The Effect of Applying the Information- Motivation-Behavioral Skills Model on Treatment Adherence in Patients with Cardiovascular Disease: A Quasi-Experimental Study

Document Type : Original Article

Authors

1 Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran;

2 Department of Nursing, School of Nursing and Midwifery, Community Based Psychiatric Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

3 Clinical Education Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

Abstract

Background: Non-adherence complicates the management of patients with cardiovascular disease.
This study aimed to determine the effect of applying the information-motivation-behavioral skills
(IMB) model on the treatment adherence among these patients.
Methods: This quasi-experimental study was conducted on 112 patients with cardiovascular disease
in Nemazee and Al-zahra hospitals in Shiraz, Iran, from October 2019 to July 2020. Eligible patients
were selected and divided into intervention and control groups. The intervention was based on an
integration of IMB model constructs and included 10 motivational-educational sessions for three
months, followed by telephone consultations for six months. Data were collected before, and three and
six months after the end of the motivational-educational sessions using adherence questionnaire in
patients with chronic diseases, and adherence in chronic disease scale for medication adherence. Data
were analyzed using SPSS 22, and descriptive statistics, chi-square, independent t-test, and repeated
measure ANOVA were performed. p Results: The intervention and control groups were homogenous based on demographic characteristics.
Repeated measure ANOVA findings revealed an increasing trend in the mean scores of the intervention
group in treatment adherence from 51.10±3.20 at baseline to 66.40±5.50 three months and 73.80±6.80
six months after the end of the intervention (p <0.001). Furthermore, based on repeated measure
ANOVA findings, the mean score of the intervention group in medication adherence significantly
increased from 20.10+3 at baseline to 24.10+2.40 three months and 24.50+3.20 six months after the
end of the intervention (p <0.001).
Conclusion: Applying the IMB model promoted adherence to treatment and medication among patients
with cardiovascular disease. Therefore, such interventions are recommended for these patients.

Keywords


INTRODUCTION

Cardiovascular disease is highly prevalent worldwide. The disease had a prevalence of 523 million people in 2019 and accounted for 18.6 million deaths worldwide. 1 Evidence has indicated that more than 80% of cardiovascular disease mortalities occur in low- and middle-income countries. 2 In Iran, According to 2019 statistics, ischemic heart disease was the leading cause of death and the mortality rate in this disease was increasing, so that compared to 2009 this rate had increased by 29.90%. 3

Considering the chronic nature of cardiovascular disorders, patients are encountered with numerous problems in the long run. The prevalence of readmission was found to be 68.70% during the first year. 4 In Iran, the frequency of cardiovascular diseases readmission was 57%. 5 Non-adherence to treatment is one of the reasons for readmission in cardiovascular disease and poorer clinical outcomes, so that it has turned into a main challenge for medical and social sciences specialists. 6 On the other hand, improvement of adherence to treatment could promote the patients’ general health and quality of life, and their clinical outcomes. 7 In cardiovascular disorders, the prevalence of non-adherence to treatment was reported to vary from 40% to 60%. 8 , 9 In Iran, this value has been computed as 41%. 10 Evidence indicates the need to improve adherence among patients with cardiovascular disease. 6 , 7

Previous studies have investigated the effect of various interventions on medication adherence in patients with cardiovascular disease. Findings of a meta-analysis showed that providing information was an effective intervention to improve medication adherence among patients with cardiovascular disease. 11 Another review study showed that behavioral interventions had the greatest effects on the adherence to cardiovascular medicine in community settings. However, the information strategies showed to have no significant effects. 12 In addition, a review study revealed that behavioral multi-professional interventions could improve medication adherence; however, only a few studies with informational intervention directly investigated patient adherence, which did not show any significant effect on medication adherence. Therefore, it is suggested that the effectiveness of long-term multiple interventions on medication adherence in cardiovascular disease should be investigated. 12

Nurses have an important role in improving adherence to treatment and promoting the health of patients with cardiovascular disease. 13 To achieve the desired goals, nurses use knowledge rooted in nursing theories and models, 14 as well as knowledge derived from other disciplines as the basis of their research and practice. 15 One of the models used to improve adherence to treatment is the information-motivation-behavioral skills (IMB) model. The IMB model was a general social psychological conceptualization presented by Fisher and Fisher in 1992 to understand and improve the health behaviors. The assumption of the model is that the combination of three constructs including information, motivation and behavioral skills is the fundamental determinant of successful performance of health behaviors. According to the IMB model, information and motivation are often independent factors that primarily influence the adherence behavior through behavioral skills. 16 This model was first used for investigation of adherence to antiviral therapies in patients with human immunodeficiency virus, and its positive impacts on other chronic diseases including renal failure and diabetes were identified gradually. 17 - 19

