Investigating the Effect of Follow-up Care on the Self-concept of Patients under Coronary Artery Bypass Grafting

Introduction: Since coronary artery angina pectoris is a chronic disease, it negatively affects patients` self-concept. In this study, the effect of follow-up care on the self-concept of patients undergoing coronary artery bypass grafting was investigated. Original Research Article Moghaddam et al.; JPRI, 32(1): 57-63, 2020; Article no.JPRI.54693 58 Materials and Methodology: In this study, the clinical trial was measured using self-concept questionnaire considering the effect of follow-up or constant care on 60 patients under coronary artery bypass grafting in Seyed-al-shohada heart center of Urmia. Eight to twelve weeks after the operation, the follow-up care, which is an Iranian native model was administered through telephon. Data collection tools included patients` demographic data collection form as well as self-concept questionnaire consisting of 25 Likert-scale items of 1 to 5 (totally positive, positive, neutral, negative, totally negative), which measured 25 features. Results: In the current study, the mean age of patients in both groups (intervention and control) was 59.68±7.43 and 59.48±5.79 years old, respectively. In addition, the mean weight of patients in both groups (intervention and control) equaled 77.82±10.67 and 75.22±7.53 kg. According to the results of the mean, the perceived threat after the intervention was 45.16±4.28 in the intervention group and it was 40.43±5.22 in the control group, showing a significant statistical difference between two groups (p<0.001). The perceived challenge after the intervention was 70.86±6.82 in the intervention group and it was 67.13±6.37 in the control group, showing a significant statistical difference between two groups (p=0.028). Conclusion: The mean of self-concept score increased after the intervention and the observed results could have positive effects on the treatment of patients.


INTRODUCTION
Coronary artery diseases are amongst the most common cardiovascular diseases and one of the main reasons of death in most of the countries in the world. Most of the patients having this kind of disease do not respond to the medical treatments, thus found themselves under coronary artery bypass grafting [1]. This is the main reason for the death resulting from various cardiovascular diseases [2]. It has been estimated that cardiovascular disease would be the first reason for inabilities in the disabling diseases' list of the world till 2020 [3].
The annual death rate due to cardiovascular ischemic diseases in a country's population aged over 40 years, is estimated to be 14 in every 1000 individuals [4]. Various methods including medicines, angioplasty through balloons, laser as well as discharging thrombosis have been used to treat coronary artery diseases. Despite developments in new treatments, operation is still the only choice of treatment in most of the cardiovascular diseases [5]. Coronary artery bypass grafting is a primary selection method for treating coronary artery angina pectoris [6]. Regardless of chronic diseases' effects on the physical dimensions of patients, such diseases can affect self-concept and quality of life, accordingly. Self-concept is the mental image of every individual that includes all his perceptions (appearances, values and beliefs) affecting his behaviors and it refers to the time one uses the word "I" [7,8].
It has been proven nowadays that those having an appropriate and positive self-concept regarding themselves, are more compatible toward disease [9] and follow health care programs better [10].
According to the study conducted by Heidari et al. in the heart center of Mashhad, there was a positive and significant correlation between selfconcept dimensions and adherence to the treatment and increasing self-concept was accompanied with the increase in the adherence to the treatment scores, which is considered a positive finding in the treatment process [11]. Therefore, this study investigated the effect of follow-up care on the self-concept of patients under coronary artery bypass grafting in Seyedoshohada Hospital of Urmia.

MATERIALS AND METHODS
In this clinical trial study, the effect of follow-up or constant care on 60 patients under coronary artery bypass grafting of Seyed-al-shohada Hospital of Urmia was measured using selfconcept questionnaire. Eight to twelve weeks after the operation, the follow-up care, which is considered an Iranian native model, was administered through telephone. This model includes 4 phases of introduction, sensitization, control and evaluation. Inclusion criteria to the study included the consent to participate in the study, having an age range of 18-75 years and not having psychological problems. Exclusion criteria, as well, included noncooperation in the rest of the research, and not participating in the follow-ups regarding the measurement of selfconcept. The sample size was calculated to be 60 patients considering Salehi Moaeni et al. study [12] as well as the calculation of 5% alpha with the confidence scope of 95% and statistical power of 80% also the variance and mean amount before and after the intervention. This number increased to 60 patients through applying 20% attrition. Data collection tools included patients' demographic data collection form and self-concept questionnaire which included 25 Likert items from 1 to 5 (totally positive, positive, neutral, negative, totally negative) measuring 25 features. The scoring process was reversed in negative questions. Considering the self-concept level`s scoring, they were rated as 33.3% meant low self-concept, 33.3-66.6% meant moderate self-concept and 66.6% and over meant high self-concept. The score scope of this questionnaire varied from 25 to 125 and higher scores meant better selfconcept.
Safavi et al. [13] in Iran measured the reliability of this questionnaire and obtained 0.80 and 0.88 reliability using internal conformity method as well as test-retest method respectively, which indicated the great reliability of this scale.

Data Analysis
To evaluate the results of the research, results from research units were codified and analyzed using SPSS, version 19, software. To have access to research purposes, descriptive statistics (frequency distribution, mean and standard deviation tables) as well as statistical analysis methods including parametric tests (in case data were normal) such as paired t-test and non-parametric tests (in case data were not normal) such as McNemar`s test were utilized. This study was confirmed by Ethics Committee (IR.UMSU.REC.1397.352) and the IRCT code having a number of IRCT20181105041560N2 was obtained.

RESULTS
This study included 60 patients and aimed at determining the effect of follow-up care model`s administration on the self-concept in patients under coronary artery bypass grafting in Seyedal-shohada heart center of Urmia during 2018-2019. The mean age of patients in both groups (intervention and control) were 59.68±7.43 and 59.48±5.79 years, respectively. To compare the mean age between two groups, t-test was utilized, which indicated that there was no statistically significant differences between two groups (p=0.9). Moreover, the mean weight of patients in both groups (intervention and control) was 77.82±10.67 and 75.22±7.53 kg, respectively, which showed that there were no differences between two intervention and control groups. Actually both groups were homogeneous in terms of age and weight (p=0.29) ( Table 1). Demographic data have been presented in Table  2. Table 3, though, indicates the comparison between the mean scores of self-concept before the intervention in two groups. According to these results, there were no significant differences between two groups in terms of the mean of self-concept dimensions before the intervention. According to the results, the mean after perceived threat was 45.16±4.28 in the intervention group and it was 40.43±5.22 in the control group after applying the intervention, showing a statistically significant difference between two groups (p<0.001). In addition, the perceived challenge in the intervention group was 70.86±6.82 and in the control group, it was 67.13±6.37 after the intervention showing a statistically significant difference between two groups (p=0.028). Overall, the mean after the intervention in the intervention group was 116.03±8.57 and it was 107.57±5.82 in the control group, showing a statistically significant difference between two groups (p<0.001) ( Table 4).

DISCUSSION
Considering the fact that the current research`s chosen treatment was coronary artery bypass grafting [5,6], the optimal treatment was of utmost importance in these patients. The improvement in the patients' self-concept is among factors affecting the treatment process. Patients do not comprehensively follow their treatment process after coronary grafting, which causes further and repeated hospitalizations [14,15]. Actually, the improvement of chronic diseases such as cardiovascular diseases is largely dependent on the adherence to the treatment [15]. In this study, the effect of followup care on the self-concept of patients under coronary artery bypass grafting was investigated in Seyed-al-shohada heart center of Urmia.  In a study similar to that of the current study, Poshtchaman et al. [14] investigated the effect of two telephonic and message follow-up care methods on patients' adherence to the treatment after coronary artery bypass grafting. Before being discharged, two telephonic and message groups received in-person trainings and educative booklets. In telephonic follow-up group, telephone calls were made three time a week for two months and in message follow-up group, one message was sent daily for two months. According to the findings of the research, telephonic as well as message followups, both, led to the improvement of patients' adherence to the treatment after coronary artery bypass grafting [14]. This study was similar to that of ours since a relational intervention had been selected and its effects on the adherence to the treatment were positive and significant. Our research was also relational and it was consistent with Poshtchaman et al.'s study. In another study conducted by Ahrari et al. [10] to investigate the self-concept role of compatibility pattern on the adherence to diet in patients suffering from heart failure, self-concept threat had a reverse relationship with the adherence to the diet and self-concept challenge had a direct relationship with the adherence to the diet. Regression test results indicated that the reduction in self-concept threat perception and its dimensions as well as the increase in selfconcept challenge perception and its dimensions led to the increase in the adherence to the diet. Therefore, nurses should search for tactics and interventions such as counseling and education so that patients having heart failure not consider their diet as a threat; rather consciously and robustly face their own diet as a challenge, so that their adherence to the diet can be increased [16]. In this respect, our study in the regression analysis showed that adherence to the treatment and self-concept dimensions had a significant relationship with the kind of therapeutic group. Thus, the amount of self-concept and adherence to the treatment changes can be predicted as compared with the allocated groups; such a relationship would be positive and significant, which means that follow-up care intervention causing the increase in the adherence to the treatment, would also lead to the increase in selfconcept, whose mutual effects in optimal treating of patients can be observed.
Furthermore, Salehitali et al. [17] explored the effect of educational interventions and constant cares at home on re-hospitalization, reference to the doctor and therapeutic costs in a 6 months follow-up period regarding heart failure patients. The results showed that the mean of rehospitalization, reference to the doctor and therapeutic costs were significantly different in both groups. In this study, the administered intervention included the education and care of patients at their homes in a 6 months period. According to the results of this study, nurses` constant educational and caring interventions at home were accompanied with the reduction in rehospitalization level and reference to the doctor [17].
To increase the adherence to the treatment, follow-up process can be performed through various methods, which may have significant effects regarding the increase in the adherence to the treatment. In the current study, follow-up care was considered as the main intervention, which was accompanied with the increase in the adherence to the treatment score. This was consistent with the results of Aroun et al. study. In a study conducted by Lina et al. in 2018 in Sweden, the effect of adherence to the treatment in patients having therapeutic resistance, who were controlled over blood pressure, was investigated. Having diabetes had a preventive significant relationship with the adherence to the treatment, which means that the ratio of calculated danger was less than 1, meaning that the increase in adherence to the treatment had preventive effects on diabetes improvement [18].
The results of the current study were consistent with this research since intervention increased the adherence to the treatment and adherence to the treatment factor had positive effects in chronic diseases` process.

CONCLUSION
The mean of self-concept score increased after the intervention. The observed results can have positive effects on the treatment procedure of patients. Forward-looking effects of self-concept in the treatment process may provide better improvement from the operation and disease.

CONSENT
Inclusion criteria to the study included the written consent to participate in the study.

ETHICAL APPROVAL
This study was confirmed by Ethics Committee (IR.UMSU.REC.1397.352) and the IRCT code having a number of IRCT20181105041560N2 was obtained.