Section D

Development and Evaluation of Self-Management Program for Patients with Coronary Artery Disease

Hyun Young Kim1, Su Hyun Kim2, Hyun Jung Jung3, Hwa Sun Kim4,*
Author Information & Copyright
1Department of Nursing, Kyungwoon University, Gumi, Republic of Korea, actoduto@hanmail.net
2Collegy of Nursing, Kyungpook National University, Daegu, Republic of Korea, suhyun_kim@knu.ac.kr
3Depatment of Diagnostics, College of Korean Medicine, Daegu Haany University, Daegu, Republic of Korea, qutelady@naver.com
4Elecmarvels, 123, Banyawolbuk-ro, Dong-gu, Dageu, Republic of Korea, daspula@daum.net
*Corresponding Author : Hwa Sun Kim, Elecmarvels, 123, Banyawolbuk-ro, Dong-gu, Daegu, Republic of Korea, +82-53-817-1512, daspula@daum.net

© Copyright 2019 Korea Multimedia Society. This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: Dec 10, 2019; Accepted: Dec 19, 2019

Published Online: Dec 31, 2019

Abstract

The purpose of this study was to develop a self-management program for patients suffering from coronary artery disease (CAD), based on the self-determination theory and subsequently perform a heuristic evaluation by professionals and a quality assessment by users. The program consisted of 6 main menus and 20 submenus. Heuristic evaluation was conducted using eight principles, and as a result, a score of 1 was assigned by a professional for five principles: consistency and mapping, good ergonomics and minimalist design, flexibility and efficiency, anesthetics, and error management. Two professionals gave the principles of ease of input, screen readability, and glanceability a score of 1. In the quality assessment by the users, the system quality category had the highest score of 4.6 out of 5, and information quality had the lowest score of 3.87 out of 5. The overall average score was 4.08, which indicated the general satisfaction regarding the quality of the application. We have reflected on all the recommendations provided by the professionals based on their heuristic evaluation and incorporated them in the program.

Keywords: Coronary artery disease; Health behavior compliance; Self-management

I. INTRODUCTION

Coronary artery disease (CAD), which is a heart disease with a fatality rate exceeding 50%, is an ischemic disease where the coronary arteries, which maintain the function of the heart by supplying oxygen-rich blood and nutrition, become narrowed or blocked, resulting in impaired blood flow to the myocardium. CAD includes myocardial infarction, which causes myocardial necrosis, and angina, which causes chest pain due to a temporary anaerobic condition [1]. CAD is a chronic disease with acute pathogenesis and has a high risk of recurrence and sudden death. More specifically, myocardial infarction has a 20–30% fatality rate for the first occurrence; the recurrence rate after treatment is approximately 68–85%, which in turn causes a higher fatality rate [2]. In the U.S., it is reported that, within two years after initial treatment, the recurrence or preventative perfusion therapy rate is 42.2%, and the fatality rate is approximately 14.6% [3]. In South Korea, it is reported that, within one year after percutaneous coronary intervention, the recurrence or preventative reperfusion therapy rate is 14.6%, and the fatality rate is 4.5% [4]. Considering these values, fundamental measures for preventing recurrence are required in addition to the primary prevention measures for CAD.

Health behavior compliance was defined by Haynes and Sackett (1979) as the extent to which the patient’s behavior complies with the treatment plans and practices recommended by their health professionals [5]. In 2013, WHO defined health behavior compliance as the subject’s behaviors such as physical activity, dietary control, smoking cessation, and sobriety that effect lifestyle changes. CAD patients should maintain their recommended health behaviors such as quitting smoking, controlling weight, blood pressure and sugar level, good eating habits, and regular exercise [6]. Health behaviors through improved lifestyle can be managed most effectively when they are established as a long-term lifestyle. Furthermore, health behaviors should be simultaneously conducted through various health controls, such as weight control, exercise, smoking cessation, and medication compliance. Due to these reasons, it is reported that the health behaviors of CAD patients are not practiced well [7].

