Educational Intervention Through a Group Discussion is Effective on the Self-Esteem of Patients with Heart Failure

AUTHORS

Maryam Ahmadi ORCID 1 , Saeed Mahmoudi ORCID 2 , * , Amir Jalali 2 , ** , Ahmad Khoshay 3 , Jamal Amirian 1

1 Rehabilitation Center, Imam Ali Cardiovascular Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran

2 Department of Psychiatric Nursing, Substance Abuse Prevention Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran

3 Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran

Corresponding Authors:

How to Cite: Ahmadi M, Mahmoudi S, Jalali A, Khoshay A, Amirian J. Educational Intervention Through a Group Discussion is Effective on the Self-Esteem of Patients with Heart Failure, J Clin Res Paramed Sci. Online ahead of Print ; 8(2):e92507. doi: 10.5812/jcrps.92507.

ARTICLE INFORMATION

Journal of Clinical Research in Paramedical Sciences: 8 (2); e92507
Published Online: June 18, 2019
Article Type: Research Article
Received: April 22, 2019
Revised: May 27, 2019
Accepted: May 29, 2019
Crossmark

Crossmark

CHEKING

READ FULL TEXT
Abstract

Background: Physical limitations in patients with heart failure (HF) affect their emotional functioning, and ultimately deteriorates their quality of life and decrease their self-esteem. Patient imagery and emotion regulation are two important components of cognitive and emotional processes that relate to patient's self-esteem. Therefore, a sensible way to improve the self-esteem of patients with HF is education through a group discussion.

Objectives: Our goal was to obtain information about the impact of interventional education through a group discussion on the self-esteem of patients with HF attending Imam Ali Cardiovascular Hospital in Kermanshah, Iran.

Methods: This quasi-experimental study was conducted in 2016 with 80 eligible individuals selected using convenience sampling method, and randomly assigned to control and intervention groups. Clinical data of patients were collected from their medical information record. A demographic questionnaire and Rosenberg self-esteem scale were used to collect demographic information and self-esteem data, respectively. All patients in the intervention group underwent 8 sessions of education through a group discussion. The statistical software R-3.2.3 was used to analyze the data.

Results: There was a significant difference between patients’ self-esteem in the control and intervention group after the intervention (P < 0.001), and educational intervention through a group discussion improved self-esteem in the intervention group, as the mean level of patients’ self-esteem improved from 12.03 before intervention to 10.90 after intervention. Furthermore, the mean of the patient's self-esteem increased by 0.55, 0.23, and 0.25, respectively for value, individual ability, and satisfaction in the intervention group.

Conclusions: It is recommended that educational interventions through a group discussion be used to improve the self-esteem of these patients.

Keywords

Heart Failure Self-Esteem Group Discussion Intervention

Copyright © 2019, Journal of Clinical Research in Paramedical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

A challenging process in heart failure (HF) is its proper management by patients (1). In many countries, the development of patient-based health plans involves a significant contribution from health resources to better care for patients (2-4). There is some evidence that disease management programs in patients with HF can be effective in reducing mortality, suffering and length of hospital stay (5). Therefore, it is necessary to consider human factor approach to improving the health status and quality of care in patients with HF (6).

HF is a common chronic progressive costly disease characterized by an impairment in function or pumping of the heart, recognized as one of the most common and complex health issues worldwide (7-9). HF disrupts the blood oxygenation process and limits the patient’s ability to expel waste materials, especially water, which can lead to serious injury to the patient (10). In addition, HF has a significant effect on the patient’s physical functioning due to symptoms such as weight gain, shortness of breath, weakness, fatigue, and swelling of the feet (11, 12), which can affect patient’s emotional function due to the psychological consequences of the disease (13).

