waist-hip ratio and income were independently associated with the first episode of

acute myocardial infarction and also compared the abnormal triglycerides and current

22
smoking were risk factors but were not statistically significant. Educational

importance needed for reduce the blood glucose levels and truncal obesity for

controlling the burden of coronary artery disease in rural Indians.

Yusuf Salim et, al (2000) Difference in Risk factors, Atherosclerosis and

Cardiovascular Disease (CVD) between Ethnic groups in Canada : “The study of

Health Assessment and Risk in Ethnic Groups (SHARE)” states that Cardiovascular

Disease (CVD) rates vary greatly between Ethnic groups in Canada. To establish

whether this variation can be explained by differences in disease risk factors and, they

undertook a population-based study of 3 Ethnic groups in Cannada ; South-Asian,

Chinnese and Europeans.

A total of 985 participants were recruited from 3 cities (Hamilton, Toronto &

Edmonton Subclinical Atherosclerosis) by stratified random sampling. Clinical

Cardiovascular Disease (CVD) was defined by history of electro-cardio graphic

findings. Carotid Atherosclerosis was measured with B-mode ultra-sonography.

Conventional (Smoking, Hypertension, Diabetes, Raised cholesterol) and novel risk

factors (makes of a prothrombic stable) were measured. Within each ethnic group and

overall, the degree of carotid atherosclerosis was associated with a higher prevalence

of Cardiovascular Disease (CVD).

Baberg HTet, al (2000) reviewed the Knowledge of patients on cardiovascular

disease risk factors was generally low: One out of 5 did not know about the

consequences of obesity, high blood cholesterol or smoking on the coronary vessels.

Over 30% did not name hypertension. Only 1 out of 3 patients mentioned diabetes

mellitus as a risk factor. There was no change in the knowledge during the hospital

stay despite a standardized and intensive information program. The results of the

23
second survey on the day of discharge were equal to the results of the admission day.

Hospital stays in the past had no influence on the knowledge. Patients with a

diagnosed coronary heart disease had the same results in the survey as patients with

other diseases. The presence of risk factors had hardly any influence on the

knowledge of these patients. The result of this study emphasizes the need for better

health information for patients. The repetitive information on health related issues

during inpatient treatment does not seem to have a positive effect on patients'

knowledge. Therefore other ways of health education have to be introduced and

evaluated in acute care.

Gariballa SE, Peet SM, et, al (1996) assessed the knowledge of 28 stroke patients on

the nature, consequences, treatment and risk factors of stroke and ischemic heart

disease was examined using a questionnaire and compared with that of 26 patients

with ischemic heart disease and 41 controls without evidence of vascular disease.

Information was also collected on the patients' willingness to change their life-style,

the information and advice they had received and their desire for more information.

The collective evidence found that about half of the elderly stroke and heart disease

patients had a reasonable knowledge of the condition and its related risk factors. Only

eight (14%) patients remembered receiving information and advice in relation to their

condition during their hospital stay compared with one (2%) control. Finally this

review concludes a significant difference between the number of stroke and heart

disease patients who wanted to know more about their condition compared with the

control group (32 vs 14; p = 0.03). The study suggests a quarter of the patients and

half of the controls knew that fruit and vegetables were good for you and excessive fat

and alcohol were less inductive to good health. Most patients with a risk factor were

willing to exercise more, stop smoking, cut down on their drinking, or lose weight.

24
These results suggest that elderly hospital patients have a reasonable basic knowledge

about vascular diseases, but that a significant number want to know more and would

be willing to change their life-style.

Pais P et, al (1996) a case-control studies among South Asians in Bangalore, India to

assess their relative importance of risk factors for IHD. Participants are Indian

patients with 1st acute MI(200) and 200 age and sex matched controls. The risk factors

for IHD: diet, smoking, alcohol use, socioeconomic status, waist to hip ratio (WHR),

blood glucose, serum insulin, oral glucose tolerance test, and lipid profile. The

findings are AMI was current smoking of cigarettes or beedis (a local form of

tobacco), with individuals who currently smoked 10 or more per day. Compared with

individuals with no risk factors, individuals with multiple risk factors had greatly

increased risk of AMI. The impact of vegetarianism was closely correlated with blood

glucose and WHR. The study recommends providing or promoting smoking

cessation, treatment of hypertension, and reduction in blood glucose and central

obesity (perhaps through dietary modification) are important in preventing IHD in

Asian Indians.

Literature related life style modification program:

Kozier, Erb, Blasis & Wilkinson, (1995) Lifestyle is defined as the values and

behaviors adopted by a person in daily life, modifying a person’s lifestyle to is to

meet new, changing or different conditions.

This study aims to highlight knowledge of LSM among cardiac patients with a

focus on providing / enhancing knowledge through self instructional module.

Knowledge in LSM is assessed through questionnaire; further improvement in

knowledge is assessed by a post test using the same questionnaire.

25
Life style modification is a key component in CAD patients for reducing progression

of disease. Recently life style modification is being reviewed in India to form the

basis of primordial prevention in CAD disease progression.

Jeannette Larsen & Ann-Dorthe Olsen Zwisler Health behaviour is often used

synonymously with lifestyle, and aspects of lifestyle such as smoking, dietary and

exercise habits are strongly related to health, life expectancy and heart disease.

Lifestyle intervention, comprising systematic education in techniques to change health

behavior, is essential for implementing changes in lifestyle and is an important

element in preventing heart disease and cardiac rehabilitation.

Daubenmier JJ et, al (2007) The Cardiac Rehabilitation Unit intervenes in patients’

lifestyles to motivate and support them in changing their lifestyles long term to

improve their heart health. This intervention is based on knowledge about the links

between heart disease and smoking, dietary and exercise habits.

The purpose is to evaluate the additive and interactive effects of 3-month

changes in health behaviors (dietary fat intake, exercise, and stress management) on

3-month changes in coronary risk and psychosocial factors among 869 nonsmoking

CHD patients (34% female) enrolled in the health insurance-based Multisite Cardiac

Lifestyle Intervention Program. In this study multiple regression analyses evaluated

changes in dietary fat intake and hours per week of exercise and stress management as

predictors of changes in coronary risk and psychosocial factors. Significant overall

improvement in coronary risk was observed. Reductions in dietary fat intake predicted

reductions in weight, total cholesterol, low-density lipoprotein cholesterol, and

interacted with increased exercise to predict reductions in perceived stress. Increases

26
in exercise predicted improvements in total cholesterol and exercise capacity (for

women). Increased stress management was related to reductions in weight, total

cholesterol/high-density lipoprotein cholesterol (for men), triglycerides, hemoglobin

A1c (in patients with diabetes), and hostility. Finally this study suggests

improvements in dietary fat intake, exercise, and stress management were

individually, additively and interactively related to coronary risk and psychosocial

factors, suggesting that multi-component programs focusing on diet, exercise, and

stress management may benefit patients with CHD.

Aounallah Skhiri H et, al (2005) review the degree of awareness and practices of

patients with cardiovascular disease .During October 2002-February 2003, we

conducted a CAP study (Knowledge, attitudes, behaviors) at some outpatient clinic

visit of Tunis District. Using a standardized questionnaire, 443 patients have been

interviewed their educational level of risk factors of CVD. The collective findings

suggested 66.9% of men have quit tobacco smoking and 19.5% still smoking 41.3%

of patients have some difficulties to change their lifestyle. During the last year,

majority of patients has had checked their blood pressure (98%), glycaemia (94%)

and cholesterolemia (94%). Most of patients are aware that healthy lifestyle can be

important in preventing heart attacks and stroke and that control of blood pressure,

cholesterolemia and glycaemia reduce recurrence of these attacks once they

happened.

This study facing the crucial question on lifestyle change and enhancing

patient’s responsibility in their own health promotion.

27
Steptoe A, Kerry S et, al (2001) This study assessed stages of change in fat intake,

physical activity, and cigarette smoking during a randomized controlled trial of

behavioral counseling. A total of 883 patients were selected for the presence of 1 or

more of the following risk factors: cigarette smoking, high cholesterol, or a

combination of a high body mass index and low physical activity. Stage of change

(precontemplation, contemplation, preparation, and action/maintenance) was assessed

at baseline and after 4 and 12 months. The odds of moving to action/maintenance for

behavioral intervention vs control patients at 4 months were 2.15 (95% confidence

interval [CI] = 1.30, 3.56) for fat reduction, 1.89 (95% CI = 1.07, 3.36) for increased

physical activity, and 1.77 (95% CI = 0.76, 4.14) for smoking cessation. The

likelihood of achieving action/maintenance was related to baseline stage for all 3

behaviors.

This study conclusion is to provide brief behavioral counseling for

encouraging healthy lifestyles among patients in primary care at raised risk of

cardiovascular disease.

A.DIET

Stigler MH et, al (2011) cross-sectional study of the microeconomic impact of

cardiovascular disease hospitalization in four low- and middle-income countries

(mainly in India). The aim of this study was to describe specific weight-related

concerns among school-going youth in Delhi, India and to assess the prevalence of

weight control behaviors, including healthy and unhealthy ones. Half of the

overweight or obese students misclassified their weight status, while about 1 in 10

non-overweight youth did the same. This study interventions are to promote healthy

weight control should be pertinent to and well-received by school-going youth in

28
India. Healthy weight control practices need to be explicitly encouraged and

unhealthy practices reduced.

Gupta R et, al (2006) Correlation of regional cardiovascular disease mortality in

India with lifestyle and nutritional factors. Mortality data were obtained from the

Registrar General of India. In 1998 the annual death rate for India was 840/100,000

population. Cardiovascular diseases contribute to 27% of these deaths and its crude

mortality rate was 227/100,000. Major differences in cardiovascular disease mortality

rates in different Indian states were reported varying from 75-100 in sub-Himalayan

states of Nagaland, Meghalaya, Himachal Pradesh and Sikkim to a high of 360-430 in

Andhra Pradesh, Tamil Nadu, Punjab and Goa.

Udipi SA et, al (2006) Variations in fat and fatty acid intakes of adult males from

three regions of India. Participants (n=25) was given to assess their dietary Fat and

fatty acid intakes of healthy adult urban males from Ghaziabad, U.P.; Goa and

Kolkata, W. Bengal. Total fat intakes ranged from 26.9 g/day to 163.2g/ day. Percent

subjects having intakes above the desirable level were 72% in Kolkata, 36% in

Ghaziabad, U.P. and only 10% in Goa. This survey highlights the need for limiting fat

intakes and modifying diets to provide fatty acids in desirable ratios.

Consoli SM et, al (2004) the study to assess the individual health behavior,

Population consisted of 59.7% males and 40.3% females. An internal HLC (Health

Locus Control) was testifying an appropriate level of knowledge. This study

recognized that by survey fewer have mis-conceptions about cholesterol and

hypercholesterolemia, for ex: overweight individuals are more prone to have

cholesterol problems or too much cholesterol may lead to cancer. This study also

associated with a closer identification between cholesterol and modem lifestyle, with

29
the belief that the best way of lowering cholesterol is to diet. Finally, internal HLC

subjects put forward less excuses for not to comply with dietary constraints. The

results should encourage physicians to take into account the HLC of their hyper-

cholesterolemic patients to pass personally tailored educational messages and to

motivate them to take responsibility for their own health.

Sexena .S.et.al, (2001) states that the three independent and modifiable risk factors

have perceived particular attention namely Cigarette smoking, Hyperlipidaemia and

Hypertension with the available evidence linking these as casual factors in the factors

for heart disease over which individuals have any control. They are partly amenable to

lifestyle modification and counseling etc, but their ultimate control study requires

pharmacological intervention. Diseases of multi-factorial origin the most important

contributors perhaps being the change in the lifestyle accompanying industrialization

and urbanization along with a high intake of saturated fats and sedentary life style.

Gambhir- D.S. et, al (2000) in his study of “Homocysteine and Coronary Heart

Disease” indicated significant increased risk for those patients with high

homocysteine levels. A study of 21,000 men who were followed for an average of 87

years. The study significantly showed higher mean homocysteine level 229 men who

died of Ischemic Heart Disease (IHD), compared to 1126 aged matched controls.

Multivariate relative risk of IHD mortality comparing the highest and lowest quartile

of homocysteine was 2.9 (9.5% confidence interval, 2.0-4.1). Their studies concluded

with prevention can be gained by efficient vitamins supplements to reduce elevated

homocysteine levels in blood in reducing the risk of Cardiovascular Disease (CVD).

30
Manson JE, Spelsberg A et, al (1996) Coronary heart disease, the leading cause of

death in women, is largely preventable. Lifestyle modifications (e.g., diet and

exercise) are the cornerstone of primary and secondary prevention. Elevated levels of

low-density lipoprotein cholesterol and triglycerides and low levels of high-density

lipoprotein cholesterol are significant risk factors for coronary heart disease.

Abundant data show inadequate utilization of lipid-lowering therapy in women. Even

when women are given lipid-lowering agents, target levels often are not achieved.