The findings of a systematic review indicate that there is insufficient evidence for sustainability of behavioral changes after application of the IMB model for behavior change among patients with chronic disease, and further studies are needed to provide sufficient evidence in this regard. 20 In addition, an Iranian study which used IMB model in patients who had undergone coronary artery bypass graft indicated that while the model was effective on the patients’ information and motivation, there was no significant effect on behavioral skills. In the mentioned study, the intervention was a brief one-session intervention and its effect was evaluated after one month. However, the long-term effects of the intervention were not studied. 21 In addition, many studies on adherence to treatment in cardiovascular patients have considered only medication adherence. 22 - 24 Given that adherence to treatment in chronic diseases is a multidimensional and complex concept, 25 there should be a more comprehensive approach to adherence, so that other aspects beyond adherence to medication should be considered in studies in this field. Furthermore, although the IMB model has been used for determination of health behaviors for more than a decade, it has been applied less frequently among patients with cardiovascular disease. 21

Based on what was mentioned above, there is a need to study the effects of long-term interventions on the adherence to treatment, 12 and the need to a comprehensive approach toward the adherence to treatment has been identified. It has been proposed that the interventions based on models and theories were stronger and more influential in comparison to those that did not follow any specific framework. 26 , 27 However, there is a gap in the existing knowledge about the effectiveness of the models such as IMB on adherence to treatment in cardiovascular disease. Therefore, the present study aimed to determine the effect of applying the IMB model on the treatment adherence among the patients with cardiovascular disease.

METHODS

This quasi-experimental study with pretest-posttest control design was conducted from October 2019 to July 2020 in Nemazee and Al-Zahra Heart Hospitals, as two main centers for hospitalization of patients with cardiac disease. The study population included all patients with cardiovascular disease hospitalized in coronary care units. Based on a similar study performed on the issue, 28 considering α=0.05 and power=0.8, σ1=9.37, σ2=13.28, and d=6.9, a 90-patient sample size was estimated for the study. However, this measure was increased to 112 considering the loss rate.

Sample size formula:

n 1 = n 2 = ( Z 1 - α 2 + Z 1-β ) 2 ( σ 1 2 + σ 2 2 ) d 2

n 1 = n 2 = ( Z 0.975 + Z 0.8 ) 2 ( 9.37 + 13.28 ) 2 47.1 = 45

At the first, 112 eligible patients were selected and divided into intervention and control groups. The inclusion criteria of the study were age above 18 years, diagnosis of cardiovascular disease by a cardiologist, the ability to read and write, residence in Shiraz, lack of disabling ailments and cognitive disorders, and willingness to take part in the research. The exclusion criteria of the study were being absent in two or more intervention sessions, suffering from acute and unstable conditions, suffering chronic disorders unrelated to cardiovascular disease, and not responding to weekly telephone contacts.

Both the intervention and control groups received the standard care programs presented by the treatment team, including periodical visits, prescription of medications, and diagnostic follow-ups throughout the investigation. The control group did not receive any other intervention. However, the patients in the intervention group were required to take part in a program designed based on the IMB model. This program was developed based on scientific resources in this area. Then, according the components of the IMB model, the program content was allocated to educational, motivational, and behavioral interventions in form of blue print. Afterwards, the sessions were held with seven experts, including three cardiologists, one cardiac rehabilitation specialist, and three individuals with PhD degrees in nursing, who were required to give their opinions, which were applied to the intervention program.

The final program incorporated the interventions based on three constructs of IMB model including informational, motivational and behavioral interventions, which are presented in Table 1. The program lasted for nine months and consisted of 10 educational-motivational sessions held for three months followed by telephone follow-ups for six months (held weekly during the first three months and every other week during the second three months). It should be noted that five weekly educational-motivational sessions were held in-person (three group sessions and two individual two-hour sessions), while the five others were telephone sessions. In the group sessions which were held at the school of nursing and midwifery, training programs were presented in homogeneous groups of 9-10 patients with similar problems. The content was presented through lectures, group discussions, short movies, educational pamphlets, and face-to-face training. Individual face to face sessions were held at the two heart clinics and were designed on the basis of the patients’ specific needs. During telephone sessions, the researcher contacted the patients via telephone on a weekly basis. One of the researchers (the first author) who was a PhD candidate in nursing and was experienced in taking care of cardiac patients was responsible for the interventions and follow-ups.