In patients with HF, patient’s mental status is affected by long-term treatment, rehospitalization, inability of the patient in social life, and complications of the disease (14, 15), and ultimately, psychological distress and ill-humouredness increase in them (16). Therefore, HF can deteriorate quality of life and decrease self-esteem by disturbing patient’s mental balance (17). Self-esteem is defined as “one’s overall evaluation of one’s worth, based on the positive and negative self-perceptions that make up one’s self-concept” (18). Self-esteem has a personal meaning and affects various aspects of their lives (19). Patient imagery and emotion regulation are two important components of cognitive and emotional processes that greatly impact patients with HF (20). These two components can be affected by patients’ self-esteem. Therefore, a sensible way to improve the condition of patients with HF is to improve their self-esteem.

Human factors approach and group training to maintain health and HF management have been considered for interventions worldwide (21). Learning through a group discussion is one of the most popular techniques in education, where ideas are exchanges on a particular topic among individuals within a group (22). In group discussions, members participate in discovering solutions to the issues being discussed by a trainer, and this increases the motivation of the group to learn. Given the low self-esteem of patients with HF due to the complications of the disease, we designed this study to use group discussion to improve self-esteem in patients with HF.

2. Objectives

Our goal in this research was to obtain information about the impact of interventional education through a group discussion on the self-esteem of patients with HF attending Imam Ali Cardiovascular Hospital in Kermanshah, Iran.

3. Methods

3.1. Study Design

This quasi-experimental study recruited patients with HF presenting to Imam Ali Cardiovascular Hospital in Kermanshah, Iran, from June to September 2016. A total of 80 patients with HF were selected using convenience sampling method. The inclusion criteria included cardiac dysfunction recorded in echocardiography report, functional classes III and IV of New York Heart Association (NYHA), ejection fraction ≤ 40%, a diagnosis of HF at least 6 months before, age range of 18 - 65 years old, and literacy to read and write Persian language. Patients did not enter the study if they suffered from a coexisting, severe, chronic debilitating disease, if they had a psychiatric diagnosis or auditory and visual impairment, if they had a private nurse or specialized education about self-esteem, if they had a valve replacement in the last 6 months or were expected to have such a treatment within 3 months, and if the patient was dissatisfied with giving information. Patients were also excluded the from the study if they did not attend more than 25% of the classes or were reluctant to continue the study.

After selecting patients and obtaining written consent, they were randomly assigned to 2 equal groups of control and intervention. The intervention group received 8 sessions of educational intervention through a group discussion (one session per week). The educational intervention included intensive, systematic and planned training on the consequences of HF in the daily life of patients, led by a researcher nurse (23), the effect of self-esteem on improving patients’ condition and how to increase the level of self-esteem in these patients.

3.2. Data Collection

At the time of registration, clinical data of patients were collected from their medical information records. This information included patient’s medical history, laboratory information, comorbidities, NYHA classification, left ventricular ejection fraction, and medication prescribed. At the same time, the patient was interviewed to collect demographic data including age, gender, marital status, socio-economic status, social support and living conditions, following Jaarsma et al. (24).

To assess self-esteem in patients with HF, Rosenberg self-esteem scale (RSES)was used. This instrument consists of 10 items with 4-point Likert scale (0 = strongly agree, 1 = agree, 2 = disagree, 3 = strongly disagree). Five items from RSES assess the individual’s positive feelings about themselves, and 5 other items assess the individual’s negative feelings about themselves (25). To rate responses, 5 items that express positive feelings are returned to their values, and their score is added to the other 5 items that express negative feelings. Therefore, following the method used by Poorgholami et al. (26), each person received a score ranging from 0 to 30, which respectively represent the best and the worst value for individual self-esteem. In a study by Rajabi and Bohloul (27) in Shahid Chamran University, validity and reliability of RSES was confirmed for Iranian society with 0.85 Cronbach alpha.

First, all patients with HF, in both control and intervention groups filled out RSES. The intervention group was then subjected to 8 sessions of educational intervention through a group discussion (weekly sessions for two months). One month later, all patients with HF filled out RSES again.