Dhawan J, Bray CL (1997) reviewed the Asian Indians, coronary artery disease, and

physical exercise. The objective of this study is to evaluate the relation of physical

activity to different clinical and biochemical risk factors for coronary artery disease

among people from different ethnic groups with angiographically proven coronary

artery disease. The study subjects at British Asians, Indian Asians, and white people

suffering from coronary artery disease, and their respective controls. The study Relate

the physical activity level to serum insulin, glucose, cholesterol, triglycerides, and

high density lipoproteins, systolic and diastolic blood pressures, and body mass index

in patients and controls. 391 male patients were studied, of whom 260 (66.5%) were

classified as sedentary. Mean serum insulin at 0, 1, and 2 hours after 75 g oral glucose

was higher among the sedentary population. Mean body mass index was also higher

among the sedentary population as were mean serum triglycerides and systolic and

diastolic blood pressures. There was no difference in the mean serum cholesterol and

high density lipoprotein between the two groups. British Asians were the most

sedentary and Indian Asians the most physically active. Finally there are marked

differences in the level of physical activity among the various ethnic groups in the

United Kingdom. In each ethnic group, physical activity reduced mean serum insulin,

body mass index, and serum triglycerides and had a favourable effect on systolic and

31
diastolic blood pressures. Promotion of physical activity could be of value for the

Asian community in the United Kingdom.

Anne H. D. Fleming referred point for heart failure patients and their current

knowledge and status related to nutritional issues. The nutritional knowledge

questionnaire could continue to be a useful tool for demonstrating understanding of

diet for patients diagnosed with congestive heart failure by assessing their

comprehension level of nutrition. Future research addressing the essence of why

patients with adequate sodium-restriction dietary knowledge are not applying this

important information into their own lives and diets is warranted. The current study

provides preliminary information upon which to build numerous other studies in the

advancement of optimal care for the congestive heart failure patient.

The American Heart Association has proposed improving overall cardiovascular

health by promoting 7 components of ideal cardiovascular health. In this study they

assess the knowledge of these 7 components, including health behaviors (not

smoking, regular exercise, and healthy diet) and health factors (ideal body mass

index, cholesterol, blood pressure, and blood glucose) by performed a cross-sectional

survey of patients at 4 primary care and 1 cardiology clinic. The survey measured

demographic data, personal behaviors/health factors, cardiovascular disease history,

and knowledge about these 7 components. The average respondent identified 4.9

components. The lowest recognition rates were for exercise (57%), fruit/vegetable

consumption (58%), and diabetes (63%). In a multivariate model, knowledge of all 7

components was positively associated with high school education. In conclusion, just

>1/3 of patients could identify all 7 components of ideal cardiovascular health.

Educational efforts should target patients in low socioeconomic strata and focus on

32
improving knowledge about healthy diet and regular exercise. Although patients with

diabetes were more likely than those without diabetes to recognize their risk, 1 in 5

were not aware that diabetes is a risk factor for cardiovascular disease.

B.HABITS

Roy A, Prabhakaran D et, al (2010) reviewed the Impact of alcohol on coronary

heart disease in Indian men. The subjects for this study are employees and their

family members aged 20-69 years in 10 medium-to-large industries from diverse sites

in India, using a stratified random sampling technique. The Information on education,

behavioral, clinical and biochemical risk factors of CHD and alcohol use was

obtained through standardized instruments. Totally 4465 subjects were present or past

alcohol users. The mean age of alcohol users and lifetime abstainers was 42.8+/-11.0

years and 42.8+/-11.1 years, respectively (p=0.90). This study suggested that Systolic

blood pressure and diastolic blood pressure were significantly higher in alcohol users.

Finally this study indicated an association in the reverse direction, suggesting possible

harm of alcohol for coronary risk in Indian men. This relationship needs to be further

examined in large, prospective study.

Wryobeck JM et, al (2007) review the Chest pain is the most frequent cocaine-

related medical event for which patients seek treatment in inner-city emergency

departments (EDs). Given that depression increases risk for poor substance use and

cardiac outcomes, knowledge of correlates of depressive symptoms among these out-

of-treatment cocaine users is crucial to developing interventions for these inner-city

populations that frequently present to the ED. A total of 219 individuals presenting to

an inner-city ED with chest pain and recent cocaine use were divided into 2 groups

based on scoring positive (42%) for moderate-to-severe depression on the Patient

33
Health Questionnaire (PHQ-9). The depression symptoms group reported a

significantly greater number of standard drinks per drinking occasion (7.1 versus 4.6)

and a greater number of heavy drinking days (9 versus 5). A significant 3-way

interaction effect found males and non-white females reporting a greater number of

heavy drinking days were more likely to be in the depression symptoms group,

whereas white females with a greater number of heavy drinking days were more

likely to be in the non-depression symptoms group. Depression is clearly a problem

among not-in-treatment cocaine users presenting to an inner-city ED; heavy drinking

in concert with cocaine use increases the risk for depression, with important

interactions by race and gender.

Debien B et, al (2006) concerning any socio-professional category, some addictive

drugs like cocaine are responsible for many complications. The authors relate two

case reports of young patients who suffered from cardiovascular accidents due to this

drug. The first one was diagnosed with an ischemic stroke caused by carotid artery

dissection and a leg distal vascular obliteration, the second one with a myocardial

infarction with transient left ventricular dysfunction. Through these two case reports,

the authors take stock of the patho-physiological and therapeutic knowledge of

cardiovascular accidents after cocaine intake.

Rastogi T et, al (2005) Bidi and cigarette smoking and risk of acute myocardial

infarction among males in urban India was estimated smoking among 309 men with

incident MI in that 56% of the individuals with MI and 26% of controls were current

smokers. Current smokers had a relative risk of 4.7 compared to never smokers.

Relative risks for smoking more than 10 cigarettes or 10 bidis daily were 9.1 and 8.1

34
respectively. It is estimated that smoking may cause 53% (of MIs among urban males

in India.

Joseph AM et, al (2005) The Reduction of Smoking in Cardiac Patients (ROSCAP).

Study is a randomized controlled trial to test the effectiveness of a smoking reduction

strategy to decrease tobacco-related harm, promote cessation, and improve

biochemical and clinical indicators of toxin exposure among patients with heart

disease. They analyzed baseline characteristics of patients enrolled for participation to

investigate predictors of spontaneous smoking reduction prior to study enrollment.

Past reducers were more likely to be males (p=.009) and had higher past peak

smoking level (p<.0001) than non-reducers. Gender and number of heart disease

diagnoses predicted the occurrence of spontaneous reduction and its extent. Age and a

history of chronic obstructive pulmonary disease also predicted the extent of

reduction. Cotinine and nicotine levels per cigarette per day were significantly higher

among past spontaneous reducers than non-reducers. Spontaneous reduction is

common among medically ill smokers. Past history of heart disease is a strong

predictor of prior reduction. There is evidence of compensation among past

spontaneous reducers.

Praveen.K. et,al (2002) studies on demographic patterns, risk factors and outcome in

Acute Coronary Syndrome (ACS) are spare in India. The create registry recruited

consecutive patients of Acute Coronary Syndrome (ACS) from 71 centers in India.

Demographic and clinical data were recorded in hospitals at 30 days. Data on patients

profile, risk factors, time patterns and mortality at 30 days of 4081 subjects were

presented here.

35
 There are 3092 Male (77%) and 989 Females (23%). Subjects less than 50

years comprised 29%. There were 1546 (37.8%) with unstable angina and 2535

(62.2%) with Acute Myocardial Infarction. Lower Middle Class and Poor patients

comprised 68.7%. current smokers were 110. Significantly more women had history

of hypertension and diabetes.

This study was shown that Indian patients with Acute Coronary Syndrome

(ACS) are younger, are from poorer-socio-economic background and have high rates

of hypertension and diabetes.

D.STRESS

H.Singh. et, al (2002) studied that there are many coronary artery diseases (CAD). 90

subjects known cases of (Cardiovascular Disease) CVD and less than 75 years of age

were taken for the present study. All subjects included in the study were subject to

A) Personality type assessment.

B) Presumptive stressful event.

The study resulted in the age was 57 years. The youngest was 42 years while

the oldest was 72 years. The Male: Female ratio was 14:1. As assessed 51 (57%) had

type A personality, 39 (43%) had type B personality. In this study mean time stressful

events were 15.83 and mean past one year stressful life events to be 3.4. He concluded

that type A personality individuals behavior is associated with higher incidence of

Coronary Heart Disease (CHD).

PHYSICAL ACTIVITY AND CVD

Harpal S.Buttar Dum Ph.D., Tino Li Ph.D., Physical activity or exercise is a part of

everyone’s life. However, it is the degree of physical exertion that differs among

people. Several evidence-based studies have consistently indicated a positive

36
correlation between physical activity and good health. Nevertheless, various aspects

of physical activity must be considered when evaluating how well controlled studies

have been conducted. Definitions of physical activity often vastly differ, rendering the

results of different studies incomparable. Fortunately, there are three areas of interest

that remain relatively consistent in defining physical activity, namely, intensity,

duration and frequency. Intensity refers to the degree or extent of exertion and is often

presented as a percentage of target heart rate or lung volume (ie, oxygen consumption

[VO2]). Duration refers to how long a particular activity is undertaken, and frequency

refers to the number of times a given activity is performed. A multitude of studies (2–

34) have been conducted showing a relationship between physical activity and overall

well-being. It has been repeatedly shown that an inverse relationship exists between

physical activity and the occurrence of CVDs (ie, with increased physical activity, the

relative risk of developing CVD is decreased). With regard to specific surrogate

markers and biological factors pertaining to CVD risk factors (eg, high BP, and

increased cholesterol and triglyceride concentrations), clinical and laboratory

evaluations have been performed to show the benefits of physical activity. Such

quantitative measurements were performed to determine the influence of exercise on

blood coagulation and fibrinolysis, vascular remodelling, BP and blood lipid profiles.

Correspondingly, these studies have also shed light on the possible adverse

consequences of exercise, especially when dealing with patients with chronic heart

failure, and the precautions that should be taken to bypass these health risks (12–30).

Influence of exercise on blood coagulation and fibrinolysis

Blood coagulation and fibrinolysis are two important physiological functions

influencing the formation and breakdown of clots within blood vessels. Fibrinolysis is

an enzyme-activated phenomenon (12). Moreover, these hematological functions are

37
influenced by various blood factors, which either inhibit or promote clot formation or

breakdown. To understand the effectiveness of the mechansims of coagulation and

fibrinolysis, serum concentrations of biomarkers such as plasma fibrinogen, factor

VIII, factor VII, tissue plasminogen activator (t-PA), plasminogen activator inhibitor-

1 (PAI-1) and fibrin D-dimer are measured (14). Blood platelet count and aggregation

are also important aspects of optimal coagulation and fibrinolysis in the body (15).

Inhibition of platelet aggregation plays a very important role in the prevention of heart

attacks and strokes. Increased concentrations of fibrinogen, platelet aggregation or

activation, factor VII, factor VIII and PAI-1 increase the probability of intravascular

coagulation. On the other hand, increased serum concentrations of t-PA increase the

probability of fibrinolysis; specifically, t-PA is responsible for promoting the activity

of plasminogen, an enzyme that actively dissolves unwanted blood clots. PAI-1

inhibits the action of t-PA by binding to it and rendering it inactive. The remaining

coagulation factors effectively act to build a clot by causing the aggregation of

platelets and by forming the rigid network that is the basis of blood clot formation

(12). A balance in the serum concentrations of coagulation and fibrinolytic factors is

important because they seem to be directly correlated to the risk of cardiovascular

ischemic events such as stroke and MI. Clotting and fibrinolytic factors play a pivotal

role in the formation of thrombi and emboli (13). Hence, in patients with CVD, it is

essential to ensure that a proper balance of these blood constituents is maintained.

Several studies have attempted to show the influence of exercise on blood coagulation

and fibrinolysis and, overall, positive effects of physical activity have been reported

(12–16).

38
 CHAPTER-III

METHODOLOGY
 CHAPTER-III

METHODOLOGY

“Methods are tools. Use them; don’t let them use you.”

Methodology is the framework for concluding a study. It indicates the general

pattern for recognizing the procedure to gather valid and reliable data for an

investigation.

This chapter gives a description of the research approach, Research design,

Variables under the study, setting of the study, Population, Sampling and Sampling

technique, Schematic representation of the study design.

The present study is aimed at assessing the knowledge of cardiac patients

regarding the lifestyle modification and to find the association between the knowledge

score with selected demographic variables with a view to develop an self instructional

module to enhance the knowledge of cardiac patients regarding the lifestyle

modification for maintaining healthy heart.

Research approach

Research approach indicates the procedure for conducting the study. In order

to accomplish the objectives of the study, a evaluative approach has been adopted.

Research design

Evaluation Research studies are an applied form of research design which

involve the judgment about how well a specific programme, practice, Procedure or

policy is working.

39
 DV:
Knowledge
Rregarding Life
Style Modification

60 Cardiac To assess the

patients knowledge
admitted regarding
with MI Lifestyle
SIM
and Modification
Angina of
Pectoris cardiovascular
IV:
disease
Age,
Educational Status,
Socio economic status,
Income and
Health Teaching

Mean, Median, X2 test to

Mode, SD, measure
Percentage the
Distribution to associatio
measure the n between
association IV & DV
between the DV

Key Words

IV: Independent variables

DV: Dependent variables

SIM: Self Instructional Module

Fig. 2 Schematic Representation of the Study Design

40
VARIABLES

A variable is a measurable component of an object or event that may fluctuate

in quantity or quality from one individual, objects or event to another individual of the

some general class.

Dependent Variables

The dependent variable is that phenomenon in the hypothesis, is not

manipulated by the investigator but accepted as it occurs. It also called the effect, the

response, the criterion measure, behavior or outcome that is researcher wishes to

predict, study and explain.

In this study the dependent variable was knowledge on lifestyle modification

for maintaining healthy heart which will be tested before and after conducting self

instructional module among cardiac patients.

