1

EFFECTIVENESS OF HEART SMART PACKAGE ON

KNOWLEDGE AND SKILL REGARDING PREVENTION
OF CORONARY ARTERY DISEASE AMONG AT RISK
CLIENTS ATTENDING CHRONIC OUTPATIENT
CLINICS AT SELECTED SETTING,
ANDHRA PRADESH

DISSERTATION SUBMITTED TO
THE TAMIL NADU Dr.M.G.R. MEDICAL UNIVERSITY,
CHENNAI.
IN PARTIAL FULFILLMENT OF REQUIREMENT FOR THE DEGREE
OF
MASTER OF SCIENCE IN NURSING
 2

APRIL 2016

Internal Examiner:

External Examiner:
 3

EFFECTIVENESS OF HEART SMART PACKAGE ON

KNOWLEDGE AND SKILL REGARDING PREVENTION
OF CORONARY ARTERY DISEASE AMONG AT RISK
CLIENTS ATTENDING CHRONIC OUTPATIENT
CLINICS AT SELECTED SETTING,
ANDHRA PRADESH

Certified that this is the bonafide work of

Mrs. K. Gayathri
Omayal Achi College of Nursing,
No.45,Ambattur road,Puzhal,Chennai-600 066.

COLLEGE SEAL:

SIGNATURE :
Dr.(Mrs) S.KANCHANA
R.N., R.M., M.Sc.(N).,Ph.D., POST DOC(RES)
Principal & Research Director,
Omayal Achi College of Nursing,
Puzhal,Chennai ± 600 066, Tamil Nadu.

DISSERTATION SUBMITTED TO
THE TAMIL NADU Dr.M.G.R. MEDICAL UNIVERSITY,
CHENNAI
IN PARTIAL FULFILMENT OF REQUIREMENT FOR THE DEGREE OF
MASTER OF SCIENCE IN NURSING
 4

APRIL 2016

EFFECTIVENESS OF HEART SMART PACKAGE

ON KNOWLEDGE AND SKILL REGARDING PREVENTION
OF CORONARY ARTERY DISEASE AMONG AT RISK
CLIENTS ATTENDING CHRONIC OUTPATIENT
CLINICS AT SELECTED SETTING,
ANDHRA PRADESH, 2015
Approved by the Research Committee in December 2014
PROFESSOR IN NURSING RESEARCH
Dr. (Mrs) S.KANCHANA _____________________
R.N., R.M., M.Sc (N)., Ph.D., Post Doc (Res).,
Principal & Research Director, ICCR,
Omayal Achi College of Nursing,
Puzhal, Chennai ± 600 066, Tamil Nadu.

MEDICAL EXPERT
DR. R. SIVAKUMAR MD., D.N.B., F.N.B (Cardio) _____________________
Interventional Cardiologist,
Billroth Hospital,
Chennai.

CLINICAL SPECIALITY - HOD

Prof. Mrs. M.SUMATHI, _____________________
R.N., R.M., M.Sc.(N)., [Ph.D(N)],
Professor and Head of the Department,
Medical Surgical Nursing,
Omayal Achi College of Nursing,
Puzhal, Chennai ± 600 066, Tamil Nadu.

CLINICAL SPECIALITY - RESEARCH GUIDE

Prof. Mrs. JOLLY RANJITH _____________________
R.N., R.M., M.Sc.(N). [Ph.D(N)],
Professor, Medical Surgical Nursing,
Omayal Achi College of Nursing,
Puzhal, Chennai ± 600 066, Tamil Nadu.

DISSERTATION SUBMITTED TO

THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY

CHENNAI
IN PARTIAL FULFILMENT OF REQUIREMENT FOR THE DEGREE OF

MASTER OF SCIENCE IN NURSING

APRIL 2016
 5

ACKNOWLEDGEMENT

³*UDWLWXGH LV WKH IDLUHVW EORVVRP ZKLFK VSULQJV IURP WKH VRXO LW FDQ QHYHU EH
expressed in words but, this is the deep perception that makes the words to flow from
RQH¶VLQQHUKHDUW

First and foremost, I offer my thanksgiving to our supreme being the omnipotent
originator and ruler of the universe for giving me capacious support, advocacy and
abundant grace till the completion of my research work, and in every walk of my life.

At the outset, I wish to express my deep sense of gratitude to the Vice

Chancellor and Research Department of The Tamil Nadu Dr. M.G.R Medical
University, Guindy, Chennai for giving me an opportunity to undertake my
Postgraduate degree in Nursing at this esteemed university.

I owe my honest gratitude to the Managing Trustees of

Omayal Achi College of Nursing for giving me an opportunity to pursue my
Postgraduate education in this esteemed and value based institution.

I take this opportunity to place on record my substantial token of gratitude to

Dr.K.R, Rajanarayanan, B.Sc.,M.B.B.S., FRSH (London), Research coordinator,
ICCR and Honorary Professor in Community Medicine for his exemplary
encouragement, exhortation and guidance in completing this study.

It gives great pleasure to express thanks with an immense sense of gratitude and
respect to Dr. (Mrs.) S. Kanchana, Principal and Research Director, ICCR ,
Omayal Achi College of Nursing for her philosophical and thought provoking ideas,
constant motivation and tangible assistance which was a key for the successful
completion of the study.

I am immensely grateful to Dr. (Mrs.) D. Celina, Vice Principal,

Omayal Achi College of Nursing for her novelty and inspiration which was an
inducement to conduct the study.
 6

I also thank the Executive Committee Members of the International Centre for
Collaborative Research (ICCR) for their constructive comments and suggestions
during the research proposal, pilot study and mock viva presentation.

A special note of whole hearted gratitude to my esteemed research guide

Prof. (Mrs). Jose Eapen Jolly Cecily, for her eloquent and intelligent guidance, highly
instructive research mentorship, grammatical corrections, moral support and intuitive
corrections which guided me in the completion of my study.

I am greatly obliged to our beloved class coordinator Prof. (Mrs).Sumathi.M,

Head of the Department, Medical Surgical Nursing for her scholarly suggestions and
appropriate corrections throughout the study.

A sincere appreciation to all the HODs and faculty for their constructive ideas
and comprehensive review during the progress of my study.

I express sincere gratitude to Prof. Venkatesan, Biostatistician for his help in

analyzing the data involved in the study.

I am very much greatful to Mr.Yayathee Subbarayalu, Senior Research fellow

(ICMR) , for his guidance in the statistical analysis of research effort.

I extend my honor of thanks to all the Nursing and Medical experts for their
valuable suggestions in validating the tool for the study.

An exceptional note of gratitude to Mr.J.Victor Dhanaraj, Headmaster,

Shree J.T.C. Jain Mission Higher Secondary School and
Dr. J. Kondala Rao MA.,MPhil.,Ph.D (Telugu) S.G.R Arts College, T.T.D., Tirupathi.
for editing this manuscript and tool in English and Telugu respectively.

I immensely thankful to the Medical Director and Head of the Department of

Medicine , RUSH Multispecialty Hospital, Tirupathi, Andhra Pradesh, for granting me
permission to conduct the pilot study and main study, and the staff of OPD for enabling
the smooth co-ordination of the study

I extend my sincere thanks to all the participants who were part of this research
lending thier co-operation and participation in completing the study.
 7

I accord my deepest thanks to Mr. Balakrishna, M.P.T for his training on Heart
Healthy exercises, without which the Heart Smart Package would not have been a
successful.

I am extremely thankful to Mr.G.K.Venkataraman, Elite Computers, for his

commitment and tireless spirit to convert this manuscript into a dissertation.

I thank all my dear senior M.sc students (2013-2015 Batch) and my own batch
mates M.Sc Nursing(2014 - 2016 Batch) for their constructive ideas and suggestions
and camaraderie throughout the two year period.

I acknowledged with deep sense of gratitude my peer reviewers

Ms. ThilagavathyT.L Ms. Monicka James Victor, Mrs.S. Pichammal, Ms. D. Anisha
Mary and Mrs.N.R. Beny for their tireless help, peer review and critiquing, which
helped me to mould my study.

Words are beyond my expressions for their blessings, advise and support of my
parents Mr. Chiranjeevi and Mrs. Radha and my dearest brothers Mr. Ramesh and
Mr. Kiran

A special memorable note of heartfelt thanks to my husband Mr. Sudhakar and

my life, Baby Yasthaa for their never failing care, everlasting love, constant
encouragement, financial support, positive reinforcement, sacrifice and guidance
throughout course, which strengthened to me fulfill my dream come true .

My whole hearted bunch of thanks to my lovable friends Ms. Pushpa Vetti,

Ms. Ramyasudha, Ms. Vimala Kumari and Ms. Geetha for their splendid affection
care and concern which motivated me throughout the study.

Finally, I thank each and everyone who helped directly and indirectly to complete
my research study successfully.
 8

LIST OF ABBREVIATIONS

ANOVA - Analysis Of Variance

BMI - Body Mass Index
BP - Blood Pressure
CAD - Coronary Artery Disease
CHD - Coronary Heart Disease
CHF - Congestive Heart Failure
CV - CardioVascular
CVD - CardioVascular Disease
DALYs - Disability Adjusted Life Years
DM - Diabetes Mellitus
ECG - ElectroCardioGram
HDL - High Density Lipoprotein
HSP - Heart Smart Package
HTN - Hypertension
IHD - Ischemic Heart Disease
KAP - Knowledge, Attitude and Practice
LDL - Low Density Lipoprotein
LMIC - Low and Middle-income Countries
LTPA - Leisure Time Physical Activity
MACE - Major Adverse Cardiovascular Events
MI - Myocardial Infarction
MVPA - Moderate-Vigorous Physical Activity
NCD - Non-communicable Disease
NPCDCS - National Programme for Prevention and Control of Cancer,
Diabetes, CVDs and Stroke
OPA - Occupational Physical Activity
PA - Physical Activity
PVD - Peripheral Vascular Disease
PYLL - Productive Years of Life Lost
RR - Relative Risk
SB - Sedentary Behavior
 9

SD - Standard Deviation
SES - Socio-Economic Status
SF - Saturated Fat
TC - Total Cholesterol
TV - TeleVision
US - United States
WC - Waist Circumference
WHO - World Health Organization
WHR - Waist Hip Ratio
 10

LIST OF SYMBOLS


F2 - Chi square
= - Equals To
< - Less than
> - More than
% - Percentage
+/- - Plus or minus
 11

TABLE OF CONTENTS

CHAPTER NO. CONTENT` PAGE NO.

ABSTRACT

1 INTRODUCTION

1.1 Background of the study 2

1.2 Significance and need for the study 10
1.3 Statement of the problem 14
1.4 Objectives 14
1.5 Operational definition 14
1.6 Assumptions 15
1.7 Null hypotheses 15
1.8 Delimitations 16
1.9 Conceptual framework 16
2 REVIEW OF LITERATURE
2.2 Sources of review of literature 21
2.3 Organization of review of literature 22
2.3.1 Critical reviews related to prevalence of CAD and its risk 22
factors
2.3.2 Critical reviews related to general awareness regarding 26
risk factors for CAD.
2.3.3 Critical reviews related to strategies for control of CAD 28
risk factors.
3 RESEARCH METHODOLOGY
3.1 Research approach 33
3.2 Research design 33
3.3 Variables 34
3.4 Setting of the study 34
3.5 Population 34
3.6 Sample 34
3.7 Sample size 35
3.8 Criteria for sample selection 35
 12

CHAPTER NO. CONTENT` PAGE NO.

3.9 Sampling technique 35
3.10 Development and description of the tool 35
3.11 Content validity 38
3.12 Ethical consideration 38
3.14 Reliability of the tool 39
3.15 Pilot study 40
3.16 Data collection procedure 41
3.17 Plan for data analysis 42
4 DATA ANALYSIS AND INTERPRETATION 44
5 DISCUSSION 69
6 SUMMARY, CONCLUSION, IMPLICATIONS, 74
RECOMMENDATIONS AND LIMITATIONS
REFERENCES 82
APPENDICES 91
 13

LIST OF TABLES
TABLE PAGE
TITLE
NO. NO.
1.1.1 Number of CHD deaths in different regions 2

1.1.2 The complete years of life lost due to CAD 7

1.1.3 Percentage of risk factors for CAD based on gender. 7

1.1.4 Prevalence of risk factors for CAD. 8

4.1.1 Frequency and percentage distribution of selected demographic 45

variables such as age, gender, education, occupation, marital status,
religion and area of residence in the experimental and control group.
4.1.2 Frequency and percentage distribution of selected demographic 46
variables such as type of family, family monthly income, family
history of CAD, nature of relationship with affected person and
history of co-morbid illness in the experimental and control group.
4.1.3 Frequency and percentage distribution of selected demographic 47
variables such as dietary pattern, any previous information regarding
prevention of CAD, source of information and habit of smoking in
the experimental and control group
4.1.4 Frequency and percentage distribution of selected biological 48
variables such as height, weight, BMI kg/m2 and fasting blood sugar
in the experimental and control group.
4.2 Frequency and percentage distribution of level of risk in the 49
experimental and control group
4.3.1 Frequency and percentage distribution of pretest level of knowledge 51
regarding prevention of CAD among at risk clients in the
experimental group.
4.3.2 Frequency and percentage distribution of post test level of 52
knowledge regarding prevention of CAD among at risk patients in
the experimental group
4.3.3 Frequency and percentage distribution of pretest level of knowledge 53
regarding CAD among at risk clients in the control group
 14

TABLE PAGE
TITLE
NO. NO.
4.3.4 Frequency and percentage distribution of posttest level of knowledge 54
regarding CAD among at risk clients in the control group
4.3.5 Frequency and percentage distribution of overall level of knowledge 55
score among the experimental and control group
4.3.6 Comparison of pretest and post test level of knowledge regarding 57
prevention of CAD among at risk clients in the experimental and control
group
4.3.7 Comparison of pre and post test level of knowledge regarding CAD 58
among at risk clients between the experimental and control group
4.4.1 Frequency and percentage distribution of post test level of skill 59
regarding prevention of CAD among at risk clients in the
experimental group
4.5 correlation of the post test level of knowledge with skill regarding 61
prevention of cad in the experimental group
4.6.1 Association of selected demographic variables with the mean 63
differed level of knowledge gain score regarding prevention of CAD
in the experimental group
4.6.2 Association of selected demographic variables with post test level of 66
skill in the experimental group
 15

LIST OF FIGURES

FIGURE
TITLE PAGE NO.
NO.
1.1.1 Main contributory factors for CVD and its complications. 5

1.1.2 Prospective studies of cardiovascular mortality in urban 6

and rural Indian population and the United States of
America.
1.1.3 High prevalence of two most common CV risk factors in 9
different decades of life.
1.1.4 Cluster of risk factors shown according to gender. 9

1.1.5 Comparison of population based Coronary Heart Disease 10

intervention, Cardiovascular Disease risk factors between
developed and developing countries.
1.9.1 Conceptual framework based on integrated WLHGHQEDFK¶V 19
Helping art of Clinical Nursing Theory and J.W.HQQ\¶V
Open System Model
3.1.1 Schematic representation of research methodology 43

4.2 Frequency and percentage distribution of level of risk in the 50

experimental and control group.
4.3.5 Frequency and percentage distribution of overall level of 56
knowledge score among the experimental and control group.
4.4.1 Frequency and percentage distribution of post test level of skill 60
regarding prevention of CAD among at risk clients in the
experimental group.
4.5 correlation of the post test level of knowledge with skill 62
regarding prevention of cad in the experimental group
4.6.1 Association of selected demographic variables with the 64 & 65
mean differed level of knowledge gain score regarding
prevention of CAD in the experimental group
4.6.2 Association of selected demographic variables with post 67&68
test level of skill in the experimental group
 16

LIST OF APPENDICES

APPENDIX TITLE PAGE NO.

A Ethical clearance certificate i
IEC approval certificate ii
B Letter seeking and granting permission for conducting iii
the main study
C Content validity
L /HWWHUVHHNLQJH[SHUW¶VRSLQLRQIRUFRQWHQWYDOLGLW\ iv
ii)List of experts for content validity v
iii)Certificate of content validity vi
D No harm certificate xi
E Certificate for English editing xiii
F Certificate for Telugu editing xiv
G i)Informed consent requisition form xv
ii) Informed written consent form. xvi
H Copy of the tool for data collection
i)English xxi
ii)Telugu

I Coding for demographic variables xxxiv

J Blue print of data collection tool xxxviii

K Intervention tool xxxix
L Plagiarism report
M Dissertation Execution plan-Gantt chart
N CD with Power point presentation and Booklet
 17

³Effectiveness of Heart Smart Package on knowledge and skill regarding prevention

of Coronary Artery Disease among at risk clients attending chronic outpatient
departments at selected settings, Andhra Pradesh.´

ABSTRACT

Aim: To assess the effectiveness of Heart Smart Package on knowledge and skill regarding
prevention of coronary artery disease among at risk clients attending chronic out patient clinic.
Methodology: A quasi experimental, pre and post test design was chosen for the study. Clients
who fulfilled the inclusive criteria were selected as samples using non probability purposive
sampling technique from the chronic op clinic of RUSH multi specialty hospital, Tirupathi, Andhra
Pradesh, India. Heart Smart Package consists of lecture cum discussion, aided power point
presentation and demonstration of heart healthy exercises and reinforcement through booklet
regarding prevention of CAD. The post test level of knowledge and skill was assessed using
structured interview schedule and observational check list scale respectively. Results: The
findings of the study revealed that comparison of post test level of knowledge scores regarding
prevention of CAD between experimental and control group, the calculated unpaired ¶W¶ value was
9.40 which denotes very high statistical significance at p<0.001.With regard to comparison of
post test level of knowledge and skill scores shows 9.40 LQ XQSDLUHG µW¶ YDOXH VKRZV YHU\ KLJK
statistical significance at p<0.001. The correlation between the post test level of knowledge with
skill score ZDVFDOFXODWHGXVLQJ.DUO3HDUVRQFRUUHODWLRQFRHIILFLHQWZLWKµU¶ value of 0.56 signifies
moderate positive correlation .The significant level of association was identified between age,
education, occupation and habit of smoking in the experimental group. Conclusion: Hence the
Heart Smart Package developed by the investigator proved to be an effective aid in enhancing
the knowledge and skill regarding prevention of CAD among at risk clients.

Key words: Heart smart package, knowledge and skill regarding prevention of CAD, CAD risk
assessment, at risk clients

INTRODUCTION
Coronary Artery Disease (CAD) it is also known as ischemic heart disease. The
heart, like all muscles, needs oxygen from the blood to function normally. The heart is
supplied by its own blood vessels, the coronary arteries, but these can become clogged
up in places with fatty deposits (atheroma) which narrow them, restricting the blood
flow. These deposits may rupture, leading to clotting, blockage of the artery and acute
myocardial infarction. The main conditions included in the category of Coronary Heart
 18

Disease are acute myocardial infarction, angina pectoris, acute coronary syndrome and
heart failure. Acute coronary events can be reduced by the early identification of risk
factors and reduction of risk factors through healthy eating, regular exercises,
management of co-morbid illness and maintaining optimum health, So that individuals at
mild and moderate risk for future CAD can be manage their risk status and there by enable its
prevention.

Objective
To assess the effectiveness of Heart Smart Package (HSP) on knowledge and
skill regarding prevention of Coronary Artery Disease (CAD) among at risk clients
attending out patient clinics at selected Hospitals, Andhra Pradesh .

Null Hypothesis
NH1 - There is no significant relationship between the post test level of knowledge and
skill regarding prevention of CAD in the experimental group

METHODOLOGY
A quasi experimental, non- equivalent, pre and post test control group design was
used to conduct this study with the setting for the experimental and control group at
RUSH Multispecialty Hospital. Totally 64 clients, who satisfied the inclusion criteria,
were selected as samples for study using non-probability purposive sampling technique.

The risk of CAD was assessed by using Framingham Cardiovascular Risk

Assessment Tool and pre test was conducted. The level of knowledge and skill was
assessed by using structured interview schedule and observational check list respectively.
The interventional tool HSP prepared by investigator , comprised of CAD risk factors
and prevention of CAD administered to at risk clients in order to improve their
knowledge and skill, and reinforcement through booklet after completion of pre test in
experimental group as an aid for continued practice and for the control group after post
test.

RESULTS
 19

The present study aimed to assess the effectiveness of HSP on knowledge and
skill regarding prevention of CAD among at risk clients attending chronic outpatient
clinics .
The level of risk assessment among at risk clients using Framingham
Cardiovascular Disease Risk Assessment Tool revealed that 23 (71.9%) had low risk,
9(28.1%) had moderate risk and 0(0%) had high risk of developing CAD in the
experimental group and 24(75.0%) had low risk, 8(25.0%) had moderate risk and 0(0%)
had high risk of developing CAD in control group.

The comparison of post test level of knowledge between the experimental group
revealed that the post test mean score of knowledge was 20.03 with SD 3.05 and for the
control group, post test mean score of knowledge was 10.63 with SD 1.79. The
FDOFXODWHG XQSDLUHG µW¶ YDOXH RI  VKRZHG KLJK VWDWLVWLFDO VLJQLILFDQFH DW S 
level.

The correlation of post test level of knowledge and skill among the experimental
group revealed that the mean score of knowledge was 20.03 with SD 3.05 and for the
PHDQ VFRUH RI VNLOO ZDV  ZLWK 6'  7KH FDOFXODWHG µU¶ YDOXH RI  VKRZHG
moderate positive correlation and it had high statistical significance at p< 0.001 level.

With regard to association of selected demographic variables with the mean

differed level of knowledge gain score regarding prevention of CAD in the experimental
group ,age and education showed mild statistical significance and family history of CAD
and habit of smoking showed high statistical significance. This indicates that clients aged
between 51 ± 60 yrs, those with middle school education, having family history of CAD
and non- smokers showed higher improvement in their level of knowledge regarding
prevention of CAD in comparison to the other samples.

With regard to association of selected demographic variables with post test level
of skill in the experimental group, age and education showed mild statistical significance
and family history of CAD and habit of smoking showed high statistical significance.
This indicates that clients aged between 51 ± 60 yrs, those with middle school education,
having family history of CAD and non- smokers showed higher improvement in their
post test level of skill regarding prevention of CAD in comparison to the other samples.
 20

DISCUSSION
There was a significant improvement of knowledge and skill regarding
prevention of CAD among at risk clients in the post test after administration of
intervention package. Thus Heart Smart Package developed by investigator proved to be
effective aid in improving the knowledge and skill regarding prevention of CAD.

CONCLUSION
The findings of this study conducted to assess the effectiveness of Heart Smart
Package on knowledge and skill regarding prevention of CAD among at risk clients
attending chronic outpatient departments, revealed that there is a significant difference in
the post test level of knowledge and skill regarding prevention of CAD among at risk
clients. This proved that the HSP was effective in enhancing knowledge and skill among
at risk clients, there by empowering them to manage their risk status more efficiently.

IMPLICATIONS
Nurses plays an essential role in building the knowledge and skill on preventive
aspects of CAD. The intervention is cost effective, and can easily can be incorporated by
nurses in all hospitals or community health centers catering to at risk clients .The nurse
educator can incorporate these findings in to the nursing curriculum there by promoting
evidence based practice and develop skill among students in assessment of the existing
risk factors of CAD. Health education regarding preventive measures to bring desirable
change in lifestyle behavior can be made a vital component of chronic medical care of at
risk clients and empowering clients to manage their risk status. The findings of the study
can be disseminated through conferences, seminars and by publishing in journals.
 21

INTRODUCTION

The Cardiovascular system or the circulatory system consists of three important

vital components such as heart, blood vessels and lymphatics. This network brings life
VXVWDLQLQJ R[\JHQ DQG QXWULHQWV WR WKH ERG\¶V FHOOV UHPRYHV WKH PHWDEROLF ZDVWH
products, and further carries hormones from one part of the body to another. The heart,
like all muscles, needs oxygen from the blood to function and hence it is supplied by its
 22

own blood vessels, the coronary arteries, but sometimes it can become clogged up in
places with fatty deposits (atheroma) which narrow them, thereby restricting the blood
flow. These deposits may rupture, leading to clotting, blockage of the artery and acute
myocardial infarction. The main conditions included in the category of Coronary Artery
Disease (CAD) were acute myocardial infarction, angina pectoris, acute coronary
syndrome and heart failure.

Global Health Action Plan for Prevention and Control of Non-communicable

diseases - WHO 2013 -2020 reports that cardiovascular diseases, chronic respiratory
GLVHDVHV GLDEHWHV DQG FDQFHUV DUH WKH ZRUOG¶V ELJJHVW NLOOHU GLVHDVHV *OREDOO\ 
million people die annually, of which 63% deaths arise from NCDs. More than 14
million individuals bite the dust between the ages of 30 and 70. The Low and Middle
Income Countries (LMIC) as of now bear 86% of the weight of these unexpected losses,
bringing about total monetary misfortunes of US $ 7 trillion. Dr. Ala Alwan, Mac Lean
MR., Leann MR., Edourd Tursan (2010) monitor the progress of non- communicable
disease in high burden countries. The result determined that progress of NCDs was high
in LIMC (Low and middle income countries. Tobacco use and obesity was found to be
common in most of the countries. The Global Burden of Diseases (GBD), Injuries and
Risk Factor Study (2010) evaluated that mortality because of NCDs has expanded from
57% of aggregate mortality in 1990 to 65% in 2010. More deaths around 80% identified
with NCDs happen in LMIC, especially in middle aged individuals.

Cardiovascular Disease (CVD) accounts for the largest ratio of deaths related to
NCDs than cancer, Chronic Obstructive disease (COPD) and Diabetes. The GBD 2010
calculated Disability-$GMXVWHG/LIH<HDUV '$/<¶V ZKLFKDUHWKHVXPRI\HDUVRIOLIH
lost from premature death and years lived with disability and estimated DALYs to have
increased to 54% worldwide in 2010 from 43% in 1990.
The projected cumulative economic loss from 2011 to 2025 all NCDs is $7.28
trillion in LMIC. CVD accounts for nearly 50% of this projected loss. Within LMIC, it is
projected that reducing CVD mortality by 10% would result in a $377 billion reduction
in economic losses from 2011 to 2025.

1.1 BACKGROUND OF THE STUDY

Global
 23

Somebody endures a coronary occasion at regular intervals, and somebody passes

on from one consistently in the USA. In Europe the death rate for CAD among men and
women was between 1 in 5 and 1 in 7 that is 16% and 25% individually.

WHO 2012 expressed that CAD is the main source of death and is anticipated to
remain so for the following 20 years every year, Approximately 3.8 million men and 3.4
million women kick the bucket from CAD. In 2020, it is assessed that this disease will be
responsible of an aggregate of 11.1 million deaths internationally. Because of this
expanding frequency over the world, CAD has been portrayed as a epidemic. American
Heart Association recommends that the average age- adjusted incidence rates of CAD
per 1,000 man years are 12.5 for white men, 10.6 for dark men and 4.0 for white women.
By American Heart Association (AHA) insights, 770 000 Americans endured another
coronary attack in 2008, and a further 430 000 encountered an intermittent attack. An
extra 190 000 silent first heart attacks are assessed to occur every year. Studies propose
that the average age- adjusted incidence rates of CAD per 1,000 man years were
observed to be 12.5 for white men, 10.6 for dark men and 4.0 for white women.

Table1.1.1: Number of CHD deaths in different regions (% change in number of

deaths from previous available total) South Asia comprises Afghanistan,
Bangladesh, Bhutan, India, Nepal and Pakistan. East Asia comprises China, north
Chorea and Taiwan.
Region
1990 2010 Percentage Change
1 Asia
East Asia 47,158 992,163 +110.1%
South Asia 704,833 1,323,551 +87.8%
South East Asia 215,719 383,323 +77.7%
Asia Pacific, High 113,347 166,853 +47.2%
income.
Central Asia 138,157 184,167 +33.3%
Australia 42.128 37.738 -10.4%
2 Europe
Eastern Europe 834,783 1.115,213 +33.6%
Central Europe 331,497 344,139 +3.8%
 24

3 Africa
North Africa and 263,978 418,019 +58.4%
Middle East
Sub-Saharan Africa 144,713 217,397 +50.2%
4 America
South America 275,187 422,584 +53.6%
North America, 703,057 619,377 -119%
high income
[Source: Global Cardiology Science and Practice Published (Jan 29, 2014)]
The Global Status Report on impact of risk factors on cardiovascular system
(2014) by WHO expressed that NCDs as of now cause a larger number of passings
than every single different caus joined and NCDs passings are anticipated to
increment from 38 million in 2012 to 15 million by 2030.

Roughly 42% of all NCDs deaths internationally happened before the age of 70
years. 48% of NCDs deaths in LMIC and 28% in high salary nations were in people
matured under 70 years.

Alcohol
WHO expressed that liquor had a causal relationship between its destructive use
and the morbidity and mortality connected with cardiovascular disease. In 2012 an
expected 3.3 million deaths or 5.9% of all deaths worldwide were ascribed to alcohol
utilization and more than half of these deaths from NCDs.

Physical activity
The WHO prescribed consistent physical activity no less than 150 min of
moderate power physical activity/week for adults, lessens the danger of CAD and DM.
Youngsters and youthful matured between 5±17 years ought to aggregate no less than
60min of physical movement of moderate to vigorous intensity every day, keeping in
mind the end goal to keep up and enhance lung and heart condition
 25

Globally 2010, 25% of adults men and 27% of adult women did not meet WHO
suggestion on physical action for wellbeing. Amongst young people matured between
11 ± 17 years, 78% of young men and 84% of young women did not meet these proposal

Salt consumption
Globally in 2010, 1.7 million yearly deaths from cardiovascular cause have been
ascribed to abundance salt/sodium consumption. High salt utilization adds to raised
circulatory strain and expands the danger of coronary illness. The present assessments
recommend that the worldwide mean intake of salt is around 10g of salt day by day.
WHO prescribes diminishing salt utilization to <5g (1 teaspoon) every day in adults to
avoid hypertension and coronary illness.

Tobacco use remains the reason for 6 million preventable deaths for each year all
around.

Blood pressure
Raised circulatory strain is one of the main danger components for worldwide
mortality and is evaluated to have brought on 9.4 million deaths and 7% of disease
burden ± as measured in disability- DGMXVWHG OLIH \HDUV í LQ  7KH ZRUOGZLGH
predominance of high BP in adults matured 18 years and over was around 22% in 2014.
Diminishing the rate of hypertension through usage of populace wide approaches to
decrease behavioral risk variables, including destructive utilization of alcohol, physical
activity, overweight, corpulence and high salt admission, is key to achieving this goal.
 26

social determinants behavioural risk metabolic risk Cardiovascular

and drivers factors factors disease

‡ Globalization ‡Unhealthy Diety ‡High blood pressure Heart attack,

‡Tobacco use ‡Obesity
‡ Urbanization ‡Physical inactivity ‡Diabetes Strokes
‡ Aging ‡Harmful use of ‡Raised lipid levels
‡ Income alcohol Heart Failure
‡ Housing

Figure 1.1.1: Main contributory factors for CVD and its complications

Obesity
In 2014, 39% of adults matured 18 years and older (38% of men and 40% of
women) were overweight. The overall pervasiveness of obesity almost multiplied
somewhere around 1980 and 2014. In 2014, 11% of men and 15% of women worldwide
were obese. Along these lines, more than a large portion of a billion adults worldwide are
classed as obese. So the WHO executed the National Multisectorial Action Plans and
strategies to prevent the coronary illness complexities.

India
India experiences amongst the highest number of potentially productive life years
lost due to CVD, expected to reach 117.9 million years by 2030. The WHO (2005)
estimated that India lost 8.7 billion US dollars in national income due to combined
mortality from CHD, stroke and diabetes.

Rajeev Gupta, Soneil Guptha, Krishna Kumar Sharma, Aravind Guptha and
Prakash Deedwania (2012) conducted a prospective study on regional variations of CAD
risk factors in India. The individual researchers had reported that there are large regional
variations of risk factors in India.
 27

Figure 1.1.2 Prospective studies of cardiovascular mortality in urban and rural

Indian populations and the United States of America.
[Source: World Journal of Cardiology, (2012)]

Nathan.D Wong (2014) reported numerous longitudinal epidemiological studies

demonstrating that CHD as the fundamental driver for CVD. The prevalence and
incidence of critical risk factors changes as indicated by gender, ethnic foundation, and
topographical district. CVD involved mainly of CHD (counting stable and unstable
angina, nonfatal MI, and coronary death), heart failure, ventricular arrhythmias and
sudden cardiovascular deaths, rheumatic coronary illness, transient ischemic attack,
ischemic stroke, subarachnoid and intracerebral haemorrhage, abdominal aortic
aneurysm, peripheral artery disease, and congenital coronary illness. Ischemic coronary
illness, which comprises essentially of CHD, is the overwhelming sign of CVD, and
causes 46% of cardiovascular deaths in men and 38% in women. Cerebrovascular
Disease is the type of CVD with the second-most astounding mortality-34% of
cardiovascular deaths in men and 37% in women. Despite the fact that the weight of
CHD was highest in western nations amid a significant part of the twentieth century, the
greatest weight of CHD now happens specifically in Asian and Middle-Eastern area.

Shraddha and Bani, (2013) reported that more than 80% of deaths and 85% of
incapacity from CVD happen in LMIC. Among these, CVD influences Indians with
more prominent recurrence and at a more youthful age than their counterparts in
developed countries, as well as many other developing countries. In addition to high
 28

rates of mortality, CVD shows here very nearly 10 years prior on a average than different
nations on the world, bringing about significant number of deaths in working age group.
In western nations where CVD is thought to be a sickness of the matured 23% of CVD
deaths happen underneath 70 years old while in India 52% of CVD deaths happen below
70 years old. Along these lines, India endures a huge loss of productivity because of
expanded pervasiveness of Coronary Heart Disease (CHD). The aggregate years of life
lost because of aggregate CVD among the Indian men and women matured 35-64 has
been assessed to be higher than comparable nations, for example, Brazil and China.
These appraisals are anticipated to increment by 2030, when contrasts might be much
more checked.
Table1.1.2: The complete years of life lost due to total CAD
Country 2000 2030
Complete
Rate per Complete years Rate per
years of life
100,000 of life lost 100,000
lost
India 9,221,165 3,572 17,937,070 3,070
Brazil 1,060,840 2,121 1,741,620 1,957
China 6,666,990 1,595 10,460,030 1,863
[Source: International Journal of Scientific and Research Publications, (2013)]
Sekhari et al, (2014) reported findings regarding prevalence of risk factors among
government employees across Indian urban population

Table 1.1.3: Percentage of risk factors for CAD based on gender.

S.No. Parameters Men Women
1 Family history of CAD 4.6% 6%
2 Smoking 11.6% 13.8%
3 BMI >25 kg/m2 47.6% 46.1%
4 BMI 25 ± 30 kg/m2 39.4% 38.6%
5 BMI >30 kg/m2 8.2% 6.6%
6 Diabetes mellitus 16.6% 12.7%
7 Hypertension 22.4% 13.4%
8 Dyslipidemia 48.27% 31.4%
[Source: British Medical Journal , (2014)]

Similarly Nageswara Rao C.H.V., et al (2015) conducted a study on assessment of

cardio-metabolic risk profile in different age groups of subjects with coronary artery
disease. Results showed significant association between age (p-0.018), smoking
 29

(p-0.0001), hypertension (p-0.001), diabetes (p-0.001), high LDL (p-0.0001) and CAD.
Physical activity (0.0001) and High HDL (p-0.001) were found to be protective for CAD.
Lastly they concluded that the risk factors concept implies that a person with one risk
factor is more likely to develop atherosclerosis event and more likely to do so earlier than
a person with no risk factor. Presence of multiple risk factors in patients further
accelerates the incidence of atherosclerosis. Similarly Abhishek Singh., et al (June 2014)
conducted a cross sectional study to assess the prevalence of coronary risk factors among
population aged 35 years and above from rural Maharastra. The results revealed that

Table 1.1.4: Prevalence of risk factors for CAD

S.No. Risk factor Results

1 Tobacco consumption 51.83%
2 Physical inactivity 31.61%
3 High diastolic pressure 29.41%
4 Obesity and Alcohol consumption 13.97%
5 Hypertriglyceridemia 22.05%
6 Fasting blood glucose 15.44%
[Source: Journal of Krishna Institute of Medical Sciences University (JKIMSU) ,
vol.3, 1, Jan-June- (2014)]

Rama Walia et al., (2014) assessed the prevalence of CVD risk factors via a
cross sectional study, the findings are shown below
 30

90
80 OB OB
OB SLS OB
OB HTN TG
70 SLS
SLS HTN
p 60
e
50
r
OB
c 40
e 30
n
t 20
a 10
g
e 0
20- 29 30-39 40-49 50-59 60-69 >70

SLS- Sedentary life style, OB- Over weight/Obesity, HTN- Hypertension,

TG- Triglycerides

Figure 1.1.3: High prevalence of two most common CV risk factors in different
decades of life
[Source: Indian Journal of Medical Research, (2014)]
Tanmay Nag, Arnab Ghosh (2014) found that CVD risk factors was higher in
males than in females

KEY

TC- Total cholesterol

TG- Triglycerides

FBG- Fasting Blood

glucose

HDL- High Density

Lipoprotein

BP- Blood Pressure

Figure 1.1.4: Cluster of risk factors shown according to gender.

[Source: International Journal of Medicine and Public Health 2015)
Researchers Srinivasa Jayachandra et al., ( November 2015), Latheef. SA, and
Subramanvam.G (2007) conducted separate studies on risk factor profile for coronary
artery disease among young and elderly patients in Andhra Pradesh. Results revealed that
 31

hypertension (20%), Smoking (22%), Diabetes mellitus (11%) and dyslipidemia

(8%),were the most common risk factors in young patients. With reference to elderly
patients, the diabetes mellitus (21%), smoking (17%), kidney disease (11%) and
dyslipidemia (9%) were the most common risk factors.

1.3 SIGNIFICANCE AND NEED FOR THE STUDY

Today, the average age persons suffering with heart diseases has come down
drastically. This is mainly due to result of changing lifestyles pattern. In fact the rate of
INTERHEART CAD in the Indian community particularly in young man is almost twice
as high as their western counter parts. There are numerous reasons or factors which have
resulted in an increase in the number of heart patients in India, the most common being
modern life style proved to be the stimulus for the growth of heart disease among the
young population. Improper food habits and lack of physical activity coupled with high
level of stress and increase in smoking and alcohol consumption are also some of the
contributing factors.

Researchers Vamadevan. S, Ajay and Dorairaj Prabhakaran (2010) in the study

showed comparison of impact of population based CHD interventions between developed
and developing countries. With increasing incidence of CAD, interventions likely to be
effective as opposed to developed countries where interventions carried when decline
secular trends were observed

Figure 1.1.5: Comparison of population based CHD intervention on CVD risk

factors between developed and developing countries.
[Source: American Heart Association, (2010)]
According to the Centre for Disease Control and Prevention, 2015
x Heart disease is the leading cause of death for both men and women,1 in every 4
deaths are due to heart disease and second cancer.
 32

x Annually more than 370,000 people killing due to CHD.

x Every 43 sec in USA someone has a heart attack, each minute someone dies form
a heart disease related event and second cancer
x The cost of health care services, medications and lost productivity for CHD US
108.9billion each year

The Indian Heart Watch (IHW) (19.02.2012) UHSRUWHGWKH³5HDVRQVIRU,QGLD¶V

growing cardiovascular disease epidemic pinpointed in largest ±HYHUULVNIDFWRUVWXG\´
This study was presented for the first time at the World Congress of Cardiology
organized by the World Heart Federation. The study assessed the prevalence of different
³OLIHVW\OHV´DQGELRORJLFDO&9'ULVNIDFWRUVDFURVVWKHFRXQWU\DQGUHVXOWVUHYHDOHGWKDW
these risk factors are now at higher levels in India than in the developed countries. 79%
of men and 83% of women were found to be physically inactive, while 51% of men and
48% of women were found to have high fat diets. Some 60% of men and 57% women
were found to have a low intake of fruits and vegetables, while 12 % of men and 0.5% of
women had smoking habit. Prof. Prakash Deedwania, University of California, San
)UDQFLVFRVDLG³India has the questionable refinement of being known as the "coronary
and diabetes capital of the world,"

WHO Global Action Plan Expected Outcome 2013-2020 recommended

converging the health care services and resources by collaborating with the
Nongovernmental organization to render the comprehensive health care services and thus
reduce the burden of chronic disease like hypertension, diabetes mellitus, cardiovascular
disease, and kidney diseases etc..

With regard to the risk factors for CAD some of the researchers reported as
fallows, Abhishek Singh et .al., (2014) conducted a cross sectional study to assess the
prevalence of coronary risk factor in rural Maharashtra, India. The results revealed that
tobacco consumption was found to be prevalent in 51.83% of the study subjects followed
by physical inactivity which was prevalent among 31.61% where as high diastolic blood
pressure was found to be prevalent in 29.41% of the study subjects. Obesity and alcohol
consumption were found to be prevalent among 13.97% of the study subjects. Among
biochemical parameters hypertriglyceridemia was found to be prevalent in 22.05%
fallowed by raised fasting blood sugar in 15.44% of the study subjects.
 33

Aniket Arole, (2013) conducted a quantitative study to assess the effectiveness of

planned teaching programme on knowledge regarding prevention of CAD amongst 60
DM patients. They found that planned health teaching program improved the knowledge
regarding prevention of CAD. Similarly Cyril James (2013) conducted a cross sectional
study on risk factors for CAD among patients with Ischemic Heart Disease in Kerala.
Results showed that among south Indians of gender, diabetes mellitus and dyslipidemia
are the real risk factors for CAD. So early recognition of diabetes mellitus and
dyslipidemia and appropriate treatment of both, before adding to the end organ harm,
play a fundamental part for the prevention of CAD.

Emily Williams D, James Nazroo N, Jaspal Kooner S, and Andrew Steptoe

(2010) conducted a cross sectional study to explore the differences in psychosocial risk
factors related to CHD. Findings revealed that 50.5% are Sikh, 28.0% Hindu, and 15.8%
are Muslim. Muslim participants were more socioeconomically deprived and
experienced higher levels of chronic stress, Muslim men smoked more, reported lower
alcohol consumption and did less physical activity than other groups.

Elizebeth Baby and Sams Larissa Martha (2015) conducted a descriptive survey
to determine the knowledge regarding CAD. Findings revealed that there was a
significant relationship between knowledge and age, occupation and education but no
significant relationship between knowledge and religion. The study concluded that
patients have moderate level of knowledge regarding CAD.

Harari G, Green M S and Zelber-Sagi S (2015) conducted a prospective cohort

study to determine CV Occupational Risk Factors, data on self reported Occupational
Physical Activity (OPA) and Leisure Time Physical Activity (LTPA) and on CHD
mortality were obtained from the National Death Registry. The study concluded that
Moderate-hard OPA may be deleterious to health and should not be a substitute to
LTPA.

Gupta. R, Sharma. K.K, Gupta. A, Agarwal. A, Mohan, Gupta V.P (2012) studied
regarding the persistence of high prevalence of CVD risk factors in urban middle class in
India and stated that there is a high prevalence of multiple CVD risk factors in India
 34

more in middle class individuals. Jarett Berry D et.al, (2012) conducted a meta-analysis
to assess the life time risks of CVD using data from 18 cohort studies involving a total of
257,384 black men and women and white men and women whose risk factors for CVD.
They observed that among participants who were 55 years of age, with an optimal risk-
factor profile had substantially lower risks of death from CVD through the age of 80
years than participants with two or more major risk factors. Sarwar N et. al, (2010)
undertook a meta-analysis of 102 prospective studies to quantify the association of DM
and fasting glucose concentration with risk of CHD. The study concluded that DM
confers about a two-fold excess risk for a wide range of vascular diseases, independently
from other conventional risk factors. Trushna Shah et.al, (2015) conducted a cross
sectional study on prevalence of CHD in different socio economic status in Gujarat,
India. The report concluded that higher social classes with dyslipidemia may have
greater CHD risk than lower social classes. This may be due to their sedentary lifestyle
diet modification and that less physical activity may play a key role.

Imes C C, Lewis F M, Austin M A, Dougherty C M (2014) conducted a single

group pre and post test to evaluate the viability of a behaviorally engaged intercession
intended to increased perceived CVD and CHD risk in youthful adults in Pittsburg,
Pennsylvania. Intervention included tailored messages about 10-year and lifetime CHD
risk based on risk factors and brief counseling on healthy lifestyle to decrease risk.
Findings revealed that intervention was effective and participants requested more
information on healthy food choices and which exercises most improve CV health.

Based on the findings of the above mentioned studies, the investigator perceived
that there is an alarming rise of CAD risk factors among young people when compared to
elderly due to urbanization, sedentary life style changes, smoking, alcohol, systolic
hypertension, elevated triglycerides, High LDL, low HDL and stress. In spite of the
widespread efforts in creating awareness, at risk patients in semi urban and rural areas
still remain unaware of the consequences of high levels of CAD related risk. Hence the
research investigator felt that there is an urgent need to initiate measure to raise
awareness of these risk factors. So that individuals at mild and moderate risk for future
CAD can be manage their risk status and there by enable its prevention.
 35

1.3 STATEMENT OF THE PROBLEM

A quasi experimental study to assess the effectiveness of Heart Smart Package on
knowledge and skill regarding prevention of Coronary Artery Disease among at risk
clients attending chronic outpatient clinics in selected hospitals, Andhra Pradesh.

1.4 OBJECTIVES
1. To assess the existing level of risk for CAD among the experimental and control
group.
2. To assess effectiveness of Heart Smart Package (HSP) on the level of knowledge
regarding prevention of CAD among at risk clients.
3. To assess the post test level of skill regarding prevention of CAD in the
experimental group
4. To correlate the post test level of knowledge with skill regarding prevention of CAD
in the experimental group.
5. To associate the selected demographic variables with the mean differed knowledge
and post test skill score regarding prevention of CAD in the experimental group.

1.5 OPERATIONAL DEFINITION

1.5.1 Effectiveness
It refers to the outcome of Heart Smart Package on knowledge and skill regarding
prevention of CAD, assessed using a structured interview schedule and observational
checklist respectively.

1.5.2 Heart Smart Package (HSP)

It refers to cardiac health focused information and strategies prepared by the
investigator and aimed at empowering individuals prone for CAD to manage their at risk
status . It comprises:
A) Lecture cum discussion aided by power point presentation for 5-7 members for about
30 min duration on,
x General information- Meaning of CAD, risk factors, causes, warning signs,
and complications of CAD
 36

x Strategies for risk reduction- Healthy diet, regular exercises, cessation of

smoking and alcohol, management of co-morbid illness and monitoring
optimum health.
B) Demonstration of cardio exercises by the investigator on warm-up, twist crunch,
squat and over head press, static lunge, deep breathing exercises and cool down
exercises to be performed for 3 min each, for a total duration of 20 min, once daily.
C) Re-demonstration of the cardio exercises by at risk clients.
D) Re-inforcement of prevention of CAD through booklet

1.5.3 Knowledge regarding prevention of CAD

It refers to the extent of awareness at risk clients regarding risk for CAD and
measures to control it by using structured interview schedule devised by the investigator.

1.5.4 Skill regarding prevention of CAD

It refers to the ability of the at risk clients to perform the cardio exercises aimed
at controlling risk for CAD, assessed using observational check list

1.5.5 At risk clients

It refers to the individuals with low or moderate risk for CAD, identified by
using Framingham Cardiovascular Disease Risk Assessment Tool which consists of risk
factors pertaining to age, total cholesterol, HDL, smokers, non-smokers and systolic
blood pressure, who attend the Chronic Out Patient Clinic.

1.6 ASSUMPTIONS
1. At risk clients may have some knowledge regarding risk for cardiovascular
disease.
2. Educating at risk clients about Heart Smart Package may enhance their
knowledge and skill regarding cardiovascular health promotion

1.7 NULL HYPOTHESES

NH1-There is no significant effect of Heart Smart Package on the level of knowledge
regarding prevention of CAD among at risk clients. at P< 0.05 level of significance.
 37

NH2-There is no significant relationship between the post test level of knowledge and
skill regarding prevention of CAD in the experimental group at P<0.05 level of
significance
NH3-There is no significant association of selected demographic variables with the mean
differed level of knowledge and post test skill regarding prevention of CAD in the
experimental group at P<0.005 level of significance.

1.8 DELIMITATIONS
The study is delimited to a period of four weeks.

1.9 CONCEPTUAL FRAMEWORK

A conceptual framework or model is the concepts of mental images of the
phenomenon. These concepts are linked together to express the relationship between
them. The conceptual framework provides the investigator the guidelines to proceed in
attaining the objectives of the study. Conceptual framework adopted is based on
integrated :LHGHQEDFK¶V+HOSLQJ Art of Clinical Nursing Theory and -:.HQQ\¶V
Open System Model. Wiedenbachs Helping Art of Clinical Nursing Theory was given
by Ernestine Wiedenbach. She views this theory as a set of interrelated concepts that
gives systematic view of a phenomenon that is explanatory and predictive in nature. The
present study is aimed at helping the at risk clients to develop adequate knowledge and
skill regarding prevention of CAD.

In 1968, Ludwig Bertanlanffy developed a general system model approach,

which was modified and put into practice as the open system model by J.W. Kenny in
1999. The open system model enumerates various aspects of system and interaction. The
open system continuously interacts with environment. The interaction takes form of
information transfer into or out of the system boundary, depending on the discipline
which defines the concept. Open system model is useful in breaking the whole process
into sequential tasks to ensure goal realization. The three major aspects of the system are:
1. Input
2. Throughput
3. Output
7KHLQYHVWLJDWRUDSSOLHG-:.HQQ\¶VRSHQV\VWHPPRGHOLQRUGHUWRDVVHVVWKH
knowledge and skill of CAD.
 38

The concepts according to the study:

Input: Identifying the need for help According to J.W. Kenny, input is a type of
information or material that enters the systems from the environment through its
boundaries. In this study it refers to the demographic variables of participants such as
age, gender, occupation, educational qualification, marital status, type of family, family
monthly income, religion, family history of CAD, nature of relationship, history of co-
morbid illness and habit of smoking. Biological variables such as height, weight, BMI
and fasting blood sugar. These are assessed by using a structured interview schedule.
According to Ernestine Weidenbach, identifying the need for help, the nurse perceives
WKH SDWLHQW DV DQ LQGLYLGXDO ZLWK XQLTXH H[SHULHQFHV DQG XQGHUVWDQGLQJ WKH SDWLHQW¶V
perception of the condition and determinHVSDWLHQW¶VQHHGIRUKHOSEDVHGRQWKH existence
of a need, whether the patient realizes the need, what prevents the patients from meeting
the need and whether the patient cannot meet the need alone. In identifying the need
there are two components:

1. General information
This comprises collecting the information to identify the need. In this study the
investigator assessed the general information which includes family history of CAD,
nature of relationship with affected member, co-morbid illness, Body Mass Index (BMI),
habit of smoking, assessment of existing level of risk of developing CAD.

2. Central purpose
The central purpose refers to what the investigator wants to accomplish. In this
study it refers to the assessment of effectiveness of Heart Smart Package on knowledge
and skill regarding prevention of CAD among at risk clients attending outpatient clinics.

Throughput: Ministering the Need for Help

Throughput is the process that occurs at some point between input and output
process. In this study throughput refers to transformation of information in form of Heart
Smart Package. In ministering the need for help, the nurse investigator formulates a plan
for meeting the at risk client need for help based on available resources, the components
are:
 39

a) Prescription
It refers to the plan of care the nature of action that will fulfil the central purpose.
In this study the investigator planned and prepared the Heart Smart Package regarding
prevention of CAD. In experimental group it will be given on the first day after the pre
test and in the control group on the last day after post test.

b) Ministering
It refers to the information transfer given by the investigator to the at risk clients.
In this study the investigator administered the Heart Smart Package regarding prevention
of CAD which includes information transfer in the form of lecture cum discussion with
the aid of a power point presentation, demonstration of heart healthy, re-demonstration
by clients and reinforcement on prevention of CAD through a booklet.

c) Realities
The realities are the immediate situation that influences the fulfillment of the
central purpose. The nurse investigator should consider the realities of the situation in
which she has to provide care. Wiedenbach defines the realities as:

1. Agent
The agent is the participating nurse who has the personal attributes, capabilities,
commitment and competence to provide nursing care. In this study the agent is the nurse
investigator.

2. Recipient
The recipient is the patient who has personal attributes, problems, capabilities,
aspirations and ability to cope. In the study the recipient are the at risk clients for
developing CAD.

3. The goal
7KHJRDOLVWKHQXUVH¶VGHVLUHGRXWFRPHLWGLUHFWVDFWLRQDQGVXJJHVWVWKHUHDVRQ
for taking those actions. In this study goal is to provide insight regarding CAD and
thereby prevent at risk clients from developing CAD.
 40

4. Means
The means are the activities and devices used by the nurse to achieve the goal. In
this study, the means is the Heart Smart Package regarding prevention of CAD which
includes information transfer in the form of lecture cum discussion with the aid of a
power point presentation, demonstration of heart healthy exercises, re demonstration by
at risk clients and re-inforcement on prevention of CAD through a booklet.

5. Framework
Framework refers to the facilities in which nursing is practiced, it comprises of
human, professional and organizational aspects of care. In this study, the framework
refers to the chronic out patients department in RUSH Multispecialty Hospital.

Output: Validating the needed help was met

Output is the expected outcome of the input by the process of throughput. It is
validating if the needed help was met through the delivered action to achieve the central
purpose. In this study it refers to change in post test assessment of level of knowledge
and skill regarding prevention of CAD.

1. Enhancement
In this study the achievement of goal or need was indicated by positive outcome
that is attainment of adequate or moderately adequate knowledge and skill which is
enhanced by continuity of practice.

2. Reassessment
Negative outcome is indicated by inadequate knowledge and skill regarding
prevention of CVD. Reassessment and reinforcement is given to such clients. By
LQWHJUDWLQJ :LHGHQEDFK¶V +HOSLQJ $UW 2I &OLQLFDO 1XUVLQJ 7KHRU\ DQG -:.HQQ\¶V
Open System Model the investigator was able to incorporate more concepts in the study,
this helped the accomplishment of the study in an organized manner.

Conclusion:
To conclude the particular theory enhance the investigator to lead a conceptual
pathway towards the study, by identifying the CAD risk clients, and for prescribing and
administering HSP. Thereby it provoked the knowledge and skill regarding prevention of
CAD.
41
42
 43

REVIEW OF LITERATURE

This chapter focuses on the preparation of review as a component of an original

study.

/LWHUDWXUHUHYLHZUHIHUVWRD³FULWLFDOVXPPDU\RIUHVHDUFKRQDWRSLFRILQWHUHVW
RIWHQSUHSDUHGWRSXWDUHVHDUFKSUREOHPLQFRQWH[W´(Polit and Beck, 2012). To be more
specific, critical review is meant as summarization and evaluation of the ideas and
information of an article.
Some important purposes of literature review is to
¾ alert the researcher to unresolved research problems
¾ identify a study for replication or comparison
¾ define ethical implications of similar studies
¾ provide a conceptual context and information on the research approach
¾ orient to what is already known
¾ determine how well the theory and research are developed in the study
¾ bring the research problem into sharper focus

The design used in this study was quasi experimental, non-equivalent control
group pre test and post test design to find the effectiveness of Heart Smart Package on
knowledge and skill regarding prevention of Coronary Artery Disease among at risk
clients attending chronic outpatient departments.

SECTION 2.2: SOURCES OF REVIEW OF LITERATURE

The literature review was collected from various sources such a primary: from
research reports, conference manual and theses, secondary: reviews from internet,
national and international journal articles and the tertiary sources from Medical
Surgical Nursing and Community Health Nursing books.

This review of literature was done using the key words such as CAD and its risk
factors prevalence, incidence, mortality, morbidity, contributing factors, , prevention,
complications, and cardio heart healthy exercises. This review was gathered from
 44

standard databases such as COCHRANE library, CINHAL, Google Scholar, MEDLINE,

PubMed, and other unpublished studies from dissertations. Collectively 200 studies were
searched out of which 75 relevant and updated studies were utilized to support the
current research topic. Among the selected supportive studies, were international and
Indian literatures.

SECTION 2.3 : ORGANIZATION OF REVIEW OF LITERATURE

Section 2.3.1 : Critical reviews related to prevalence of CAD and its risk factors
Section 2.3.2 : Critical reviews related to general awareness regarding risk factors for
CAD
Section 2.3.3 : Critical reviews related to strategies for control of CAD risk factors

SECTION 2.3.1: CRITICAL REVIEWS RELATED TO PREVALENCE OF CAD

AND ITS RISK FACTORS
Chiuve SE, McCullough ML, Sacks FM, Rimm EB. (2010) conducted a cohort
study on healthy of life elements in the prevention of coronary illness among US male
health professionals aged 40-75 years. The researcher ascertained the population
inferable risk of low risk lifestyle variables utilizing Cox corresponding hazard model to
assess relative danger of CHD. Results found that more than 16 years of screening, there
were 2,183 cases of CHD. Men with 5 low risk of lifestyle components were at
diminished danger for episode CHD, contrasted with men who did not make way of
lifestyle switching follow-up, Those who received •H[WUDlifestyle factors had a 95%
generally safe of CHD and the researcher concluded that adherence to sound way of
lifestyle habits might prevent a dominant part of CHD occasions among US healthy men.

A series of researches by Azza Greiw H., Ahmed Mandil, Mervat Wagdi, Ali
Elneihoum (2010), Al-Nooh A A., Abdulabbas Abdulla Alajmi A and Wood D (2014).,
Vaccarino V., Borgatta A., Gallus G., Sirturi CR (2010) and De Fatima M, Nelson AS.,
Armondo JM.(2010) reported on the prevalence of risk factors among adult population.
1381 (46%)were females and 1619 (54%) males, lack of exercise (67.3%), cholesterol
>200 mg/dl (56.6%), overweight (42.1%), obesity (17.0%), hypertension (18.2%),
smoking (12.4%), and diabetes mellitus (2.5%), 24.3% were not eating daily servings of
fruits and vegetables, 16.1% were current smokers, 95.35% had either no or <3 CVD risk
factors and 4.65% had 3-5 risk factors. They concluded that adult population is at high
 45

level risk of CAD and hence an urgent decision to address the nation for the control
measures of CAD is required.

In a descriptive study Bhattacharya P., Marimuthu P., Chowdhari RN., Sarkar

AK., Adak SK., Banarji KK., (2011) reported that the above mentioned risk factors are
responsible for developing 64% of myocardial infarction in the age group of 30 ± 40
years. With regard to gender, Sharma. R et.al, (2011) reported that there was a critical
pervasiveness of risk factors for both men and women separately as to smoking or
tobacco use in 209(37.6%) and 12(2.2%), obese in 303(54.5%) and 350(61.3%),
hypertension in 322(57.9%) and 279(48.9%), diabetes in 88(25.9%) and 64(21.1%) and
low HDL cholesterol 103(30.3%) and 83(27.3%) subjects. The study concluded that
there is a critical pervasiveness of numerous cardiovascular danger components in this
population group. In the mortality and morbidity weekly report with regard to age
Sara E, Luckhaupt MD, Geoffrey M, Clavert MD (2014) observed higher prevalence of
CHD in the age between 40 ± 50 years in United States. Jarett Berry D et. al,(2012)
conducted a meta-analysis to evaluate the life time dangers of CVD utilizing information
from 18 associate studies including a sum of 257,384 dark men and women and white
men and women whose risk factors for CVD were measured at the ages of 45, 55, 65,
and 75 years. BP, cholesterol level, smoking and DM status were utilized to stratify
members as per risk factors. They observed that among members who were 55 years old,
with an ideal risk factor profile had considerably bring down risk of death from CVD
through the age of 80 years than members with two or more major risk factors.

With regard to socioeconomic status Rajeev Gupta et al (2012) conducted a

country wide mortality statistics and morbidity survey to evaluate risk factors in middle
socioeconomic subjects in India by stratified random sampling using house-to-house
survey. The author demonstrated that there is a high prevalence of multiple CV risk
factors in Indian middle class individuals, Trushna Shah, Geetanjali Purohit, Shah RM.
and Harsoda JM. (2015) reported that LDL, TC and BMI significantly is high in upper
class people. The study that higher social class people had high risk of CHD than lower
social class people due their sedentary lifestyle changes, dietary pattern and physical
inactivity which may play a key role in the development of CHD.
 46

A series of prospective and meta analysis, including cohort studies done by the
Anders Grontved, Frank B (2011); and Earl Ford S and Carl Casperson J (2012)
determined the associations between screen time and sitting time for fatal and non-fatal
CVD. Findings revealed that greater sedentary time (TV viewing) is associated with an
increased risk of fatal and non-fatal CVD. It was concluded that this may better shape
future guideline development as well as clinical and public health interventions to cut
down the measure of sedentary behavior in advanced societies.

Eva-Maria Backe., Andreas Seidler., Ute Latza., Karin Rossnagel and Barbara
Schumann (2011). conducted a systematic review to proof for relationship between
various models of anxiety at work, and CV morbidity and mortality among industry
laborers, 26 publications were incorporated, depicting 40 investigations out of 20
cohorts. The risk evaluations for work anxiety were connected with a statistically
significant expanded risk of CVD in 13 out of the 20 cohorts. Glozier N., Tofler GH.,
Colquhoun DM (2013) reported that work related stress and work movements may have
direct physiological impact on cardiovascular influencing so as to wellbeing and aberrant
impact behavioral factors such as obesity and smoking. The study concluded that other
than individual measures to oversee stress and to adapt to requesting work
circumstances, hierarchical changes at the working environment should be considered to
discover alternatives to reduce the occupational risk factors for CVD.

Rod Taylor S, Kate Ashton E, Tiffany Moxham, Lee Hooper and Shah Ebrahim
(2011) conducted a systematic review and meta-analysis of studies assessing the effect of
alcohol consumption on multiple CV outcomes. 84 studies were included from 4,235
prospective cohort studies. The pooled adjusted relative risks for alcohol drinkers
relative to non drinkers was 0.75 for CVD mortality, 0.71 for incident CHD and 0.75 for
CHD mortality. Dose-response analysis revealed that the lowest risk of CHD mortality
occurred with 1±2 drinks a day but mechanism remained unclear, Similarly Klatsky AL
(2015) reported the impact of alcohol on cardiovascular health as a low level of alcohol
drinking has no clear relation to increased risk of any cardiovascular condition except
stroke. Some supportive evidence shows that type of drinking beverage (particularly red
wine) suggest that it might have extra CAD protection. The study concluded that light to
moderate alcohol consumption is associated with a reduced risk of multiple CVoutcome
 47

Bessonova L et al (2011) examined the relationship between BMI and mortality

among 115,433 women participating in the California Teachers Study. During follow up,
10,574 deaths occurred. Findings revealed that obesity was associated with increased all
cause mortality, as well as death from any cancer and cardiovascular and respiratory
diseases. These results help to identify groups at risk for BMI-related poor health
outcomes. Hajian ± Tilaki KO. Heidari B (2009), Feldsteiri CA. Akopian M. Olivieri
AO. Kramer AP, Nasi M, Garrido D (2010) and Janghorbani M et al (2009) conducted a
cross sectional survey on the prevalence of obesity and comparison of BMI and Waist
Hip Ratio (WHR) as indication of HTN among adult population, the results showed that
in women with high values of WHR, 24 h DBP was higher in those with BMI<25 than in
those with BMI> or =25. Only in women mean pulse pressure (PP) significantly
correlated with age (r=0.38; P<0.0001), WC (r=0.22; P<0.005), WHR (r=0.21, P<0.008),
and BMI (r=0.20; P<0.01) while in men there was no significant correlation between
variables. They concluded that outcomes showed a high pervasiveness of overweight-
obesity (more than 56% of ZRPHQ¶V and 75% of men) in our hospital based sample of
essential hypertension and that the WHR offers extra data past BMI and WC to foresee
the hypertension hazard condition and thereby it prevent the CAD complication.

A series of cross sectional surveys conducted by Logaraj M., Balaji R., John K
R., Shailendra Kumar B., Hegde(2014)., Sharma et al ( 2011)., Sukanta Mandal., Jyoti
Bikash Saha., and Partha Pratim Pal (2009) to compare the prevalence of CAD risk
factors among urban and rural population, results demonstrated that there was significant
prevalence of risk factors of both men and women respectively with smoking or tobacco
use in 209(37.6%) and 12(2.2%), obesity in 303(54.5%) and 350(61.3%), hypertension
in 322(57.9%) and 279(48.9%), diabetes in 88(25.9%) and 64(21.1%) and low HDL
cholesterol 103(30.3%) and 83(27.3%) subjects and reduced intake of vegetables and
fruits were more prevalence in rural population whereas reduced PA, increased BMI,
systolic and diastolic HTN was noticed in urban population.

Jihyun AN et al (2014) conducted a retrospective study among 1,045 patients

with liver cirrhosis. The main aim was to investigate the prevalence of silent CAD
compared with the general population by using purposive sampling The results showed
the prevalence of occult obstructive CAD among asymptomatic cirrhotic patients and
non-hepatic subjects. Conventional cardiovascular danger variables were observed to be
 48

identified with basic coronary stenosis in cirrhotic patients, and consequently might be
useful indicators for more watchful preoperative assessment of coronary danger.

SECTION 2.3.2 CRITICAL REVIEWS RELATED TO GENERAL AWARENESS

REGARDING RISK FACTORS FOR CAD
Goyal A, Yusuf S (2010) conducted a hospital-based, cross sectional study at All
India Institute of Medical Sciences (AIIMS), a major tertiary care hospital in New Delhi,
India. Participants (n = 217) recruited from patient waiting areas randomly were
provided with standardized questionnaires to assess their knowledge of modifiable risk
factors. The risk factors specifically included smoking, hypertension, elevated
cholesterol levels, diabetes mellitus and obesity. Identifying 3 or less risk factors from a
total of 5 was regarded as poor knowledge level, whereas identifying 4 or more risk
factors was regarded as a good knowledge level. A multiple logistic regression model
was used to isolate independent demographic markers predictive of a participant's level
of knowledge. 41% of the sample surveyed had a good level of knowledge. 68%, 72%,
73% and 57% of the population identified smoking, obesity, hypertension, and high
cholesterol correctly, respectively. 30% identified diabetes mellitus as a modifiable risk
factor. In multiple logistic regression analysis independent demographic predictors of a
good knowledge level with a statistically significant (p < 0.05) adjusted odds ratio (aOR)
were: routine exercise of moderate intensity aOR 8.41 (compared to infrequent or no
exercise), no history of smoking, aOR 8.25, and former smokers, aOR 48.28 (compared
to current smokers). Although statistically insignificant, a trend towards a good
knowledge level was associated with higher levels of education.

Several descriptive cross sectional studies were done to determine the knowledge
and awareness of risk factors for CVD among general public in different places. One of
the studies by Joby Francis, Josmi Jose, Joyse Sunny K, Juvairiya U S and Sanil
Varghese (2014) reported that 98% had average level of knowledge regarding CV risk
factors. There was a significant association between knowledge and age and knowledge
and education. Hence it is necessary to educate the people in community regarding CV
risk factors. Kirkland SA, MacLean DR, Langelle DB, Joffres MR, McPherson KM,
Andrew P (2009) demonstrated the findings smoking and stress were manifested as a
major cause of heart disease by the greatest proportion of participants (41% men and
44% women respectively). Hypertension was mentioned only by 16% men and women
 49

did not differ in their awareness of high BP (23%), smoking (41%), excess weight
(30%), and physical inactivity (28%) as causes for heart disease.

McDermott MM, Mandapat AC, Moates A, Albay M, Chiou E, Celic L (2010),

Bayne-Smith M, Fardy PS, Azzollini A, Magel J, Scmitz KH, Agin D (2010) conducted
a cross sectional survey by using a purposive sampling to determine knowledge and
awareness regarding CAD and coronary angiography among students. The mean score of
48% students correctly defined coronary angiography. Knowledge of 55% of students
was based on personal and family experience of heart disease. Only half of the students
were aware about coronary angiography. The mean knowledge score among them was
above the median score, but not up to the mark. Similarly Familoni I F and Familoni O
B (2011) evaluated the knowledge and awareness to CAD risk factors in Oyo state,
Nigeria among sedentary teachers and reported that the information level was deficient
and the capability in pure science did not drastically influence this knowledge. The study
reasoned that knowledge base of the teachers should be made strides.

The twin researchers Haidinger T. et al and Uchenna D I. Ambakederemo T E.

Jesuorobo D E. and Uchenna D I. , Ambakederemo T E. , Jesuorobo D E (2012)
conducted two different cross sectional studies to assess individual CVD risk factors
awareness, preventive action taken and the barriers to CV health among 573 women and
336 men who were randomly chosen. The results showed that knowledge about risk
factors for CVD needs to be improved in both sexes.. Uchenna et al (2012) stated that
there was no significant difference between level of education and gender with
awareness of heart disease and its prevention. This study concluded that education on
disease and lifestyle modification is necessary. However great effort is needed to inform
men, compared with women, about the various ways to prevent CVD and to motivate
them to take preventive action.

Jerilyn Allen K, Alison Purcell, Sarah Szanton, and Cheryl Dennison R (2010)
conducted a cross sectional study among DM patients from a low socio economic
background to determine the CVD risk perception 143 DM patients at urban community
were the samples in Baltimore. Results revealed that 75% perceived that they had a 50%
or smaller risk of developing CVD. The study concluded that comprehensive care for
urban, poor, diabetic patients calls for effective communication of CVD risk and its risk
 50

factors. Liesbeth Claassen et al (2011) reported that the association between risk factors
and perceived CVD risk were weak with increased risk for CVD (aged 57±79 yrs) .The
study concluded that to improve risk perception, health professionals need to educate
about how personal risk factors can contribute to the development of CVD.

Jibril Mohammed (2012) and Seef S, Jeppsson A, Stafstrom M (2013) conducted

a descriptive cross sectional studies to assess knowledge about CHD, attitude towards
prevention and risk reduction barriers. The studies revealed that majority of the samples
had moderate knowledge and had poor attitude towards prevention of CAD and thus
concluded that the health system needs to engage patients in their plans and break related
barriers, with development of health education programs based on needs assessment.
Mukattash T L et al (2012) also reported on this study finding that geneal public had a
limited knowledge and awareness of CVD but had moderate attitude towards prevention
of CAD.

Lori Mosca et al., (2009) conducted an experimental study on National Study of

Physician Awareness and Adherence to Cardiovascular Disease Prevention Guidelines.
An online investigation of 500 randomly selected physicians(300 primary care
physicians, 100 obstetricians/gynecologists, and 100 cardiologists) utilizing an
standardized questionnaire to survey awareness of, selection of, and boundaries to
national cardio vascular disease. Counteractive action rules by specialty. The study
concluded that perception of risk was the essential component connected with
cardiovascular diseases preventive recommendations. Educational interventions for
doctors are expected to enhance the quality of cardio vascular illness preventive care and
lower morbidity and mortality from cardio vascular disease for men and women.

SECTION 2.3.3: CRITICAL REVIEWS RELATED TO STRATEGIES FOR

CONTROL OF CAD RISK FACTORS
Radha Acharya Pandey, Smith Khadka, (2012) reported in a cross sectional study
that 42.2% of the samples had inadequate knowledge on coronary heart disease. This
study recommended that awareness programmes could be beneficial on prevention of
coronary heart disease. A series of researchers Ms. Leela Maheswari, (2015), Ajitha
Ninan., Juny Acosta., Theodora Kulesza., Patrick Mattis., Chery Holly (2013) and
Attarchi M., Mohammad S., Nojomi M and Labbafinejad Y., (2014) conducted cross
 51

sectional studies to assess the effectiveness of structured teaching programs(STP) on

knowledge regarding prevention of CAD among attending in outpatient department of
selected hospitals. Findings revealed that most of the people gained good knowledge
after administration of STP. It shows the effectiveness of STP to prevention of CAD.
Similarly Shalet Alex, Anacy Ramesh, Vidya Sahare (2014) reported that 65% of
samples increased satisfactory knowledge in risk factors of CAD, 73% of samples gained
knowledge with regular checkups, and 49% of samples had a good level of knowledge.
The regression investigation revealed that the female gender, age above 28 yrs,
instruction level higher than secondary school training, BMI >25 k/m2, history of
lipidemia, DM, every day activity and practice were significantly related with great
knowledge of CAD

A cohort study by Chiuve SE., McCullough ML., Sacks FM., Rimm EB., (2010)
to assess the level of risk and prevention of CAD among different population, concluded
that adherence to healthy lifestyle habits may prevent a majority of CHD events among
US healthy men. Similarly Franklin et al., (2009) reported the results that in the control
community the risk of CVD increased over two years, but in the intervention
communities there was a substantial and sustained decrease in risk following adherence
to healthy lifestyle habits. The net difference in estimated total risk between control and
intervention samples was 23-28%.

With regard to HTN Pearson TA et al., (2011) , Bazzarre TL et al (2010),

Chobanian AV et al (2009) conducted cohort studies to assess the effectiveness of
intervention strategies to reduce HTN and reported that behavioral and pharmacological
strategies can effective in reducing B.P, but Appel LJ et al ( 2009 ), Brag GA et al (2010)
and Sacks et al (2009) reported that dietary changes, sodium reduction and weight
reduction is effective in control of B.P. were as Svetlceyz, Earlinger TP, Vollmer WM,
Feldstein A et al ( 2010 ) and Douglas JG et al (2011) conducted a PREMIER trail and
compared the effectiveness of a multi component lifestyle intervention (group and
individual counseling on weight loss, reduced sodium intake, increased PA and limited
alcohol consumption) with the same intervention enhanced with the DASH diet or advice
only. The study identified that Multicomponent Lifestyle intervention significant and
reduced B.P. Whereas Pickering TG., Miller NH., Ogedeghe G., Karakoff LR., Artinian
NT and Goff D et al (2010) stated that self monitoring is effective in improving the B.P
 52

control. But Ramon Estruch et al (2013) stated that along Mediterranean diet
supplemented with extra-virgin olive oil or nuts reduced the mortality of major CV
events.

With regard to hyper cholestremia Davis et al ( 2009 ) conducted a cross sectional

study on dyslipidemia intervention among chronic outpatients and the result showed that
a brief dietary assessment and 5 ± 10 min dietary counseling sessions with video showed
that effective in reducing in reducing the total cholesterol and LDL in intervention group
than in control group.

A series of prospective studies by Louis J., Ignarro, Maria Leisia Balestrien,

Clauedio Napote (2010) and Napoli et al (2009), Thamson et al (2009), Wannamethee et
al (2010) and Michael J., Lamonte, Steveon N., Blair and Timothy S church (2009)
assessed the effectiveness of exercises on cardiovascular health among at risk clients for
CVD. The results demonstrated that light/moderate exercises are reduce the CVD risk
and progression of atherosclerosis in CAD by increasing the bio availability of nitric
oxide and vascular protection by Napoli et al ( 2009 ), Kingwell et al ( 2010 ) and
Stetano GB (2010). Whereas inactivity enhances vascular oxygen radical production,
endothelial dysfunction and atherosclerosis.

With regard to exercise strengthening program, the meta analysis studies by

Tanasesw .M et al (2009) and Smart. N, Marwick. TH (2008) and Manson et al (2010)
explained the effectiveness of 30 min/day strength training or vigorous exercises may
reduce the risk of an initial coronary event and .pulmonary events. Similarly Pollock et al
in AHA science advisory (2009) stated that physical exercises enhances the
cardiovascular health, reduction of sub-maximal heart rate, systolic blood pressure and
there by decrease myocardial oxygen requirements during moderate to vigorous activities

A series of cohort and observational studies such as British Regional Heart Study,
Men and Women in the study of Estern Finnus and women in the Iowa, Womens Health
6WXG\ DQG 1XUVHV¶ +HDOWK 6WXG\ :RPHQV +HDOWK 6WXG\ DQG :RPHQV +HDOWK ,QWLDWLYH
(2013) and Manson et al (2010) DPRQJZRPHQ¶VUHSRUWHGWKDWSK\VLFDODFWLYLW\KDGD
33% lower age ± adjusted risk of developing DM compared with women reporting no
exercise (p < 0. 000 ).
 53

Svetlana, Helena Lira, Jenni leppavuri, Taina Remes, Heikki Tikkanen and
Kaisupitkala (2013) , Craig .A Emter et al (2009), Adamu B, Sani MU, Abdu A. (2010),
Lippincott MF, Desai A, (2011) and Carlow et al (2011) studied the effectiveness of
exercise intervention regarding prevention of CAD risk factors, the researchers reported
that exercise training had anti ± inflammatory effect, slow the progression of progression
or partially reduce the severity of CAD and help in weight loss. Similarly endurance
phase can reduce the B.P, serum triglyceride, increase the HDL, improves in insulin
sensitivity and glucose homeostasis, thereby reduces the incidence of obesity, decrease
the sympathetic tone and enhanced parasympathetic tone, Shane. A, Philips, Emon Das,
Jingli Wang, Kirk Wood Pritchard and David. D, Guttermant in (2011) explained the
effectiveness of aerobic exercise on protection against the impaired endothelium and
dependent vasodilatation in sedentary samples, following an acute episode of HTN.

After an acute episode of HTN among sedentary samples Shane A., Philips,
Emon Das, Jingli Wang, Kirk Wood Pritchard and David D., Guttermant (2011) proved
the effectiveness of aerobic exercise on protection against the impaired endothelium and
dependent vasodilatation.
Joann Manson. MD in (2009) and Larcroise AL et al (2009) conducted a
prospective from a large cohort studies among women and compared effectiveness of
brisk walking with vigorous exercises and both. The result stated that who engaged both
brisk walking and vigorous exercise had greater reduction in coronary events than who
participated in either walking or vigorous exercise alone. It indicated that combinations
of brisk walking and vigorous exercise had good effect in reducing the CHD.

The Global Recommendations on physical activity for health by WHO (2015)

stated that in order to make exercise effective, it should be sustained for long term, be
regular, and for at least 4 ± 5 times / week about 30 min.

SUMMARY
After extensive review of literature investigator found that prevalence of CAD
ULVN IDFWRUV DPRQJ \RXQJHU¶V WKDQ WKH ROGHU SRSXODWLRQ DQG FRPSDULQJ ZLWK YDULRXV
studies indicate that the mortality and morbidity rate of CAD can reduced by promoting
the knowledge and practice skill through the various educational resources.
 54

RESEARCH METHODOLOGY

Methodology of research organizes all the components of study in a way that

most likely will lead to valid answers for the problems that have been posted (burns and
groove). this chapter deals with the methodology adopted for the study. it includes the
research approach, research design, variables, setting, population, sample and criteria for
selection of the sample, sample size, sampling technique, development and description of
tool, content validity, pilot study, and reliability of the tool, data collection procedure and
plan for data analysis.

3.1 RESEARCH APPROACH

A quantitative research approach was used in this study.

3.2 RESEARCH DESIGN

. Based on Polit and Becker (2011) this study design was termed as quasi-
experimental, as the investigator has incorporated an intervention and a control group but
no randomization in sample selection. The schematic representation of the design is
shown below
Group Pretest (O1) Intervention (×) Post test (O2)
Framingham Risk Assessment Tool to identify clients with
Assessment the level of risk for developing CAD by using

Heart Smart Package (HSP):

Lecture cum discussion aided
by power point presentation Assessment of the
regarding CAD risk factors and post-test level of
Assessment of
its prevention. knowledge and skill
Experimental the pre test
mild or moderate risk.

Demonstration of cardio by using structured

group level of
exercises. interview schedule,
knowledge
Re-demonstration of cardio and observational
regarding
exercises. checklist.
prevention of
Reinforcement on prevention of
CAD using
CAD through a booklet.
structured
Hospital routine management
interview
and information (pharmacy Assessment of the post
schedule.
Control therapy, laboratory test level of knowledge
group investigations and regular using structured
checkups for manage risk interview schedule.
factors )
 55

3.3 VARIABLES
3.3.1 Independent Variable
Heart Smart Package on prevention of CAD.

3.3.2 Dependent Variables

Level of Knowledge and skill regarding prevention of CAD.

3.3.3 Extraneous Variables

Previous exposure to teaching on control of CAD related risk, presence of
physical disabilities

3.4 SETTING OF THE STUDY

The setting was RUSH Multispecialty Hospital which is a 450 bedded semi
government hospital rendering outpatient and inpatient services. It has cardiology,
urology, nephrology, gastroenterology, endocrinology, casualty, maternity, ENT and
medical departments. The Chronic outpatient dept. functions in with two different
blocks, which is situated within the hospital and caters to about 80 patients per day. They
do not conduct any medical camp or outreach services

3.5 POPULATION
3.5.1 Target population
Clients who are at mild or moderate risk of developing CAD based on the
Framingham Risk Assessment Tool

3.5.2 Accessible Population

At risk clients who were visiting Chronic Outpatient Department at RUSH
Multispecialty Hospital, Tirupathi, Andhra Pradesh.

3.6 SAMPLE
Clients who had mild or moderate risk of developing CAD and who fulfilled the
sample selection criteria.
 56

3.7 SAMPLE SIZE

Sample of 64 at risk clients (32 each in the experimental and control group), who
fulfilled the inclusion criteria.

3.8 CRITERIA FOR SAMPLE SELECTION

3.8.1 Inclusion criteria: Clients who
1. were aged between 20-70 years
2. had low or moderate risk for CAD (identified using Framingham Risk
Assessment Tool )
3. were attending Chronic outpatient clinics
4. were willing to participate.
5. were able to understand Telugu/English

3.8.2 Exclusion criteria: Clients

1. who were acutely ill
2. with severe visual/ auditory/ cognitive impairment.
3. who were physically challenged
4. who had undergone any awareness program on prevention of CAD.
5. who had already been diagnosed with CAD or any other cardiac disorders.

3.9 SAMPLING TECHNIQUE

Purposive sampling technique was used to select samples. Clients with low and
moderate score on the Framingham Cardiovascular Disease Risk Assessment Tool were
included in the study with samples attending chronic outpatient in block I as experimental group
and block II as control group.

3.10 DEVELOPMENT AND DESCRIPTION OF THE TOOL

After a broad review of literature, examination with the specialists and with the
investigators proficient experience, a interview schedule was produced to assess the level
of knowledge and observational checklist to evaluate the skill of the participants.

The tool constructed in this study has two parts:

3.10.1: Assessment Tools
3.10.2: Intervention tool ± Heart Smart Intervention Package
 57

3.10.1 Assessment Tools

Tool I: Framingham Cardiovascular Disease Risk Assessment tool
Tool II: Assessment of the demographic variables.
Tool III: Structured interview schedule to assess the knowledge level of clients regarding
risk factors and prevention of CAD.
Tool IV: Observational checklist to assess skill in performing Cardio exercises

Tool I: Framingham Cardiovascular Disease Risk Assessment Tool

It consists of risk factors such as age, gender, total cholesterol, HDL, smokers,
non-smokers and systolic hypertension categorized separately for men and women.

Scoring
Each risk factor has separate criteria with points added together and given a
percentage to classify patients into low, moderate and high risk respectively

Interpretation of Framingham cardiovascular risk assessment tool

Score Inference

<10% Mild risk

10-20% Moderate risk

>20% High risk

Tool II: Demographic Profile:

It consists of demographic variables:
x Age, gender, educational qualification, occupation, marital status, religion, family
income, area of residence, type of family, family history of CAD, nature of relationship
history of co-morbid illness, diet pattern and any habit of smoking of smoking
x Biological variables: Height, weight, BMI and fasting blood sugar level.

Tool III: Structured interview schedule

This part consisted of structured interview schedule to assess the knowledge level
of at risk clients regarding risk factors and prevention of CAD. It consists of 25
questions.
 58

Each question ended with multiple choices. Risk clients were asked to select the
most appropriate answer from the four options given.

Scoring key
(DFK FRUUHFW DQVZHU ZDV JLYHQ µ¶ PDUN DQG ZURQJ DQVZHU RU XQDWWHQGHG
TXHVWLRQZDVJLYHQµ¶PDUN7KHUDZVFRUHZDVFRQYHUWHGWRWRLQWHUSUHWWKHOHYHORI
knowledge. The overall score was 25.
Score Level of Knowledge
” Inadequate level of Knowledge
51-75% Moderate level of Knowledge
>75% Adequate level of Knowledge

Tool IV: Observational check list

It consists of 20 questions, 7KHVFRULQJJLYHQLVPDUNIRU³<HV´DQGPDUNIRU
³1R´7KHWRWDOVFRUHLVZLWKDPLQLPXPVFRUHRIDQGPD[LPXP

Interpretation

Score Interpretation

” Needs improvement in skill

51%-74% Fair skill

• Good skill

3.10.2 INTERVENTION TOOL

The interventional tool prepared by the investigator is the Heart Smart Package,
consisting of a set of interventions, administered to at risk clients, in order to improve
their level of knowledge and skill regarding prevention of CAD, through:
A) Lecture cum discussion aided by power point presentation for 5-7 members for about 30
min duration on
‡ General information on meaning of CAD, risk factors, causes, warning signs, and
complications of CAD
 59

‡ Strategies for risk reduction: Healthy diet, regular exercises, cessation of

smoking and alcohol, management of co-morbid illness and monitoring optimum
health.
B) Demonstration of cardio exercises by the investigator on warm-up, twist crunch,
squat and over head press, static lunge, deep breathing exercises and cool down
exercises to be performed for 3 min each, for a total duration of 20 min, once daily.
C) Re-demonstration of the cardio exercises by risk clients.
D) Re-inforcement on prevention of CAD through a booklet.

3.11 CONTENT VALIDITY

The content validity of the data collection tool and intervention tool was
DVFHUWDLQHGZLWKWKHH[SHUW¶VRSLQLRQLQWKHIROORZLQJILHOGRIH[SHUWLVH
‡ Cardiologist-2
‡ Medical-Surgical Nursing experts - 4
‡ Physiotherapist ± 1
Modifications suggested by the experts in the tool included inclusion of few
additional changes in knowledge questionnaire. These changes were incorporated in the
tool. All the experts had their consensus and then the tool was finalized.

3.12 ETHICAL CONSIDERATION

Ethics is a system of moral values that is concerned with the degree to which the
research procedures adheres to the professional, legal and social obligations to the study
participants, Polit and Hungler (2012).
The ethical principles followed in the study were:
The investigator followed the fundamental ethical principle of beneficence by adhering
to
1. Beneficence
a) Freedom from harm and discomfort
The study was beneficial for the samples as it enhanced their knowledge regarding
prevention of CAD. Safe environment was provided for the samples to re demonstrate the cardio-
exercise.
b) Protection from harm and discomfort
The investigator explained the procedure and the nature of the study to the participants
and ensured that none of the participants were exploited or denied fair treatment.
 60

2. Respect For Human Dignity

The investigator followed the second ethical principle of respect for human dignity. It
includes the right to self determination and right to self disclosure.
a) The right to self determination
The investigator gave full freedom to the participants to decide voluntarily
whether to participate in the study or to withdraw from the study at any point of time and
the right to ask questions.
b) The right to full disclosure
The researcher fully described the nature and it purpose and steps involved in the
VWXG\ 7KH SHUVRQ¶V ULJKW WR UHIXVH SDUWLFLSDWLRQ DQG WKH UHVHDUFKHU¶V UHVSRQVLELOLWLHV
based on which both oral and written informed consent was obtained from the
participants.

3. Justice
The selection of the study participants was completely based on research requirements.
Privacy was maintained throughout the data collection.
a) Right to fair treatment
The researcher selected the study participants based on the research
requirements. The investigator followed the rules and regulations of the Institutional
ethical committee (ICCR). After completion of post test in the control group Heart
Smart Package was administered
b) Right to privacy
The UHVHDUFKHUPDLQWDLQHGWKHSDUWLFLSDQW¶VSULYDF\WKURXJKRXWWKHVWXG\

4. Confidentiality
The researcher maintained confidentiality of the data provided by the participants.
3.13 RELIABILITY OF THE TOOL

Variable Tool Method Value Inference

Structured interview
Knowledge Inter- rater 0.92 Reliable
schedule

Skill Observational checklist Inter-rater 0.95 Reliable

The above table shows that the tool was highly reliable and feasible for utilization in the
main study.
 61

3.14 PILOT STUDY

Pilot study was conducted at RUSH Multi Specialty Hospital at Tirupathi,
Andhra Pradesh. A formal written permission was obtained from the Principal of
Omayal Achi College of Nursing, and the Director and Head of the Department of
General Medicine of RUSH Multi Specialty Hospital .The pilot study was conducted for
a period of one week from 22-5-2015 to 27-5-2015. .

The investigator screened the clients who were at risk for developing CAD using
Framingham Cardiovascular Disease Risk Assessment Tool. Using non-probability
purposive sampling technique, 5 patients at risk for CAD were allotted to the
experimental group and 5 to the control group. A brief explanation was given regarding
the purpose of the study and written consent was obtained from the participants.

On the first day, the experimental group samples were seated comfortably in a
conducive room and demographic details were obtained from them. The knowledge
regarding CAD was assessed using structured interview schedule, following which the
investigator administered the Heart Smart Package to the experimental group. This
included lecture cum discussion, power point presentation regarding strategies for
prevention of coronary artery disease for 30-35 min, along with demonstration of cardio
exercises for 20 min. The reinforcement booklet was also given to participants. The
same sequence was followed for the control group except for hospital routine instead of
HSP. At the end of 7th day, post test was conducted using the same questionnaire for both
the experimental and control group and the post test level of skill through re-
demonstration by the groups, was assessed by using the observational check list. The
HSP was administered to the control group after the post test.

The pilot study analysis revealed that the t value of 9.750 to determine the
effectiveness of selected nursing intervention package showed high significance at
p<0.001 level. The results of pilot study revealed that the assessment and intervention
tool was reliable, feasible, and practicable to conduct the main study.
 62

3.15 PROCEDURE FOR DATA COLLECTION

The main study was conducted after obtaining formal permission from the
Principal of Omayal Achi College of Nursing and the Director and Head of the
Department of General Medicine of RUSH Multi Specialty Hospital at Tirupathi,
AndhraPradesh. The data collected for a period of 1 month duration
(19-05-15 to 20-06-15).

A brief self introduction along with an explanation of the purpose of the study
was given to the participants. After obtaining written informed consent from participants,
data collection commenced with the control group followed by the experimental group.

The investigator screened 40 patients from Block-I by using Framingham

Cardiovascular Disease Risk Assessment Tool and found that 32 patients were in low
and moderate risk for CAD respectively in the experimental group. Similarly, the
investigator screened 38 clients from Block-II using the same tool and found that 32
patients had low and moderate risk for CAD respectively in the control group. Therefore
a total of 64 clients (32 each in the experimental and control group) were selected as
samples.

On the first day, the experimental group samples were seated comfortably in a
conducive room and demographic details were obtained from them. The knowledge
regarding CAD was assessed using structured interview schedule, following which the
investigator administered the Heart Smart Package to the experimental group, which
included Lecture cum discussion, power point presentation regarding strategies for
prevention of coronary artery disease for 30-35 min, along with demonstration of cardio
exercises for 20 min. The reinforcement booklet was also given to participants. The
same sequence was followed for the control group except for hospital routine instead of
HSP. At the end of 7th day, post test was conducted using the same questionnaire for both
the experimental and control group and the post test level of skill through
redemonstration by the groups, was assessed by using the observational check list. The
HSP was administered to the control group after completion the post test.
 63

3.16 PLAN FOR DATA ANALYSIS

Data was analyzed by using both descriptive and inferential statistics.

Descriptive Statistics
1. Frequency and percentage distribution to analyze the demographic data among at risk
clients.
2. Mean and standard deviation was used to assess level of knowledge and skill.

Inferential Statistics
1. 3DLUHGµW¶DQGXQSDLUHGµW¶WHVWWRFRPSDUHWKHGDWDEHWZHHQWKHH[SHULPHQWDODQGFRQWURO
group.
2. Correlation co-efficient to find the relationship between the mean differed level of
Knowledge and skill between experimental and control group.
3. *DLQVFRUH$129$XQSDLUHGµW¶DQGFKLVTXDUHZDVXVHGWRDVVRFLDWHWKHPHDQGLIIHUHG
level of demographic variables with the level of knowledge and skill among at risk
clients.
 64

Fig.3.1.1 SCHEMATIC REPRESENTATION OF RESEARCH METHODOLOGY

DESIGN ± Quasi experimental non-equivalent control group pre test and post test design

Target population: Clients who were at mild or moderate risk of developing CAD based on
Framingham Risk Assessment Tool

Accessible population: At risk clients visiting chronic outpatient department at RUSH

Multispecialty Hospital, Tirupathi.

Sampling technique: Non probability purposive sampling technique (low or moderate level of
risk for CAD)

Sample: 64 at risk clients who satisfied the inclusion criteria

Experimental group -32 Control group -32

Pre test level of knowledge was

Pre test level of knowledge was assessed using structured
assessed using structured interview schedule
interview schedule

Hospital routine management

(pharmacological therapy,
Administration of HSP package laboratory investigations and
reviews for managing risk
factors)

Post test level of knowledge

and skill was assessed by
Post test assessment by structured
interview schedule and checklist
interview schedule on 7th day.
on the 7th day

Data analysis and interpretation

 65

DATA ANALYSIS AND INTERPRETATION

Data analysis refers to the process of organizing and synthesizing the data in
such a way that the research question can be answered and hypothesis tested (Polit and
Hungler, 2010).

This chapter deals with the analysis and interpretation of the data to assess the
effectiveness of Heart Smart Package on knowledge and skill regarding prevention of
CAD among at risk clients attending chronic outpatient department, in selected hospitals
at Andhra Pradesh.

The collected data was grouped and analyzed using descriptive and inferential
statistics, and the results are presented under the following sections.

ORGANIZATION OF THE DATA

Section 4.1: Description of demographic variables in the experimental and control
group.
Section 4.2: Assessment of the level of risk for developing CAD in the experimental
and control group.
Section 4.3: Assessment of the effectiveness of Heart Smart Package on the level of
knowledge regarding prevention of CAD among at risk clients.
Section 4.4: Assessment of the post test level of skill regarding prevention of CAD
among the experimental group
Section 4.5: Correlation of the post test level of knowledge with skill regarding
prevention of CAD in the experimental group.
Section 4.6: Association of the selected demographic variables with the mean differed
knowledge and post test skill score regarding prevention of CAD among at
risk clients
 66

SECTION 4.1: DESCRIPTION OF DEMOGRAPHIC VARIABLES OF AT RISK

CLIENTS IN THE EXPERIMENTAL AND CONTROL GROUP.
TABLE 4.1.1: Frequency and percentage distribution of selected demographic
variables such as age, gender, education, occupation, marital status, religion and
area of residence in the experimental and control group.
N=64(32+32)
Group
S.No. Demographic variable Experimental (n=32) Control (n=32)
n % n %
1 Age (years)
20-40 4 12.5 2 6.3
41-50 13 40.6 13 40.6
51-60 15 46.9 17 53.1
2 Gender
Male 16 50.0 16 50.0
Female 16 50.0 16 50.0
3 Education
Non- literate 2 6.3 2 6.3
Primary School 7 21.9 5 15.6
Middle school 18 56.3 13 40.6
High school 3 9.4 9 28.1
Higher school 2 6.3 3 9.4
4 Occupation
Unemployed 4 12.5 7 21.9
Unskilled worker 6 18.8 6 18.8
Semi skilled workers 16 50.0 9 28.2
Skilled worker 4 12.5 6 18.8
Own business 1 3.1 2 6.3
Professional 1 3.1 2 6.3
5 Marital status
Married 31 96.9 31 96.9
Unmarried 1 3.1 1 3.1
6 Religion
Hindu 26 81.3 24 75.0
Muslim 5 15.6 6 18.8
Christian 1 3.1 2 6.3
7 Area of residence
Slum 4 12.5 2 6.3
Rural 4 12.5 3 9.3
Semi Rural 10 31.2 11 34.4
Urban 14 43.8 16 50.0

The above table shows that in the experimental and control group most of the
clients were aged between 51 ± 60 yrs, had completed middle school education, were
employed semi skilled workers, were married, were Hindu and resided in urban areas.
Equal number of males and females were present in the both the groups
 67

Table 4.1.2: Frequency and percentage distribution of selected demographic

variables such as type of family, family monthly income, family history of CAD,
nature of relationship with affected person and history of co ± morbid illness.
N=64(32+32)
Group
Experimental Control
S.No. Demographic variable
(n=32) (n=32)
n % n %
8 Type of family
Nuclear family 21 65.6 13 40.6
Joint family 9 28.1 16 50.0
Extended family 2 6.3 3 9.4
9 Family monthly income( in rupees)
< Rs.1802 1 3.1 2 6.3
1801-5386 2 6.3 1 3.1
5387-8988 1 3.1 1 3.1
8989-13494 12 37.5 12 37.5
13495-17999 16 50.0 16 50.0
18000-36016 1 3.1 1 3.1
10 Family history of CAD
Yes 17 53.1 14 43.2
No 15 46.9 18 56.3
11 Nature of relationship with affected person
Paternal 15 46.9 18 56.3
Maternal 5 15.6 3 9.4
Siblings 4 12.5 2 6.3
Others 8 25.0 9 28.1
12 History of co-morbid illness
Hypertension 8 37.5 14 62.5
Diabetes 9 44.5 8 55.5
Both 10 60.0 5 40.0
Others 5 60.0 5 40.0

The above table shows that in the experimental group most of the samples
belonged to nuclear family with a family monthly income of Rs. 13495 ± 17999 and
more than half of samples had a family history of CAD. Out of which, most of them
were afflicted with paternal relationship and had a history of diabetes and HTN as a co ±
morbid illness.
In the control group, most of the samples belonged to joint family, with a family
monthly income of Rs. 13495 ±  ZKR GLGQ¶W KDG IDPLO\ KLVWRU\ RI &$' RXW RI
which, most of them were afflicted with paternal relationship and had a history of HTN
as a co ± morbid illness.
 68

Table 4.1.3: Frequency and percentage distribution of selected demographic

variables such as dietary pattern, any previous information regarding prevention of
CAD, source of information and habit of smoking in the experimental and control
group.
N=64(32+32)
Group
Experimental Control
S.No Demographic variable
(n=32) (n=32)
n % N %
13 Dietary pattern
Vegetarian 2 6.3 1 3.1
Non vegetarian 30 93.7 31 96.9
14 Any previous information regarding
prevention of CAD
Yes 0 0 0 0
No 32 100 32 100
15 ,Iµ\HV¶VSHFLI\WKHVRXUFH
Nil 32 100 32 100
16 Any habit of smoking
Yes 13 40.6 15 46.9
No 19 59.4 17 53.1
17 ,Iµ\HV¶KRZPDQ\FLJDUHWWHVSHUGD\
1 pack 5 38.5 2 13.3
1- 2 packs 4 30.8 6 40.0
> 2 packs 4 30.8 7 46.7

The above table shows that majority of them consumed non-vegetarian diet and
none of them were having any previous information regarding CAD.

Similarly in both the groups, about half of the population were non-smokers and
remaining were reported with the habit of smoking with more than 2 packs per day in the
control group, while in the experimental group, it was either 1- 2 packs or >2packs/day
 69

Table 4.1.4: Frequency and percentage distribution of selected biological variables

such as height, weight, BMI kg/m2 and fasting blood sugar in the experimental and
control group.
N=64(32=32)
Group
Experimental Control
S.No. Biological variable
(n=32) (n=32)
n % n %
18 Height (cm)
145-155 2 6.3 1 3.1
156-165 20 62.5 23 71.9
166-175 10 31.3 8 25.0
19 Weight (kg)
< 50 2 6.3 1 3.1
51-60 13 40.6 12 37.5
61-70 17 53.1 19 59.4
2
20 BMI(kg/m )
18-24 25 78.1 21 65.6
> 24 7 21.9 11 34.4
21 Fasting blood sugar(mg/dl)
71-100 mg/dl 8 75.0 20 62.5
101-200 mg/dl 28 25.0 12 37.5

In the both group, most of them were in the height of 156-165cm with a weight of
61-70kg and the BMI was 18-24.

Whereas the FBS was 71-100mg/dl in the control group and 101-200 mgldl in the
experimental group.
 70

SECTION 4.2: ASSESSMENT OF THE LEVEL OF RISK FOR DEVELOPING

CAD IN THE EXPERIMENTAL AND CONTROL GROUP.
Table 4.2.1: Frequency and percentage distribution of level of risk in the
experimental and control group
N=64(32+32)
Low Risk Intermediate Risk High Risk
Risk
No. % No. % No. %
Experimental group 23 71.9 9 28.1 0 0
Control group 24 75.0 8 25.0 0 0

The above table shows that frequency and percentage distribution of level of risk in
the experimental and control group. The results showed that in both groups, majority of clients
had low risk for CAD. None of them had high risk in both groups.
 71

Experimental Group
100 Control Group

90
75
80 71.9

70

60
Percentage

50

40
28.1 25
30

20

10
0 0
0
Low Risk Intermediate Risk High Risk

Level of Risk

Figure 4.2.1: Percentage distribution of level of risk in the experimental and

control group
 72

SECTION 4.3: ASSESSMENT THE EFFECTIVENESS OF HEART SMART

PACKAGE ON THE LEVEL OF KNOWLEDGE REGARDING PREVENTION
OF CAD AMONG AT RISK CLIENTS.
Table 4.3.1: Frequency and percentage distribution of pretest level of knowledge
regarding prevention of CAD among at risk clients in the experimental group.
n=32

Moderately
Inadequate Adequate
Adequate
Knowledge ” (>75%)
(51 ± 75%)
No. % No. % No. %
General Information
Risk factors 31 96.9 1 3.1 0 0.0
Causes 27 84.4 5 15.6 0 0.0
Warning signs 30 93.8 2 6.2 0 0.0
Prevention 0 0.0
Diet 25 78.1 7 21.1 0 0.0
Management of Co-morbid
31 96.9 1 3.1 0 0.0
illness
Maintaining optimum
30 93.8 2 6.2 0 0.0
health
Overall 29 90.6 3 9.4 0 0.0

The above table denotes frequency and percentage distribution of pretest level of
knowledge regarding prevention of CAD among at risk patients in the experimental
group, shows majority of clients were reported with inadequate knowledge
 73

Table 4.3.2: Frequency and percentage distribution of posttest level of knowledge

regarding prevention of CAD among at risk patients in the experimental group
n=32
Moderately
Inadequate Adequate
Adequate
Knowledge ” (>75%)
(51 ± 75%)
No. % No. % No. %
General Information
Risk factors 0 0 6 18.8 26 81.3
Causes 0 0 8 25.0 24 75.0
Warning signs 0 0 10 31.3 22 68.7
Prevention
Diet 0 0 11 34.4 21 65.6
Management of Co-morbid 40.6 19 59.4
0 0 13
illness
Maintaining optimum health 0 0 12 37.5 20 62.5
Overall 0 0 10 31.3 22 68.7

The above table regarding frequency and percentage distribution of posttest level
of knowledge regarding prevention of CAD among at risk clients in the experimental
group, shows that majority of clients had adequate knowledge

The result showed that that the Heart Smart Package was effective in improving
the level of knowledge regarding prevention of CAD among at risk clients in the
experimental group.
 74

Table 4.3.3 Frequency and percentage distribution of pretest level of knowledge

regarding CAD among at risk clients in the control group
N=32
Moderately
Inadequate Adequate
Adequate
Knowledge ” •75%)
(51 ± 75%)
No. % No. % No. %
General Information
Risk factors 30 93.8 2 6.3 0 0.0
Causes 26 81.3 6 18.8 0 0.0
Warning signs 29 90.6 3 9.4 0 0.0
Prevention
Diet 24 75.0 8 25.0 0 0.0
Management of Co-morbid illness 29 90.6 3 9.4 0 0.0
Maintain optimum health 30 93.8 2 6.3 0 0.0
Overall 28 87.5 4 12.5 0 0

The above table regarding frequency and percentage distribution of pretest level
of knowledge regarding prevention of CAD among at risk clients in the control group,
shows that majority of clients had inadequate knowledge.
 75

Table 4.3.4: Frequency and percentage distribution of posttest level of knowledge

regarding CAD among at risk clients in the control group
N=32
Moderately
Inadequate Adequate
Adequate
Knowledge ” •75%)
(51 ± 75%)
No. % No. % No. %
General Information
Risk factors 30 93.8 2 6.3 0 0
Causes 24 75.0 8 25.0
Warning signs 28 87.5 4 12.5 0 0
Prevention
Diet 22 68.8 10 12.5 0 0
Management of Co-morbid
28 87.5 4 6.3 0 0
illness
Maintain optimum health 30 93.8 2 6.3 0 0
Overall 27 84.4 5 12.5 0 0

The above table regarding frequency and percentage distribution of posttest level
of knowledge regarding prevention of CAD among at risk clients in the control group,
shows that in control group majority of samples had inadequate knowledge.

The results show that with routine health care information alone, there is no
increase in the level of knowledge regarding prevention of CAD disease among the
control group.
 76

Table 4.3.5: Frequency and percentage distribution of overall level of knowledge

score among the experimental and control group
N=64(32+32)
Experimental Control
Chi-square
Level of knowledge score (n=32) (n=32)
test
n % n %
Inadequate 29 90.6 28 87.5 F2=0.16
Pretest Moderately adequate 3 9.4 4 12.5 P=0.69
Adequate 0 0.0 0 0.0 N.S
Total 32 100 32 100
Inadequate 0 0.0 27 84.4 F2=50.67
Posttest Moderately adequate P=0.001
10 31.3 5 15.6
S***
Adequate 22 68.7 0 0.0
Total 32 100 32 100
(*** 9HU\KLJKVLJQLILFDQWDWS”16 QRWVLJQLILFDQW)

The above table regarding frequency and percentage distribution of pre and the
post test overall level of knowledge among the experimental and control group, shows
that majority of clients in the experimental group gained adequate knowledge whereas in
the control group most of the clients continued to have inadequate knowledge regarding
prevention of CAD in the post test.

The post test chi-square value shows very high statistical significance at p<0.001,
indicating that both the groups were homogenous in the pretest but after the
administration of HSP, the experimental group showed significant improvement in the
overall level of knowledge regarding prevention CAD.
 77

100 Experimental
90.6
Control
87.5
90 84.4

80
68.7
70

60

50

Percentage
40
31.3

30

15.6
20 12.5
9.4
10
0 0 0 0
0
Inadequate Moderately Adequate Inadequate Moderately Adequate
adequate adequate
Pretest Posttest

Figure 4.3.5: Percentage distribution of overall level of knowledge score among the experimental and control group
 78

Table 4.3.6: Comparison of pretest and posttest level of knowledge regarding prevention
of CAD among at risk clients in the experimental and control group
N=32

Pre test Post test

Level of knowledge 3DLUHGµW¶WHVW
Mean SD Mean SD
t=21.33
Experimental
9.22 2.07 20.03 3.05 p= 0.001
group
***S
t=1.83
Control group 9.59 1.72 10.63 1.79 p=0.07
N.S
(* 6LJQLILFDQWDWS”** +LJKO\VLJQLILFDQWDWS”*** Very highly significant at
S”16 QRWVLJQLILFDQW)

The above table shows the comparison between pretest and post test knowledge
scores regarding prevention of CAD among at risk clients in the experimental and control
group

,QWKHH[SHULPHQWDOJURXSWKHFDOFXODWHGSDLUHGµW¶WHst value of 21.33 shows very

high significance at p<0.000 indicating the effectiveness of HSP in enhancing their
knowledge when compared to the control group which showed a non-significant paired
µW¶YDOXH
 79

Table 4.3.7 Comparison of pre and post test level of knowledge regarding CAD
among at risk clients between the experimental and control group
N=64(32+32)
Student independent
Group Mean S.D
µW¶WHVW
Experimental 9.22 2.07 t=0.38
Pre test p=0.43
Control 9.59 1.72
N.S
Experimental 20.03 3.05 t=9.40
Post test p=0.001
Control 10.63 1.79
*** S
(*** 9HU\KLJKO\VLJQLILFDQWDWS”16 QRWVLJQLILFDQW

The above table shows the comparison of pre and post test knowledge scores
regarding prevention of CAD between the experimental and control group.

,Q WKH SUHWHVW WKH FDOFXODWHG XQSDLUHG µW¶ YDOXH RI   VKRZHG QR VWDWLVWLFDO
VLJQLILFDQFH ZKHUHDV WKH SRVWWHVW XQSDLUHG µW¶ YDOXH RI  VKRZHG KLJK VWDWLVWLFDO
significance at p<0.001 level indicating the effectiveness of Heart Smart Package in
improving the post test level of knowledge regarding prevention of CAD in the
experimental group.
 80

SECTION 4.4: ASSESSMENT OF THE POST TEST LEVEL OF SKILL

REGARDING PREVENTION OF CAD AMONG THE EXPERIMENTAL
GROUP
Table 4.4.1: Frequency and percentage distribution of posttest level of skill
regarding prevention of CAD among at risk clients in the experimental group
n=32

No. of Experimental group

Exercises
questions Mean SD %
Warm up exercises 4 3.84 .37 96.0
Twist crunch 4 3.75 .62 93.8
Squat and over head press 4 3.38 .79 84.5
Static lunge 4 2.47 1.34
Deep breathing exercises 61.8
Cool down exercises 1 .66 .48 66.0
Total 3 2.63 .55 87.7
Overall 20 16.72 1.30 83.6

Needs Skill
Fair skill Good skill
Improvement
Post test (51 ± 75%) (>75%)
”
No. % No. % No. %
Skill 0 0 5 15.6 27 84.4

The above table reveals the post test level of skill regarding cardio exercises
among at risk clients in the experimental group, 5 (15.6%) of the samples had fair skill
and 27 (84.4%) had good skill.
 81

Needs skill improvement

Fair skill
Good skill
100
84.4
90

80

70

60
Percentage

50

40

30
15.6
20

10 0

0
Needs skill Fair skill Good skill
improvement
Level of Skill

Figure 4.4.1: Percentage distribution of posttest level of skill regarding prevention

of CAD among at risk clients in the experimental group
 82

SECTION 4.5: CORRELATION OF THE POST TEST LEVEL OF

KNOWLEDGE WITH SKILL REGARDING PREVENTION OF CAD IN THE
EXPERIMENTAL GROUP
N=32

Variables Mean SD µU¶YDOXH

Knowledge score 20.03 3.05

Post test

r = 0.56

Skill score 16.56 0.84 P=0.001***

(*** 9HU\KLJKO\VLJQLILFDQWDWS”16 QRWVLJQLILFDQW

The above table regarding correlation between post test knowledge and skill
score regarding prevention of CAD among at risk clients in the experimental group
VKRZVWKHµU¶value of 0.56 which indicates moderate positive correlation signifying that
an improvement in knowledge has a positive influence on increasing the skill among at
risk clients.

This proves that enhancement of the knowledge of at risk clients through the
Heart Smart intervention package significantly improved the skill of the clients by
enhancing their mastery of performing cardio exercises.
 83

20

18

16

14

12

10
12 14 16 18 20 22 24 26

Posttest knowledge score

Figure 4.5.1: Correlation of the post test level of knowledge with skill regarding
prevention of CAD in the experimental group
 84

SECTION 4.6: ASSOCIATION OF SELECTED DEMOGRAPHIC VARIABLES

WITH THE MEAN DIFFERED KNOWLEDGE AND SKILL SCORE
REGARDING PREVENTION OF CAD IN THE EXPERIMENTAL GROUP
Table 4.6.1: Association of selected demographic variables with the mean differed
level of knowledge gain score regarding prevention of CAD in the experimental
group N=32
Level of knowledge gain score
Demographic Below average Above Chi square
S.No. Total
variables ” average(>10.81) test
n % n %
1 Age
F2=6.18
20-40 yrs 3 75.0 1 25.0 4
P=0.05*
41-50 yrs 9 69.2 4 30.8 13
Significant
51-60 yrs 4 26.7 11 73.3 15
2 Education
Non- literate 2 100.0 0 0.0 2
Primary 4 57.1 3 42.9 7 F2=10.86
School P=0.05*
Middle school 10 55.6 8 44.4 18 Significant
High school 0 00.0 3 100.0 3
Higher school 0 00.0 2 100.0 2
3 Family
history of F2=6.14
CAD P=0.01**
Yes 5 29.4 12 70.6 17 significant
No 11 73.3 4 26.7 15
4 Any habit of
F2=6.35
smoking
P=0.01**
Yes 10 76.9 3 23.1 13
significant
No 6 31.6 13 68.4 19
(* 6LJQLILFDQWDWS”** +LJKO\VLJQLILFDQWDWS”*** Very highly significant at
S”16 QRWVLJQLILFDQW)

The above table shows the association between the level of knowledge gain score
and selected demographic variables of the experimental group such as age, education,
family history of CAD and habit of smoking.
Age and education showed mild statistical significance and family history of
CAD and habit of smoking showed high statistical significance. This indicates that
clients aged between 51 ± 60 yrs, those with middle school education, having family
history of CAD and non- smokers showed higher improvement in their level of
knowledge regarding prevention of CAD in comparison to the other samples
 85

100 100 100

100 Below Average
Above Average
90

80 75 73.3 73.3
69.2 70.6
70
57.1 55.6
60

50 42.9 44

% of Patients
40
30.8 29.4
25 26.7 26.7
30

20

10
0 0 0
0
20 - 40 yrs 41 - 50 yrs 51 - 60 yrs Non-literate Primary Middle High school Higher Yes No
school school school
Age Education Family hisory of CAD

Table 4.6.1: Association of selected demographic variables with the mean differed level of knowledge gain score regarding prevention of
CAD in the experimental group
 86

Below Average

100 Above Average

90 76.9
80 68.4

70
% of patients

60

50
31.6
40
23.1
30

20

10

0
Smokers Non-smokers

Figure 4.6.1: Association of selected demographic variables with the mean differed
level of knowledge gain score regarding prevention of CAD in the
experimental group
 87

Table 4.6.2: Association of selected demographic variables with post test level of
skill in the experimental group.
N=32
Demographic Post test Level of Skill score
S.No. Fair Good Total Chi square test
variables
N % n %
1 Age yrs
20-40 3 75.0 1 25.0 4 F2=14.69
P=0.01**
41-50 1 7.7 12 92.3 13
Significant
51-60 1 6.7 14 93.3 15
2 Educational status
Non- literate 2 100.0 0 0.0 2
Primary School 2 28.6 5 71.4 7 F2=14.07
P=0.01**
Middle school 1 5.6 17 94.4 18
Significant
High school 0 0.0 3 100.0 3
Higher school 0 0.0 2 100.0 2
3 Family history of
CAD F2=9.37
Yes 0 0.0 17 100.0 17 P=0.01**
No 15 Significant
5 33.3 10 66.7
4 Any habit of
smoking F2=3.84
Yes 4 30.7 9 69.3 13 P=0.05*
Significant
No 1 5.2 18 94.8 19
* 6LJQLILFDQWDWS”** +LJKO\VLJQLILFDQWDWS”*** Very highly significant at
S”16 QRWVLJQLILFDQW

The above table shows the association between the post test level of skill and
selected demographic variables of the experimental group such as age, education, family
history of CAD and habit of smoking.

Age and education showed mild statistical significance and family history of CAD
and habit of smoking showed high statistical significance. This indicates that clients aged
between 51 ± 60 yrs, those with middle school education, having family history of CAD
and non- smokers showed higher improvement in their post test level of skill regarding
prevention of CAD in comparison to the other samples.
 88

100 100 100 100

100 93.3 94.4 Below
92.3
Average
90
80 75
71.4
66.7
70
60
50
40 33.3

% of patients
28.6
30 25

20
7.7 6.7 5.6
10
0 0 0 0
0
No

Yes

20 - 40 yrs
41 - 50 yrs
51 - 60 yrs
High school

Non-literate
Higher school

Middle school

Age Primary school Education Family hisory of CAD

Figure 4.6.2: Association of selected demographic variables with post test level of skill in the experimental group
 89

Below Average
Above Average 94.8
100

90

80 69.3

70
% of patients

60

50

40 30.7

30

20
5.2
10

0
Smokers Non-smokers

Figure 4.6.2: Association of selected demographic variables with post test level of
skill in the experimental group
 90

DISCUSSION

This chapter discusses the findings of the study, based on the objectives. The
current study was undertaken to assess the effectiveness of Heart Smart Package on
knowledge and skill regarding prevention of coronary artery disease among at risk
clients, at selected hospitals, Andhra Pradesh.

5.1 The findings of the demographic and biological variables among at risk clients
in the experimental and control group.
The demographic variables of at risk clients considered in this study was age in
years, gender, education, occupation, type of family, area of residence, religion, family
history of CAD, nature of relationship with affected person, presence of co- morbid
illness, diet pattern, habit of smoking and biological variables of at risk clients such as
height, weight, BMI and fasting blood glucose level.

In the experimental and control group most of the clients were aged between
51 ± 60 yrs, had completed middle school education, were semi skilled workers, were
married, belonged to Hindu religion and residing in urban areas. Equal number of male
and female were present in the both the groups.

In the experimental group most of the samples belonged to nuclear family with a
family monthly income of Rs. 13495 ± 17999 and more than half of the samples had a
family history of CAD. Out of which, most of them were afflicted with paternal
relationship and had a history of diabetes and HTN as a co - morbid illness.

In the control group, most of the samples belonged to joint family, with a family
monthly income of Rs.13495 ± 17999, no family history of CAD and had a history of
HTN as a co ± morbid illness. Among those with family history of CAD, most of them
were afflicted through paternal relationship.

With regard to biological variables the height of most of the samples as between
156 ± 165 cm, weight between 61 ± 70 kgs, BMI between 18 ± 24 and FBS between 101
± 200 mg/dl in both groups.
 91

Latheef SA, Subramanav. G (2011) conducted a study on prevalence of CAD and

coronary risk factors in an urban population of tirupathi, reported that females had high
danger of creating CAD and distinguished certain risk factors for CAD which
incorporates hypertension, low LDL values, family history of CAD. Rea TD et al (2010)
Huxley and Wood (2012) reported that there is a causal association between cigarette
smoking and coronary illness. Individual who expend more than 20 cig/day by day have
2 to 3 fold in danger for getting coronary illness and intermittent heart attacks.

Frank.B, Walter C., (2010) conducted a prospective study on optimal diet for
prevention of CHD, which found that bottomless utilization of fruits , vegetables,
unsaturated fat and sufficient omega - 3 unsaturated fats can protect against CHD.
Howard BV, Rodriguez BL, Bemett PH, Haris MI, Haman R and Kuller LH (2009)
suggested that patient with Diabetes mellitus are 2 ± 8 times more likely to experience
future CVD. Shah et al (2009) distinguished history of 40 yrs of depression and history
of endeavored suicide are significant autonomous indicators of premature CVD and IHD
in both males and females.

5.2 The first objective was to assessment of the level of risk for developing CAD in
the experimental and control group.
Frequency and percentage distribution of level of risk in the experimental and control
group, shows that in both groups majority of clients had low risk for CAD. None of them had
high risk in both groups.

Risk assessment guidelines (2013) by American College of Cardiology (ACC)

and AHA released updated risk assessment rules. The most grounded indicators of 10-
year risk identified were age, sex, race, total cholesterol, HDL, BP, BP with treatment,
DM and smoking.

5.3 The second objective was to assessment of the effectiveness of Heart Smart
Package on the level of knowledge regarding prevention of CAD among at risk
clients.
The pretest level of knowledge regarding prevention of CAD among at risk
patients in the experimental group, showed that majority of clients had inadequate
knowledge
 92

The post test level of knowledge regarding prevention of coronary artery disease
among at risk clients in the experimental group, showed that majority of clients had
adequate knowledge.

Comparison of pretest and post test knowledge scores regarding prevention of

CAD among experimental and control group, WKHFDOFXODWHGSDLUHGµW¶WHVWYDOXHRI
shows very high statistical significance at S” DPRQJ H[SHULPHQWDO JURXS and the
FDOFXODWHGSDLUHGµW¶WHVWYDlue of 1.03 indicates no statistical significance among control
group.

It indicates that both groups were homogenous in the pre test but after the
administration of HSP, the experimental group showed significant improvement in the
overall level of knowledge regarding prevention CAD.

Mamta Chowdhary, Kapil Sharma, Jaspreet, and Kaur Sodhi (2014) conducted an
experimental study on level of knowledge in regards to preventive measures of CAD
among patient going to outpatient department of selected hospital, the outcomes
uncovered that just 15.33% had satisfactory knowledge and 84.67% had poor level of
knowledge with respect to anticipation of CAD, the study suggests the need of awareness
regarding preventive measures of CAD to diminish the burden of such devasting illness.

Comparison of post test knowledge scores regarding prevention of CAD between

e[SHULPHQWDO DQG FRQWURO JURXS VKRZHG WKDW WKH XQSDLUHG µW¶ YDOXH  VKRZV KLJK
statistical significance at p<0.001 level.

The results showed that Heart Smart Package is effective in improving in level of
knowledge regarding prevention of coronary artery disease among at risk clients in the
experimental than the control group.

Hence the null hypothesis NH1 VWDWHGWKDW³There is no significant effectiveness

of Heart Smart Package on the level of knowledge regarding prevention of CAD
among at risk clients rejected for experimental group and accepted for control
group.
 93

5.4. Third objective was to assessment of the post test level of skill regarding
prevention of CAD among the experimental group.
With regard to post test level of skill majority of them gained good skill in
experimental group.

It shows effectiveness of Heart Smart Package and demonstration of exercises by

investigator among experimental group.

Gerhard Schuler, Volter Adams and Yoichi Goto (2013) conducted a study on
role of exercise in prevention of CVD reported that 15 min use of regular exercise, was
associated with significant reduction in the risk of CVD.

5.5. Fourth objective Correlation of the post test level of knowledge with skill
regarding prevention of cad in the experimental group among at risk clients.
Correlation between post test knowledge and skill score regarding prevention of
&$' DPRQJ DW ULVN FOLHQWV LQ WKH H[SHULPHQWDO JURXS VKRZV µU¶ YDOXH  LQGLFDWHV
moderate positive correlation signifying that an improvement in knowledge has a
positive influence on increasing the skill among at risk clients.

Abinav Vaidya, Umesh Raj, Aryal, and Alexandra Karettek (2013) conducted a
cross sectional study among 777 samples using random sampling technique to assess the
knowledge, attitude and practice on CV health in urban community of Nepal. with a
structured questionnaire. Results revealed that most of them were reported with adequate
knowledge, attitude and good skill. The researcher concluded that as the knowledge
increase, the practice also increasing 6.9% to 13.4%.

A cross sectional studies by (Dr. Jhon Botomwito Ikombele.,2011 and

Kiberenge W.M 2010) on knowledge, attitude and practice regarding prevention of
CAD among DM patients attending Mamelodi Hospital, Pretoria, Gauteng. positive
correlation were found for the knowledge (0.171) and practice (r=0.037) where as frail
positive non significant correlation observed between knowledge and practices.
 94

Thus the null hypothesis NH2 that was stated before ³7KHUH LV QR VLJQLILFDQW
relationship between the post test level of knowledge and skill in the experimental
JURXS´ It was rejected in the experimental group.

5.6. The fifth objective was to assessment of association of the selected demographic
variables with the mean differed knowledge and post test skill score regarding
prevention of CAD in the experimental group among at risk clients.
Age and education showed mild statistical significance, whereas family history of
CAD and the habit of smoking showed high statistical significance. This indicates that
there was significant improvement in their level of knowledge and post test level of skill
regarding prevention of CAD among client aged between 51 ± 60 yrs, those with middle
school education, having family history of CAD and non- smokers, in comparison to the
other samples.

Abinav Vaidya et.Al, (2013) explained association of the selected demographic

variables like age and education with the knowledge, attitude and practice on in regards
to counteractive action of CVD.

Thus the NH3 stated before that ³There is no significant association of selected
demographic variables with the post test level of knowledge and skill in the
experimental group´was rejected for the selected demographic variables such as age,
education, history of CAD and non-smokers with mean differed level of knowledge and
skill was improved regarding prevention of CAD in the experimental group.
 95

SUMMARY, CONCLUSION,
IMPLICATION, RECOMMENDATIONS AND LIMITATIONS

This chapter represents the summary, conclusion, implications, recommendations

and limitations of the study.

6.1 SUMMARY
CAD is a plaque formation within the walls of the coronary arteries until the
EORRGIORZWRWKHKHDUW¶VPXVFOHLVOLPLWHG2WKHUZLVHFDOOHGDV,VFKHPLDKHDUWGLVHDVH,W
may be a chronic narrowing of coronary artery over time and limiting of the blood
supply to part of the muscle. Or it can be acute, resulting from a sudden rupture of a
plaque and formation of a thrombus or blood clot. Risk factors for CAD were
categorized into modifiable and non-modifiable. Age, family history of CAD, gender
(non- modifiable factors). Systolic hypertension, high total cholesterol, high LDL, low
HDL, obesity, and stress (modifiable risk factors). Risk factor modification through
healthy eating, regular exercises, cessation of smoking and alcohol, management of co-
morbid illness and maintaining optimum health can reduce clinical events and premature
death in people with established CAD as well as in those who are at high risk for CAD
due to one or more risk factors.

The Heart Smart Package booklet provides an overall knowledge and skill
regarding prevention of CAD to at risk clients, there by empowering people to manage
their risk factors independently.

The purpose of the study was to create awareness among at risk clients attending
chronic outpatient clinics.³,QGLD KDV WKH GXELRXV GLVWLQFWLRQ RI EHLQJ known as the
³FRURQDU\DQGGLDEHWHVFDSLWDORIWKHZRUOG´VDLGProf. Prakash Deedwania, University
of California, San Francisco, USA.( Indian Heart Watch 2012)

The objectives of study were

1. To assess the existing level of risk for CAD among the experimental and control
group.
 96

2. To assess the effectiveness of Heart Smart Package on the level of knowledge

regarding prevention of CAD in the experimental and control group.
3. To assess the post test level of skill regarding prevention of CAD among the
experimental group
4. To correlate the post test level of knowledge with skill regarding prevention of
CAD in the experimental group.
5. To associate the selected demographic variables with the mean differed
knowledge and post test skill score regarding prevention of CAD in the
experimental group.

The study was based on assumptions that

x At risk clients may have some knowledge regarding risk for cardiovascular
disease.
x Educating at risk clients about Heart Smart Package may enhance their
knowledge and skill regarding cardiovascular health promotion.

The null hypotheses formulated were

NH1- There is no significant effect of Heart Smart Package on the level of knowledge
regarding prevention of CAD between the experimental and control group.
NH2- There is no significant relationship between the post test level of knowledge and
skill regarding prevention of CAD in the experimental group
NH3- There is no significant association of selected demographic variables with the post
test level of knowledge and skill regarding prevention of CAD in the experimental
group

7KH UHYLHZ RI OLWHUDWXUH SUDFWLFDO H[SHULHQFH DQG H[SHUW¶V JXLGDQFH SURYLGHG
strong support for the study. The reviews were developed a basis for conceptual
framework, aided to design the methodology and formulation of the tool.

In view of explaining and relating various aspects, the investigator had adopted
the concepts of :LHGHQEDFK¶V+HOSLQJ$UW2I&OLQLFDO1XUVLQJ7KHRU\DQG-:.HQQ\¶V
Open System Model.
 97

The investigator adopted a quasi experimental, non-equivalent control group pre

test and post test design to assess the effectiveness of Heart Smart Package on
knowledge and skill regarding prevention of coronary artery disease among at risk
clients attending chronic outpatient clinics. 62 samples were selected using non
probability purposive sampling technique.

The tool constructed had 2 parts. Data collection tool, which consisted of 5 parts.
Part I consisted of Framingham Cardiovascular risk assessment tool, which comprised of
age, total cholesterol, HDL, smokers, non- smokers and systolic hypertension. Part II
consisted of, structured questionnaire to assess the demographic and biological variables.
Part III consisted of structured interview schedule to assess the level of knowledge
regarding CAD among at risk clients (25 questions). Part IV consisted of observational
checklist to assess the skill performance by risk clients. This consists of 20 items. The
VFRULQJJLYHQLVPDUNIRU³<HV´DQGPDUNIRU³1R´7KHWRWDOVFRUHLVPDUNV

The tool-II consisted of interventional tool (Heart Smart Package) prepared by

the investigator is including : Lecture cum discussion aided by power point presentation
for 5-7 members for about 30 min duration on, a) General information- Meaning of
CAD, risk factors, causes, warning signs, and complications of CAD. b) Strategies for
risk reduction- Healthy diet, regular exercises, cessation of smoking and alcohol,
management of co-morbid illness and monitoring optimum health. c)Demonstration of
cardio exercises by the investigator on warm-up, twist crunch, squat and over head
press, static lunge, deep breathing exercises and cool down exercises to be performed for
3 min each, for a total duration of 20 min, once daily. d) Re-demonstration of the cardio
exercises by at risk clients. e) Re-inforcement of prevention of CAD through booklet.

The content validity of the data collection tool was obtained from 1 cardiologist,
4 Medical-Surgical Nursing experts and 1 Physiotherapist. The reliability of the tool was
established by inter rater method for knowledge questionnaire and observational check
list. The feasibility and practicability of the study was analyzed by conducting a pilot
study on 10 samples at RUSH Multi Specialty Hospital Tirupathi, Andhra Pradesh, India.

The data collection for the main study was also at done at RUSH Multi Specialty
Hospital, Block-I and Block-II. purposive sampling technique was used and the sample
 98

size was 64 clients who fulfilled the sample selection criteria. Ethical principles were
adhered throughout the study.

The data collected was analyzed and interpreted based on the objectives and null
hypotheses using descriptive and inferential statistics. The findings revealed that there
was a significant improvement in the level of knowledge and skill after being provided
with the Heart Smart package.

The major findings of the study were as follows

The analysis regarding level of risk of developing CAD in experimental group,
revealed that 23(71.9%) had low risk, 9 (28.1%) had moderate risk and none (0%) had
high risk whereas in the control group, 24(75.0%) had low risk, 8 (25.0%) had moderate
risk and 0(0%) had high risk.

The pre test analysis of knowledge among at risk clients revealed that in the
experimental group, majority 29(90.6%) had inadequate knowledge regarding prevention
of CAD whereas in the post test it improved to 22(68.7%) gaining adequate knowledge
and 10(31.3%) moderately adequate knowledge. In the control group, majority
28(87.5%) had inadequate knowledge in the pretest while in the post test it remained
similar with 27(84.4%) having inadequate knowledge.

The analysis of effectiveness of Heart Smart Package on knowledge and skill

DPRQJ DW FOLHQWV VKRZHG WKDW ERWK WKH FDOFXODWHG SDLUHG µW¶ YDOXH RI  DQG WKH
XQSDLUHGµW¶YDOXHRIW ZDVIRXQGWREHKLJKO\VWDWLVWLFDOO\VLJQLILFDQWDWS
level. This clearly indicates that the Heart Smart Package regarding prevention of CAD
administered to the risk clients in the experimental group had impacted a significant
improvement in their level of knowledge than the control group.

The analysis of post skill among the experimental group, showed that 5 (15.6%)
had fair skill and 27 (84.4%) had good skill following the administration of HSP.

The correlation between knowledge and skill in the experimental group, revealed
WKHFDOFXODWHG.DUO3HDUVRQ¶VFRUUHOation coefficient value of r = 0.56, which indicates
moderate positive correlation and high statistical significance at p<0.00 level. This
 99

clearly indicates that when the level of knowledge increased following the administration
HSP, it enabled the experimental group to gain adequate skill in performing the cardio
exercises.

A statistically high significant level of association (p<0.001 level) was identified

between the demographic variables age, education, family history of CAD and non-
smokers and the level of knowledge and skill gained by the experimental group, this
indicated that these aged 51-60 yrs, having completed middle school education with
family history of CAD and non- smokers showed greater interest in knowing about
prevention of CAD than the other samples.

6.2 CONCLUSION
The current study assessed the effectiveness of Heart Smart package on
knowledge and skill regarding prevention of coronary artery disease among at risk
clients attending chronic outpatient departments at selected hospitals Andhra Pradesh.

The study revealed that in comparison to the control group, the experimental
group showed a significant improvement in the level of knowledge and skill regarding
prevention of CAD following the administration of Heart Smart Package, thereby
concluding that the Heart Smart Package was effective in enabling the at risk clients to
gain awareness and skill regarding prevention of CAD and managing their risk status.

6.3 IMPLICATIONS
The investigator has drawn the following implications from the study in the field
of nursing practice, nursing education, nursing administration and nursing research.

6.3.1 Nursing Practice

Nurses have a vital role in educating the patients to improve their knowledge and
skill in prevention of CAD.
This can be facilitated by motivating the nurses to:
x Utilize the findings of the study to plan regular periodic health for CAD related
risk screenings and education sessions in hospitals and community health centers
regarding CAD and its prevention.
 100

x Implement mass educational program me on awareness of CAD using Heart

Smart Package.
x Encourage the public to engage in health promotion and health screening camps
to monitor for CAD related to risk.
x Perform a risk assessment using the Framingham Cardiovascular Disease Risk
Assessment Tool and then based on results behavior and lifestyle modifications
for those at risk are to be done.
x The chronic outpatient Department nurses can utilize this package in their daily
routine of health teaching.
x Motivate nurses to develop skill in teaching patients to perform heart
healthy/cardio exercises

6.3.2 Nursing Education

x The nurse educator can integrate the major study findings in the nursing curriculum
at various levels to build up and train the students to identify risk clients using
Framingham Cardiovascular Disease Risk Assessment Tool to prevent of CAD
leading to other major life threatening conditions.
x The nurse educator may facilitate the student nurses to gain skill required to
perform cardio exercises to educate at risk clients.
x The educational institutions must offer opportunities for the nursing students to
gain exposure to training programmes on heart health and prevention and control of
CAD related risk factors.

6.3.3 Nursing Administration

x Nurse administrator can play an extended role in counseling those who are at risk
for developing CAD
x Nurse administrators can plan and implement a protocol for nurses to aid in
enhancing the knowledge in prevention of CAD among at risk clients as a part of
routine hospital care.
x Nurse administrators can plan for awareness programmes and reach-out to a
larger group of population
 101

6.3.4 Nursing Research

x The findings of the study can be disseminated to the nurses working in chronic
outpatient department and student nurses through various media.
x The study plan can be further replication in various other settings and larger
population.

6.4 RECOMMENDATIONS
x This particular intervention package and risk assessment tool has been utilized in
x Omayal Achi Community Health Centre in Arakambakkam, Thiruvallur District,
Tamilnadu, during mega health camp. Hence it can be utilized similarly at other
health centres also
x The nurse investigator encourages the use the HSP booklet by chronic outpatient
department in RUSH multi specialty hospital ollowinf the communication of
study findings to the Health Administrator.
x Chronic OPDs should be equipped with booklets for creating awareness among
general population
x Similar study can be done in a larger population.
x Awareness programmes on CAD risk prevention could be conducted at
community level.
x Mixed method study and comparison between rural and urban group could be
done in larger population
x A similar study can be conducted on risk groups like sedentary workers, obese
individuals etc to enhance their ability to manage the risk status.

6.5 LIMITATION
x Investigator found difficulty in getting setting permission.

6.6 PLAN FOR RESEARCH DISSEMINATION

x The research findings will be disseminated through Medical Surgical Nursing
Journal, TNAI Journal and Health Action Journal and podium presentations both
in National and International conferences.
 102

6.7 PLAN FOR RESEARCH UTILIZATION

x The research findings will be incorporated in schools, colleges, work-sites,
hospitals and health centers
 103

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WEBSITES:
https://en.wikipedia.org/wiki/Non-communicable_disease
https://en.wikipedia.org/wiki/Cardiovascular_disease
https://en.wikipedia.org/wiki/Caroronary artery_disease
https://www.health.gov.au/internet/mainpublishing.nsf/content/chronic_cardio
http://www.uniassignment.com

REPORTS:
American College of Cardiology (2012)
American Heart Association (2011)
American Diabetes Association (2015)
British Regional Heart Study.
Centre for Disease Control and Prevention, (2015).
Global Burden of Disease (2010) Study.
Global Action Plan Expected Outcome 2013-2020.
Global Status Report on impact of risk factors on cardiovascular system (2014)
Indian Heart Watch (2012)
International Heart Protection Summit (2011)
Injuries and Risk Factor Study (2010).
National Health and Nutrition Examination Survey (2012)
Womens Health Study and Health Initiative (2013)
World Health Organization (2012)
 111

APPENDIX ± I

CODING FOR DEMOGRAPHIC VARIABLES

DEMOGRAPHIC VARIABLES CODE NO.

1. Age (years)
a) 20-40 1
b) 41-50 2,
c) 51-60 3
d) 61-70 4

2. Gender
a) Male 1
b) Female 2

3. Education
a) Non- literate 1
b) Primary School certificate 2
c) Middle school certificate 3
d) High school certificate 4
e) Higher school certificate 5

4. Occupation
a) Unemployed 1
b) Unskilled worker 2
c) Semi skilled workers 3
d) Skilled worker 4
e) Own business
f) Professional

5. Type of family
a) Nuclear family 1
b) Joint family 2
c) Extended family 3
d) Separated family 4
 112

6. Area of residence
a) Slum 1
b) Rural 2
c) Semi- rural 3
d) Urban 4

7. Family monthly Income (in Rs)

a) <1802 1
b) 1801-5386 2
c) 5387-8988 3
d) 8989-13494 4
e) 13495-17999 5
f) 18000-36016 6
g) >36017 7

8. Religion
a) Hindu 1
b) Muslim 2
c) Christian 3
d) Others 4

9. Marital status
a) Married 1
b) Unmarried 2

10. Family history of CAD

a) Yes 1
b) No 2

11. If yes, nature of the relationship with affected person

a) Paternal 1
b) Maternal 2
c) Siblings 3
d) Others 4
 113

12. History of co-morbid illness

a) Hypertension 1
b) Diabetes 2
c) Both 3
d) Others 4

13. Dietary pattern

a) Vegetarian 1
b) Non-vegetarian 2

14. Any recent information /participation in cardiac health promotion activity

a) Yes 1
b) No 2

15. If yes, specify the source

a) News paper 1
b) internet 2
c) Posters 3
d) Others 4

16. Any habit of smoking?

a. Yes 1
b. No 2

17. If yes, how many cigarettes per day?

a. <1 pack 1
b. 1- 2 packs 2
c. > 2 packs 3
 114

2. BIOLOGICAL VARIABLES
18. Height (cm)
a) 145-155 1
b) 156-165 2
c) 166-175 3

19. Weight (kg)

a) <50 1
b) 51-60 2
c) 61-70 3
d) >70 4

18. BMI (kg/m2 )

a) <18 1
b) 18-24 2
c) >24 3

21. Fasting blood sugar level (mg/dl)

a) <70 1
b) 71-100 2
c) 101-200 3
d) 201-300 4
e) > 300 5
 115

APPENDIX ± J

BLUE PRINT

S.
Content Item Total items Percentage
no
1 Framingham Cardiovascular 1±6 6 100%
Disease Risk Assessment
Tool
2 Background variables 1 ± 21 21 100%
3 Structured interview
schedule 1±8 36%
x General information 9 ± 17 25 64%
x Prevention strategies for
CAD risk factors
Total 1 ± 25 25 100%
4 Observational check list 1 ± 20 20 100%
 116

APPENDIX ± K

HEART SMART PACKAGE



x Lecture cum discussion regarding prevention of CVDD
x Demonstration on cardio exercises
x Booklet on prevention on CAD
117
 118

LESSON PLAN ON HEART SMART PACKAGE FOR PREVENTION OF HERT DISEASE

Topic : Heart Smart Package (HSP) for prevention of coronary artery disease (CAD)
Group : Clients at risk for CAD
Place : RUSH Multispecialty Hospital
Duration : 30-45 minutes
Teaching method : Lecture cum discussion
Instructor : Investigator
Instructional Aids : Power point presentation, Booklet
Seating arrangement : Theatre method

GENERAL OBJECTIVE : At the end of the health education the clients will gain adequate knowledge and skill regarding Heart Smart
Package for prevention of CAD

SPECIFIC OBJECTIVES : At the end of the health education the client will able to

x state the meaning of CAD

x specify the incidence of CAD
x enlist the risk factors and causes CAD
x explain the pathophysiology of CAD
x denote the clinical manifestations of CAD
x discuss the Heart Smart Package for prevention of CAD.
x enlist the complications of CAD
 119

TIM SPECIFIC CONTENT A.V INVESTIGATOR EVALUAT

E OBJECTIVES AIDS ±LEARNER ION
ACTIVITY
2min Introducing the 1.Introduction PPT Investigator
topic Coronary Artery Disease is the most common form of heart disease introduces the
which affects the mainly the heart ,by deposition of fat in the arteries there topic ,learners
by reducing blood flow. are listen
1min state the 1.1 Meaning PPT Investigator state State the
meaning of Coronary artery disease (CAD) is a narrowing of the small blood vessels the meaning, meaning
CAD that supply blood and oxygen to the heart caused by accumulation of learner listens of CAD
fatty substances on the walls of the arteries.

1min specify the 1.2 Incidence PPT Investigator Specify

incidence of Globally -17.3 million deaths due to CAD, Each year, approximately 3.8 specify the the
the CAD million men, 3.4 million women died from CAD. incidence incidence
India -WHO estimates that 1.03% billon cases are prevalent in India ,learner listen of CAD
Tamilnadu -36% of heart attack cases are due to CAD
Age -CAD is higher in the age group of 35-65 years
Gender -CAD is more among men than women due smoking and alcohol

2min enlist the risk 1.3Non- Modifiable risk factors 1.3Modifiable risk factors PPT Investigator lists What are
factors the risk factors the risk
1.Age MAJOR: ,learner listen factors
2.Gender 1.Elevated triglycerides and LDL
3.Family history 2.Decreased HDL
4.Genetic predisposition 3.Systolic blood pressure >140/90
4.Tobacco use
5.Alcohol use
6.Physical inactivity
7.Obesity- waist circumference
.>102 cm or 39.8 inches in women
 120

9.BMI- >30kg/m2
CONTRIBUTING:
1.Blood sugar levels >120mg/dl
2.Psychological stress
2min explain the 1.4 Pathophysiology PPT Investigator Explain
pathophysiology Consumption of high fat food cause explain the pathophysi
of CAD pathophysiology, ology
learner listen
The accumulation of fatty flakes inside the arteries of heart

Because of this accumulation of fatty streaks reduce the blood flow to the heart
muscles

Due to less blood supply to the heart, individuals may get the chest pain
3min denote the 1.5 Clinical Manifestations PPT Investigator Denote the
clinical denotes warning warning
manifestations x Retrosternal chest pain\chest heaviness sign and learner signs
x Nausea and vomiting listen
x Dizziness
x Lightheadedness
x fainting
121
122
 123

1min enlist the 1.6 Complications PPT Investigator enlist the

complications of x Clots in blood vessels of legs discuss the complicatio
CAD x Ischemic stroke Complications ns
x Angina ,learner listen
x Cardiac death

15 discuss the HSP 2.Heart Smart Package for prevention of CAD PPT Investigator discuss
min for prevention of discuss the HSP the
CAD
Goal:
x To maintain healthy weight strategies strategies
x To reduce the excess cholesterol ,learner listen to reduce
x To prevent the CAD. the risk of
2.1 DIET CAD
Recommendations for improving HDL lipid levels
x HDL is good cholesterol whereas LDL is bad cholesterol to the body

x Excess weight increases blood cholesterol, triglycerides and blood

pressure and lowers HDL cholesterol.
x It also increases your risk of diabetes.
x Fat concentrated in your abdomen puts you at greater cardiovascular risk
than extra fat concentration in the arms and legs.
x Waist measurements for women should be less than 35 inches. Men
should aim for a waist less than 40 inches
 124

x Eat at least five to seven servings of vegetables and fruits daily

x Eat soya products and legumes daily- it decreases the cholesterol level
x Increase the intake of garlic- it reduces the cholesterol level
x Take soluble fiber - it increases the excretion of bile and cholesterol
x Reduce intake of salt and hypertensive clients have to take salt 1/2
teaspoon/day according to WHO
x Limit/avoid trans fat diet such as egg yolk, Meat, Butter chicken/butter
fried fish, Milk fat ± full cream milk, Hidden fat- biscuits and cakes.

Cooking oils
x Increase intake of polyunsaturated oils-ground nut oil, olive oil
x Omega 3 fatty acids reduces triglycerides-fish oil, marine fish, salmon
fish
 125

2.2 Exercise
Recommendations
x 30 minutes of moderate-intensity physical activity, such as brisk walking,
five days a week.
x 20 minutes of vigorous aerobic activity, such as jogging, three days a week.
x Light exercise as part of your daily routine. Take the stairs and walk around
garden
Which includes
I. Deep breathing exercises
II. Weight reducing exercises
9 Warm up phase
9 Enduration phase
9 Cool down phase
 126

Deep breathing exercises

Through the deep breathing
exercises it improves the
blood circulation to the
heart

x sit in a comfortable chair, maintaining good posture. Your body should be as

relaxed as possible. Close your eyes. Scan your body for tension.
x Pay attention to your breathing. Place one hand on the part of your chest or
abdomen that seems to rise and fall the most with each breath. If this spot is
in your chest you are not utilizing the lower part of your lungs.
x Place both hands on your abdomen and follow your breathing, noticing how
your abdomen rises and falls.
x Breathe through your nose.
x Notice if your chest is moving in harmony with your abdomen.
x Now place one hand on your abdomen and one on your chest.
 127

x Inhale deeply and slowly through your nose into your abdomen. You should
feel your abdomen rise with this inhalation and your chest should move only
a little.
x Exhale through your mouth, keeping your mouth, tongue, and jaw relaxed.
x Relax as you focus on the sound and feeling of long, slow, deep breaths.

A. Warm up phase

x Warm up for 5 min to improve the blood circulation stretch the muscles
x Cool down exercises are to decrease heart rate

Those are

x Neck movements ±flexion, extension and rotation of neck

x Hand movements- flexion, extension and rotation of hand
x Leg movements -flexion, extension and rotation of leg
x Trunk movements-flexion, extension and rotation of trunk
B. Enduration phase/condition phase
 128

Weight reducing exercise

x The twist crunch
This will tone the obliques and core.Lie on your back. Put the rope under your
feet and hold on to the handles.keep your shoulders off the floor.bring your right
elbow and left knee up to meet in atwisting motion and then repeat on the other
side

x Squat and over head press

Keep your feet hip-width apart with the rope under your feet.hold on to the
handles and bring your hands to shoulder-height,while bending your knees to the
squat position . stand up out of the squat position and strech your arms above
your head . keep the elbow flexed
 129

x Static lunge and bicep curl

Put the rope under your front foot and lift your back heel. Put your hands by
your side while holding the rope handles. Keep your palms up. Bend both knees
equally to a 90 degree angle while pulling the palms towards the shoulders. Keep
the elbows fixed by your side

C. Cool down phase

 130

Arm stretch
Trunk stretch
Leg stretch
2.3 Cessation of smoking and alcohol
x Smoking may increase the blood pressure and damage the blood vessels.
x Cigarette smoke contains more than 4000 chemicals and 200 of those
chemical are poisonous

Start your stop smoking plan with START

S = Set a quit date.

Choose a date within the next 2 weeks, so you have enough time to prepare
without losing your motivation to quit. If you mainly smoke at work, quit on the
weekend, so you have a few days to adjust to the change.

T = Tell family, friends, and co-workers that you plan to quit.

Let your friends and family know your plan to quit smoking and tell them you
 131

need their support and encouragement to stop.

A = Anticipate and plan for the challenges you'll face while quitting.

Most people who begin smoking again do so within the first 3 months. You can
help yourself make it through by preparing ahead for common challenges, such
as nicotine withdrawal and cigarette cravings.

R = Remove cigarettes and other tobacco products from your home

car, and work

Throw away all of your cigarettes (no emergency pack!), lighters, ashtrays,
and matches. Wash your clothes and freshen up anything that smells like smoke.

T = Talk to your doctor about getting help to quit.

Your doctor can prescribe medication to help with withdrawal and suggest other
alternatives.

Stop alcohol consumption

 132

Long term drinking

damages the heart muscles
and reduces blood supply

2.4 Managing co-morbid illness

I. Control your blood sugar levels
x Controlling diabetes is essential for reducing your risk of CAD, because
diabetes is a major independent risk factor for cardiovascular disease and
raises the level of LDL and triglycerides, lowers HDL, and elevates
blood pressure.
x Keep the condition under control with diet, exercise, faithful monitoring
of blood glucose and other measures recommended by the doctor
monitoring you.
II. Controlling blood pressure levels:
x Adults should have their blood pressure checked at least once every 2
years
x If you have high blood pressure practice laughter therapy, restrict salt
diet ,walk daily, avoid stress ,eat healthy diet and avoid high fat foods
III. Medication adherence:
x If lifestyle changes and complementary treatments are not enough to
prevent coronary artery disease, medication may be necessary. Drugs
are used to treat high blood pressure, elevated cholesterol levels and
certain contributing diseases such as diabetes. Always follow-up with
 133

new prescriptions in high-risk patients

2.5Maintain the optimum health

Regular follow up checkups:
x The regular checkups to prevent the immediate complications promptly.
x Maintain a diary to note the fluctuation of B.P, blood sugar and
cholesterol values.
x Carry a medic alert card specifying your condition, medications and
close family members contact number for use in any emergency
situation
x Monthly once at risk clients have to visit physician for further
evaluation of health
Know your numbers

Normal cholesterol levels

LDL Cholesterol Level LDL-Cholesterol Category

Less than 100 mg/dL Optimal

160-189 mg/dL High

Total Cholesterol Level Category

Less than 200 mg/dL Optimal

240 mg/dL and above High

Blood pressure:
 134

Category Systolic (top number) Diastolic (bottom number)

Normal 120 And 80

High blood pressure 140±159 90±99

TAKE HOME MESSAGE

Play It Smart, Take Care of Your Heart

x Diabetes, overweight, high blood pressure, rich meals, desserts, high

waist measure, lack of physical activity, and poor nutrition will bring
bad news from your physician.
x Take action now to prevent disease, reduce the fat, STOP SMOKING,
PLEASE!
Keep lots of fruits and veggies on your table and when you shop, read
the food label.
x Turn off the TV and go for a walk.
 135

Go with a friend and enjoy a good talk.

Plan for the future and increase your chances of attending your kids'
graduations and dances
x Change your lifestyle now-Play it smart
x Start living healthy, and guard your heart

Conclusion:

Heart disease is often avoidable. Following a heart healthy life style which GRHVQ¶WKDYHWREHFRPSOLFDWHG DQGLWGRHVQ¶WPHDQ\RXQHHGWROLYHDOLIHRIVHOI
deprivation. Instead find ways to incorporate heart healthy habits in to your lifestyle and you may well enjoy a healthier life for years to come
 OMAYAL ACHI COLLEGE OF NURSING
PUZHAL
PREVENTION OF CORONARY ARTERY DISEASE

HEALTHY HEART

HEALTHY PEOPLE
By
K. Gayathri
M.sc (N) II ± Year
Medical Surgical Nursing
THE DR.M.G.R MEDICAL UNIVERSITY
AS A PART OF THE PARTIAL FULFILMENT
OF M.SC NURSING

1
2
 INDEX

S.no  CONTENT PAGE

NUMBER
INTRODUCTION 1
1 GENDRAL INFORMATION
REGARDING CAD
1.1 WHAT IS CORONARY ARTERY 1
DISEASE
1.2 RISK FACTORS 1
1.3 CLINICAL MANIFESTATIONS 3
2 HEART SMART PACKAGE FOR 3
PREVENTION OF CAD
2.1 DIET 3
2.2 MAINTAIN HEALTHY WEIGHT 4
2.3 CESSATION OF SMOKING AND 6
ALCOHOL
2.4 MANAGEMENT OF CO-MORBID 8
ILLNESS
2.5 MAINTAIN OPTIMUM HEALTH 9

3
1. GENDRAL INFORMATION REGARDING CAD
1.1 MEANING
Coronary artery disease (CAD) is a narrowing of the small blood
vessels that supply blood and oxygen to the heart caused by
accumulation of fatty substances on the walls of the arteries.

1.2 RISK FACTORS

™ Non- modifiable risk factors

x Family history

4
 x Increasing Age

™ Modifiable risk factors

x Elevated triglycerides and LDL
x .Decreased HDL
x .Systolic blood pressure >140/90
x Tobacco use

x Alcohol

5
 x Decreased physical activity

x Obesity

x Stress

6
 1.3 Clinical manifestation of CAD

x Retrosternal chest pain/ chest heaviness.

x Chest discomfort
x Arm or back discomfort
x Neck and Jaw discomfort
x Trouble breathing, with or without chest discomfort
x Feeling sick or discomfort in your stomach
x Feeling light headed or breaking into a cold sweat.
1.4 Complications

x Clots in blood vessels of legs

x Ischemic stroke
x Angina
x Cardiac death

7
2.2 Heart Smart Package for prevention of CAD
2.1 DIET
Recommendations for improving lipid levels

x Eat at least five to seven servings of

vegetables and fruits daily
x Eat soya products and legumes daily- it
decreases the cholesterol level
x Increase the intake of garlic- it reduces the
cholesterol level
x Take soluble fiber - it increases the
excretion of bile and cholesterol

x Reduce intake of salt ± especially 1/2 teaspoon/day have to take by

hypertension clients
x Limit/avoid trans fat diet such as egg yolk, Meat, Butter chicken/butter
x Increase intake of monounsaturated oils-ground nut oil, olive oil
8
x Omega 3 fatty acids reduces triglycerides-fish oil, marine fish,
 2.2 Maintain healthy weight

x HDL is good cholesterol whereas

LDL is bad cholesterol to the body
x Excess weight increases blood
cholesterol, triglycerides, and blood

™ Exercise regularly
Goal :
x It reduce the cholesterol level .

x It improve the blood circulation of Heart

Recommendations for exercises

x 30 minutes of moderate-intensity physical activity, such as

brisk walking, five days a week.
x 20 minutes of vigorous aerobic activity, such as jogging, three
days a week.
x Light exercise as part of your daily routine. Take the stairs and
walk around while on the phone.
Which includes :
9 Deep breathing exercises
9 Weight reducing exercises
x Warm up phase
x Enduration Phase
x Cool down phase

9
9 Deep breathing exercises

Through the deep

breathing exercises it
improves the blood
circulation to the heart

x sit in a comfortable chair, maintaining good posture. Your body

should be as relaxed as possible. Close your eyes. Scan your
body for tension.
x Pay attention to your breathing. Place one hand on the part of
your chest or abdomen that seems to rise and fall the most with
each breath. If this spot is in your chest you are not utilizing the
lower part of your lungs.
x Place both hands on your abdomen and follow your breathing,
noticing how your abdomen rises and falls.
x Breathe through your nose.
x Notice if your chest is moving in harmony with your abdomen.
x Now place one hand on your abdomen and one on your chest.
x Inhale deeply and slowly through your nose into your abdomen.
You should feel your abdomen rise with this inhalation and your
chest should move only a little.

10
 x Exhale through your mouth, keeping your mouth, tongue, and
jaw relaxed.
x Relax as you focus on the sound and feeling of long, slow, deep
breaths.
A. Warm up phase
x Warm up for 5 min to improve the blood circulation stretch
the muscles
Those are

x Neck movements ±flexion, extension and rotation of neck

x Hand movements- flexion, extension and rotation of hand
x Leg movements -flexion, extension and rotation of leg
x Trunk movements-flexion, extension and rotation of trunk

B. Enduration phase/condition phase

9 The twist crunch
9 Squat and over head press
9 Static lunge and bicep curl
o The twist crunch
This will tone the obliques and core.Lie on your back. Put the rope
under your feet and hold on to the handles.keep your shoulders off
the floor.bring your right elbow and left knee up to meet in
atwisting motion and then repeat on the other side

11
o Squat and over head press
Keep your feet hip-width apart with the rope under your feet.hold
on to the handles and bring your hands to shoulder-height,while
bending your knees to the squat position . stand up out of the squat
position and strech your arms above your head . keep the elbow
flexed.

12
 o Static lunge and bicep curl
Put the rope under your front foot and lift your back heel. Put your
hands by your side while holding the rope handles. Keep your
palms up. Bend both knees equally to a 90 degree angle while
pulling the palms towards the shoulders. Keep the elbows fixed by
your side

C. Cool Down Phase

x Cool down exercises are to decrease heart rate

9 Arm stretch
9 Trunk stretch
9 Leg stretch
2.3 Cessation of smoking and alcohol
x Smoking may increase the blood pressure and damage the blood
vessels.

13
 x Cigarette smoke contains more than 4000 chemicals and 200 of
those chemical are poisonous

Stop
smoking

Start your stop smoking plan with START

x S = Set a quit date.

Choose a date within the next 2 weeks, so you have enough time to
prepare without losing your motivation to quit. If you mainly
smoke at work, quit on the weekend, so you have a few days to
adjust to the change.

x T = Tell family, friends, and co-workers that you plan to quit.

Let your friends and family know your plan to quit smoking and
tell them you need their support and encouragement to stop.

x A = Anticipate and plan for the challenges you'll face while

quitting.

Most people who begin smoking again do so within the first 3

months. You can help yourself make it through by preparing ahead
for common challenges, such as nicotine withdrawal and cigarette
cravings.
14
x R = Remove cigarettes and other tobacco products from your
home car, and work

Throw away all of your cigarettes (no emergency pack!), lighters,

ashtrays, and matches. Wash your clothes and freshen up anything
that smells like smoke.

x T = Talk to your doctor about getting help to quit.

Your doctor can prescribe medication to help with withdrawal and

suggest other alternatives.

x Stop alcohol consumption

Long term drinking

damages the heart
muscles and reduces
blood supply

15
2.4 Management of co- morbid illness disorders

16
 x Control your blood sugar levels:
I. Controlling diabetes is essential for reducing your risk of CAD,
because diabetes is a major independent risk factor for
cardiovascular disease and raises the level of LDL and triglycerides,
lowers HDL, and elevates blood pressure.
II. Keep the condition under control with diet, exercise, faithful
monitoring of blood glucose and other measures recommended by
the doctor monitoring you
x Controlling blood pressure levels:
I. Adults should have their blood pressure checked at least once
every 2 years
II. If you have high blood pressure practice laughter therapy, restrict
salt diet ,walk daily, avoid stress ,eat healthy diet and avoid high
fat foods

17
x Medication adherence:

I. If lifestyle changes and complementary treatments are not enough

to prevent coronary artery disease, medication may be necessary.
Drugs are used to treat high blood pressure, elevated cholesterol
levels and certain contributing diseases such as diabetes

2.5 Maintain the optimum health

Regular follow up checkups:
x The regular checkups to prevent the immediate complications
promptly.
x Maintain a diary to note the fluctuation of B.P, blood sugar and
cholesterol values.

18
x Carry a medic alert card specifying your condition, medications
and close family members contact number for use in any
emergency situatio
Know your numbers;
Cholesteriol

LDL Cholesterol Level LDL-Cholesterol Category

Less than 100 mg/dL Optimal
160-189 mg/dL High
Total Cholesterol Level Category
Less than 200 mg/dL Optimal
240 mg/dL and above High

Blood pressure

Systolic (top Diastolic (bottom

Category number) number)
Normal Less than 120 And Less than 80

High blood
pressure 140±159 90±99

References
.RWWNH-)UHGHULFN/HKPDQQ)-XVWXV  .UXVHQ¶V
Handbook of Physical Medicine and Rehabilitation. W.B
Saunders publications. Philadelphia

19
 Lemone Priscilla., Burke Karen. (2008). Medical Surgical
Nursing Critical Thinking in Client Care. Dorling
Kindersley publishers. New Delhi
Reports
x Centre for Disease Control and Prevention, (2015).
x American Diabetes Association (2015)
x World Health Organization (2012)

20
Start living healthy, and guard your heart

21
 APPENDIX - L

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