3.3. Data Analysis

R-3.2.3 software was used to analyze the data. Kolmogorov-Smirnov test was used to examine the data distribution, and the Levene’s test was used to examine the homogeneity of variance. Reporting and describing variables were performed through descriptive statistics (frequency and percentage, mean and standard deviation (SD)). Independent t-test, chi-square test, Mann-Whitney test and covariance analysis were used for statistical analysis of variables. The acceptable probability level was α = 0.05.

4. Results

4.1. Demographics and Clinical

The results of this study revealed no significant differences between the two groups in terms of demographic and clinical (normal ejection fraction) variables (P < 0.05). Of the total 80 patients surveyed, 61.2% (49 persons) were male, with 27 men in the control group and 22 men in the intervention group, while 38.8% (31 persons) were female, with 13 women in the control group and 18 women in the intervention group. The description of other demographic variables (place of residence, marital status, occupational status, education and income status) in the patients is presented in Table 1. Mean ± SD of patients’ age in the control and intervention groups was 58.6 ± 6.9 and 57.3 ± 8, respectively. The mean ± SD of the normal ejection fraction in the control and intervention groups was 26.5 ± 8 and 25.8 ± 7.6, respectively (Table 2).

Table 1. Comparison of Patients in the Control and Intervention Groups Based on Demographic Variables (Chi-Square Test)
VariablesControlInterventionTotalP Value
Gender0.025
Male27 (67.5)22 (55)49 (61.2)
Female13 (32.5)18 (45)31 (38.8)
Residence0.60
City27 (67.5)26 (65)53 (66.2)
Suburb8 (20)6 (15)14 (17.5)
Rural5 (12.5)8 (20)13 (16.3)
Marital status0.19
Single8 (20)3 (7.5)11 (13.8)
Married32 (80)37 (92.5)69 (86.2)
Occupation0.89
Employee15 (37.5)13 (32.5)28 (35)
Services12 (30)13 (32.5)25 (31.2)
Self-employed13 (32.5)14 (35)27 (33.8)
Education level0.92
Primary28 (70)28 (70)56 (70)
High school8 (20)10 (25)18 (22.5)
Academic4 (10)2 (5)6 (7.5)
Income, Rials0.83
≤ 10 Million19 (47.5)18 (45)37 (46.2)
> 10 Million21 (52.5)22 (55)43 (53.8)
Table 2. Comparison of Patients in the Control and Intervention Groups Based on Age and Normal Ejection Fraction (t-Test)
VariablesControlInterventionP Value
NMinMaxMean ± SDNMinMaxMean ± SD
Age40386558.6 ± 6.940226557.3 ± 80.41
Ejection fraction40103526.5 ± 840103525.8 ± 7.60.67

4.2. Self-Esteem

The results of covariance analysis indicated a significant difference between patients’ self-esteem after educational intervention (P < 0.001) by controlling patients’ self-esteem before intervention. After educational intervention, the mean ± SD of self-esteem score in the control and intervention group was 12.45 ± 4.9 and 10.9 ± 4.4, respectively (Table 3). Nonparametric analysis of covariance for dimensions of self-esteem scale (value, individual ability and satisfaction) revealed that by controlling patients’ self-esteem in these dimensions before intervention, there was a significant difference between patients’ self-esteem after educational intervention (P < 0.001). Table 4 shows patients’ self-esteem in the control and intervention groups according to three dimensions of self-esteem scale.

Table 3. Comparison of Patients’ Self-Esteem in Control and Intervention Groups with Control of the Effect of Patients’ Self-Esteem Before Intervention (Covariance Analysis)
GroupsBeforeAfterP Value
Control11.78 ± 4.612.45 ± 4.90.001
Intervention12.03 ± 5.310.9 ± 4.4
Table 4. Comparison of Patients’ Self-Esteem in Control and Intervention Groups According to Their Dimensions with Control of the Effect of Patients’ Self-Esteem Before Intervention (Nonparametric Analysis of Covariance)
Dimensions of Self-EsteemBeforeAfterP Value
Value0.001
Control4.1 ± 1.854.4 ± 2
Intervention4.6 ± 2.34.05 ± 1.9
Individual ability0.001
Control4.2 ± 1.74.3 ± 1.8
Intervention4.02 ± 1.83.7 ± 1.6
Satisfaction0.002
Control3.5 ± 1.83.7 ± 1.9
Intervention3.4 ± 1.73.15 ± 1.5