Independent Variables

The independent variable is that phenomenon in the hypothesis that, in the

non-experimental study, to test the hypothesis, is not manipulated by the investigator.

It is also called the cause, stimulus, non-experimental variable that is manipulated by

the researcher in order to study the effect upon the dependent variable.

In this study the independent variable was Age, Educational status, income

And health teaching.

Setting of the study:

The setting is the location where the study is conducted. For the present study

the setting was in Apollo Hospital, Madurai. This setting was selected because of the

41
availability of the sample, feasibility of conducting the study of the investigator with

the setting.

Population:

Polit and Hungler (2004), referred population as the entire set of individuals or

subjects having common characteristics, sometimes referred to as universe.

Population may be of two types, target population and accessible population. In this

study two populations were described.

Sample

Sample refers to subset of a population that is selected to participate in a

study. It is a portion of a population that represents the entire population. In this study,

sample consists of 60 patients of selected hospital, Madurai.

Sampling Technique

Sampling defines the process of selecting a group of other elements with

which to conduct a study. In this study non – probability random sampling technique

was adopted.

Random sampling involves selection of sample on basis of probability. Each

of the population has an equal chance of being selected.

Criteria for sampling

a) Inclusion criteria

1. The patients with the CAD who are admitted in selected hospitals at Madurai .

2. The patients with the CAD who are able to read and understand Tamil OR

English.

3. Patients who are willing to participate in the study

4. Patients who are available during the period of collecting data

42
b) Exclusion criteria

1. The patients with the CAD admitted in selected hospitals at Madurai and who

are not willing to participate in the study.

2. The patients with the CAD who are not able to read and understand Tamil or

English.

DEVELOPMENT OF THE TOOL

The most important aspect of any investigation is the collection of appropriate

information, which will provide necessary data to answer the question raised in the

study.

A Self Instructional Module was selected based on the objectives of the study,

as it was considered to be the most appropriate instrument to elicit the responses from

the participants.

An interview schedule demographic Performa was prepared to identify the

demographic variables, self administered questionnaire was prepared to assess the

knowledge of the patients those who are affected by Cardiovascular Disease.

Knowledge questionnaire consisted of 34 questions each of it carried a score of 1.

The tool was developed:

• After reviewing the related literature.

• After reviewing the related studies from journals and periodicals.

• Based on the experience of the investigator and

• Based on the contact and consultation of the subject experts

All these helped in the ultimate development of the tool.

43
DESCRIPTION OF THE TOOL

Based on the objectives of the study, the following tool was developed to

generate the data.

The tool consists of following sections,

Section A: It consist of demographic data of the patients with CAD

Section B: Self administered questionnaire to assess the knowledge regarding the Life

Style Modification for maintaining Healthy Heart among cardiac patients.

SECTION A:

It consists of demographic data which gives base line information of the

patients with the CAD such as:

1) Age

2) Sex

3) Religion

4) Education

5) Occupation

6) Family income

7) Marital status

8) Type of family

9) Type of diet

10) Personal habits

11) Duration of illness

12) Medical diagnosis

13) Number of admissions in one year

14) Number of visit for follow-up etc.

44
SECTION B:

It consists of self-administered questionnaire to assess the knowledge

regarding the Life Style Modification for maintaining healthy heart among cardiac

patients in selected hospital at Madurai.

In mainly consists of five parts:

Part I : General knowledge related to heart disease

Part II : General information about Life Style Modification

Part III: Knowledge related to dietary modification & weight loss

Part IV: Knowledge related to exercise & stress management

Part V : Knowledge related to habits

All the five parts of questionnaire consists of 34 multiple choice questions,

each having more than 4 options from which the correct option was to be chosen.

Each correct item was scored 1 mark.

The subject who got a score of ˂50% were considered as inadequate

knowledge, scores of 50-75% were considered as moderately adequate knowledge,

scores of 75% were considered as well adequate knowledge .

CONTENT VALIDITY OF THE TOOL

Validity refers to whether a measuring instrument accurately measures what it

is supposed to measure.

The content validity of the tool and self instructional module was ascertained

in consultation with experts in the field of Medical & Surgical Nursing. Validation

checklist was sent and was completed by the experts for content validation. The

experts were requested to give their opinion regarding relevance, appropriateness and

45
degree of agreement in each item in the tool. Suggestions and recommendations given

by the experts.

Suggestion elicits from experts

On knowledge questionnaire:-

One of the experts suggested adding the general knowledge regarding cardiac

problems and avoiding unnecessary questions about anatomy and physiology of heart

and neglecting adding more all of the above in the answer options.

The items were included and answer options were changed.

On demographic data:-

One of the experts suggested modify the data type questions. Accepted the

suggestion and the items were changed.

Criteria rating scale for validation of tool was developed.

Part – I, comprised of demographic data and Part - II, comprised of self administered

questionnaire on Life Style Modification for cardiac patients

Check list for the tool had relevant, need modification, not relevant options

and remarks of experts.

TAMIL TRANSLATION

The tool was translated by the language experts into Tamil and it was

translated to English by another expert to determine its content validity.

ETHICAL CONSIDERATION:

 An ethical clearance was obtained from the Apollo Hospital.

 Consent was taken from all the participants.

46
RELIABILITY OF THE TOOL

Reliability of research instrument is defined as the extent to which the

instrument yields the same result on respected measure. It is then concerned with

consistency, accuracy, precision, stability, equivalence and homogeneity.

The final tool was tested for reliability. The self administered questionnaire

was administered to 10 patients. The reliability of the tool was established by testing

the stability and internal consistency.

The stability of the tool is assessed by test retest method (Karl Pearson

Coefficient formula) and the stability of the tool is 0.7 which indicate that tool is

stable. The internal consistency of the tool is assessed by split half method and the

internal consistency of the tool is 0.91.It indicates that the tool was reliable.

PILOT STUDY

A Pilot study is a small scale version or trial run, done in preparation for the

major study. It is designed to acquaint the researcher with the problems to be

encountered in preparation for the larger project.

It also provides the researcher to try out the procedure for collecting the data.

The function of pilot study is to obtain information for improving the project or

assessing its feasibility.

The subject selected for the pilot study possessed the same characteristics of

the major study in order to maintain homogeneity. The consent was taken by

explaining the purpose of the study.

Pilot study was conducted in to assess the effectiveness of self instructional

module regarding lifestyle modification among cardiac patients in Apollo hospital,

Madurai..

47
 After that Self Instructional Module was administered. After 3 days gap post-

test was done to the same subjects by using the same questionnaire.

Statistical analysis done with the help of paired ‘t’ test to observe the

significant difference in the knowledge scores of subjects before and after the self

instructional module.

. The sample taken for pilot study was not considered in the main study.

The Purpose of pilot study was

 To find out the feasibility on conducting the final study.

 Refine the tool.

 To determine the method of data analysis.

After conducting the pilot study, it was found that the study was feasible ,

authentic and clients was cooperative, the questionnaire and the teaching plan were

relevant and time and cost of the study were within the limits .

Tool to validate the effectiveness of Self Instructional Module:

The same structured questionnaire which was used for pre-test used to assess

the effectiveness of the Self Instructional Module on Life Style Modification among

Cardiac patients in selected hospital, at Madurai.

Prior to the actual data collection, written permission was obtained from the

higher authorities from hospitals and concern from the cardiac patients to conduct

interview. Data collection was carried out in three phases on the basis of inclusion

criteria.

48
PHASE 1:

Pre-test will be conducted to assess the knowledge regarding the Life Style

Modification for maintaining healthy heart among cardiac patients using self

administered questionnaire. Duration: 2 days.

PHASE 2:

Self Instructional module regarding the Life Style Modification for

maintaining healthy heart among cardiac patients was administered after phase1.

PHASE 3:

After 3 days post-test was administered to assess the level of knowledge

regarding the Life Style Modification for maintaining healthy heart among cardiac

patients to the same subjects with the help of same questionnaire duration of the

study: 8-10 days

DESCRIPTION OF THE INTERVENTION

The samples were drawn from the patients those who have been admitted in

Apollo hospital, Madurai. The investigator was contacted around 60 patients and

explained the objectives and need of the study and administers the Self instructional

Module.

The score were given such as lesser the score; reflect inadequate knowledge.

Based on the scores, the self instructional module were planned and prepared by the

investigator and it send to the experts for the tools validity. Based on the suggestion

given by the experts and guide the tool was modified for final data collection.

The total sample consisted of 60 cardiac patients for self instructional module

were administered.

49
 The pre – test and post – tests knowledge level on life style modification to

maintain healthy heart were evaluated to find out the effectiveness of self instructional

module.

PLAN FOR DATA ANALYSIS

The collected data will be planned and analyzed in the form of descriptive and

inferential statistics. The analyzed was presented in the form of tables and figures by

using mean, median, mode, percentage, standard deviation, chi-square test.

HUMAN RIGHTS PROTECTION:

The study was conducted after getting the approval from the ethical

Committee. Permission was obtained from authority of particular Hospital. The

purpose and other details of the study were explained to the study subjects and

oral consent was obtained from them.

50
 CHAPTER-IV
DATA ANALYSIS
AND
INTERPRETATION
 CHAPTER IV

DATA ANALYSIS AND INTERPRETATION

SECTION A

Description of sample characteristics.

A sample of 60 patient of selected hospital was drawn, based on the specific

criteria. The data on sample characteristics were analyzed using descriptive statistics

and presented in terms of frequency, percentage and diagrams.

The data obtained from sample are presented in terms of age, sex, occupation,

education, family income, type of habitat, type of diet, family history of cardiac

problems, duration of illness, number of admission in one year, exposure to type of

media, patient visits for follow-up, and awareness about life style modification.

51
 SECTION A
Table-1
FREQUENCY AND DISTRIBUTION DEMOGRAPHIC
VARIABLES OF CARDIAC PATIENTS
S.No Demographic characteristics No %

1 Age
a. 26 -35 years 9 15.00
b. 36 – 45 years 10 16.67
c. 46 – 55 years 26 43.33
d. 56 -65 years 8 13.33
e. 65 years and above 7 11.67
2. Gender
a. Male 37 61.67
b. Female 23 38.33
3 Education
a. Non-literate 14 23.33
b. Primary education 12 20.00
c. High school 13 21.67
d. PUC 10 16.67
e. Degree 7 11.67
f. Post Graduate 4 6.66
4 Occupation
a. Labourer 26 43.33
b. Government employee 10 16.66
c. Private employee 13 21.67
d. Business 4 6.67
e. Others 7 3.67
5 Religion
a. Hindu 36 60.0
b. Christian 6 10.0
c. Muslim 18 30.0
d. Any other 0 0.0

52
6 Marital status
a. Married 56 93.33
b. Widow (er) 4 6.67
7 Type of family
a. Nuclear 37 61.67
b. Joined 23 38.33
8 Monthly family income
a. More than Rs-5000 34 56.67
b. Rs.5001-10,000 17 28.33
c. ˃Rs.10,000-20,000 9 15.00

Table1- shows 9 (15.00%) of belongs to 26 years to 35 years of age, 10 (16.67%) of

belongs to 36 years to 45 years of age, 26 (43.33%) of belongs to 46 years to 55 years

of age, 8 (13.33%) of belongs to 56years to 65 years of age, (11.67%) belongs to 65

years and above.

It was inferred that majority of patients were in the age group of 46 to 55 years

and followed by the age of 36-45 years.

The data presented in the above table reveals that majority of the respondents

of the study were Males (n=37), (67%) and 23 respondents (38.33%) were Female.

The data presented in the above table reveals that education of the patients. In

that non-literate 14(23.33 %), Primary education n=12(20.00%), High school n=13

(21.67%), PUC n=10 (16.67%), Degree n=7 (11.67%), and Post graduate only n=4

(6.66%). So majority of the cardiac patients were non-literate 23.33% (n=14),

followed the high school 21.67% (n=13), and primary education 20% (n=12).

The data presented in the above tables reveals the occupational status of the

cardiac patients. In that participants n=26 (43.33%) person belongs to laborer, n=10

(16.66%) belongs to Government employee, n=13 (21.67%) belongs to Private

53
employee n=4 (6.67%) belongs to Business man, and n=7 (11.67%) belongs to some

other works.

The data presented in the above table reveals that majority (60%) of the

participants in the present study were Hindu n=36, followed the Muslim n=18

(30.0%), and minority were Christian people n=6 (10%)

The data presented in the above table reveals that majority (93.33%) of the

participants in the present study were married people, and others were n=4 (6.67%)

widower.

Table-7 in respect of the type of family majority of the participants n=37

(61.67%) belongs to nuclear family type, and others are n=23 (38.33%) belongs to

joined family.

The data presented in the above table reveals that majority=37 (61.67%) of

the participants in the present study were belongs to nuclear family type, N=23

(38.33%) of the respondents were joined family.

When considering total income of family n=34 (56.67%) belongs to More than

Rs-5000 group, n=17 (28.33%) belongs to Rs-5001-10,000-group, and remaining

members n=9 (15.00%) belongs to ˃Rs-10,000-20,000.

54
 43.33
45.00
40.00
35.00

Percentage 30.00
25.00
20.00 16.67
15.00
13.33
15.00 11.67

10.00
5.00
0.00
26 -35 years 36 – 45 years 46 – 55 years 56 -65 years 65 years and
above
Age in Years

FIGURE-3 FREQUENCY AND PERCENTAGE DISTRIBUTION OF AGE OF CARDIAC PATIENTS.