Constructs Content presented during the study stages
Educational motivational sessions Telephone follow-ups
Informational intervention • Pathophysiology of cardiovascular disease and its risk factors • The informational content was reviewed during telephone sessions.
• Surgical therapies • The learned information were assessed.
• Nutrition • The benefits of applying home care advices were explained.
• Exercise and activity
• Smoking cessation • Patients’ ambiguities about the disease and treatment measures were assessed and resolved.
• Stress management
• Medication consumption and importance of adherence to treatment and risks of non-adherence
Motivational intervention • A two-hour motivational interview conducted in groups by a psychiatric nurse with MSc degree in order to enhance the patients’ motivation to change. • During the follow ups, patients’ values and attitudes were sought.
• The methods used for empowerment of motivation were applied in all training sessions included: • Patients’ positive attitudes towards adherence to treatment were reinforced.
o determining the patients’ motivations to change • Benefits of adherence and costs of non-adherence were discussed.
o encouraging the patient’s personal and social motivations to treatment adherence • Patients’ confidence to treatment program and their readiness to change were explored.
o encouraging patients’ self-reinforcement over time • The change program was planned with the help of the patient.
• The patients were guided through asking open questions, empathic listening, confirmation, and provision of feedback. • The techniques such as asking open-ended questions and active listening were applied during follow ups to improve patients’ motivation to adherence.
Behavioral interventions • Focused on the application of trainings in daily life • During the follow-up period, the researcher assessed the patients’ execution of the intervention program and recorded the information in notebooks which its contents emphasized the patients’ performance as well as their progress in adherence to the guidelines and home care.
• Specific techniques for integration of educational programs to daily activities were searched for each patient and emphasized • Patients’ improvements were reinforced and if needed changes in activities was recommended during follow ups.
• The patients’ adherence to the programs as well as their progress was explored • The patients’ problems in implementing the intervention program at home were investigated.
• Patients’ weak points were determined, and they were guided for better execution of the treatment program. • Appropriate solutions to the patients’ problems with the help of patients themselves were sought.
• The focus of the behavioral intervention was on the following areas:
o examining how to apply the recommendations at home
o how to control signs and symptoms (e.g. chest pain, dyspnea)
o performing daily activities
o the amount of exercise and activity and how to do it
o assessing the process of quitting smoking
o dietary management (asking the patient’s weekly diet)
o stress management
o patients’ using relaxation techniques
o taking medications and how to control their side effects
Table 1.Contents of the interventions based on three constructs of the information-motivation-behavioral skills model

The data were collected using a demographic information questionnaire, Adherence Questionnaire in Patients with Chronic Disease, 25 and a scale for medication adherence, i.e. Adherence in Chronic Disease Scale (ACDS). 29 Adherence Questionnaire in Patients with Chronic Disease was designed in the Iranian context by Sayyed Fatemi et al. and its psychometric properties were assessed in 2013. This questionnaire contained 40 items divided into seven dimensions, including making effort for treatment, intention to take the treatment, adaptability, integrating illness into life, sticking to treatment, commitment to treatment, and indecisiveness for applying treatment. The items could be responded via a five-point likert scale from completely disagree (1) to completely agree (5). The initial scores range from 40 to 200 that are converted to a range of zero to 100. Accordingly, scores 0-25, 26-49, 50-74, and 75-100 represented weak, moderate, good, and very good adherence to treatment, respectively. The content validity index (CVI) of the questionnaire was 0.91 and its reliability was confirmed by Cronbach’s alpha α=0.92. 25 This questionnaire has been used in another study in Iran. 10 In the present study, the content validity was reviewed by experts from nursing and medicine disciplines and the reliability of the tool was confirmed by Cronbach’s alpha α of 0.91.

ACDS was designed by Kubica et al. and contained seven items. The items were responded via a Likert scale from zero to four. As a result, the scores could range from zero to 28. Accordingly, scores below 20, between 21 and 26, and above 27 represented low, moderate, and high medication adherence, respectively. 29 This questionnaire was used in a study on adherence to treatment among patients with cardiovascular disease, and its reliability was confirmed by Cronbach’s alpha=0.75. 30 Since the reliability and validity of the Persian version of the questionnaire were not investigated before, translation, back-translation, and cultural adaptation were carried out in the present study. In order to determine the validity, qualitative face and content validity were determined. The results revealed content validity ratio of 0.89 and CVI of 0.94. Moreover, the reliability of the questionnaire was evaluated using the test-retest method and investigation of internal consistency. The results indicated intra-class correlation coefficient of 0.91 and α=0.85. The questionnaire was used after the confirmation of its psychometric properties.