For continuous health behavior compliance by CAD patients once they have left the hospital, it is important to provide motivation to satisfy their basic psychological desires to encourage self-regulation for compliance with health behaviors, and further, encourage changes in lifestyle, which can be accomplished by developing and applying a self-management program constructed based on the self-determination theory. For this reason, in this study, a self-management application to support CAD patients based on the self-determination theory is developed. A heuristic evaluation and quality assessments by users are conducted to ensure that the application meets the needs of the users.

II. HEALTH BEHAVIOR COMPLIANCE

The American Heart Association claimed in 2009 that various factors such as age, sex, family history, smoking, hyperlipidemia, lack of exercise, obesity, diabetes, stress, drinking, and eating habits could affect CAD. If the patient is aware of these reversible risk factors and realizes the necessity and importance of lifestyle changes such as weight loss, dietary change, regular exercise, smoking cessation, and the regular taking of medication, then continuous good health behaviors can be achieved [8]. These types of health behavior compliance have positive effects on the recovery, avoidance of recurrence, and health maintenance of CAD patients [9]. Unfortunately, the awareness of these risk factors was found to be very low in the outpatients of the university hospitals receiving follow-up treatments after CAD [10]. Furthermore, patients with acute coronary syndrome who were hospitalized in the department of internal cardiovascular medicine were found to have a very understanding of their disease [11]. Also, according to a study conducted on the knowledge of patients with CAD, the awareness of risk factors and the benefits of diet, exercise, and rest were good, but detailed knowledge related to CAD itself and medication and lifestyle issues were misunderstood or incomplete [1]. Recognition of risk factors and a better understanding of their disease can improve their behavior by motivating lifestyle changes and thereby lowering risk factors, and, in turn, reducing recurrence and fatality rates. However, due to the current limited awareness of the risk factors and the knowledge of their disease, health behavior compliance is not well maintained. As a result, the fatality rate in patients with myocardial infarction is reported at 8.3% within one year of leaving the hospital, and for the case of percutaneous coronary intervention, recurrence or revascularization therapy is reported at 14.6% with a fatality rate of 4.5% [3]. Therefore, due to the nature of recurrences of a disease that has fatal consequences, it is important to undertake measures to prevent such recurrences. To reduce recurrence and cardiac deaths in patients suffering from CAD, the WHO (2013) emphasized the importance of post-discharge care and recommended health behavior compliance through actions such as disease prevention and management, medication to control risk factors, smoking cessation, dietary control, increase in physical exercises, exercise habits, blood pressure control, weight control, and regular check-ups to improve functional status and psychological well-being.

III. CONCEPTUAL FRAMEWORK OF THE STUDY FOR THE SELF-MANAGEMENT PROGRAM

This study was designed to develop a self-management program for patients with CAD and to evaluate the effectiveness of the application. A conceptual framework of the study was constructed based on the self-determination theory by Deci and Ryan (2002), as shown in Fig. 1 [12].

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Fig. 1. Relation between research Framework and program intervention.
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The constructive concepts of the health behavior compliance model for CAD patients are based on the self-determination theory that every patient has a basic psychological desire and self-deterministic motivation. Basic psychological desire consists of three components: autonomy, competence, and relatedness. Based on the satisfactory level of basic psychological desire, self-regulation, which is a dynamic internalized process of motivation, can be strengthened to promote healthy behavior and encourage motivation for self-determination.

In sum, coronary artery patients have basic psychological desires of autonomy, competence, and relationship, and by using a self-management program that supports their health behavior compliance, these three desires can be satisfied. In turn, self-regulation and the intrinsic motivation of the self-determination process are promoted. As a result, these internalized self-regulations improve self-efficacy to comply with health behaviors.

Table 1 shows the components and details that reflect the three basic psychological desires of the CAD self-management program.

Table 1. Components and details that reflect the three basic psychological desires of the CAD self-management program.
Component Strategy Description
Autonomy Health issue awareness -CAD risk type assessment
-Healthy lifestyle assessment
-Stress and depression level assessment
Disease management alternatives search -Provide knowledge and technical information services on managing hypertension, diabetes, and dyslipidemia
-Provide knowledge and technical information services on managing diet, medication, exercise, smoking, and stress
Self-selection -Encourage users to select the right alternatives through risk factor assessment of CAD
Clear evidence provision -Provide information on CAD
-Provide information and guidelines on the CAD-causing factors
-Provide information and guidelines on the management of CAD
Support for autonomy by health professionals -Positive feedback from health professionals
Competence Setting proper goals -Setting realistically achievable goals by the users
Provide feedback -Provide feedback on health care results
-Provide feedback on lifestyle management results
Enhance self-efficacy -Provide knowledge and technical information on lifestyle management
-Provide knowledge and technical information on management of disease-causing factors
-Provide monitoring service for self-management
Relationship Self-help community sharing -Provide a place for participants to share realistic situations and help each other
-Provide an information message board where participants can share useful information
Communication -Motivate users to share real-time information and to give emotional support among participants
-Support and information provided by health professionals
Download Excel Table

IV. DEVELOPMENT OF SELF-MANAGEMENT PROGRAM FOR CAD

4.1. Preliminary Research

This research was approved by the Kyungpook National University Industry Foundation Board (IRB 2018-0154). Surveys were performed to provide preliminary research regarding the disease-related knowledge and educational needs of CAD patients. These surveys were conducted on 58 CAD patients who visited the Internal Medicine Department of C Hospital in G City, Gyeongsangbuk-do from December 2016 to March 2017, and the survey results were taken into account when developing the program [13].

4.2. Design and Development

Table 2 shows the six services the main menu of the program: (1)introduction of the well-being heart charging station, (2)intelligent self-management tool, (3)my information management, (4)view my results, (5) knowledge information service, (6) and automatic weekly summary reminder service. In addition to the above six main menus, the program consists of 20 submenus. The domain was named as wellbeingheart.com, and the program was developed as a hybrid application utilizing an application and the web to enable users to be able to perform self-management from any location.

Table 2. Hierarchical structure of CAD Self-Management Program main menus and submenus.
Main menu Submenu Description
Introduction of wellbeingheart.com Description of the research -Expectations and goal for the program
General information on CAD -Symptoms of CAD
-Knowledge about CAD
-How does cardiac arrest affect me?
Intelligent Self-Management Tools Risk factor type measurement -Risk factor of CAD
Stress management -Stress score of Health Promoting Life Profile
Health behavior compliance -Health behavior Coronary Heart Disease Patients
Dietary types -Diagnostic Diets for Coronary Heart Disease Patients
Depression -Depression score of Patient Health Questionnaire-2
My Information My lifestyle management -Make an activity plan for daily or one week and assess each activity as positive or negative
My health management -Make a list of desirable activities
My diet management -Implement one or more desirable activities in their activity plan
My rssults My lifestyle information -Review negative activities in their activity plan and reduce the number of negative activities
My health information
My diet information
Knowledge Information Service Lifestyle management Identify problems in their everyday life, list several possible solutions for each problem, test one solution, and evaluate the chosen solution
Disease management
Blogs -Blogging with a professional
Questions -Contact with a professional
Live chat -Live chat with a professional or colleagues
Automatic Weekly Summary Reminder Service Auto mailing service Review and summarize the program and identify what they have learned
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Patients can use the intelligent self-management tool to immediately identify their risk factors and manage their risk factors at any time from the My Information and My Results menu. Additionally, warning notifications are given for the risk factors of the patient. Warning notifications are a way to allow patients to voluntarily manage their health. Patients can ask health professionals through live chats and they can create blogs among patients.

V. EVALUATION

5.1. Heuristic Evaluation

Heuristic evaluation requires about three to five professionals, as proposed by Neilsen et al.. In this study, a total of 8 professionals were selected for the evaluation.

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Fig. 2. Main screen and Main menu.
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Fig. 3. Risk group identifications and health behavior achievement ratings using intelligent self-management tools.
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The evaluators were as follows: two medical professionals with more than five years of experience, two professionals from the computer engineering field, one professional from the medical informatics field, and three professionals from the nursing field. The heuristic evaluation tool used in this study is a tool modified and supplemented for chronic patients by Jae-hee Jeon [14]. This tool is based on the ten heuristic principles developed by Nielson, which was then revised by Bertini et al. to combine Nielsen’s Severity Ranking Scale (SRS) with eight mobile heuristic evaluation principles, which were supplemented for mobile use.

