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Purpose of the theory:

To help nurses know and understand the major determinants of health behaviors as a foundation for behavioral counseling to promote well-being and healthy lifestyles

Acts as a complementary counterpart to models of health protection.

Develops to incorporate behaviors for improving health and applies across the life span.

Scope or level of theory:

Middle-range theory

Origin of theory:

first published in 1982; later improved in1996 and 2002.

Major Concepts:
1. Health promotion
2. Health protection
3. Individual characteristics and experiences
4.Behavior-specific cognitions and affect
5.Behavioral outcomes

(Parveen, 2021)

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Results show HPM-based training can positively affect and improve overweight/obese women’s nutritional behaviors.

Recommends that the nutritional behaviors should be changed through promoting people’s education about nutrition so that inappropriate nutritional behaviors are replaced with appropriate nutritional ones.

(Khodaveisi, Omidi, Farokhi, Soltanian, 2017)

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Background:

Changes in lifestyle and eating habits have put women at risk of obesity and overweight more than ever. This aim of this study was to investigate the effect of Pender's Health Promotion Model (HPM) to improve the nutritional behavior of overweight and obese women admitted to Fatemiyeh Hospital clinics in Hamadan, west Iran in 2015.

Methods:

In this quasi-experimental study, 108 eligible women were selected and randomly assigned to two groups: one experimental and one control. Data were gathered using three questionnaires: demographics, Pender's HPM constructs, and nutritional behavior. The questionnaires were filled out by both groups as pre-test and two months later. A Pender's HPM-based intervention was conducted for the experimental group. The data were analyzed by paired and independent t-tests, ANCOVA, and Spearmans' correlation coefficient in SPSS/16. The level of significance was considered to be <0.05.

Results:

The mean score of nutritional behavior was 41.75±3.28 and 42.36±3.69 before the intervention and 79.09±5.27 and 49.72±9.49 after it in the experimental and control groups, respectively. The difference was significant only between before and after the intervention in the experimental group (P<0.001). Furthermore, the mean scores of the following variables were significantly different between before and after the intervention in the experimental group: nutritional behavior, perceived benefits, perceived self-efficacy, commitment to action, interpersonal and situational influences, behavior-related affect, and perceived barriers (P<0.001).

Conclusion:

The results showed that Pender's HPM-based training improved nutritional behavior and some constructs of the model. Therefore, this educative model can be used by healthcare providers to improve the nutritional and other health promoting behaviors.

Pender's health promotion model, Obesity, Women, , Nutritional behaviours

INTRODUCTION

Obesity is the most important nutritional disease in developed and developing countries, and has quickly become prevalent in the recent decades. Studies have shown that changes in lifestyle and certain factors such as inappropriate nutritional behaviors, stress, and physical inactivity are important causes of obesity. Obesity has been known as a chronic disease and a major risk factor for hypertension, cardiovascular diseases, diabetes, and impaired quality of life, from both psychosocial and physiological perspectives, in men and women since 1985.

Practicing health-promoting behaviors is one of the best approaches to maintain health. Health-promoting behaviors include activities that enable people to monitor their health and are, therefore, useful to improve individual and community health. In this regard, the results of different studies show that education and intervention about nutrition can be effective if it emphasizes behavior rather than just knowledge.

Pender's health promotion model (HPM) is one of the widely used models to plan for and change unhealthy behaviors and promote health. Different studies have highlighted the efficiency of this model to control unhealthy behaviors. The HPM is based on social cognitive theory according to which cognitive-perceptual factors (perceived benefits, barriers, and self-efficacy) influence engagement in health-promoting behaviors. Modifying factors (demographic characteristics, interpersonal influences, and behavioral factors) are considered to interact with each other to influence cognitive perceptual processes. The Pender's HPM consists of variables that comprise the main part of the interventions. These components provide a rich source of interventional content and strategies. The increasing rate of obesity and strong influence of lifestyle factors, including diet, on the etiology of obesity have been frequently reported by the studies conducted in the western world, but the evidence is limited on developing countries.