The study data were gathered prior to the intervention in the wards where the patients were hospitalized. Three months after the end of the educational-motivational sessions, all patients in both intervention and control groups completed the questionnaires in the cardiovascular clinics when they had referred for medical visits. Before the intervention and three months after the end of the intervention, the data were collected using paper questionnaires. However, six months after the end of the educational-motivational sessions, due to the spread of the Coronavirus, the same questionnaires were designed electronically and the data were collected after providing the respondents with sufficient information about completing them. Furthermore, two patients in the control group were excluded due to death. Therefore, at the end of the study, the data of 110 patients (56 in the intervention group and 54 in the control group) were analyzed.

This study was approved by the Ethics Committee of the University (code: IR.SUMS.REC.1398.575) as well as by the hospitals’ authorities. It should also be mentioned that the study objectives were explained to the patients and their written informed consent forms were obtained. To encourage the patients to continue participation in the study, free transportation services were provided and intervention sessions were adjusted based on their free time.

The collected data were entered into the SPSS software, version 22. The variables were presented using descriptive statistics. Kolmogorov-Smirnov test showed normal distribution of treatment adherence (P=0.22) and medication adherence (P=0.13) data. Independent t-test was used to compare the two groups with respect to the means of quantitative variables. Besides, Chi-square test was employed to assess the relationship between the two qualitative variables. Moreover, repeated measure ANOVA was utilized in order to investigate the means of changes through the three stages of the intervention. To prevent the effect of time-group interaction on the findings, the data of treatment adherence and medication adherence were split according to the groups and repeated measure ANOVA was performed in each group separately. Therefore, the data within the group were reported separately and to compare between-groups data, independent t-test was used. Furthermore, Bonferroni post-hoc test was used to assess the changes in different stages of the research. Finally, Cohen’s d effect size for t-test was calculated for between-groups comparison of adherence to treatment and medication adherence mean scores.

RESULTS

The results indicated that the mean age of the patients was 58.8±10.8 years. In addition, the mean ages of the intervention (57.1±11.0) and control groups (60.6±10.5) were matched (P=0.08). The majority of the patients were male (70.5%) and married (93.8%) and had middle school degrees (37.5%) (Table 2). Prior to the intervention, no significant difference was observed between the two groups in terms of demographic data and various dimensions of adherence to treatment and medication adherence (Tables 2 and 3).

Groups Intervention Control P value*
Demographic characteristics N (%) (n=56) N (%) (n=56)
Sex 0.33
Male 41 (73.20) 38 (67.90)
Female 15 (26.80) 18 (32.10)
Marital status 0.13
Married 50 (89.30) 55 (98.20)
Single 6 (10.70) 1 (1.80)
Education 0.11
Primary School 12 (21.40) 14 (25)
Guidance School 16 (28.60) 26 (46.40)
High School 22 (39.30) 13 (23.20)
Academic Education 6 (10.70) 3 (5.40)
Smoking History 0.77
Cigar 17 (30.40) 15 (26.80)
Waterpipe 3 (5.40) 5 (8.90)
Opium 2 (3.60) 1 (1.80)
Opium & Cigar 4 (7.10) 2 (3.60)
None 30 (53.60) 33 (58.90)
Previous Admission History 0.11
Once 13 (23.20) 18 (32.10)
Twice 9 (16.10) 9 (16.10)
Three Times 8 (14.30) 1 (1.80)
More than Three 1 (1.80) 0 (0)
None 25 (44.60) 28 (50)
Duration of Illness 0.33
Less than 1 Year 10 (17.90) 8 (14.30)
1 Year 21 (37.50) 27 (48.20)
2 Years 10 (17.90) 14 (25)
2-5 Years 4 (7.10) 2 (3.60)
More than 5 Years 11 (19.50) 5 (8.90)
*Chi square
Table2.Comparison of frequency distribution of demographic and clinical variables between the intervention and control groups
Variable Time Intervention Group Control Group P value*
Mean±SD Mean±SD
Making effort for Treatment Pre intervention 22.60±2.10 22.80±2.80 0.70
3 Months after the intervention 31.10±2.80 24.60±3.10 0.018
6 Months after the intervention 33.90±4.30 23.80±6.40 <0.001
P value** <0.001 0.24
Intention to take the Treatment Pre intervention 18.40±2.10 18.50±1.70 0.76
3 Months after the intervention 23.80±2.60 19.30±1.80 <0.001
6 Months after the intervention 25.90±2.50 18.60±2.40 <0.001
P value** <0.001 0.10
Adaptability Pre intervention 18.60±2.40 18.20±2.30 0.32
3 Months after the intervention 23.50±2.40 18.90±2.80 <0.001
6 Months after the intervention 25.10±2.50 18.60±1.30 <0.001
P value** <0.001 0.30
Integrating illness into life Pre intervention 13.60±1.80 13.30±1.40 0.39
3 Months after the intervention 14.46±2.07 11.70±1.70 <0.001
6 Months after the intervention 18.48±1.91 11.50±1.20 <0.001
P value** <0.001 0.013
Sticking to Treatment Pre intervention 9.10±1.50 9.60±1.10 0.07
3 Months after the intervention 12.80±1.71 9.30±1.10 <0.001
6 Months after the intervention 14.50±2.10 9.60±1.60 <0.001
P value** 0.001 0.26
Commitment to Treatment Pre intervention 12.60±1.90 12.10±1.70 0.14
3 Months after the intervention 16.60±1.60 12.70±1.20 <0.001
6 Months after the intervention 18.10±2.20 12.37±1.30 <0.001
P value** <0.001 0.08
Indecisiveness for applying Treatment Pre intervention 7.10±1.30 6.80±1.30 0.16
3 Months after the intervention 10.20±1.20 6.80±1.10 0.001
6 Months after the intervention 10.70±1.10 6.40±1.10 <0.001
P value** <0.001 0.06
Total Score of Treatment Adherencea Pre intervention 51.10±3.20 50.60±3.30 0.50
3 Months after the intervention 66.40±5.50 51.90±3.80 <0.001
6 Months after the intervention 73.80±6.80 52.40±6.10 <0.001
P value** <0.001 0.12
Medication Adherence Pre intervention 20.10±3 19.20±4.20 0.16
3 Months after the intervention 24.10±2.40 22.20±2.80 <0.001
6 Months after the intervention 24.50±3.20 19.60±1.70 <0.001
P value** <0.001) 0.23
*Independent sample t-test; **Repeated measure ANOVA; aTotal score of treatment adherence converted to a range of zero to 100.
Table3.Comparison of treatment adherence before and after the end of the intervention within and between groups

The results of independent t-test revealed significantly higher total score of treatment adherence in the intervention group compared to the control group three and six months after the end of the intervention (P<0.001). Additionally, the mean score of medication adherence in the intervention group was significantly higher than the control group three and six months after the end of the intervention (P<0.001) (Table 3).

Repeated measure ANOVA findings revealed an increasing trend in the total mean scores of treatment adherence in the intervention group from 51.10±3.20 at baseline to 66.40±5.50 three months and 73.80±6.80 six months after the end of the intervention (P<0.001) (Table 3). The results of Bonferroni post-hoc test showed a significant difference between the mean scores at baseline and three months after the end of the intervention, those at baseline and six months after the end of the intervention, and those three and six months after the end of the intervention (P<0.001).

The results of repeated measure ANOVA indicated that in the control group, the total mean score of adherence to treatment was 50.60+3.30 before the intervention, which increased to 51.90+3.80 three months and 52.40+6.10 six months after the end of the intervention (P=0.12) (Table 3). The results of Bonferroni post-hoc test revealed no significant change in the overall score of adherence to treatment in the control group three months (P=0.25) and six months after the end of the intervention (P=0.24) in comparison to the baseline. However, based on Bonferroni post-hoc findings, improvement was observed in several dimensions of adherence, including making effort for treatment (P=0.01), intention to take the treatment (P=0.004), and adaptability (P<0.001), in the control group three months after the end of the intervention compared to the baseline.

Based on repeated measure ANOVA findings, the mean score of medication adherence in the intervention group significantly increased three months (24.10±2.40) and six months (24.50±3.20) after the end of the intervention compared to the baseline (20.10±3) (Table 3). The results of Bonferroni post-hoc test revealed a significant difference between the mean scores of medication adherence in the intervention group at baseline and three and six months after the end of the intervention (P<0.001). However, no significant difference was observed between the mean scores obtained three and six months after the end of the intervention (P=0.17).

Based on repeated measure ANOVA findings, in the control group, the mean score of medication adherence was 19.20±4.20 before the intervention, which increased to 22.20±2.80 three months after the end of the intervention and decreased to 19.60±1.70 six months after the end of the intervention (P=0.23) (Table 3). The results of Bonferroni post-hoc test demonstrated a significant difference between the mean scores of medication adherence in the control group before the intervention and three months after the end of the intervention (P<0.001). However, a significant decline was observed in the mean score of the control group six months after the end of the intervention compared to three months after the end of the intervention (P=0.004). A non-significant difference was also observed between the mean scores obtained prior to the intervention and six months after the end of the intervention (P=0.31).

DISCUSSION

The results indicated that applying the IMB model could improve the adherence to treatment among the patients with cardiovascular disease. The results revealed a significantly ascending trend in the mean scores of all dimensions of treatment adherence and medication adherence in the intervention group three and six months after the end of the intervention. Additionally, the effect size of the between-group comparisons indicated the clinical significance of the findings. Similarly, the results of a systematic review showed the positive effects of the interventions based on the IMB model on promotion of adherence to treatment among patients with chronic diseases. 20 Additionally, a research in South Korea indicated the effectiveness of this model in improvement of adherence to treatment among patients with type II diabetes during a three-month period. 31 Nonetheless, the studies conducted on the application of the IMB model in patients with cardiovascular disease revealed the effectiveness of this model on the knowledge and motivation for adherence to treatment, but not on the behavioral skills, 21 , 28 which was not consistent with the results of the present investigation. In this study, ascending trend in all dimensions of treatment adherence in the intervention group indicated an improvement in the patients’ performance. The difference between the results might be attributed to the design of the intervention in the current study. This study benefitted from a larger number of training sessions carried out for a longer time. Moreover, consultation follow-ups were continued for six months, which could play a pivotal role in promotion of the patients’ behavioral skills. This implies that in order to achieve a high adherence, trainings have to be continued in the long run. 32 It is necessary to note that understanding and recognizing the disease plays an important role in increasing adherence to treatment. 8 In addition, promoting the patients’ motivation is recognized as a necessary factor in treatment adherence. 33 In the present study, motivational educational content presented through establishing effective communication, strengthening and facilitating the care processes and feedbacks could be effective in promoting adherence to treatment among the patients. It is suggested that a good relationship between the patients and healthcare providers can improve adherence to treatment after discharge from the hospital. 34 Evidence has also confirmed the effectiveness of social supports on the part of the nurses and physicians in promotion of adherence to treatment after percutaneous coronary intervention. 34 Of course, the importance of the integration of informational, motivational and behavioral interventions in achieving the desired outcomes should not be overlooked. The findings demonstrate the long-term effectiveness of IMB model on adherence to treatment and medication among patients with cardiovascular disease. However, the existence of the IMB model does not eliminate the need for specific nursing models in improving treatment adherence in cardiovascular disease, and it is necessary for nurses to design nursing models in this field.

In the present study, significant positive changes were observed in some dimensions of adherence to treatment as well as in medication adherence in the control group three months after the end of the intervention. However, these changes were non-significant six months after the end of the intervention, and a significant decline was observed in some dimensions like ‘integrating illness to life’. It seems that patients make their best attempts to coordinate their treatments with their living conditions during the first days and weeks after discharge. Furthermore, they are more inclined to carry out more understandable therapeutic measures as well as those that are in line with their financial status. However, they tend to make less effort as time goes by. Acute condition after discharge is yet another factor that can affect drug consumption. In other words, medication adherence tends to decrease with the improvement in the patients’ condition. 35 In this respect, the World Health Organization announced that adherence to treatment was higher in patients with acute disorders compared to chronic disorders, but it was abandoned after six months. 30 For instance, adherence in patients with cardiovascular disease was high percentage immediately after discharge from the hospital, 36 while the consumption of statins was disrupted in forty to seventy five percent of the patients after six months. 37

In the present study, adherence to treatment at the time of hospitalization was low in both study grous. Previous studies have reported that the rate of adherence varies in chronic disorders like cardiovascular diseases. 9 Most of the patients in this study were older adults. Adherence to treatment in older people is lower than younger population. This is related to such factors as decreased abilities, dependence on others, and poor management of treatment due to physical problems. 38 , 39 Considering the fact that weak adherence to treatment and medications consumption can be accompanied by intensification of the symptoms and readmission, 40 this issue should be taken into account seriously among the patients with cardiac diseases. Hence, further studies are recommended to be conducted on improvement of adherence to treatment and prevention of complications and readmission.

In comparison to other studies conducted on the issue, the current study benefitted from several positive points. The first strong point of the study was the intervention. In fact, the interventions were designed by a coherent pattern on the basis of the patients’ needs for ten sessions. Another strong point of the research was the six-month follow-up in the intervention group, which was carried out weekly during the first three months and every other week within the second three months. Finally, yet importantly, various instruments were used for data collection in order to obtain more reliable results. As mentioned earlier, adherence questionnaire in patients with chronic disease and ACDS, which has been designed in the Iranian context, was utilized in this study. However, the study had some limitations, as well. The first study limitation was the fact that blinding was not possible due to the nature of the intervention because the patients were aware of their study groups. Another study limitation was the obligation to use online questionnaires six months after the end of the intervention due to the spread of the Coronavirus. Finally, although we excluded the individuals with chronic disorders unrelated to cardiovascular disease, we did not consider the number of medications that may affect their medication adherence.

CONCLUSION

The findings demonstrated that applying the IMB model could improve the adherence to treatment and medication among the patients with cardiovascular disease. Therefore, nurses can play an important role in improving the patients’ treatment adherence through continuous training and follow ups, motivating patients, facilitating the care processes, and providing feedbacks. Providing these services requires constant nurse-patient communication which is possible in specialized community-based nursing clinics or through home nursing programs. Additionally, we recommend that nurse researchers investigate the effect of such interventions on the treatment adherence in other areas of community based nursing. In addition, there is a need for developing models specific to nursing explaining treatment adherence in cardiovascular disease.

References

  1. Roth GA, Mensah GA, Johnson CO, et al. Global burden of cardiovascular diseases and risk factors, 1990-2019: update from the GBD 2019 study. Journal of the American College of Cardiology. 2020; 76:2982-3021.
  2. Bowry ADK, Lewey J, Dugani SB, Choudhry NK. The burden of cardiovascular disease in low-and middle-income countries: epidemiology and management. Canadian Journal of Cardiology. 2015; 31:1151-9.
  3. Institute for Health Metrics and Evaluation. Measuring what Matters: Iran (Islamic Republic of). US: University of Washington; 2021. [Cited 2 April 2021]. Available from: http://www.healthdata.org/iran.
  4. Oliveira LMSMd, Costa IMNBdC, Silva DGd, et al. Readmission of Patients with Acute Coronary Syndrome and Determinants. Arquivos Brasileiros de Cardiologia. 2019; 113:42-9.
  5. Heydari A, Ziaee ES, Ebrahimzade S. The frequency of rehospitalization and its contributing factors in patient with cardiovascular diseases hospitalized in selected hospitals in Mashhad in 2010. The Horizon of Medical Sciences. 2011; 17:65-71.
  6. Zhang Y, Kaplan CM, Baik SH, et al. Medication adherence and readmission after myocardial infarction in the Medicare population. The American Journal of Managed Care. 2014; 20:e498-505.
  7. Souza ACCd, Borges JWP, Moreira TMM. Quality of life and treatment adherence in hypertensive patients: systematic review with meta-analysis. Revista de Saude Publica. 2016; 50:71.
  8. Holmes EAF, Hughes DA, Morrison VL. Predicting adherence to medications using health psychology theories: a systematic review of 20 years of empirical research. Value in Health. 2014; 17:863-76.
  9. Mondesir FL, Carson AP, Durant RW, et al. Association of functional and structural social support with medication adherence among individuals treated for coronary heart disease risk factors: Findings from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. PLoS One. 2018; 13:e0198578.
  10. Poshtchaman Z, Jadid Milani M, Atashzadeh Shoorideh F, Akbarzadeh Bagheban A. The effect of two ways of using the phone and SMS follow-up care on treatment adherence in Coronary Artery Bypass Graft patients. Iranian Journal of Cardiovascular Nursing. 2014; 3:6-14.
  11. Chase JAD, Bogener JL, Ruppar TM, Conn VS. The effectiveness of medication adherence interventions among patients with coronary artery disease: a meta-analysis. The Journal of Cardiovascular Nursing. 2016; 31:357-66.
  12. Van Dalem J, Krass I, Aslani P. Interventions promoting adherence to cardiovascular medicines. International Journal of Clinical Pharmacy. 2012; 34:295-311.
  13. Hayman LL, Berra K, Fletcher BJ, Houston Miller N. The role of nurses in promoting cardiovascular health worldwide: the global cardiovascular nursing leadership forum. Journal of the American College of Cardiology. 2015; 66:864-6.
  14. Khademian Z, Kazemi Ara F, Gholamzadeh S. The Effect of Self Care Education Based on Orem’s Nursing Theory on Quality of Life and Self-Efficacy in Patients with Hypertension: A Quasi-Experimental Study. International Journal of Community Based Nursing and Midwifery. 2020; 8:140-9.
  15. Theofanidis D, Fountouki A. Nursing theory: A discussion on an ambiguous concept. International Journal of Caring Sciences. 2008; 1:15-20.
  16. Fisher WA, Fisher JD. A general social psychological model for changing AIDS risk behavior. In: Pryor JB, Reeder GD, eds. The social psychology of HIV infection. Lawrence Erlbaum Associates: Mahwah (US); 1993.
  17. Fisher WA, Fisher JD, Harman J. The information-motivation-behavioral skills model: A general social psychological approach to understanding and promoting health behavior. In: Suls J, Wallston KA, eds. Social Psychological Foundations of Health and Illness. Blackwell Publishing Ltd: US; 2003.