The heuristic evaluation used in this study includes the following eight principles: (1)visibility of system status, (2) match between system and the real world, (3)consistency and mapping, (4)good ergonomics and minimalist design, (5)ease of input, screen readability, and glanceability, (6) flexibility and efficiency, (7)aesthetics, and (8)error management. Each principle was evaluated based on the severity level on a five-point scale with a score of zero representing no issues with the principle and score closer to 4 representing the need for corrections.

As a result of heuristic evaluation, a score of 1, which means that a usability problem exists but does not necessarily require repair, was given by an evaluator in each of the following five principles: consistency and mapping, ergonomics and minimalist design, flexibility and efficiency, aesthetics, and error management. Two evaluators gave the ease of input, screen readability, and glanceability principle a score of 1. Our research team modified the program to reflect the minor opinions of a problem existing but not necessarily needing to be fixed.

5.2. Quality Assessment by Users

The program was assessed by eight CAD patients using a quality evaluation tool based on the information systems success model [15], [16]. The program quality was measured using 24 questions based on a five-point scale. The questions were as follows: seven questions on system quality, six questions on information quality, five questions on service quality, three questions on user satisfaction, and three questions on program usage. The system quality category had the highest score with 4.6 out of 5, and the information quality had the lowest score with 3.87 out of 5. The overall average score was 4.08, which represented general satisfaction on the quality.

Table 3. Results of quality assessment by users.
Variable Mean ± standard deviation
System Quality 4.50±0.63
Information Quality 3.87±0.53
Service Quality 3.90±0.54
Satisfaction 4.33±0.57
Actual Use 3.83±0.61
Total 4.08±0.57
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VI. FUTURE PLANS AND CONLUSION

The reason for receiving a score of one from two professionals on the ease of input, screen readability, and glanceability principle in the heuristic evaluation was due the order of the menu, but this issue has been handled and modified in the application. The assessment of the quality of the program evaluated by the patients was found to be generally satisfactory. If the quality assessment score is high score, it appears to have an Intention to use continuously.

We will continue to study that the factors in the quality assessment can continue to affect the intention to use by increasing the number of users. And, the developed self-management program for CAD patients is planned to be applied to actual patients for a total of 4 weeks, beginning in March 2020. During this period, the program will receive more specific evaluations from the users. For future work, a mobile app could be easy-to-use and very helpful for patients.

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Authors

Hyun Young Kim

jmis-6-4-317-i1

Hyun Young Kim received her MS degrees in the Department of Nursing from Kyungpook National University, Korea in 2004. In 2008, she joined the Department of Nursing for pursuing her PhD degree at Kyungpook National University.

From March 2014 to Now, she has been assistant professor in the Department of Nursing at Kyungwoon University, Korea.

Her research interests include elderly care and acute care.

Su Hyun Kim

jmis-6-4-317-i2

Su Hyun Kim received her BS and MS degrees in the Department of Nursing from Kyungpook National University, Korea, in 1996 and 1999, respectively. In 2005, she received a Ph.D. degree in the Department of Nursing from University of North Carolina. From March 2006 to Now, she has been professor in the Department of Nursing at Kyungpook National University, Korea. Her research interests include chronic diseases nursing.

Hyun Jung Jung

jmis-6-4-317-i3

Hyun Jung Jung received her BS, MS and Ph.D. degrees in the Department of Korean Medicine from Dongguk University, Korea, in 2003, 2007 and 2011, respectively. From March 2011 to Now, she has been associate professor in the Department of Diagnostics, College of Korean Medicine, Daegu Haany University, Korea. Her research interests include image coding algorithms, standard medical technology and Fast Healthcare interoperability resources.

Hwa Sun Kim

jmis-6-4-317-i4

Hwa Sun Kim received her MS degrees in the Department of Computer Engineering from Inje University, Korea, in 2003. In 2007, she received a Ph.D. degree in the Department of Medical informatics from Kyungppook National University, Korea. Now, she is the CEO of Elecmarvels. Her research interests include Fast Healthcare interoperability resources and HL7.