5. Discussion

In this study, there was a significant difference between patients’ self-esteem in the control and intervention group after intervention (P < 0.001), and educational intervention through a group discussion improved patients’ self-esteem. In the intervention group, the mean level of patients’ self-esteem improved from 12.03 before intervention to 10.90 after intervention, while in the control group, the mean level of patients’ self-esteem in the end (12.45) was worse than that at the beginning of the study (11.8). This may be explained as education helps patients with HF better understand their physical condition, and thus become more compatible with their life challenges. Therefore, learning through a group discussion improves their self-concept, changes their lifestyle, and improves their perspective on their condition and thus increases their self-esteem. In conformity with our results, Poorgholami et al. (26) conducted a study on patients undergoing hemodialysis in Motahari Hospital in Jahrom, Iran, and concluded that level of patients’ self-esteem significantly increased through education and intervention.

We observed a significant difference between the scores of different dimensions of self-esteem in the control and intervention groups after intervention (P < 0.001). Educational intervention through a group discussion increased the mean of patients’ self-esteem in terms of value, individual ability and satisfaction in the intervention group by 0.55, 0.23, and 0.25, respectively. Improving the patient’s understanding of their condition improves their mental condition, which can lead to their adapting to the limitations and thereby enhancing their sense of value. Guillon et al. (28) studied the relationship between self-esteem and psychiatric disorders in adolescents, and found that these disorders were related to their low self-esteem, and appropriate treatment interventions can be effective to improve their self-esteem.

Our interpretation of the results of this study is that education reduces the gap between self-perceived and self-ideal in patients in the intervention group, which increased their individual ability. Rahimi et al. (29) examined the effect of applying continuous care model on self-esteem of the hemodialysis patients, and they found that it had a positive effect on self-esteem levels. As one of the educational topics in the intervention group was having a sense of self-control in relation to the present condition, this could lead to an increase in the sense of satisfaction in them. Sanaie et al. (30), by studying the effect of family-centered empowerment on self-efficacy and self-esteem of the patients undergoing coronary bypass graft surgery, concluded that sense of empowerment increases self-esteem in these patients.

5.1. Conclusions

Patients with HF usually feel weakness, inability and lack of control over their physical condition due to complications of the disease, unavailability and isolation, and all these feelings can affect their self-esteem. Therefore, the development of new educational methods and interventions for treating these patients is very important. In this study, interventional education through a group discussion was effective in improving the level of self-esteem in patients with HF and significantly improved the overall score of self-esteem among patients in the intervention group. All dimensions of self-esteem scale (value, individual ability and satisfaction) of patients in the intervention group were significantly improved as before the intervention. Therefore, it is recommended that educational interventions through a group discussion be considered to improve the self-esteem of these patients in designing and planning interventions.

Acknowledgements

Footnotes

References

  • 1.

    Lambrinou E, Kalogirou F, Lamnisos D, Papathanassoglou E, Protopapas A, Sourtzi P, et al. The Greek version of the 9-item European heart failure self-care behaviour scale: A multidimensional or a uni-dimensional scale? Heart Lung. 2014;43(6):494-9. doi: 10.1016/j.hrtlng.2014.07.001. [PubMed: 25109661].

  • 2.

    Aidemark J, Askenäs L, Mårtensson J, Strömberg A. Challenges for heart failure patients’ self-care systems – analysis of patients’ needs. Proc Technol. 2014;16:1256-64. doi: 10.1016/j.protcy.2014.10.141.

  • 3.

