Original Article

Introducti on

In the past two decades, coronary artery disease (CAD) has been the most prevalent heart disorder sweeping developing countries. 1 Among cardiovascular diseases (CVD), CAD is the most common cause of morbidity and mortality worldwide. 2 In Iran, there has been rapid growth in the prevalence of CAD and in its resulting morbidity and mortality. CAD has been the cause of 46% of mortality cases and its incidence rate is 181.4 in every 100,000 individuals. 3 Although medications have been helpful in controlling CAD, coronary artery bypass graft surgery (CABG) is a necessary option for many of these patients. 4 In all of the heart surgeries, CABG is very common. Among patients who have had CABG surgery, fear, anxiety, and tension may appear, which can result in the loss of faith in their ability, and therefore in their self-efficacy.

Albert Bandura's (1977) theory of self-efficacy was developed within the framework of social cognitive theory. 5 Selfefficacy beliefs are not judgments about one's skills, objectively speaking, but rather about one's judgments of what one can do with those skills. 6 Self-efficacy refers to the individual's confidence in fulfilling specific health behaviors to accomplish a desired goal. 7 Good self-efficacy is a critical concept in dealing with tensions and stressful situations resulting from the CAD. Self-efficacy thus has an important psychological role in diminishing negative effects caused by the CABG. 8 Cardiac selfefficacy (CSE) is a cardiac-specific measure of one's belief regarding his/her ability to perform activities related to the symptoms and challenges of CVD. 9 Low CSE is related to poor health and depression in patients and they are very vulnerable to complications of the disease. 10 Previous studies to increase CSE in CABG surgery patients are limited. However, some studies have been conducted among patients with acute myocardial infarction [11][12][13] and coronary syndrome. 14 Patients undergoing CABG surgery should be educated regularly to be prepared for unanticipated situations postoperatively. 15 Peer education is defined as a tool applied by people who share the same experiences. 16 Peer-based interventions have become a common method to effect important health-related behavior changes. 17 Peer-based intervention is a strategy in which individuals from a target group provide information, training, or resources to their peers. 18 Based on the literature, peer-based interventions in CVD have caused lifestyle changes regarding improvements in physical activity and eating behavior, 19 higher baseline health status, functioning, social support, 20 improved heart health, 21 significant

Randomized Controlled Trial of a Peer Based Intervention on Cardiac Self-Efficacy in Patients Undergoing Coronary Artery Bypass Graft Surgery: A 3-Year Follow-up Results

improvement in knowledge, 22 and reduced risk of coronary heart disease. 23 Considering the great importance of peer education, there has not been any study to investigate and follow up the effects of peer-based intervention on self-efficacy in patients undergoing CABG surgery. Therefore, this study aims to investigate a peerbased intervention on CSE in patients undergoing CABG surgery; a 3-year follow-up is the result.

Materials and Methods

The present study is a randomized controlled trial ( Figure 1). This study was conducted on 60 patients who were undergoing CABG surgery. The patients were selected from Imam Khomeini and Shariati Hospitals in Tehran, Iran. The patients in the control and intervention groups were selected from the two hospitals equally. Participants were selected on the basis of a simple sampling strategy. Next, random allocation [block randomization (block size: 6)] was conducted. The inclusion criteria were as follows: patients who did not have any record of CABG surgery, understand, and talk the Persian language; willingness to participate in the research; aged between 40 and 70 years; and did not have dementia, confusion, mental, and psychological problems, which might hinder their participation.

In addition, exclusion criteria in this study were as follows: patient's death; serious physical problems after CABG surgery such as severe pain from chest and leg incisions, wound infection, loss of appetite, fatigue, emergency and unexpected surgeries, or cancelation of the CABG surgery due to patient's situation. The selected patients were randomly assigned into two groups, control and intervention, using the block randomization method. 24 A demographic questionnaire and CSE scale were used for collecting the data. The validity of the demographic questionnaire was checked using the content validity method; therefore, 10 faculty members approved it. The CSE scale was used to assess CSE. 25 This instrument was developed to measure self-efficacy related to heart diseases. This scale consists of 16 items divided into two main sections: symptom control items and functioning maintenance items consisting of, respectively, eight and five items. There are three additional items associated with obesity, smoking, and dietary habits, which were applied to subjects requiring modification of risk factors. Each item was scored on a 5-point Likert scale, ranging from 0 (i.e., strongly disagree) to 4 (i.e., strongly agree). 13,26 The CSE scale is a valid and reliable measure when evaluating self-efficacy in patients with Acute Coronary Syndrome (ACS). 9,14,[25][26][27] Sample size (in each group, 30 participants), based on the Parent and Fortin (2000) study, was calculated based on the requirement to achieve 80% power at a significance level of 5%. 28 The peers were selected from the patients who had already undergone CABG surgery and could be accessed for participation in the study. The factors upon which the authors tried to select the peers were as follows: 29-31 diploma graduate; 1 year from their last CABG surgery; showed a high level of self-efficacy using the CSE scale. According to the aforementioned criteria, two peers were selected. The peers were educated by related experts through lectures and interactive discussions during three sessions (Table 1). Furthermore, the peers discussed the educated topics at the end of each session and also their educational experiences.