55
 61.67
70.00

60.00
38.33
50.00
Percentage

40.00

30.00

20.00

10.00

0.00
Male Female
Gender

FIGURE-4 FREQUENCY AND PERCENTAGE DISTRIBUTION OF GENDER OF THE CARDIAC PATIENTS

56
 23.33
20.00
25.00 21.67
16.67
20.00
Percentage 11.67
15.00 6.66
10.00
5.00
0.00

EDUCATIONAL STATUS

FIGURE-5 FREQUENCY AND PERCENTAGE DISTRIBUTION OF EDUCATIONAL STATUS OF CARDIAC PATIENTS

57
 43.33
45.00
40.00
35.00
Percentage

30.00
25.00 21.67

20.00 16.66

15.00 11.67

10.00 6.67

5.00
0.00
Labourer Government Private Business Others
employee employee
Occupation

FIGURE-6 FREQUENCY AND PERCENTAGE DISTRIBUTION OF OCCUPATIONAL STATUS OF CARDIAC PATIENTS

58
 Religion

Hindu
Christian
Muslim
Any other

FIGURE- 7 FREQUENCY AND PERCENTAGE DISTRIBUTION OF RELIGION

59
 93.33

100.00
90.00
80.00
70.00
Percentage
60.00
50.00
40.00 6.67
30.00
20.00
10.00
0.00
Married Widow (er)
Marital status

FIGURE-8 FREQUENCY AND PERCENTAGE DISTRIBUTION OF MARITAL STATUS OF CARDIAC PATIENTS

60
 70.00
61.67
60.00

50.00
Percentage

38.33
40.00

30.00

20.00

10.00

0.00
Nuclear Joint
Type of family

FIGURE-9 FREQUENCY AND PERCENTAGE DISTRIBUTION TYPE OF FAMILY

61
 56.67

60.00
50.00
40.00 28.33
Percentage
30.00 15.00
20.00
10.00
0.00
More than Rs-5000 Rs.5001-10,000 ˃Rs.10,000-20,000

Monthly family income

FIGURE-10 FREQUENCY AND PERCENTAGE DISTRIBUTION OF MONTHLY FAMILY INCOME OF CARDIAC PATIENTS

62
 DEMOGRAPHIC VARIABLES OF PATIENTS
TABLE-2
FREQUENCY AND PERCENTAGE DISTRIBUTIONS OF
DEMOGRAPHIC VARIBALES OF PATIENTS

S.No Demographic characteristics No %

9. Duration of illness
a.1-3 years 27 45.00
b.4-6 years 10 16.67
c.7-12 years 11 18.33
d.˃13 years 12 20.33
10. Type of deit
a. Vegetarian 14 23.33
b. Non-vegetarian 46 76.67
11 Habits
a. Alcoholic 21 35.00
b. Smoking/alcoholic 17 28.33
c. Tobacco chewing 18 30.00
d. No habits 4 6.67
12 Type of habitat
a. Urban 36 60.0
b. Rural 24 40.0
13 Medical diagnosis
a. Myocardial infarction 42 70.0
b. Angina pectoris 18 30.0
14 No. of admissions in one year
a. One time 27 45.00
b. 2 times 25 41.67
c. 3 times 6 10.00

d. More than 3 times 2 3.33

63
 15 Exposure to type of media
a. Television 33 55.00
b. News paper 17 28.33
c. Magazine 6 10.00
d. All of the above 4 6.67
Patients visits physicians for follow-
16
up
a. Once in a week 6 10.00
b. Once in a month 22 36.67
c. Once in 2 month 18 30.00
d. As needed 14 23.33
Awareness about lifestyle
17
modification
a. Yes 39 65.0
b. No 21 35.0

With regard to the duration of illness of participants n=27 (45%) belongs to 1-

3 years duration, n=10 (16.67 %) belongs to 4-6 years of duration, n=11 (18.33 %)

belongs to 7-12 years of duration, and n=12 (20.33%).

When considering the dietary pattern, maximum number 14(23.33%) of them

were vegetarian whereas n=46 (76.67%) were vegetarians.

When considering the personal habits, maximum number 21 (35.00%) of

them had alcoholic, whereas n=18 (30.00%) of them had tobacco chewing, n=17

(28.33%) had both smoking and alcoholic habits, n=4 (6.67%) of them had no habits.

When considering the type of habitat, maximum number 36 (60.00%) of them

belongs to urban area, remaining members 24 (40.00%) of them belongs to rural area.

regarding the medical diagnosis most participants n=42 (70.00%) of them had

myocardial infarction, remaining members n=18 (30.0%) of them had angina pectoris.

64
 When calculating the no. of admissions in one year most participants n=27

(45.00%) of them came for admission one time only, n=25 (41.67%) of them came for

admission 2 times, n=6 (10.00%) of them came for 3 times, n=2 (3.33%) of them

came for more than 3 times in one year.

When considering the exposure of type of media most n=33 (55.00%) of them

exposed to television, n=17 (28.33%) of them exposed to news paper, n=6 (10.00) of

them exposed to magazine, and remaining members n=4 (6.67%) of them exposed to

all type of media.

When considering the patients visits for follow-up most participants n=22

(36.67%) of them came for once in month, n=18 (30.00%), n=14 (23.33%) of them

came for only when needed, remaining of them n=6 (10.00%) came for once in week.

When considering the awareness about the life style modification among

cardiac patients most n=39 (65.0%) of them know about that, remaining members

n=21 (35.0%) do not know about the awareness of life style modification.

65
 50.00
45.00
45.00
40.00
35.00
Percentage

30.00
25.00
20.00
20.00 18.33
16.67
15.00
10.00
5.00
0.00
1-3 years 4-6 years 7-12 years ˃13years
Duration of illness

FIGURE-11 FREQUENCY AND PERCENTAGE DISTRIBUTION OF ILLNESS OF CARDIAC PATIENTS

66
 80.00

70.00

60.00

50.00
Percentage

76.67
40.00

30.00

20.00
23.33
10.00

0.00
Vegetarian Non-vegetarian
Type of diet

FIGURE-12 FREQUENCY AND PERCENTAGE DISTRIBUTION OF TYPE OF DIET CARDIAC PATIENTS

67
 35
35 30
28.33
30

25

20
Percentage

15

10 6.67

Habits

FIGURE-13 FREQUENCY AND PERCENTAGE DISTRIBUTION OF TYPE OF CARDIAC PATIENTS

68
 60

60
40
50

40
Percentage

30

20

10

0
Urban Rural
Type of habitat

FIGURE-14 FREQUENCY AND PERCENTAGE DISTRIBUTION OF TYPE OF HABITAT OF CARDIAC PATIENTS

69
 70

70

60

50
30
Percentage

40

30

20

10

0
Myocardial infarction Angina pectoris

Medical Diagnosis

FIGURE-15 FREQUENCY AND PERCENTAGE DISTRIBUTION OF MEDICAL DIAGNOSIS CARDIAC PATIENTS

70
 45 41.67
45
40
35
Percentage 30
25
20
10
15
3.33
10
5
0
One time 2 times 3 times More than 3
times

No of admissions in one year

FIGURE-16 FREQUENCY AND PERCENTAGE DISTRIBUTION OF NUMBER OF ADMISSIONS IN ONE YEAROF CARDIAC

PATIENTS

71
 60.00
55.00

50.00

40.00
Percentage

30.00 28.33

20.00

10.00
10.00 6.67

0.00
Television News paper Magazine All of the above

FIGURE-17 FREQUENCY AND PERCENTAGE DISTRIBUTION OF TYPE OF EXPOSURE TO MEDIA OF CARDIAC

PATIENTS.

72
 40.00 36.67

35.00 30.00
30.00
23.33
Respondents(%)
25.00
20.00
15.00 10.00
10.00
5.00
0.00
Once in a week Once in a month Once in 2 month As needed

Patients visits physicians for follow-up

FIGURE-18 FREQUENCY AND PERCENTAGE DISTRIBUTION OF PATIENTS VISITS FOR FOLLOW-UP OF CARDIAC

PATIENTS

73
 35%

65%
Yes
No

Awareness about lifestyle modification

FIGUR-19 FREQUENCY AND PERCENTAGE DISTRIBUTION OF AWARENESS ABOUT LIFE STYLE MODIFICATION

AMONG CARDIAC PATIENTS

74
 SECTION-B
TABLE -3
DISTRIBUTIONS OF RESPONDENTS ACCORDING TO THEIR
KNOWLEDGE LEVELS.

n=60

No of Respondents
Level of knowledge Score
No %

Inadequate > 50% 38 63.33

Moderate 50--75% 22 36.67

Adequate >75% 0 0.00

The above table depicts the knowledge of the respondents based on the test

score on life style modification for cardiac patients. Majority n=38 (63.33%) of the

respondents had inadequate knowledge on life style modification for cardiac patients.

n=22 (36.67%) of the respondents had average knowledge and only 0 percentage of

the respondents had adequate knowledge on the topic.

75
 63.33
70

60

50 36.67
Percentage
40

30

20
0
10

0
Inadequate Moderate Adequate
Level of knowledge

FIGURE 20 PERCENTAGE AND DISTRIBUTIONS OF RESPONDENTS ACCORDING TO THEIR KNOWLEDGE LEVELS.

76
 SECTION-C

TABLE -4

ASPECT WISE PRE INTERVENTIONAL KNOWLEDGE SCORE

n=60

Inadequate Moderate Adequate

Aspect wise knowledge (< 50%) (50--75%) (>75%)

No % No % No %

General knowledge 40 66.67 20 33.33 0 0.00

Life style modification 11 18.33 49 81.67 0 0.00

Dietary modification & weight loss 31 51.67 21 35.00 8 13.33

Exercise & stress management

32 53.33 14 23.33 14 23.33

Habits 25 41.67 27 45.00 8 13.33

Overall 38 63.33 22 36.67 0 0.00

The above table depicts the aspect wise pre interventional knowledge score of

the respondents based on the test score on general knowledge on cardiac problems in

that Majority n=40 (66.67%) of them respondents had inadequate knowledge

modification for cardiac patients. n=20 (33.33%) of the respondents had average

knowledge and only 0 percentage of the respondents had adequate knowledge on the

topic.

When considering the knowledge score on life style modification most of the

participants n=49 (81.67%) of them had moderate knowledge, n=11 (18.33%) of them

had inadequate knowledge, n=0 (0%) of them had adequate knowledge.

When considering the knowledge score on dietary modification & weight loss

most of the participants n=31 (51.67%) of them had inadequate knowledge, n=21

77
(35.00%) of them had moderate knowledge, n=8 (13.33%) of them had adequate

knowledge.

When considering the knowledge score on exercise & stress management most

of the participants n=32 (53.33%) of them had inadequate knowledge, n=14 (23.33%)

of them had moderate knowledge, n=14 (23.33%) of them had adequate knowledge.

When considering the knowledge score on habits most of the participants n=27

(45.00%) of them had moderate knowledge, n=25 (41.67%) of them had inadequate

knowledge, n=8 (13.33%) of them had adequate knowledge.

When considering the overall knowledge score on life style modification most

of the participants n=38 (63.33%) of them had inadequate knowledge, n=22 (36.67%)

of them had moderate knowledge, n=0 (0%) of them had adequate knowledge.

78
 Inadequate Moderate Adequate

100
81.67
66.67
80 63.33
53.33
51.67
Percentage

41.67
60 45 36.67
33.33 35 23.33
40 23.33
18.33 13.33 13.33
20
0 0 0
0

Aspects wise -Level of pre test knowledge

FIGURE- 21 FREQUENCY AND ASPECT WISE PRE INTERVENTIONAL KNOWLEDGE SCORE

79
 SECTION C
TABLE -5
NO OF RESPONDENTS OF POST INTERVENTIONAL KNOWLEDGE
SCORE

No of Respondents

Level of knowledge Score

No %

Inadequate > 50% 0 0.00

Moderate 50--75% 2 3.33

Adequate >75% 58 96.67

The above table depicts the number of respondents of post interventional

knowledge score on life style modification of cardiac patients. Majority n=58

(96.67%) of the respondents had adequate knowledge, n=2 (3.33%) of the respondents

had moderate knowledge and only 0 percentage of the respondents had inadequate

knowledge of life style modification after administration of self instructional module.

80
 96.67

100
90
80
70
Percentage

60
50
40
30
20 0 3.33
10
0
Inadequate Moderate Adequate
Level of knowledge

FIGURE 22 FREQUENCIES AND NO OF RESPONDENTS OF POST INTERVENTIONAL KNOWLEDGE SCORE

81
 TABLE -6

ASPECT WISE POST TEST INTERVENTIONAL KNOWLEDGE

SCORE

n=60
Inadequate (< Moderate (50-- Adequate
Aspect wise knowledge 50%) 75%) (>75%)
No % No % No %
General knowledge related to
heart disease 0 0 24 40 36 60
General information about Life
style modification 0 0 0 0 60 100
Knowledge related to dietary
modification & weight loss 4 6.7 13 21.7 43 71.7
Knowledge related to exercise
& stress management 0 0 3 5 57 95
Knowledge related to habits 0 0 5 8.3 55 91.7
Overall 0 0 2 3.3 58 96.7

The above table depicts the aspect wise post interventional knowledge score of

the respondents based on the test score on general knowledge on cardiac problems in

that Majority n=36 (60%) of them respondents had adequate knowledge and n=24

(40%) of the respondents had moderate knowledge and only 0 percentage of the

respondents had inadequate knowledge on the topic.