This quasi-experimental study was conducted using two groups, and pre-test and post-test to examine the effect of the Pender's HPM on nutritional behaviors of overweight women. The study protocol was approved by the Ethics Committee of the Hamadan University of Medical Sciences (approval no: p/16/35/9/5858) and written informed consent was obtained from the participants. The participants were enrolled from October 2014 to May 2015. The study population consisted of all overweight women referring to Fatemiyeh Hospital clinics in Hamadan in 2015. The sample size was decided to include 54 people in each group, according to the formula below, according to a similar study and considering test power: 80%, α: 0.05, mean difference: 1.6, dropout rate: 20% and SD: 2.97, 2.89. Accordingly, 108 women who met the inclusion criteria were selected by random convenience sampling and randomly assigned to two groups of 54 each, experimental and control, by random number table.

The inclusion criteria were being 18-60 years old, having body mass index (BMI) of 25 and higher, having physical ability, not being pregnant or breast feeding, having no underlying diseases influencing adherence to diet and diagnosed by a physician, being consent to participate in the study, not experiencing any acute events resulting in mental and physical problems within the previous month, and not using medications affecting obesity (e.g. oral contraceptive pills). Exclusion criteria were withdrawal from the study for any reasons such as death or movement and absence in more than one session.

The data were collected using these researcher-developed inventories: A. a demographic and BMI data inventory consisting of 10 items; B. an inventory on the components of the Pender's HPM, including perceived benefits (11 items), perceived barriers (11 items), perceived self-efficacy (12 items), and behavior-related affect, (11 items), interpersonal influences (12 items), and situational influences (5 items) with five-point Likert scale (5: very high, 4: high, 3: relative, 2: low, and 1: very low); and commitment to action (12 items) with four-point Likert scale (1: never, 2: sometimes, 3: often, and 4: always); C. nutritional behavior inventory consisting of 20 items with four-point Likert scale (1: never, 2: sometimes, 3: often, and 4: always). The scores were categorized into three levels: favorable (mean score of higher than 75), partly favorable (mean score between 75-50), and unfavorable (mean score of less than 50).

To ensure the content validity, the inventories were developed using reliable scientific resources and 10 experts confirmed their content validity. The reliability of the inventories was determined using test-retest. Each of the components and the entire test showed an acceptable reliability, as the overall reliability was 0.854. In this study, the inventories were filled out by both groups in the pretest. A training intervention was then held for the experimental group through lectures, questioning and answering, and group discussions in three 30-minute sessions within two weeks in the Lecture Hall of Fatemiyeh Hospital. In the first session, certain materials about the benefits of healthy nutritional behaviors and practical skills to promote them were presented. In the second session, the barriers to healthy nutritional behaviors and the ways to overcome them were presented. In the third session, the measures to promote women's self-efficacy and commitment to healthy nutritional behaviors were presented.

On the completion of the training sessions, a training manual with a content based on the interventional strategies to change the components of the model was given to women in the experimental group, and they were asked to apply the nutritional behavior promotion program in daily life. The post-test was administered two months after the intervention.

Certain indexes, such as mean, standard deviation, and contingency tables were used to describe the data. Paired t-test was used to compare mean values before and after the intervention in each group, and independent t-test to compare the data of the two groups after the intervention. Analysis of covariance was used to compare the scores of components after the intervention in both groups. Spearman's correlation coefficient was used to determine the correlation between nutritional behavior and the components of the Pender's HPM and demographic characteristics. The significance level was considered to be <0.05, and SPSS/16 was used to analyze the data.

The mean age of the participants was 38.09±9.34 and 38.5±9.11 years, and mean BMI 29.12±2.12 and 29.09±24 in the experimental and control groups, respectively. The Independent t-test did not show any significant difference in age, BMI, educational level, occupation, place of residence, number of children and family size, and parity between the two groups (P>0.05). Therefore, the participants in the two groups were matched for demographic variables.

shows the overall and qualitative comparison of the nutritional behaviors between the experimental and control groups before and after the intervention. Overall and qualitative comparison of the nutritional behaviors between the two groups demonstrated that the number of people with nutritional behaviors at the unfavorable level decreased and the number of people with nutritional behaviors at the favorable level increased ().