    Archer N, Fevrier-Thomas U, Lokker C, McKibbon KA, Straus SE. Personal health records: A scoping review. J Am Med Inform Assoc. 2011;18(4):515-22. doi: 10.1136/amiajnl-2011-000105. [PubMed: 21672914]. [PubMed Central: PMC3128401].

  • 4.

    Ryan D, Price D, Musgrave SD, Malhotra S, Lee AJ, Ayansina D, et al. Clinical and cost effectiveness of mobile phone supported self monitoring of asthma: Multicentre randomised controlled trial. BMJ. 2012;344. e1756. doi: 10.1136/bmj.e1756. [PubMed: 22446569]. [PubMed Central: PMC3311462].

  • 5.

    Jaarsma T, Arestedt KF, Martensson J, Dracup K, Stromberg A. The European heart failure self-care behaviour scale revised into a nine-item scale (EHFScB-9): A reliable and valid international instrument. Eur J Heart Fail. 2009;11(1):99-105. doi: 10.1093/eurjhf/hfn007. [PubMed: 19147463].

  • 6.

    Holden RJ, Schubert CC, Mickelson RS. The patient work system: An analysis of self-care performance barriers among elderly heart failure patients and their informal caregivers. Appl Ergon. 2015;47:133-50. doi: 10.1016/j.apergo.2014.09.009. [PubMed: 25479983]. [PubMed Central: PMC4258227].

  • 7.

    Kumar M, Pachori RB, Rajendra Acharya U. An efficient automated technique for CAD diagnosis using flexible analytic wavelet transform and entropy features extracted from HRV signals. Expert Sys Appl. 2016;63:165-72. doi: 10.1016/j.eswa.2016.06.038.

  • 8.

    McRae MP, Bozkurt B, Ballantyne CM, Sanchez X, Christodoulides N, Simmons G, et al. Cardiac scorecard: A diagnostic multivariate index assay system for predicting a spectrum of cardiovascular disease. Expert Sys Appl. 2016;54:136-47. doi: 10.1016/j.eswa.2016.01.029.

  • 9.

    Samuel OW, Asogbon GM, Sangaiah AK, Fang P, Li G. An integrated decision support system based on ANN and Fuzzy_AHP for heart failure risk prediction. Expert Sys Appl. 2017;68:163-72. doi: 10.1016/j.eswa.2016.10.020.

  • 10.

    Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: Executive summary: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):1495-539. doi: 10.1016/j.jacc.2013.05.020.

  • 11.

    Durairaj M, Sivagowry S. A pragmatic approach of preprocessing the data set for heart disease prediction. Int J Innovative Res Comput Commun Eng. 2014;2(11).

  • 12.

    Rahimi K, Patel A, MacMahon S. Two decades of research on innovative models of care delivery for patients with heart failure: the end or just the beginning? Arch Iran Med. 2012;15(7):439-45.

  • 13.

    Burke RE, Jones J, Ho PM, Bekelman DB. Caregivers' perceived roles in caring for patients with heart failure: what do clinicians need to know? J Card Fail. 2014;20(10):731-8. doi: 10.1016/j.cardfail.2014.07.011. [PubMed: 25084216].

  • 14.

    Enache RG. The relationship between anxiety, depression and self-esteem in women with breast cancer after surgery. Proc Soc Behav Sci. 2012;33:124-7. doi: 10.1016/j.sbspro.2012.01.096.

  • 15.

    Mohd-Sidik S, Akhtari-Zavare M, Periasamy U, Rampal L, Fadhilah SI, Mahmud R. Effectiveness of chemotherapy counselling on self-esteem and psychological affects among cancer patients in Malaysia: Randomized controlled trial. Patient Educ Couns. 2018;101(5):862-71. doi: 10.1016/j.pec.2018.01.004. [PubMed: 29336859].

  • 16.

    Moser DK, Dracup K, Evangelista LS, Zambroski CH, Lennie TA, Chung ML, et al. Comparison of prevalence of symptoms of depression, anxiety, and hostility in elderly patients with heart failure, myocardial infarction, and a coronary artery bypass graft. Heart Lung. 2010;39(5):378-85. doi: 10.1016/j.hrtlng.2009.10.017. [PubMed: 20561849]. [PubMed Central: PMC2939239].