The intervention and control groups were given routine information about surgery and recovery during the hospitalization by health professionals. After the peers were prepared with three educational sessions, the patients in the intervention group also went through two educating sessions on 2 consecutive days before CABG surgery; it is noteworthy that each session lasted for 1 h with peers. However, the control group only received the routine education provided by the hospitals. Patients in the intervention group underwent peer education preoperatively and the education was presented 1 day preoperatively. Educational sessions were held in the open-heart surgery ward of the hospital; also, the researcher had a supervisory role during the sessions. Then, the intervention groups were evaluated two times to complete the CSE scale (5 days and 36 months postoperatively).

The Research Ethics Committee (No: 90/D/130/2329) affiliated to the Tehran University of Medical Sciences, Tehran, Iran, approved the study and the consent form. Moreover, the Iranian Registry of Clinical Trials registered the study with the number IRCT201205029623N1. In this study, the selected participants were thoroughly informed about both the purpose and the process of the study. Moreover, they were assured that participation in and withdrawal from, the project were voluntary, and the permission to use the CSE scale was granted by Professor Mark Daniel Sullivan.

Data were analyzed using Statistical Package for the Social Sciences (SPSS) (version 16.0, for Windows). We used the chisquare test, Fisher's exact test, independent-samples, and Kolmogorov-Smirnov tests.

Results

The Kolmogorov-Smirnov test shows that the data had a normal distribution in each group (sig=0.8). The patients in both groups were homogenous in terms of demographic data. All information about the demographic data of both groups is given in Table 2. The CSE of the patients was checked in the order of 5 days and 3 years postoperatively ( Table 3). The CSE of the patients in the intervention group was higher, compared with that of patients in the control group (P<0.001).

Discussion

This study evaluated the role of a peer-based intervention (peer education) on cardiac self-efficacy of patients undergoing CABG surgery. Cardiac self-efficacy is a person's belief in his/her ability to manage the challenges posed by a coronary disease, and its role has been evaluated in several coronary populations using the CSE scale. Based on the results, peer education could be considered as a practical, clinical, effective, and suitable tool to be applied for increasing the CSE, which can contribute to an increase in patients' self-confidence to develop physical activity. CSE is in fact due to a direct relationship between self-efficacy, self-confidence, and physical activity in patients with CVD. 32 The levels of CSE determine the degree of confidence and that reflects the own functional abilities of patients. Thus, if patients have not shown even improvement in CSE, we must perform an educational program to develop that.

We found low levels of CSE among control group patients who participated in this study. Similar to reports by Cajanding (2015), those 143 patients perceived a structured discharge planning program among patients with cardiac problems. 13 The average score of CSE in the patients of the intervention group at 5 days (P<0.001) and 3 years follow up (P<0.038) is significantly higher, compared with the control group. In a study conducted by , a similar relationship between the CSE and receiving education in the control and intervention groups was found. Wu et al. (2012), in their research project entitled "Peer supporters for cardiac patients with diabetes: a randomized controlled trial," found that significant improvement in knowledge was achieved for the intervention group. But significant improvements in selfefficacy and self-care behavior were not observed. 22 The result of Wu et al. (2012) was in opposition to our study. Design of peer base intervention is an essential component to the accomplishment of the project. 33 Walker and Avis (1999) mentioned in their article why peer education fails and explained common reasons for that. 34 The top reasons are as follows:

1-A lack of clear aims and objectives for the project.

2-An inconsistency between the project design and the external environment/constraints which should dictate the project.

3-A lack of investment in peer education.

4-A lack of appreciation that peer education is a complex process to manage and requires highly skilled personnel.

5-Inadequate training and support for peer educators.

6-A lack of clarity around boundary issues and control. 7-A failure to secure multi-agency support.

In our study, we tried to comply with these topics.