EFFECTIVENESS OF NURSES-LED CARDIAC REHABILITATION PROGRAM AMONG CORONARY ARTERY DISEASE PATIENTS ATTENDING A TEACHING HOSPITAL, BHARATPUR

Background: Cardiac rehabilitation (CR) is a comprehensive secondary prevention program, delivered by multidisciplinary team including nurses. This portion in health care sector is found to be lacking and communication between health care providers and cardiac patients is frequently suboptimal. The aim of this study was to identify the effectiveness of nurse-led cardiac rehabilitation program among coronary artery disease patients attending a teaching hospital in Bharatpur, Nepal.


INTRODUCTION
Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with majority of deaths occurring in low to middle income countries including Nepal. 1 Among CVDs, Coronary artery disease (CAD) is the most common diagnosis. [2][3] Nurses ought to play a key role in the prevention of CAD 4 and have the responsibility to educate patients on several aspects of the disease. Self-educational module can be used to raise awareness about cardiac rehabilitation (CR) program. Being aware of the CAD can be considered the first step to reduce the risk of cardiac complications. 5 Nurse-led CR program designed to improve self-care management in patients with CAD showed significant difference in the physical dimension as well as in depression of CAD patients. 6 An inadequate understanding of the disease may cause noncompliance with medical advice and unnecessary disease progression 7 ; hence CAD knowledge is pivotal to the survival of patients. 8 As of yet, patients' knowledge on CR is found to be suboptimal. [9][10] Educational intervention program should be held as an effort to increase level of knowledge about the dis-ease. 11 In a recent study out of 600000 cardiac patients, 12.2% participated in a CR program. After 1 year, there was a 2.2% mortality rate for cardiac rehabilitation participant's vs 5.3% for non-participants. 12 Hence, knowledge regarding CR should be considered vital in determining the effectiveness of an educational program. Few studies have addressed this issue therefore this study aims to find-out effectiveness of nurse-led CR program among CAD patients attending a tertiary level hospital at Bharatpur, Nepal.

METHODS
A pre-experimental one group pretest posttest research design was applied for this research to examine effectiveness of nurse-led cardiac rehabilitation with 85 CAD (angina pectoris, myocardial infarction and ischemic heart failure) patients attending outdoor department of Chitwan Medical College and Teaching Hospital (CMC-TH), Bharatpur, Nepal. Non-probability, consecutive sampling technique was chosen for this study.
Inclusion criterias of this study were (1) patients who are clinically diagnosed with coronary Artery disease by cardiologist (2) residing in Chitwan district attending at OPD for follow up treatment at CMC-TH.
Data was collected by using structured tool consisting of four sections such as socio-demographic (total items-9) and disease related characteristics (total items-4), behaviour patterns (total items-6), and CADE-Q (total items-19). CADE-Q questionnaire for education on CAD, 13 which include four areas such as (1) pathophysiology and signs and symptoms of the disease; (2) risk factors and lifestyle; (3) diagnosis, treatment, and medication; and (4) physical exercise. Each item has 4 alternatives or statements that correspond to a knowledge level: a correct statement representing 'full knowledge', a correct statement representing 'incomplete knowledge', an incorrect statement representing 'wrong knowledge', and an 'I do not know' statement representing no knowledge. Each alternative is scored as follows: 3 = complete knowledge; 1 = incomplete knowledge; and 0 = wrong knowledge or "do not know." The sum of the final scores leads to a mean total knowledge (maximum of 57 points), which classifies into five level such as great (90-100%), good (70-89%), acceptable (50-69%), poor (30-49%), and insufficient (<30%) about knowledge about coronary disease and CR 5 The instrument was pretested and internal consistency of this tool was assessed using Cronbach ά (r= 0.82).
Data was collected in month of October to December, 2019 by using face to face interview method, it takes around 20 minutes to complete. Prior to data collection, the study was approved by the Institutional Review Committee (IRC) CMC-TH for the protection of human subjects. The participants were informed about the purpose of the study. In addition to this, they were also informed that responses would be kept confidential, and they would have the right to withdraw from the study at any time. Educational Package on cardiac rehabilitation (pamphlet) was developed based on AHA guideline and extensive literature search and distributed to the each respondent after pre-test data collection and after one month post-test was also collected from same sample to evaluate effectiveness of nurseled cardiac rehabilitation program.
Data was analyzed using statistical package for the social sciences (SPSS) version for window version 16.0. Descriptive (Percentage, frequency, mean and standard deviation) analysis also has been used to test and inferential statistic (Wilcoxon signed rank test) was used to find out effectiveness of educational package as well as pre and post test score difference of the respondents. Study sample of the participant are restricted by the classification level of knowledge in Ghisi et al. (2010) due to study design researchers had chosen. Therefore, to find a p-value the collapsing of range needed to be performed in order to classify the level of knowledge which was an acceptable (50-69%), good (70%-89%) and an excellent knowledge (90%-100%) has to be combined and considered as an acceptable knowledge (≥50%). For insufficient (<30%), and poor knowledge (30%-49%), these had been merged together and considered as non-acceptable knowledge with range <50%. The significance value was set at p<0.05. Table 1 shows that the majority of the respondents were older aged (43.5%), male (52.9%), resided in urban (64.7%), living single (50.6%), Brahmin/Chhetri (52.9%), Hindu (78.8%), nuclear family (57.6), literate (54.1), and housework (42.4).  Table 2 shows that the disease related characteristics of the respondents. Majority of them had been diagnosed with Angina pectoris (56.5%) and 1 year or above duration of treatment (56.5%). Similarly, common mode of treatment was CMT (52.9%), presence of HTN (68.2%), DM (40.0%) and high cholesterol (58.8%) as common comorbidities among CAD patients.  Table 3 shows that before and after behaviour patterns of respondents. Most of the respondents had smoking habit (before-56.5% and after 44.7%), tobacco use (before 48.2% and after 40.0%), and alcohol consumption (before 52.9% and after 45.9%), eat red meat (before 82.4% and after 69.4%), eat fatty substance (before 82.4% and after 65.9%) and sedentary life style (before 51.8% and 43.5%).   Table 5 shows the area of knowledge regarding CR among CAD patients. The highest mean percent score of knowledge area was found in A1 (physiopathology, signs and symptoms area) for both pre (50.4%) and post-test (69.4%) and all areas of knowledge (A1-A4) were increased in post-test than pretest mean score and mean percent. This clearly indicates that educational intervention has positive effects on four areas of knowledge on CR among CAD patients.  Possible range 0-3; *Using Wilcoxon signed rank test Table 6 reveals mean difference of 19 items of CADE-Q for pre and post-test. As given, pretest mean difference was found to be lower than post-test in each item, which is statistically significant at the level of p-value <0.005) by using Wilcoxon signed rank test. Table 7 shows the level of knowledge regarding CR among CAD patients. The level of knowledge classified into five as shown in table. The pre-test percentage on given knowledge illustrates higher proportion on Poor (52.9%) level of knowledge while in post-test higher proportion was on Good (45.9%). Similarly, in pretest majority of respondent had poor knowledge on cardiac rehabilitation. However, after receiving educational intervention program their level of knowledge regarding the CR improved. This finding was consistent with various other studies. 13,15 Moreover, a systematic review reported that cardiac rehabilitation program have shown to reduce risk factors, such as clinical and behaviour related intervention including physical, diet, and smoking habit. These core components of CR program intervention lead to improved knowledge score among CAD patient. 22 Due to use of only one group pre-test and post-test design the result of this study might have been affected by maturation and history effect. Likewise sampling might also have affected the result or conclusion of the study and cannot represent an entire population.

CONCLUSION
It is concluded that level of knowledge on cardiac rehabilitation among CAD patients in Nepal was found to be non-acceptable in pre-test however in the post test, level of knowledge of the CAD patient raised to an acceptable level after educational intervention. It is also reported that there is an improvement in the level of knowledge after an immediate post-test data from non-acceptable to an acceptable level of knowledge compared to pre-test data. Thus, we can conclude that the health education regarding CR is very crucial to increase the level of knowledge among CAD patients. Hence, every tertiary level hospital should have a nurse-led cardiac rehabilitation unit in their institution for a better prognosis and quality of life of patients suffering from CAD. Table 8 demonstrates the outcomes of comparison of nonacceptable and acceptable level of knowledge with pre and post-test score among study sample (n=85). There was statistically significance difference between pre and post-test score with level of knowledge in this study (p=<0.001). The non-acceptable knowledge during pre-test has declined in post-test whereas for an acceptable knowledge there was rise in posttest compared to pre-test score.

DISCUSSION
Findings of this study suggested that the educational intervention program was successful in bringing significant changes in the knowledge about cardiac rehabilitation in CAD patients. The result from this study was found to be consistent with other interventional studies. 13,[19][20][21][22][23] Regarding selected variables, majority were male, literate, continues medical treatment, hypertensive. These findings were similar to the findings of a study done in Brazil. 5 After diagnosis of disease they changed their behaviour patterns which was also consistent with a study done in India. 12 This study also reported that median score was improved in post-test than pre-test. The non-acceptable knowledge level during pre-test has declined in post-test whereas for an accept-