  18. Chang TY, Zhang YL, Shan Y, et al. A study on the information–motivation–behavioural skills model among Chinese adults with peritoneal dialysis. Journal of Clinical Nursing. 2018; 27:1884-90.
  19. Mayberry LS, Osborn CY. Empirical validation of the information–motivation–behavioral skills model of diabetes medication adherence: a framework for intervention. Diabetes Care. 2014; 37:1246-53.
  20. Chang SJ, Choi S, Kim SA, Song M. Intervention strategies based on information-motivation-behavioral skills model for health behavior change: a systematic review. Asian Nursing Research. 2014; 8:172-81.
  21. Zarani F, Besharat MA, Sarami G, Sadeghian S. An information–motivation–behavioral skills (IMB) model-based intervention for CABG patients. International Journal of Behavioral Medicine. 2012; 19:543-9.
  22. Leslie KH, McCowan C, Pell JP. Adherence to cardiovascular medication: a review of systematic reviews. Journal of Public Health. 2019; 41:e84-94.
  23. Al‐Ganmi AH, Perry L, Gholizadeh L, Alotaibi AM. Cardiovascular medication adherence among patients with cardiac disease: a systematic review. Journal of Advanced Nursing. 2016; 72:3001-14.
  24. Ni Z, Dardas L, Wu B, Shaw R. Cardioprotective medication adherence among patients with coronary heart disease in China: a systematic review. Heart Asia. 2019; 11:e011173.
  25. Seyed Fatemi N, Rafii F, Hajizadeh E, Modanloo M. Psychometric properties of the adherence questionnaire in patients with chronic disease: A mix method study. Koomesh. 2018; 20:179-91.
  26. Glanz K, Rimer BK, Viswanath K. Health behavior: Theory, research, and practice. Jossey-Bass: San Francisco (US); 2015.
  27. Khademian F, Aslani A, Bastani P. The effects of mobile apps on stress, anxiety, and depression: overview of systematic reviews. International Journal of Technology Assessment in Health Care. 2020; 37:e4.
  28. Zarani F, Besharat MA, Sadeghian S, Sarami G. The effectiveness of the information-motivation-behavioral skills model in promoting adherence in CABG patients. Journal of Health Psychology. 2010; 15:828-37.
  29. Kubica A, Kosobucka A, Michalski P, et al. The Adherence in Chronic Diseases Scale - a new tool to monitor implementation of a treatment plan. Folia Cardiologica. 2017; 12:19-26.
  30. Kosobucka A, Michalski P, Pietrzykowski Ł, et al. Adherence to treatment assessed with the Adherence in Chronic Diseases Scale in patients after myocardial infarction. Patient Preference and Adherence. 2018; 12:333-40.
  31. Liu T, Wu D, Wang J, et al. Testing the information-motivation-behavioural skills model of diabetes self-management among Chinese adults with type 2 diabetes: a protocol of a 3-month follow-up study. BMJ Open. 2018; 8:e020894.
  32. El-Toukhy H, Omar A, Abou Samra M. Effect of acute coronary syndrome patients’ education on adherence to dual antiplatelet therapy. Journal of the Saudi Heart Association. 2017; 29:252-8.
  33. Zhou Y, Liao J, Feng F, et al. Effects of a nurse-led phone follow-up education program based on the self-efficacy among patients with cardiovascular disease. Journal of Cardiovascular Nursing. 2018; 33:E15-23.
  34. Shin ES, Hwang SY, Jeong MH, Lee ES. Relationships of factors affecting self-care compliance in acute coronary syndrome patients following percutaneous coronary intervention. Asian Nursing Research. 2013; 7:205-11.
  35. Aggarwal B, Liao M, Allegrante JP, Mosca L. Low social support level is associated with non-adherence to diet at 1 year in the Family Intervention Trial for Heart Health (FIT Heart). Journal of Nutrition Education and Behavior. 2010; 42:380-8.
  36. Lu J, Zhang L, Lu Y, et al. Secondary prevention of cardiovascular disease in China. Heart. 2020; 106:1349-56.
  37. Banach M, Stulc T, Dent R, Toth PP. Statin non-adherence and residual cardiovascular risk: there is need for substantial improvement. International Journal of Cardiology. 2016; 225:184-96.
  38. Khatib R, Marshall K, Silcock J, et al. Adherence to coronary artery disease secondary prevention medicines: exploring modifiable barriers. Open Heart. 2019; 6:e000997.
  39. Yap AF, Thirumoorthy T, Kwan YH. Medication adherence in the elderly. Journal of Clinical Gerontology and Geriatrics. 2016; 7:64-7.
  40. Mikaili N, Ghasemi MA, Salari S, Sakeni Z. Theoretical and Practical Dimensions of Adherence to Treatment in Patients: A Review Study. Medical Journal of Mashhad University of Medical Sciences. 2019; 62:1403-19.