Independent t-test showed that the two groups were to a large extent similar in terms of the components of healthy nutritional behaviors before and after the intervention (). According to paired t-test, in the experimental group, there was a significant difference between the mean scores of perceived benefits, perceived barriers, perceived self-efficacy, behavior-related affect, interpersonal and situational influences, commitment to action, and nutritional behaviors between before and after the intervention (P<0.001) ().

Table 3

and show the results on the correlation of nutritional behavior with the components of the Pender's HPM and demographic characteristics of the two groups. The analysis showed that there was a significant relationship between educational level and nutritional behaviors (Anova); also, there was a significant correlation with feeding behavior between married and location)Independent t test).

DISCUSSION

In this study, 87.1% of the women in the experimental group had breakfast after the intervention; this result is consistent with Khodaveisi's study but inconsistent with Lee's study. The inconsistency might be due to cultural and social differences because Iranian families insist on having breakfast, as there are relevant proverbs in Persian language. The healthy nutritional behaviors, in the experimental group, improved after learning the perceived benefits. Similarly, in a study conducted by Gomes Guedes et al.'s study, the mean score of perceived benefits significantly changed after the intervention.

There was a significant difference in the mean score of interpersonal influences before and after the intervention in the experimental group. Studies show that if an individual has positive attitudes toward a behavior, and significant others confirm the performance of that behavior, he decides to perform that behavior. Therefore, people are more likely to perform healthy nutritional behaviors when they feel their family members and relatives expect and encourage them frequently to perform those behaviors. In this study, nurses and physicians were the most influential people on healthy nutritional behaviors in terms of interpersonal norms; this finding highlights the role of nurses in health promotion. Besides, children and husbands were the most influential people on healthy nutritional behaviors in terms of interpersonal modeling; this emphasizes the role of social support following health-promoting behaviors. Thus, failure of husband and even children to cooperate with the mother in making appropriate changes in lifestyle may be a barrier to adherence to healthy nutritional behaviors. SooYoung et al. showed that if parents have higher levels of knowledge about appropriate nutritional patterns, adolescents consume healthy foods, such as fruit and vegetables, more frequently. Jenkins et al. emphasized the role of parents as a main constituent of behavior moderating programs in adolescents. However, Ramezani showed that children are interested in nutritional pattern of their family, including mother. Accordingly, it can be argued that there is a reciprocal relationship between nutritional behavior of mothers and children.

In this study, BMI significantly correlated with high-salt snacks, sweetened beverages, and different sandwiches. Menezes et al.'s study showed a significant correlation between some body composition indexes and the consumption of fat and sweet foods.

There was a positive, significant correlation between perceived self-efficacy and nutritional behaviors. In other words, the more strictly people adhere to healthy nutritional behaviors regardless of their conditions and facilities, the more likely they are to become successful in this regard. This finding is consistent with Denise et al.'s study. Clinical trials have also shown that self-efficacy promotion programs are effective, and people's self-efficacy and nutritional habits and behaviors may become more health-oriented after training interventions. Iranagh et al. emphasized that instructors of healthy nutrition should pay attention to self-efficacy, as an important index, in implementing training interventions.

A positive significant correlation was found between situational influences and nutritional behaviors in this study; this result is in agreement with Khodaveisi et al.'s study1 but inconsistent with Bahmanpour et al.'s study. The participants were most likely to practice healthy nutritional behaviors at home and workplace. This result was not unexpected because of easy access to food and the fact that people spend most of the time in these locations.

Based on the results, training programs in this study did not significantly change the BMI and weight in the experimental and control groups, which was not unexpected given the relative short duration of the studied intervention. However, continuous implementation of such interventions with appropriate strategies can cause desired changes. Studies have shown that a slight decrease in weight and BMI improves health. Although a weight loss of 2-3 kg may not be desirable to parents, they should be informed that a slight loss of weight can reduce many disease risk factors.

A limitation of this study was that it was not possible to observe nutritional behaviors, and thus nutritional behaviors were examined using a self-report questionnaire. This might result in insufficiently accurate description of some variables. The strength of this study was high participation rate of the participants in the training sessions, which can imply their consent to and support of the nutritional behavior promoting interventions.

CONCLUSION

The results showed that the Pender's HPM-based training can positively affect and improve the women's nutritional behaviors. Therefore, it is recommended that the nutritional behaviors should be changed through promoting people's knowledge about nutrition so that inappropriate nutritional behaviors are replaced with appropriate nutritional ones. Furthermore, it is recommended that programs should be made on the effects of mass media, especially television, and sociocultural factors on nutritional behaviors, obesity, and prevalence of chronic diseases. Considering that a major constituent of nutritional pattern in a community is the collection of nutritional habits, culture, and public knowledge, and that nutritional habits and behaviors differ from one community to another, interventions on nutritional behaviors should be adapted to the cultural context of communities.

Regarding the results of this study, health care authorities are recommended to develop training programs to promote nutritional behaviors and inform families, especially women, about healthy foods, methods of cooking healthy and diverse foods that are adaptable to taste of all family members, and appropriate lifestyle including regular exercise, reducing television viewing duration, reducing the consumption of fatty and fast foods, and increasing the consumption of fruits and vegetables to control weight and prevent all types of obesity.

ACKNOWLEDGEMENT

This study was derived from an MSc thesis entitled "Use of Pender's Health Promotion Model for Improvement of Nutritional Behaviors in Overweight Women admitted to Clinics of Fatemiyeh Hospital in Hamadan" funded by Hamadan University of Medical Sciences (grant no. 6228). The authors gratefully thank the professors and authorities for their sincere cooperation with this study.

Conflict of Interest: None declared.

5. Atanda-lawal B. Health Promotion for overweight Children between the ages of 7 to 12 [thesis] Germany: University of Applied Sciences; 2012. [ Google Scholar]

11. Pender NJ, Murdaugh CL, Parsons MA. Health Promotion in Nursing Practice. 6th ed. Boston, MA: Pearson; 2010. [ Google Scholar]

23. Health Canada. Canada's food guide. Ottawa, Canada: Minister of Health Canada; 2011. [ Google Scholar]

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The Effect of Pender's Health Promotion Model in Improving the Nutritional Behavior of Overweight and Obese Women

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Changes in lifestyle and eating habits have put women at risk of obesity and overweight more than ever. This aim of this study was to investigate the effect of Pender's Health Promotion Model (HPM) to improve the nutritional behavior of overweight ...

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Educational intervention based on Pender's HPM is more effective on treatment adherence than the routine method in the patients with CAD. It is recommended to integrate Pender's HPM into practice as a nursing care program for these patients.

(Faroughi, Shahriari, Keshvari, Shirani, 2021)

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Abstract

Background:

Increasing of hospitalization rates of Coronary Artery Disease (CAD) management have created major challenge for the health system. Poor adherence to treatment is one of the main reasons for treatment failure, prolongation of treatment, and increase care costs. The aim of this research was to determine the effect of educational intervention based on Pender's Health Promotion Model (HPM) on adherence in patients with CAD.

Materials and Methods:

This randomized controlled clinical trial was held in an educational hospital in Isfahan, Iran, February 2018-May 2019. Data were collected from 64 patients with CAD, before, 1 and 3 months after the intervention. The instrument used included treatment adherence questionnaire and a checklist Pender's HPM. The study group received dietary, exercise, and medication education based on Pender's HPM in four sessions which were held in 4 weeks. The control group received the routine educational program of the hospital. The data was analyzed using descriptive statistics, repeated measures ANOVA, independent t, Chi-square, and Mann-Whitney tests via SPSS software.

Results:

The mean score of treatment adherence was significantly different between two groups in one (z = 5.28, df = 2, p < 0.001) and three (z = 4.51, df = 2, p < 0.001) months after the intervention. The mean (SD) of treatment adherence in the study group was 139.82 (27.44) 3 months after the intervention.

Conclusions:

Educational intervention based on Pender's HPM is more effective on treatment adherence than the routine method in the patients with CAD. It is recommended to integrate the Pender's HPM as a nursing care program for these patients.

Keywords: Coronary artery disease, health promotion, Iran, nursing, treatment adherence and compliance

Introduction

Cardiovascular diseases, especially Coronary Artery Disease (CAD) are the most common causes of disability and mortality in the most of the countries in the world wide.[ 1] The prevalence of CAD and subsequent mortality are increasing in Iran and account for almost 43% of all deaths per year[ 2] and in Isfahan is 19.4%.[ 3] Considering the increase in the number of the people with chronic diseases in recent years, healthcare providing systems have experienced many problems in providing care for these patients. In this regard, many believe that in order to organize these patients for recovery and health promotion, care must be provided by the individual.[ 4] Based on definition of the World Health Organization (WHO), adherence is the level of behavior performed by a person includes medication, diet or lifestyle changes in accordance with the recommendations provided by health care personnel.[ 5]

Non-adherence treatment is one of the reasons for treatment failure, increased complications, prolonged treatment, and increased in health costs.[ 6] The Pender's Health Promotion Model (HPM) is comprehensiveness and application in recognizing behavioral determinants to predict health-promoting behaviors in the field of lifestyle, exercise, and eating habits.[ 7] The predictive and explanatory structures of health behavior in this model include of perceived benefits, perceived barriers, feelings related to behavior, perceived self-efficacy, interpersonal and situational influences.[ 8] Pender's HPM tries to promote the health status by benefiting from individual's experiences and characteristics, their emotions, specific cognition, and behavioral outcomes.[ 9] This model is mostly used in chronic diseases such as diabetes and kidney diseases. In the study of Gulumser et al., application of Pender's HPM was used in post myocardial infarction patients.[ 10]

Regarding the widespread prevalence of cardiovascular diseases and their complications, unsuccessful current methods on improve of adherence treatment and lack of studies about effects of application of Pender's HPM on adherence treatment in patients with CAD. This research aimed to investigate the effect of Pender's HPM on the treatment adherence in the patients with CAD.

Materials and Methods

This 2-group, 3-stage clinical trial (IRCT20180227038886N1) was conducted from February 2018 to May 2019. 64 participants were recruited from patients who admitted to the cardiac wards of an educational hospital in Isfahan, Iran. The sample size considering similar studies[ 11] and the confidence interval of 95% and test power of 80% was calculated as 25 subjects in the study and control group. Based on the researcher's assumption of a 20% drop in the number of subjects, 32 subjects were assigned to each of the two groups. The subjects were selected in terms of the inclusion criteria using convenience sampling method, and were then random allocation assigned into two groups of study and control. To fulfil this, one Card No. 1 and one Card No. 2 were placed in closed pocket. The people who selected Card No. 1 were placed in the study group and the people who selected Card No. 2 were placed in the control group. Inclusion criteria included the patients diagnosed with CAD, a history of at least 6 months of CAD, the physician's permission regarding the patient's participation in the program, patients aged 30-75 years old, lack of simultaneous participation in the educational intervention during the research, and having at least a reading and writing literacy for the patient or family caregivers. Exclusion criteria were as follows: unwillingness to continue participating in the intervention, irregular participation in the educational program or being absent in more than two sessions, failure to complete the questionnaire, and patient death or any problem in a way that the patient cannot continue participating in the research.

The data collection tool was a four-section questionnaire and a check list of constructs of Pender's HPM. The first part included demographic characteristics. The second part contained of 30 questions on dietary regimen. This part of the questionnaire was scored based on 5-point likert scale ranging from 0 (non-healthy diet behaviors) to 4 (completely healthy diet behaviors). The maximum and minimum scores were from 0 to 120. The third part consisted of 10 questions on medication adherence. These items were from 0 (non- optimal adherence) to 4 (optimal adherence). The maximum and minimum scores were from 0 to 40. The fourth part of the questionnaire was related to the exercise scale with 14 items, which scoring from 0 (non-optimal adherence) to 4 (optimal adherence). The maximum and minimum scores were from 0 to 56. Finally total scoring for this questionnaire was from 0 to 216. The scores below 50% (scores below 108), 50-75% (scores between 108 and 162), and above 75% (scores above 162), were indicated the non-optimal, relatively optimal, and optimal adherence, respectively.[ 12] A checklist with 112-item was used to evaluate the constructs of Pender's HPM in three domains of dietary, exercise, and medication. Perceived benefits were categorized into all three domains using a 4-pont Likert scale (agree, to some extent agree, disagree, to some extent disagree) and other questions were divided into three domains using a Likert scale (high, somewhat, low). The possible score range in Pender's model was 0-352 and the scores were then turned into percentages. The non-optimal, relatively optimal, and optimal adherence rates were indicated using the scores below 50% (scores below 176), 50-75% (scores between 176 and 264) and above 75% (scores above 264), respectively.[ 7] Validity and reliability of the questionnaire on adherence to the treatment regimen was measured by Sanaei et al. The reliability of this instrument has been estimated as r = 0.83 based on test-retest. Content validity was used to determine the validity of this tool.[ 13]Validity and reliability of the Pender's model checklist were determined by Khodaveisi. The validity of this checklist was examined by 10 experts in the field, and the reliability of that was reviewed using test-retest method.[ 7]

After getting informed written consents and giving information to the all participants and his/her companion about the questionnaire and checklist, they were completed by samples of two groups before the discharge from hospital. In this research, based on the extracted valid texts and educational needs and the views of the expert physician and the research team, important aspects of adherence to the dietary, medication, and exercise regimen of the CAD patients were extracted. Lecture, question and answer; and group and individual discussion methods were used to eliminate the treatment adherence barriers and move toward increased treatment adherence and use of group experiences in the training sessions. In the study group, in order to establish better communication and create better dynamics among the subjects, the samples were divided into one group consisting of 10 individuals and two groups with 11 individuals. The researcher then coordinated with them for the training sessions. The sessions were held in the research environment during the morning shift. To remind the individuals their sessions, they were contacted the day before each session. The Pender's HPM-based group care program was held for each of the three groups in four consecutive sessions in each week by researcher team. Each session lasted 45-60 min. The training of each course was delivered to the participants as a manual at the end of each session. After conducting this educational program, the telephone follow-up was done by the researcher once every 2 weeks for 5-10 min. and the patients talked about the care program, the removal of implementation barriers, and the questions. In control group, a session was held on the importance of the medication, dietary, and exercise regimen. In addition, they received a booklet on the importance of the treatment regimen. By passing 1 month and 3 months from the completion of the interventions,[ 14] the questionnaire was recompleted by both of the groups after the coordinating with them regarding the right time, we had three drop-out cases in the samples of each groups []. In order to achieve the research results, the data was collected and analyzed by descriptive, repeated measures ANOVA to measure the effect of intervention at different times, independent t-test, Chi-square, and Mann-Whitney tests to measure demographic data and mean score via SPSS ver. 18 (version 18, SPSS Inc., Chicago, IL, USA).

Ethical considerations

This study was approved by the Ethics Committee in Research (IR.MUI.REC.1396.3.916). The participants were informed of the purpose and procedure of the study. Also, participation was voluntary and written informed consent was obtained and they could leave the study at any stage. In addition all the participants were assured about the confidentiality of their personal data.

Results

A total of 58 patients participated in the research. Chi-square and Mann-Whitney tests showed no significant difference between two groups in terms of their mean age, height, frequency distribution of gender, and education level. Independent t and Mann-Whitney tests showed differences between two groups in terms of the pre-intervention weight and BMI variables, respectively. By covariance analysis, control effect of these two variables were performed and showed that weight and BMI had no effect on the results of this research []. Results of the independent t and Mann-Whitney tests on Pender's model showed no significant difference between two groups in Pender's dietary exercise and medication variable [].

Table 1

Table 2

Independent t-test showed no significant difference between two groups in terms of the mean scores of adherence to the medication, dietary, and exercise regimen before the intervention (t = 1.69, P = 0.09). This test also showed a significant difference between two groups in terms of the mean score of adherence to the medication, dietary, and exercise regimen between one (z = 5.28, df = 2, p < 0.001) and three (z = 4.51, df = 2, p < 0.001) months after the intervention. To compare the medication, dietary, and exercise adherence for two groups before, 1 month and 3 months after the intervention; repeated measures ANOVA was performed by assuming the normal data distribution. The results showed that, medication, dietary, and exercise adherence were significantly different between the study and control groups at three times of before, 1 month and 3 months after the intervention; that is, it was higher in the study group. Also, the results of Bonferroni-corrected post-hoc test showed the significant differences between two groups before and 1 month after intervention and before and 3 months after the intervention and there was also no statistically significant difference between 1 and 3 months after the intervention [Tables -].

Table 3

Table 5

Table 4

Variable

Mean (SD)

ANOVA with repeated measures before, one month and three months after intervention

Bonferroni test

Before intervention

One month after intervention

Three months after intervention

Before and one month after intervention

Before and three months after intervention

One and three months after intervention

Discussion

The aim of this research was the effect of an educational intervention based on Pender's HPM on treatment adherence in the patients with CAD. Based on the result, there was significant difference in medication adherence between two groups 1 and 3 months after the intervention. The results of Fakhri research showed that theory planned behavior affected the improvement of medication adherence in hypertensive elderly.[ 15] It is in line with the results of the present study, which can be because of the evaluation of the patient's needs and attention to them and coverage of the needs of the study group during the intervention. However, the study of Luu showed that the level of adherence to anticoagulants gradually decreased over the follow-up period at 1 month, 6 months, and 1 year after the onset of drug usage.[ 16] The study of Matsuda and Kohno showed that education program was effective in accepting the drug therapy; however, it did not change their knowledge on the disease and the complications of drug therapy.[ 17] The difference in the results of these researches may be because of the different patients under research, the different clinical environment, the different durations of follow-ups, and the difference in intervention methods.

Results showed no significant difference between two groups in terms of the mean score of adherence to the dietary regimen before the intervention, but there was a significant difference between two groups 1 and 3 months after the intervention. The results of Karimi et al.'s research showed that the health belief model based on education model can remove the perceived barriers and improve the performance of this group of mothers in terms of dietary adherence by increasing their perceptions of risk factors and making them aware of the benefits of behavioral changes.[ 18] When the effective factors of non-adherence to the patient's treatment are identified in the training program and during the training to try to eliminate them and emphasize the benefits of adherence and the patient is encouraged to improve the current situation and maintain interaction with the patient can help increase treatment adherence. Research of Shively showed in their research that self-management program has a positive effect on improving the patients' adherence to dietary regimen, but this effect is not statistically significant.[ 19] The difference between the results of the above-mentioned research and the present research may be because of the differences in the durations of the follow-ups, difference in natures of the disease, difference in the patients under the research and difference in the intervention methods are among other reasons for such discrepancy.

There was no significant difference between two groups in terms of the mean score of exercise regimen before the intervention, but there was a significant difference between the study and control groups one and three months after the intervention. The study of Noroozi showed that an education by using constructs of perceived self-efficacy, perceived benefits and barriers, family support, and previous related behaviors could improve the mean of physical activity in the study group in the third and sixth months, which is consistent with the results of the present research.[ 20] The results of Moosavifar also demonstrated that telephone follow-up has a positive effect on improving the adherence to the exercise programs.[ 14]

There was no significant difference between two groups in terms of the mean score of treatment adherence that includes dietary, medication, and exercise adherence before intervention, but there was a significant difference between the study and control groups 1 and 3 months after the intervention. The study of Shahsavari showed that nurse-led telephone follow-up was an effective method for improving the glycemic and treatment adherence among the patients with type 2 diabetes, which is consistent with the results of the present research.[ 21] In addition, the results of Esmkhani showed that the implementation of educational program, lecture, discussion, exchange of views on treatment adherence would improve the quality of life of the patients with schizophrenia.[ 22]

Sedri's research showed that there was a significant difference among the three groups in terms of the adherence to the anticoagulant regimen after 3 months. The mean score of post-intervention adherence to the treatment regimen in the interactive group was higher than the other two groups, which is consistent with the results of the present research.[ 23] Deif et al. indicated that nurses can help the patients to learn the problem solving skills, determine their goals, and understand their progressions in managing multiple aspects of their disease. An educational approach can support the patient's self-management and be effective on increasing the adherence to the treatment regimen by combining beliefs, behaviors, and feelings of the patient, culture, economic status, ability, and knowledge of the disease and its treatment.[ 24] Explaining this finding, it can be said that the purpose of Pender's HPM is to encourage people to perform health behaviors by training and managing them properly, helping them to do properly and convincing people to change unhealthy habits. Motivating to want change by increasing one's sense of self-efficacy and changing one's attitudes and beliefs is one of the key steps to growth and self-fulfillment.

The study of Dehdari showed that Pender's model can improve interpersonal communication, increase the power of perception and self-efficacy, and improve the health culture and dietary patterns.[ 25] Educational intervention based on Pender's HPM has been more effective than routine training programs by paying more attention to the characteristics and experiences of the samples and focusing on the perceived barriers and perceived benefits, feelings, self-efficacy, interpersonal and situational influences and behavioral outcomes. A limitation of this study was that patients might not participate in the training classes, so attempts were made to partly resolve this problem by changing the session time to a time when they all can participate in it after coordinating with them but we had drop-out cases.

Conclusion

The results indicate that the application of the Pender's HPM has been more effective on the various components of therapeutic adherence, including medication, dietary, and exercise adherence in patients with CAD. Since adherence to the treatment regimen, in addition to playing an important role in controlling the patient's disease, will also be effective on controlling the costs imposed to the health system; the necessary training should be given to these patients on the value of adherence to the treatment regimen including medication, dietary and exercise and we suggest that an educational intervention based on Pender's HPM is implemented in patients with CAD and other researchers are advised to conduct such a study for a longer period of time.

Financial support and sponsorship

Isfahan University of Medical Sciences

Conflicts of interest

Nothing to declare.

Acknowledgments

Hereby, the authors would like to express their gratitude to the Vice-Chancellor for Research of Isfahan University of Medical Sciences (Project No: 396916) for its financial support and all those who have helped them in this research. We are thankful to the patients who participated in this study.

References

2. World Health Organization. Noncommunicable Diseases Country Profiles 2018. WorldHealthOrganization 2018. 2018. (Noncommunicable diseases country profiles 2018. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO.):CIP data are. available from: https://apps.who.int/iris/handle/10665/274512 .

17. Matsuda M, Kohno A. Effects of the nursing psychoeducation program on the acceptance of medication and condition-specific knowledge of patients with schizophrenia. Arch Psychiatr Nurs. 2016;30:581-6. [[ PubMed] Google Scholar]

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The Effect of an Educational Intervention based on Pender's Health Promotion Model on Treatment Adherence in the Patients with Coronary Artery Disease

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Increasing of hospitalization rates of Coronary Artery Disease (CAD) management have created major challenge for the health system. Poor adherence to treatment is one of the main reasons for treatment failure, prolongation of treatment, and increase care costs.