When considering the knowledge score on life style modification all of the

participants n=60 (100%) had adequate knowledge.

When considering the knowledge score on dietary modification & weight loss

most of the participants n=43 (71.7%) of them had adequate knowledge, n=13

82
(21.7%) of them had moderate knowledge, n=4 (6.7%) of them had adequate

knowledge.

When considering the knowledge score on exercise & stress management most

of the participants n=57 (95%) of them had adequate knowledge, n=3 (5%) of them

had moderate knowledge, n=0 of them had inadequate knowledge.

When considering the knowledge score on habits most of the participants

n=55 (91.7%) of them had adequate knowledge, n=5 (8.3%) of them had moderate

knowledge, n=0 of them had inadequate knowledge.

When considering the overall knowledge score on life style modification most

of the participants n=58 (96.7%) of them had adequate knowledge, n=2 (3.3%) of

them had moderate knowledge, n=0 (0%) of them had inadequate knowledge.

83
 Inadequate Moderate Adequate

95
100 91.7 96.7
100
71.7
80
Percentage 60
60
40
40 21.7
0 6.7 0 5 0 8.3 3.3
20
0 0 0
0

Aspects wise -Level of Post test knowledge

FIGURE 23 FREQUENCY AND ASPECT WISE POST TEST INTERVENTIONAL KNOWLEDGE

84
 SECTION-D

TABLE -7

COMPARISON BETWEEN PRE-TEST AND POST- TEST KNOWLEDGE

n=60

Pre test Post test

Level of knowledge
No % No %

Inadequate (<50%) 38 63.33 0 0

Moderate (50--75%) 22 36.67 2 3.33

Adequate (>75%) 0 0.0 58 96.67

Table reveals comparison of knowledge score between pre-test and post-test. When

considering pre test the number of participants n=38 (63.33%) of them had inadequate

knowledge, n=22 (36.67%) of them had moderate knowledge, n=0 of them had

adequate knowledge before administered self instructional module.

When considering post test knowledge score n=58 (96.67%) of them had

adequate knowledge, n=2 (3.33%) of them had moderate knowledge after

administered of self instructional module.

85
 96.67
100

90

80 63.33
70

60
Percentage

50 36.67
40

30

20 3.33
0
10 0
0
Inadequate Moderate Adequate

Level of knowledge - Pre and Post test

FIGURE 24 COMPARISONS BETWEEN PRE-TEST AND POST- TEST KNOWLEDGE SCORE

86
 TABLE-8
COMPARISON BETWEEN PRE AND POST TEST KNOWLEDGE SCORE
Comparison of mean, SD, and mean percentage for the knowledge variable
in the pre and post test.
n=60
Aspect wise Pre test Post test Enhancement
knowledge Mean SD Mean% Mean SD Mean% Mean SD Mean%
General knowledge
related to heart 1.81 1.04 30.27 4.71 0.8 78.5 2.9 1.13 48.3
disease
General information
about Life style 2.98 0.79 49.72 5.35 0.48 89.2 2.37 0.93 39.5
modification
Knowledge related to
dietary modification 2.56 0.85 51.33 4.18 1.12 83.6 1.62 1.04 32.4
& weight loss
Knowledge related to
exercise & stress 2.13 1.5 42.66 4.76 0.53 95.2 2.63 1.5 52.6
management
Knowledge related to
5.03 2.04 50.33 9.23 0.98 92.3 4.2 1.83 42
habits
Overall 14.53 2.25 45.41 28.25 1.84 88.3 13.72 2.29 42.9

Reveals the status of the patients improved regarding general information

about life style modification with the highest mean in post-test (5.35 plus or minus

0.48) mean=89.2% when compared with pre-test (2.98 plus or minus 0.79)

mean=49.72%.

The overall improvement with mean score was 28.25 plus or minus 1.84 and

mean percentage was M=88.3% in post-test for patients which was higher than the

overall mean score 14.53 plus or minus 2.25 and mean percentage was M=45.41% in

pre-test. Thus it indicates that there is an enhancement of knowledge among patients

about life style modifications.

87
 TABLE -9

COMPARISON OF MEAN, SD, AND MEAN PERCENTAGE FOR THE

KNOWLEDGE VARIABLE IN THE PRE AND POST TEST.

Evaluation of the effectiveness of SIM on Life Style Modification for maintaining

healthy heart among cardiac patients

n=60
Enhancement Paired 't'
Aspect wise knowledge
Mean SD Mean% test
General knowledge related to heart disease 2.9 1.13 48.3 19.87**
General information about Life style
modification 2.37 0.93 39.5 19.54**
Knowledge related to dietary modification &
weight loss 1.62 1.04 32.4 12**
Knowledge related to exercise & stress
management 2.63 1.5 52.6 13.34**
Knowledge related to habits 4.2 1.83 42 17.68**
Overall 13.72 2.29 42.9 46.38**
**Significant at P<0.01 level

Reveals that the overall improvement in mean score was 13.72, SD=2.29,

Mean percentage=42.9 with paired‘t’ value 46.38. The mean post-test knowledge

score was significantly higher than the mean pre-test knowledge scores of patients.

Effectiveness self instructional module was highly significant at the level of P < .001

level. Thus, the research hypothesis was accepted.

88
 TABLE-10

IMPROVEMENT OF MEAN SCORE OF KNOWLEDGE VARIABLES

BETWEEN PRE AND POST TEST.

Domain
Mean SD Mean% paired 't' test

Pre test
14.53 2.25 2.25

46.38**
Post test
28.25 1.84 88.3

NS= not significant. S= Significant, * p < 0.05 level, ** p < 0.01 level, ***

p < 0.001 level.

Depicts Mean, Standard deviation, mean percentage of aspect wise knowledge

for patients in pre-test and post-test.

Patients obtained the highest mean in knowledge of life style modification in

post-test (28.25 plus or minus 1.84) and mean percentage is 88.3 than compared with

pre-test (14.53 plus or minus 2.25) and mean percentage is 2.25.

89
 SECTION-E

TABLE-11

ASSOCIATION OF LEVEL OF KNOWLEDGE ON PATIENTS WITH

DEMOGRAPHIC VARIABLES

n=60
Level of Knowledge
< Median ≥Median Chi
S.No Demographic variables No %
(27) (33) square
No % No %
1 Age
a. 26 -35 years 9 15.00 5 18.5 4 12.1 4.32
b. 36 – 45 years 10 16.67 7 25.9 3 9.1 df 4
c. 46 – 55 years 26 43.33 10 37.0 16 48.5 N.S
d. 56 -65 years 8 13.33 3 11.1 5 15.2

e. 65 years and above 7 11.67 2 7.4 5 15.2

2 Gender
a. Male 37 61.67 21 77.8 16 48.5 5.4*
b. Female 23 38.33 6 22.2 17 51.5 df 1 S
3 Education
a. Non-literate 14 23.33 11 40.7 3 9.1 16.2*
b. Primary education 12 20.00 8 29.6 4 12.1 df 5
c. High school 13 21.67 4 14.8 9 27.3 S
d. PUC 10 16.67 2 7.4 8 24.2
e. Degree 7 11.67 2 7.4 5 15.2
f. Post Graduate 4 6.66 0 0.0 4 12.1
4 Occupation
a. Labourer 26 43.33 14 51.9 12 36.4 3.4

b. Government employee 10 16.66 2 7.4 8 24.2 df 4

c. Private employee 13 21.67 6 22.2 7 21.2 N.S

d. Business 4 6.67 2 7.4 2 6.1
e. Others 7 11.67 3 11.1 4 12.1
5 Religion
a. Hindu 36 60.0 11 40.7 25 75.8 8.4*
b. Christian 6 10.0 3 11.1 3 9.1 df 2
c. Muslim 18 30.0 13 48.1 5 15.2 S

d. Any other 0 0.0 0 0.0 0 0.0

90
6 Marital status
a. Married 56 93.33 25 92.6 31 93.9 0.04
b. Widow (er) 4 6.67 2 7.4 2 6.1 df 1 N.S
7 Type of family
a. Nuclear 37 61.67 12 44.4 25 75.8 6.1*
b. Joined 23 38.33 15 55.6 8 24.2 df 1 S

8 Monthly family income

a. More than Rs-5000 34 56.67 16 59.3 18 54.5 0.6

b. Rs.5001-10,000 17 28.33 8 29.6 9 27.3 df 2

c. ˃Rs.10,000-20,000 9 15.00 3 11.1 6 18.2 N.S

9 Duration of illness
a. 1-3 years 27 45.00 16 59.3 11 33.3 8.4*
b. 4-6 years 10 16.67 6 22.2 4 12.1 df 3
c. 7-12 years 11 18.33 3 11.1 8 24.2 S
d. ˃13years 12 20.00 2 7.4 10 30.3
10 Type of diet
a. Vegetarian 14 23.33 7 25.9 7 21.2 0.18
b. Non-vegetarian 46 76.67 20 74.1 26 78.8 df 1 N.S

11 Habits
a. Alcoholic 21 35.00 16 59.3 5 15.2 15.4*
b. Smoking/alcoholic
17 28.33 7 25.9 10 30.3 df 3

c. Tobacco chewing 18 30.00 4 14.8 14 42.4 S

d. No habits 4 6.67 0 0.0 4 12.1
12 Type of habitat
a. Urban 36 60.0 12 44.4 24 72.7 4.9*
b. Rural 24 40.0 15 55.6 9 27.3 df 1 S
13 Medical diagnosis
a. Myocardial infarction
42 70.0 16 59.3 26 78.8

b. Angina pectoris 18 30.0 11 40.7 7 21.2

91
 No. of admissions in one
14 year
a. One time 27 45.00 13 48.1 14 42.4 1.8
b. 2 times 25 41.67 11 40.7 14 42.4 df 3
c. 3 times 6 10.00 3 11.1 3 9.1 N.S
d. More than 3 times
2 3.33 0 0.0 2 6.1

15 Exposure to type of
media
a. Television 33 55.00 16 59.3 17 51.5 4.6
b. News paper 17 28.33 7 25.9 10 30.3 df 3
c. Magazine 6 10.00 4 14.8 2 6.1 N.S
d. All of the above 4 6.67 0 0.0 4 12.1
Patients visits physicians
16
for follow-up
a. Once in a week 6 10.00 3 11.1 3 9.1 4.97
b. Once in a month 22 36.67 13 48.1 9 27.3 df 3
c. Once in 2 month 18 30.00 8 29.6 10 30.3 N.S
d. As needed 14 23.33 3 11.1 11 33.3
Awareness about
17 lifestyle modification
a. Yes 39 65.0 12 44.4 27 81.8 9.1*
b. No 21 35.0 15 55.6 6 18.2 df 1 S
N.S- Not Significant, *S- Significant at P<0.05 level

Table-26 shows the association of demographic variables of patients with

knowledge score. it reveals that gender of the patients X2=5.4, education of the

patients X2=16.2, religion of the patients X2=8.4, type of family of patients X2=6.1,

duration of illness of patients X2=8.4, type of habits X2=15.4, type of habitat X2=4.9

and awareness of illness X2=9.1 has significant association with chi square test which

is highly significant at the level of P˂0.05.

92
 Other demographic variables like age of the patients, occupation of the

patients, marital status of the patients, monthly family income of the patients, type of

diet of the patients, number of admissions in one year, exposure to type of media and

patients visits physicians for follow-up showed no significant association with

knowledge of patients.

93
CHAPTER- V
DISCUSSION
 CHAPTER-V

DISCUSSION

The present study was conducted to evaluate the effectiveness of self

instructional module regarding Life Style Modification among patients those who are

admitted in selected hospital, at Madurai.

In order to achieve the objectives of the study, one group pre-test and post-

design with non-experimental design was adopted. The sample comprised of 60

patients. The data were collected from them before and after the administration of self

instructional module using a self administered questionnaire.

The findings of the study are discussed under the following sections:

Section A:

Findings related to demographic variables of patients.

Section B:

Distribution of Respondents according to their knowledge levels.

Section C:

Aspect wise pre interventional knowledge score

Section D:

Comparison between pre-test and post- test knowledge

Section E:

Association between knowledge score with selected demographic variables.

94
Findings related to demographic variables of patients.

Findings revealed that the highest 43.33% of belongs to 46 years to 55 years

of age, and followed by the age of 36-45 years, majority of the respondents were

Males 67% and 23 respondents (38.33%) were Female, 21.67% of the respondents

were educated up to high school, followed 20% of the respondents were educated up

to primary education,43% of the respondents were lobourer,60% of the participants

were hindu, 93.33% of the participants were married people, 61.67% of the

participants belongs to nuclear family type,56.67% of the respondents total family

income More than Rs-5000, 45% of the respondents had the duration of illness 1-3

years duration, 76.67% of participants were non- vegetarians,35% of them had

alcoholic, 30% of them had tobacco chewing, 60% of them belongs to urban area,

regarding the medical diagnosis 70.00% of them had myocardial infarction, 45% of

them admitted only one time in one year, 55% of them expose to media mainly

television only, 36% of them came once in month for visits, 65% of them know about

the awareness about life style modifications.

Objectives:

To assess the existing level of knowledge of patients regarding life style

modification of cardiac patients.

When considering the overall knowledge score on life style modification most

of the participants n=38 (63.33%) of them had inadequate knowledge, n=22 (36.67%)

of them had moderate knowledge, n=0 (0%) of them had adequate knowledge.

It was inferred that majority of patients admitted in selected hospital, at

Madurai overall there is a need for self instructional module to enhance knowledge on

life style modification for maintaining healthy heart among cardiac patients.

95
 To evaluate the effectiveness of the self instructional module

 Majority 96.67% of the respondents had adequate knowledge, on life style

modification after administration of self instructional module.

 To compare the pre and post-test knowledge score after self instructional module

 When comparing pre and post-test knowledge score after administered self

instructional module patients knowledge was improved from the 63% to 96%.

 To find out the association of level of knowledge with demographic variables.

 The association of demographic variables of patients with knowledge in chi

square score. it reveals that gender of the patients X2=5.4; education of the

patients X2=16.2; religion of the patients X2=8.4; type of family of patients

X2=6.1; duration of illness of patients X2=8.4; type of habits X2=15.4,;type of

habitat X2=4.9; and awareness of illness X2=9.1.

Therefore, it was inferred that the socio-demographic factors such as gender,

educational status, religion, types of family, type of habitat, duration of illness, type

of habit, and awareness about life style modification of the respondents shows there is

a significant association level of knowledge with demographic variables (P ˂ 0.05).

Other demographic variables like age of the patients, occupation of the patients,

marital status of the patients, monthly family income of the patients, type of diet of

the patients, number of admissions in one year, exposure to type of media and patients

visits physicians for follow-up showed no significant association with knowledge of

patients.

96
SUMMARY

This chapter deals with the analysis of findings of the data collected from 60

patients those who are admitted with cardiovascular disease in selected hospital, at

Madurai The data gathered were summarized in the master sheet and both descriptive

and inferential statistics were used for analysis. The discussions of the findings were

based on the study.

97
 CHAPTER- VI
SUMMARY AND

RECOMMENDATIONS
 CHAPTER-VI

SUMMARY AND REOMMENDATIONS

SUMMARY

This chapter gives a summary of the study salient features, implications and

recommendations of nursing practice, nursing education and nursing research also

given addition to the limitation of the study.

India has the highest burden of acute coronary syndromes in the world.

Several factors appear likely to have contributed to the acceleration of Coronary

artery disease epidemic in India. In the recent times these are demographic transition

to an older population as a result of increasing life expectancy, confluence of both

conventional risk factors like hypertension, diabetes, hypercholestroleaemia, smoking

etc owe their origin to growing urbanization and western “acculturation” amongst

Indians and Non-conventional risk factors like hyperinsulinemia, insulin resistance,

lipoprotein-A are determined genes. The gravity of this situation is emphasized by a

recent projection from the WHO and the Indian council of medical research (ICMR)

which predicts that India will be the MI capital of the world 2020.

Most of the patients having cardiac problems are unaware and has inadequate

knowledge regarding life style modification. So, this led the investigator for selecting

this study.

STATEMENT OF THE PROBLEM

“A study to assess the effectiveness of a Self Instructional Module on

knowledge regarding Life Style Modification for maintaining healthy heart among

cardiac patients in selected hospital at Madurai”.

98
OBJECTIVES

1. To assess the level of knowledge regarding the life style modification for

maintaining healthy heart among cardiac patients.

2. To develop and administer Self Instructional Module regarding the life style

modification like, dietary modification & weight loss, Regular physical

activity & stress management, and changing or modifying bat habits for

maintaining healthy heart among cardiac patients.

3. To evaluate the effectiveness of the Self Instructional Module regarding the

life style modification for maintaining healthy heart among cardiac patients.

4. To compare the pre-test and post-test knowledge score after the Self

Instructional Module.

5. To find the association between knowledge regarding the life style

modification for maintaining healthy heart among cardiac patients with

selected demographic characteristics like Age, Sex, Education, Occupation,

Marital status, type of family, Income, Duration of illness, Diet, Habits,

Number of admission in one year.

6. To find out the association between the mean differences of gain in knowledge

regarding the lifestyle modification program

HYPOTHESIS

 H1 – The mean post test knowledge score regarding the life style modification

for maintaining healthy heart among cardiac patients will be significantly higher than

the pre-test knowledge score.

 H2 – There will be significant association between the mean pre-test

knowledge score regarding the life style modification for maintaining healthy heart

among the cardiac patients and their selected demographic variables.

99
CONCEPTUAL FRAME WORK

The conceptual frame work adopted for the study was “Nola J Pender’s health

promotion model” of nursing and it provided the comprehensive framework for

achieving the objectives of the study.

Reviews of related literatures were done through the primary and secondary

sources which helped the investigator to collect ideas to support the selected research

problem, design, the methodology, conceptual framework and to develop the tool.

The investigator organized the review of literature under the following sections.

1. Literature related to incidence and prevalence of cardiovascular disease

2. Literature related to risk factors of cardiovascular disease

3. Literature related to life style modification

i. Literature related to diet and physical exercise for cardiac patients

ii. Literature related to habits (smoking alcohol and tobacco chewing)

iii. Literature related to stress

In the methodology, the investigator selected non experimental one group

pre test post test research design to assess the effectiveness of self instructional

module. The sample size was 60 and samples were selected by using probability

random sampling technique.

The tool used for data collection was self administered questionnaire and

which was used before and after the administration of self instructional module. The

tool consisted of 34 items divided under five aspects. Experts, five from medical,

three from medical, and one biostatistician validated the tool and the tool was found

to be reliable and feasible. The reliability of the tool was confirmed by test the ‘r’

value obtained was 0.91 which showed reliability.

100
 The pilot study was done prior to the main study and which was conducted

among 6 patients with cardiovascular disease admitted in Apollo Hospital at Madurai.

A period of two weeks was allotted for conducting the pilot study. After obtaining

formal permission from the head of the institution and informed consent from the

subjects, the study was conducted. The practicability and feasibility of the pilot study

enabled the investigator to proceed to the main study.

The main study was conducted among 60 patients with cardiovascular disease

in the ICU of “Apollo hospital”, Madurai, during specified four weeks periods. On the

first day, pre-test was conducted and followed by that self instructional module was

administered to them after 2 days of pre test. After 3 days, a post-test was conducted.

The collected data were analyzed and interpreted as per the objectives of the study by

using descriptive and inferential statistical methods after careful editing, coding the

data’s and was transferred to computer, then tabulating and decoding was done.

Major findings of the study were

Findings related to demographic variables of patients regarding life style

modification for cardiac patients.

i. Most of the mothers 43.33% were in the age group of 45-55 years.

ii. The majority of the patients 37 (61.67%) belongs to gender group male.

iii. Majority of the patients 13(21.67%) had up to high school education.

iv. Most of the mothers 46(76.7%) were house wives.

v. Majority of patients 26(43.33%) were lobourer

vi. Majority of patients 36(60%) were Hindus

vii. Majority of patients 56(93.33%) were married

viii. Majority of patients (60.61%) were nuclear family

ix. Majority of patients 34 (56.67%) income of more than Rs.5000

101
 x. Majority of patients 46(76.67%) were non vegetarians

xi. Most of the patients 21(35%) were alcoholic.

xii. Majority of patients 36(60%) were belongs to urban area.

xiii. Most of the patients 42(70%) had myocardial infarction.

xiv. Majority of the patients 27 (45%) were admitted only one time per year

xv. Most of the patients 33 (55%) exposed to media

xvi. Majority of patients 22 (36.67%) come for follow-up visits.

To assess the existing level of knowledge of patients regarding life style

modification of cardiac patients.

When considering the overall knowledge score on life style modification most

of the participants n=38 (63.33%) of them had inadequate knowledge, n=22 (36.67%)

of them had moderate knowledge, n=0 (0%) of them had adequate knowledge.

It was inferred that majority of patients admitted in Apollo hospital, at Madurai;

overall there is a need for self instructional module to enhance knowledge on life

style modification for maintaining healthy heart among cardiac patients.

• To evaluate the effectiveness of the self instructional module

Majority 96.67% of the respondents had adequate knowledge, on life style

modification after administration of self instructional module.

• To compare the pre and post-test knowledge score after self instructional

module

When comparing pre and post-test knowledge score after administered self

instructional module patients knowledge was improved from the 63% to 96%.

102
• To find out the association of level of knowledge with demographic

variables.

The association of demographic variables of patients with knowledge in chi

square score. it reveals that gender of the patients X2=5.4; education of the patients

X2=16.2; religion of the patients X2=8.4; type of family of patients X2=6.1; duration

of illness of patients X2=8.4; type of habits X2=15.4,;type of habitat X2=4.9; and

awareness of illness X2=9.1.

Therefore, it was inferred that the socio-demographic factors such as gender,

educational status, religion, types of family, type of habitat, duration of illness, type

of habit, and awareness about life style modification of the respondents shows there is

a significant association level of knowledge with demographic variables (P ˂ 0.05).

Other demographic variables like age of the patients, occupation of the

patients, marital status of the patients, monthly family income of the patients, type of

diet of the patients, number of admissions in one year, exposure to type of media and

patients visits physicians for follow-up showed no significant association with

knowledge of patients.

CONCLUSION

The aim of the “study to assess the effectiveness of Self Instructional module

on knowledge in on lifestyle modification among cardiac patients to maintain healthy

heart in selected hospital, at Madurai.”

The present study assesses the knowledge of patients regarding life style

modification for cardiac patients. The study concluded saying that there was

significant improvement in subject knowledge in the post-test after administration of

103
self instructional module. Thus, SIM was found effective in improving the knowledge

of patients regarding life style modification for cardiac patients. In the present study it

was also found that there is a significant association of knowledge level with selected

demographic variables such as age, gender, educational status, type of family type

habitat, type of deit, duration of illness.

Nursing Implications

The nurse’s role may be essentially unchanged or it may entail different duties

by possessing and practicing competencies making nurses better prepared to handle

all types of diseases. The investigator has drawn the following implications in the

field of nursing education, nursing service, nursing administration and nursing

research.

Nursing Practice

Nurses are key personnel of a health team, who play a major role in the health

promotion and maintenance. Nursing is a practicing profession so, the investigator,

generally integrates findings into practice.

1. Any form of education like continuing education, learning materials such as self

instructional booklet or self instructional module will enhance quick reference

and knowledge in practice.

2. Nurses can conduct teaching sessions for patients during their hospital stay and

during their visits to the hospital which will help in improving the knowledge of

nurses as well as the patients on knowledge of life style modification for cardiac

patients.

3. Nurses, being the key member of the health team have a vital role to play in

handling the situation with competencies at the site of caring, reducing and

managing the further risk factors of cardiac problems.

104
Nursing Administration

Staff development program in any organization is the prime responsibility of

the nurse administrator. In the era of development of advanced technology, demand

for quality and competent care, improved awareness on dignity of life, all poses a

challenge to nurse administrators to demonstrate their efficiency in providing

education to the patients with cardiac problems on life style modification.

1. The nurse administrator should assume leadership roles in training and

providing health education programmes to nursing professional, paramedical

staffs including grass root level workers in health care settings by making use

of media and audio visual aids.

2. Nurse administrator should facilitate funding to have adequate number of

books and journals in the library related to care of lifestyle modification.

Nursing Education

It emphasis that adequate knowledge owned by the nurses may help to update

themselves on the recent advancements, which in turn helps the nurses to give health

education for the patients on life style modification to follow prior instructions and

precautions in early identification and prevention of complications and also to

improve the health. In order to achieve this, the Diploma as well as Degree curriculum

should have adequate chapters on care and cure aspects of life style modification for

cardiac patients.

1. Student nurses should be provided awareness on various aspects of life style

modification for cardiac patients with complications which arise due to lack of

care.

105
 2. The student nurses from School of nursing and College of nursing should be

encouraged to attend for specialized courses and seminars regarding life style

modification for cardiac patients.

3. There must be adequate teaching strategies such as demonstration, simulation

exercises conducted to the students by making use of video films, computer

based teaching and learning on life style modification for cardiac patients.

4. Topics on life style modification can be included in continuing education

programmes for the student nurses.

Nursing Research

Nursing research is the means by which nursing profession is growing; more

research should be done related to life style modification in order to prevent the

complications and reduce the mortality and morbidity rate of cardiac problems.

Dissemination of findings through conference and professional journals will make

application of research findings to be effective.

1. There is a need for extensive and intensive research in this area so that strategies

for educating nurses and the patients on life style modification can be developed.

2. This study will serve as a valuable reference material for future investigators.

Limitations

1. The study is limited to the cardiac wards or ICUs or the selected hospital.

2. Patients who are admitted to cardiac wards or ICUs with cardiac problems like

myocardial infarction and angina pectoris.

3. Assessment is limited only to the patients who are having myocardial infarction,

angina pectoris.

106
 4. This study is limited to the patients with the CAD who are willing to participate

in the study.

5. Cardiac patients who all are can able to read & write English and Tamil

Recommendations

On the basis of the study that had been conducted, certain suggestions are given for

future studies.

1. Replication of this study can be done with larger samples in different settings to

validate and generalize the findings.

2. Similar study could be conducted on attitude and practice of patients regarding

life style modification.

3. The same study can be conducted with an experimental research approach

having a control group

4. A comparative study can be done to assess the effectiveness of care of patients

in home setting (out patient i.e., Cardiac Rehabilitation) and hospital setting

(inpatient).

5. Alternative teaching strategies like interactive learning sessions, structured

teaching programme etc can be conducted and evaluated.

107
 

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Indian Heart Journal.

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Prakasha; 2002

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modification

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24. Kader P. Nursing research: Principles, process and issues. 2nd Ed. New York:

Palgrave Macmillan; 2006

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Prakasha; 2002.

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the Causation of Cancer. N Engl J Med, Jul 13; 343(2):78-85. 2000.

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JE, ed. Prevention of myocardial infarction. New York: Oxford University

Press,1996:241–73

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Acute Coronary Syndrome are space in India.(2002)

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Lippincott; 1999.

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Philadelphia: J.B Lippincott Company; 2001

31. Perkins-Porras L 2006 Oct “Patients' beliefs about the causes of heart disease:

relationships with risk factors, sex and socio-economic status” ;13(5):724-30.

32. Pais P, Risk factors for acute myocardial infarction in Indians: a case-control

study. 1996 Aug 10;348(9024):358-63.

33. Ramraj MD et al (2008) “Indian Poverty and cardio vascular disease”, The

American Journal of Cardiology, vol I , Feb-2008,pages-102-106

34. Roy. A. “Impact of alcohol on coronary heart disease in Indian men”. 2010

Jun;210(2):531-

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35. Rastogi T Bidi and cigarette smoking and risk of acute myocardial infarction

among males in urban India. 2005 Oct;14(5):356-8.

36. Suchman EA. Evaluative research. New york: Russell sage foundation; 1967.

p.152

37. Steptoe A. et,al (2001) “The impact of behavioral counseling on stage of change

in fat intake, physical activity, and cigarette smoking in adults at increased risk of

coronary heart disease".

38. Singh et al (2002) studies on Cardiovascular Disease (CAD)

39. Stigler MH Weight-related concerns and weight-control behaviors among

overweight adolescents in Delhi, India: a cross-sectional study. 2011 Feb 7;8:9.

40. Saeed Omar, Gupta Vineet, Naveen Dhawan.et al Knowledge of modifiable risk

factors of Coronary Atherosclerotic Heart Disease (CASHD) among a sample in

India AIIMS study, Biomed central health and human rights, Feb, 2009 Vol:9

41. Udipi SAVariations in fat and fatty acid intakes of adult males from three regions

of India. 2006 Jul-Sep;50(3):179-86.

42. Viswanathan. M. et.al. “Prevalence of coronary artery disease and its relationship

to lipids in selected population in south India”. The Chennai Urban Population

Study (CUPS No. 5) journal of American Cardiology 2001, 38:682-87

43. World health organization, “The world health report 2002 Incidence, life Geneva;

World health organization; 2002.

44. Wryobeck JM Dec 2007Complexities of cocaine users presenting to the

emergency department with chest pain: interactions between depression

symptoms, alcohol use, and race. ;1(4):213-21.

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45. Xavier.D, Pais P et al. (2008) “Treatment and outcomes of acute coronary

syndromes in India (CREATE): a prospective analysis of registery data”, Lancet

Apr 26:37 (9622):1394

46. Yusuf Salim (2000) Acute Coronary Syndrome in young Indian Heart Journal.

39:682-87

47. Yusuf salim and Sonia .S. Anand et.al, (2000) “Difference in Risk Factors

atherosclerosis and cardiovascular disease between Ethinic groups in Cannada

Journal References:

 Abhinav Goyal, Salim Yusuf. The burden of cardiovascular disease in Indian

subcontinent. Indian Journal of Medical Research; 124:235-244. (s) ,2006.

 American journal of cardiology

 Indian journal of cardiology

 Nursing times sept, oct-2011, 2010

Net References:

www.cdc.gov/gshs/ accessed on 29/3/08. (s)

www.elsevier.com

www.google.com

www.hsph.harvard.edu/organizations/bdm/GBDseries_files/gbdsum6.pdf accessed on

29/3/2008. (s)

http://www/isc.ernet.in/currsci/apr102005/1052.pdf accessed on 29/3/08. (s)

http://indianheartjournal.com/2001-5/NovDec2002

www.medline.com

Newindpress.com, Diabetes Spreading in India, November 23, 2007

www.pubmed.com

112
APPENDICES
APPENDIX- I

i
 APPENDIX- II

CONTENT VALIDITY

From
Mr.Martin Daniel,
M.Sc Nursing IInd Year,
Sakthi College of Nursing.
Oddanchatram, Dindigul.

To
Respected Sir / madam,

Sub:-Requisition from expert opinion and content validity reg.

I am II year MSc Nursing student, studying in Sakthi College of Nursing
Oddanchattram, Dindigul under Tamilnadu Dr.MGR Medical University.
As a partial fulfillment of M.Sc Nursing Degree program, I am conducting a
research study “A study to assess the effectiveness of a self instructional module on
knowledge regarding life style modification for maintaining healthy heart among
cardiac patients in seleted hospital at madurai.
I am sending the research tool for content validity and request you to give your
expert and valuable review and opinion. I will be very thankful if you return at the
earliest. Here with I have enclosed the necessary documents.
Thanking you.

Yours Sincerely.
Date: 7-8-2015
( Mr.Martin Daniel)
Place : Oddanchatram

Enclosed:

Statement of the problem and objectives of the study.

Tool with blueprint and scoring key.

Brief note on the research Methodology and intervention tool.

Certificate of content validity.

ii
 APPENDIX -III

CERTIFICATE OF CONTENT VALIDITY

TO WHOM SOEVER IT MAY CONCERN

This is to certify that the tool prepared by Mr.Martin Daniel. P M.Sc(N) II

year student of Sakthi College of Nursing for the conduction of the study. “A study to

assess the effectiveness of a self instructional module on knowledge regarding

life style modification for maintaining healthy heart among ardiac patients

in selected hospital at madurai” is valid. He can proceed in conducting the data

collection with it.

Place:

Date: Signature

iii
 APPENDIX –IV

LIST OF EXPERTISE

1.Dr.Ramesh Babu Kesavan M.D

Apollo hospitals,

Madurai-62520.

2.Prof.janahi Devi,Msc(nsg)

Principal,

Sakthi College of Nursing,

Oddanchatram.

3.Prof.Dr.Radha.Msc(nsg)

Department of Medical Surgical Nursing,

Aruna college of nursing,

Vellore.

4.Asso.prof.Kalpana Msc(Nsg)

Department of Medical & Surgical Nursing,

Bishop’s College of Nursing,

Dharapuram.

5.Dr.Muthuramalingam, M.S ,

Subam Hospital,

Nagercoil.

K.K District.

iv
6.Dr.Bensam ,M.S, F.R.C.S,

Bensam hospital,

Nageroil,

K.K.Distrit.

7.Mr.mani Msc.Phil,

Statistiian,

Madurai.

v
 APPENDIX -V

CERTIFICATE FOR TAMIL EDITING

TO WHOM SOEVER IT MAY CONCERN

This is to certify that the dissertation fitted “A study to assess the

effectiveness of a self instructional module on knowledge life style

modification for maintaining healthy heart among cardiac patients in

selected hospital at Madurai.” By Mr.Martin Daniel. P M.Sc(N) II Year student

of Sakthi College of Nursing was edited for Tamil Language appropriateness by

Mr.V.Sakthivel, M.A,.B.Ed.,A.M.A., Vice Principal, Sakthi College of Arts and

Science.

vi
 APPENDIX -VI

CERTIFICATE FOR ENGLISH EDITING

TO WHOM SOEVER IT MAY CONCERN

This is to certify that the dissertation fitted “A study to assess the

effectiveness of a self instructional module on knowledge life style

modification for maintaining healthy heart among cardiac patients in

selected hospital at Madurai.” By Mr.Martin Daniel. P, M.Sc(N) II Year student

of Sakthi College of Nursing was edited for English Language appropriateness by

Ms.Sathiya, M.A.,M.Phil.,M.B.A., HOD of English Department, Sakthi College of

Arts and Science.

vii
 APPENDIX VII

TOOL FOR THE STUDY

Self –administered questionnaire to assess the knowledge of Life Style

Modification for maintaining healthy heart among cardiac patients in selected

hospitals at Madurai

INTRODUCTION:
The tool has two sections
Section A:
It consist of demographic data which gives base line information of the

patients with the CAD such as age, sex, religion, education, occupation, family

income, marital status, type of family etc.

Section B:

It consists of self-administered questionnaire to assess the knowledge

regarding the Life Style Modifications for maintaining healthy heart among cardiac

patients in selected hospitals at Bangalore.

It mainly consists of five parts

Part I: General knowledge related to heart disease

Part II: General information about Life style modification

Part III: Knowledge related to dietary modification & weight loss

Part IV: Knowledge related to exercise & stress management

Part V: Knowledge related to habits

viii
 SECTION- A

Demographic data

CODE NO:

1. Age

a) 26 years to 35 years

b) 36 years to 45 years

c) 46 years to 55 years

d) 56 years to 65 years

e) 65 years and above

2. Gender

a) Male

b) Female

3. Education

a) Non-Literate

b) Primary education

c) High school

d) PUC

e) Degree

f) Post Graduate & above

4. Occupation

a) labourer

b) Government employee

c) Private employee

d) Business

e) others

ix
5. Religion

a) Hindu

b) Christian

c) Muslim

d) Any other

6. Marital status

a) Married

b) Unmarried

c) Widow

d) Sep/divorced

7. Type of family

a) Nuclear

b) Joint

c) Extended

8. Monthly family income

a) Less than Rs-5000

b) Rs. 5001-10,000

c) Rs.10,000-20,000

d) More than Rs. 20,000

9. Duration of illness

a) 1-3 years

b) 4-6years

c) 7-12 years

d) 13-years & above

x
10. Type of diet

a) Vegetarian

b) Non-vegetarian

11. Habits

a) Alcoholic

b) Smoking

c) Tobacco chewing

d) No habits

12. Type of habitat

a) Urban

b) Rural

13. No. of admissions in one year

a) One time

b) 2 times

c) 3 times

d) More than 3 times

14. Exposure to type of media

a) Television

b) News paper

c) Magazine

d) Internet/health care provider

e) All of the above

xi
15. Patient visits physicians for follow-up

a) Once in a week

b) Once in a month

c) Once in 2 month

d) As needed

16. Awareness about lifestyle modification

a) Yes

b) No

17. Medical diagnosis

a) Myocardial infarction

b) Angina pectoris

xii
 SECTION-B

ASSESSMENT OF KNOWLEDGE ON LIFE STYLE MODIFICATION

AMONG CARDIAC PATIENTS IN SELECTED HOSPITAL AT

MADURAI

Part I: General knowledge related to heart disease

Part II: General information about Life style modification

Part III: Knowledge related to dietary modification & weight loss

Part IV: Knowledge related to exercise & stress management

Part V: Knowledge related to habits

PART-I

GENERAL KNOWLEDGE RELATED TO HEART DISEASE

1. What is mean by cardiovascular disease

a) Affects the heart, arteries & veins,

b) Affects the brain

c) Affects the kidney,

d) Affects the liver

2. Symptoms of heart diseases can include

a) Dizziness, weakness, arm pain, pressure in the chest.

b) Back pain, giddiness, sweating, fever

c) Nausea, vomiting, stomach pain

d) Leg pain, swelling in the leg

xiii
3. Risk for heart disease include

a) Low-cholesterol level

b) Peptic ulcer

c) Low blood sugar level

d) High Blood Pressure & High Cholesterol

4. What is mean by Myocardial Infarction

a) Heart failure

b) Heart attack

c) Brain aneurism

d) Peptic ulcer

5. Angina pectoris means

a) Fever

b) Vomiting

c) Pain

d) Head ache

xiv
 PART-II

GENERAL INFORMATION ABOUT LIFE STYLE

MODIFICATION

6. What are the life style modifications important for cardiac patient?

a) Tobacco chewing

b) Intake of fatty diet

c) Intake of alcohol

d) Diet and regular physical exercise

7. What are the benefits of life style modifications?

a) Reduce the risk factors of Tuberculosis (TB)

b) prevent ulcer and stomach cancer

c) Reduce the risk of cancer

d) It reduce the risk of further heart disease event

xv
 PART-III

PATIENTS KNOWLEDGE REGARDING DIETARY

MODIFICATION & WEIGHT LOSS

8. A healthy diet is important because

a) It maintain health

b) It prevent migraine

c) To reduce headache

d) To reduce stomach pain

9. What type of diet is good for cardiac patient?

a) Healthy diet

b) Solid diet

c) Low protein diet

d) Semi-solid diet

10. Which of the following oil is best for cardiac patients?

a) Ground nut oil

b) Pure ghee

c) Olive oil

d) Coconut oil

xvi
11. Egg yolk contains

a) 50-90 mg of cholesterol

b) 100-150 mg of cholesterol

c) 225-300 mg of cholesterol

d) 400-500 mg of cholesterol

12. Cardiac patients can consume

a) 1 egg per day

b) 2 egg per day

c) 4 egg per day

d) No egg should be consumed

13. The following items are rich in cholesterol

a) Meat & egg

b) Ghee & vanaspathi

c) Cereals & pulses

d) A&b

14. The heart healthy diet are

a) Fruits & Vegetables

b) Grains

c) Low fat or Non-fatty dairy products

d) Fish

e) Legumes

f) All of the above

xvii
15. The following food items can be permitted to cardiac patient

a) Fresh fruits & vegetables

b) Egg & meat

c) Fried chicken

d) Butter

16. Diet used for cardiac patients to reduce constipation & maintain Bp is

a) High-caloric diet

b) High-fiber & low-salt diet

c) High-sugar diet

d) High-salt diet

17. Benefits of weight loss

a) Increase the blood sugar level,

b) Lower the cholesterol level,

c) Reduced risk of gastritis

d) Reduce the risk of cancer

18. The weight of cardiac patients should be checked

a) Daily

b) Weekly

c) Monthly

d) Quarterly

xviii
 PART-IV

PATIENTS KNOWLEDGE REGARDING EXERCISE & STRESS

MANAGEMENT

19. Exercise is important for cardiac patients

a) It reduce the leg pain

b) It reduce the swelling

c) It improve the circulation

d) It increase the blood sugar level

20. The regular physical activity helps to

a) Prevent obesity

b) Reduce the swelling

c) Reduce stress

d) Reduce back pain

21. What are the exercises is needed for cardiac patients?

a) Over Muscle stretching

b) Heavy weight bearing exercises

c) Jogging, jumping, lifting heavy objects

d) Running, walking, climbing stairs

22. When the cardiac patients start to do exercise?

a) Either before or after work

b) After meals

c) Before dinner

d) After breakfast

xix
23. Which of the following activity should be avoided by cardiac patients?

a) Running

b) Regular physical activity

c) Irregular physical activity

d) Brisk walking

24. Cardiac patient should take rest

a) After meals

b) After exercise

c) After strenuous work

d) After dinner

25. Cardiac problems are common in

a) Over active people

b) Inactive & obese persons

c) Malnurised person

d) Poor people

26. The following techniques can reduce stress & emotion

a) Relaxation by listening music, reading magazine & exercise

b) Taking medication

c) Drinking alcohol

d) Smoking

27. Patients with cardiac problems should avoid the following situation

a) The work which creates mental agitation & tension

b) The situation which creates happiness

c) The situation which creates encouragement

d) Calm & quit environment

xx
 PART-V

PATIENTS KNOWLEDGE REGARDING HABITS

28. Cardiac patients should avoid the following habit

a) Smoking & tobacco chewing

b) Listening music

c) Reading magazine

d) Playing Games

29. Cardiac patients those who are addicted to alcohol should

a) Moderate the alcohol consumption

b) Completely stop alcohol consumption

c) Occasionally stop alcohol consumption

d) Can drink to tolerance

30. What are the benefits of moderate alcohol consumption?

a) Reduce your risk developing heart disease

b) Reduce your risk of dying of a HIV

c) Reduce your risk of cancer in uterus,

d) Reduce your ulcer

31. Which of the following alcohol drink should be avoided by cardiac patients?

a) Wine

b) Beer

c) Whisky

d) Fresh juice

xxi
32. How much alcohol is safe for cardiac patients?

a) 1 drink for male & 2 drink for female per day

b) 3 drink per day

c) 2 drink per day

d) 1 drink per day

33. Cardiac patients with smoking habits should

a) Completely stop smoking

b) Partially Stop smoking

c) Occasionally smoke

d) Can smoke to tolerance

34. What are the health benefits of quitting smoking?

a) Prolong your life

b) Reduce your risk of cardiovascular disease

c) Reduce your risk of developing a variety of other conditions

d) Improve your sense of taste & smell

e) All of the above

xxii
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¬)ã¨Ä¨Â ¾¡ìÌÅÐ
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¬)ÓÐÌÅÄ¢, ÁÂì¸õ,Å¢Â÷¨Å,¸¡öîºø
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xxvii
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7.Å¡ú쨸 Ó¨È Á¡üÈò¾¢ý ÀÄý¸û

«)¸¡º§¿¡Â¢ý ¸¡Ã½¢¸¨Ç ̨ÈôÀÐ
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xxviii
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16.þվ §¿¡Â¡Ç¢Â¢ý ¯½×¸û ÁÄîº¢ì¸¨Ä Ì¨Èì¸

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17.±¨¼į̀ÈôÀ¾ý ÀÄý
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18.±¨¼¨ÂÀ¡¢§º¡¾¨É ¦ºöЦ¸¡ûÇ §ÅñÎõ

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20.Ó¨ÈÂ¡É ¯¼üÀ¢üº¢ ¯¾×¸¢ýÈÐ

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25.þվ À¢Ãîº¨É ¦À¡ÐÅ¡¸

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þ)²ú¨Á ¿¢¨Ä
xxxii
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28.þվ §¿¡Â¡Ç¢¸û ±ó¾ ÀÆì¸ò¨¾ ¾¨¼ ¦ºöÂ
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xxxiii
30.ÁÐ «ÕóО¢ý ÀÄý ±ýÉ?
«)þվ §¿¡Â¢ý «È¢ÌÈ¢¨Â ̨ÈôÀÐ
¬)±öðŠ §¿¡¨Â ̨ÈôÀ¾üÌ
þ)¸÷ôÀô¨À ÒüÚ§¿¡¨Â ̨ÈôÀ¾üÌ
®)Å¢üÚôÒñ ̨ÈôÀ¾üÌ

31.±ó¾ Ũ¸Â¡É ¬ø¸†¡ø ¯ð¦¸¡ûÙŨ¾ ¾Å¢÷ì¸

§ÅñÎõ?
«)´Â¢ý
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þ)Å¢Š¸¢
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32.±ùÅÇ× ¬ø¸†¡ø ¿ÁÐ ¯¼õÀ¢üÌ À¡Ð¸¡ôÀ¡ÉÐ?

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33.þվ §¿¡Â¡Ç¢¸û ÁüÚõ Ò¨¸ôÀ¢ÊìÌõ ÀÆì¸õ

¯ûÇÅ÷¸û
«)ÓüÚÁ¡¸ Ò¨¸ À¢ÊôÀ¨¾ ¿¢ÚòÐÅÐ
¬)¾ü¸¡Ä¢¸Á¡¸ ¿¢ÚòÐÅÐ
þ)±ô¦À¡Ø¾¡ÅÐ Ò¨¸ À¢ÊôÀÐ

xxxiv
34.Ò¨¸ôÀ¢ÊôÀ¨¾ ¿¢ÚòО¡ø ²üÀ¼ìÜÊ ÀÄí¸û
±ýÉ?
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¬)þվ §¿¡¨Â ¾ÎôÀ¾üÌ
þ)þվ §¿¡ö ²üÀ¼ìÜÊ ¸¡Ã½¢¸¨Ç ¾ÎôÀ¾üÌ
®)Å¡º¨É ÁüÚõ Ѹ÷× ¯½÷¨Â «¾¢¸ôÀÎòÐÅÐ
¯)§ÁüÜȢ «¨ÉòÐõ

xxxv
 APPENDIX VIII

SCORE KEY

Item no. Correct response Score

1. A 1
2. A 1
3. D 1
4. B 1
5. C 1
6. D 1
7. D 1
8. A 1
9. A 1
10. C 1
11. C 1
12. D 1
13. D 1
14. F 1
15. A 1
16. B 1
17. B 1
18. B 1
19. C 1
20. A 1
21. A 1
22. A 1
23. C 1
24. C 1
25. B 1
26. A 1
27. A 1
28. A 1
29. A 1
30. A 1
31. C 1
32. A 1
33. A 1
34. E 1

xxxvi
SCORING PATTERN

Each Correct answer score - 1 Mark

Each Wrong answer score - 0 Mark

Minimum Score - 34 Mark

INFERENCE WILL BE DRAWN BELOW

Inadequate knowledge level = <50%

Moderately adequate knowledge level = 50%-75%

Well adequate knowledge level = 75%

xxxvii
 APPENDIX IX

CRITERION CHECKLIST FOR VALIDATING THE TOOL

Dear Sir/Madam,

Kindly go through the content and place right mark () against questionnaire

in the following columns ranging from relevant to not relevant. If the items need to be

modified, please give your valuable opinion in the remarks column.

Section-A: Demographic Data:

SI. Items Relevant Needs Not Remarks

No Modification Relevant
1.

2.

3.

4.

5.
6.

7.

8.

9.

10.
11.
12.
13.
14.
15.
16.

xxxviii
 SECTION-B
SELF ADMINISTERED QUESTIONNAIRE TOASSESS THE
KNOWLEDGE ON LIFE STYLE MODIFICATION AMONG CARDIAC
PATIENTS FOR MAINTAINING HEALTHY HEART

SI. Items Relevant Needs Not Remarks

No Modification Relevant
1.

2.

3.

4.

5.
6.

7.

8.

9.

10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.

xxxix
SI. Items Relevant Needs Not Remarks
No Modification Relevant
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.

xl
 Healthy diet is important to maintain health for heart •
patients.
Switch from whole-fat to low-fat or non-fat dairy
products.
CARDIO VASCULAR DISEAS
• Add more fiber to your diet (25 to 30 grams per • Limit intake of sweetened beverages. AND ITS PREVENTION
day) by eating raw vegetables and fruits, whole Monitor Your Health
grains and beans.
• Blood pressure
• Consume lean meats and poultry and remove the • Blood sugar levels
skin.
• Manage diabeti melatus.
• Consume less than 6 grams of salt per day.
• limit alchohol, and avoid wisky.
• Cut back on foods containing partially
• Weight should be checked weekly or if possible
hydrogenated vegetable oils or "trans fats," such as
daily.
hard margarine and shortening, and most baked
goods. • Body mass index (BMI)

• Use better Olive oil, canola oil, flaxseed oil, etc. • Cholesterol levels (Total, HDL, LDL and
triglycerides)
• Eat at least two servings of fish per week.
• Waist circumference — a man with a waist of
• Limit alcohol consumption to one drink per day for more than 40 inches or a woman with a waist of FOR BENEFICIARY OF SOCIETY
women and two drinks for men more than 35 inches are considered high-risk. PROCEEDING
• Stop smoking.. • Be physically active everyday, redue stress,
• Eat more vegitable and fruits. Rest and stress
BY
• Adequate sleep at night is important to heart
patients. MARTIN DANIEL P
• Take rest after strenuous work. M.Sc., NURSING IInd YEAR.
• Vegitables are cabbage, pumpkin, carrot, • Reduce the stress and emotions levels .
cauliflower, green beans, spinach,tomato etc. • Avoid tension and agitation.eg, hear music
yoga,read magazine etc. GUIDED BY,
• Fruits are orange, papaya,cherries, staw berries,
apple, pin apple, mango, grapes,banana, water
melon. Etc.
Asso.Prof.Mrs. Reena.
• High fiber and low salt diet helps to prevent Sakthi College of Nursing
constipation and maintain blood pressure.
Oddanchatram
• Eat some grain foods.
Dindugul Dit,
• Eat some legumes , sea food, egg,poultry &meat,
• Eat some oily foods, eg,tuna, kingh fish, salman.
Tamilnadu
• Eat some milk yogurt, fat reduced heese, nut, seeds
etc.
 • Sedentary lifestyle • Manage diabetes (diabetics are two to four times m
WHAT IS MEAN BY CARDIO VASCULAR • Smoking likely than non-diabetics to develop cardiovascu
DISEASE? Risk Factors You Might Not Know About By gender: disease)
• Males are at greater risk of heart attack than • Reduce blood cholesterol to less than 200 mg/dL
females and they have them earlier in life. • Reduce stress. stop smoking.
• Though their heart attack risk is lower, women are
twice as likely as men to die after a heart attack,
partly because they tend to be older when the
incident occurs.
By racial or ethnic group:
Heart disease is the nation's leading killer,It is • African-Americans, particularly females, have a
Modify Your Lifestyle
generally refers to condition that involve narrowed or greater risk of developing high blood pressure and
Life style modification helps to reduce furthe
blocked blood vessels that can lead to a heart cardiovascular disease than Caucasians.
heart disease.it is onsists proper diet and regula
attack,(myocardial infarction) chest pain (angina pectoris) • Indians have the fastest growing incidence of
exercise. exercise should be done either before or afte
which is affect the heart, arteries& veins. heart disease of any racial or ethnic group in the
work.
United States.
Exercise (Age 18 to 65)
• Asian-Americans are at increased risk of heart
• 30 minutes of moderate-intensity aerobic phys
disease, partly due to higher rates of obesity and
activity, such as brisk walking, five days a week.
diabetes.
• 20 minutes of vigorous aerobic activity, such
Know the Top 5 Heart Attack Warning Signs
jogging, three days a week.
• Chest discomfort, such as pain, pressure, squeezing
• Light exercise as part your daily routine. Take
or fullness in the center of your chest, lasting more
stairs, do yard work or walk around while on
than a few minutes or going away and then coming
phone.
back
• Swimming,muscle stretching exercise
• Discomfort elsewhere in the upper body, such as in
one or both arms, back, neck, jaw or stomach, • Avoid irregular physical activity. Regular phys
Know the Risk Factors
activity helps to prevent obesity and improve blo
The top risk factors for heart disease include: • Lightheadedness
circulation.
• Nausea
• Age 65 or older • Walking,and swimming are weight reducing exerc
• Shortness of breath
• Depression for cardiac patients.weight loss helps to decrease
Take Control of Your Health
• Diabetes cholesterol level.
To prevent a heart attack:
• Excessive drinking • Start to exercise before or after work.
• Eat a healthy diet
• Family history of heart disease Diet
• Engage in physical activity every day
• High blood pressure
• Limit alcohol
• High cholesterol
• Stop smoking.
• High stress
• Lower blood pressure to less than 120/80 mmHg
• Obesity
• Maintain a healthy weight
• Poor nutrition or dietary habits
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• fhŒf¿fŸK£il…nfhÞ,ór¡fhŒ bfhŸtJ.
• kJit… if…ÉLtJ
nf…u£, fhÈãst®, g¢ir…¥g£lhÂ
• òif…¥ão¥gij… ÃW¤JtJ
grÈ¡Ñiu…, j¡fhË.
PHOTO GRAPH
APPENDIX X

xli
xlii