  • 17.

    Cajanding RJ. The effectiveness of a nurse-led cognitive-behavioral therapy on the quality of life, self-esteem and mood among Filipino patients living with heart failure: A randomized controlled trial. Appl Nurs Res. 2016;31:86-93. doi: 10.1016/j.apnr.2016.01.002. [PubMed: 27397824].

  • 18.

    El-Wahab SDA, Eita LH. Impact of counseling on self-esteem and anxiety levels among nursing students. J Nurs Educ Prac. 2015;5(6). doi: 10.5430/jnep.v5n6p106.

  • 19.

    Moreira NS, Sousa CS, Poveda VB, Turrini RNT. Self-esteem of cancer patients' caregivers with reduced functional capacity. Escola Anna Nery. 2015;19(2). doi: 10.5935/1414-8145.20150043.

  • 20.

    Wierenga KL. Emotion regulation and perceptions of illness coherence and controllability on regimen adherence and negative cardiac health events in African American women with heart failure. J Cardiovasc Nurs. 2017;32(6):594-602. doi: 10.1097/JCN.0000000000000403. [PubMed: 28398917]. [PubMed Central: PMC5633482].

  • 21.

    Carayon P, Wetterneck TB, Rivera-Rodriguez AJ, Hundt AS, Hoonakker P, Holden R, et al. Human factors systems approach to healthcare quality and patient safety. Appl Ergon. 2014;45(1):14-25. doi: 10.1016/j.apergo.2013.04.023. [PubMed: 23845724]. [PubMed Central: PMC3795965].

  • 22.

    Aamodt MG. Academic ability and student preference for discussion group activities. Teach Psychol. 2016;10(2):117-9. doi: 10.1207/s15328023top1002_22.

  • 23.

    Jaarsma T, Halfens R, Cleuren G. [Education and guidance of a patient with chronic heart failure. A case study]. Verpleegkunde. 1997;12(4):205-16. Dutch. [PubMed: 9469126].

  • 24.

    Jaarsma T, Halfens R, Huijer Abu-Saad H, Dracup K, Gorgels T, van Ree J, et al. Effects of education and support on self-care and resource utilization in patients with heart failure. Eur Heart J. 1999;20(9):673-82. doi: 10.1053/euhj.1998.1341. [PubMed: 10208788].

  • 25.

    Rosenberg M. Society and the adolescent self-image. United States of America: Princeton University Press; 1965. doi: 10.1515/9781400876136.

  • 26.

    Poorgholami F, Javadpour S, Saadatmand V, Jahromi MK. Effectiveness of self-care education on the enhancement of the self-esteem of patients undergoing hemodialysis. Glob J Health Sci. 2015;8(2):132-6. doi: 10.5539/gjhs.v8n2p132. [PubMed: 26383201]. [PubMed Central: PMC4804061].

  • 27.

    Rajabi G, Bohloul N. Reliability and validity assessment of Rosenberg self-esteem scale among students. Psychol Educ Res. 2007;3(2):33-48.

  • 28.

    Guillon MS, Crocq MA, Bailey PE. The relationship between self-esteem and psychiatric disorders in adolescents. Eur Psychiatr. 2003;18(2):59-62. doi: 10.1016/s0924-9338(03)00002-6.

  • 29.

    Rahimi A, Ahmadi F, Gholyaf M. Effects of applying continuous care model on self esteem in hemodialysis patients. J Zanjan Univ Med Sci. 2005;13(53):16-21.

  • 30.

    Sanaie N, Bahramnezhad F, Zolfaghari M, Alhani F. The effect of family-centered empowerment model on treatment plans adherence of patients undergoing coronary artery bypass graft. J Crit Care Nurs. 2016;In Press(In Press). doi: 10.17795/ccn-6494.

  • COMMENTS

    LEAVE A COMMENT HERE: