Factors Affecting Health-Promoting Behaviors in Patients Diagnosed with Myocardial Infarction

Background: Cardiovascular diseases, including myocardial infarction (MI), represent a significant global health burden, particularly in developing countries like Pakistan. Health-promoting behaviors (HBs) play a crucial role in the management and prevention of MI, potentially reducing morbidity and mortality rates among affected individuals. Objective: This study aimed to identify the factors influencing health-promoting behaviors among patients diagnosed with myocardial infarction and to evaluate the level of engagement in such behaviors. Methods: A cross-sectional descriptive study was conducted at a tertiary care hospital in Pakistan from September 2022 to June 2023. The study population consisted of 318 patients diagnosed with MI (ST and non-STEMI), selected through purposive sampling. Data were collected on demographic characteristics, health behavior data using the Song-and-Lee Health Behaviors Checklist, and analyzed using SPSS version 25 for descriptive and inferential statistics, including independent t-tests, ANOVA, and multiple linear regression. Results: The overall mean score of health-promoting behaviors among participants was 2.14 ± 0.21, indicating a moderate level of engagement. The highest mean score was observed in eating behaviors (2.26 ± 0.34), while the lowest was in health responsibility (2.00 ± 0.40). Gender and smoking status significantly influenced health-promoting behaviors, with females and non-smokers exhibiting better HB scores. Significant differences in HBs were noted across gender, co-morbidity, and history of hospitalization, but not within age, BMI, and smoking groups. Conclusion: The study concluded that myocardial infarction patients exhibit a moderate level of engagement in health-promoting behaviors, with significant variations influenced by gender and smoking status. There is a need for targeted nursing strategies to enhance health-promoting behaviors, particularly focusing on dietary habits, smoking cessation, and health responsibility among MI patients.


INTRODUCTION
Cardiovascular diseases (CVD) represent a significant health challenge globally, contributing to an estimated 17.5 million deaths annually, of which coronary artery disease (CAD) is responsible for 7.5 million (1).In the United States alone, myocardial infarction (MI) affects over 750,000 individuals each year (2).The burden of cardiovascular diseases is particularly pronounced in developing countries, contributing to the global escalation of CVD rates.Pakistan, representative of these nations, faces a severe impact from CAD, characterized by high morbidity, mortality, and a substantial economic burden on both its public health infrastructure and the affected individuals (3).Heart disease, and specifically heart attacks, are a leading cause of death in Pakistan, with ischemic heart disease, under which heart attacks are classified, being responsible for over 186,000 deaths in 2019 according to the Global Burden of Disease Study (4).Health behaviors (HB), as defined by Edelman and Mandle (2010), encompass actions undertaken by individuals to promote health, combat illness, manage symptoms, and prevent diseases (5).These behaviors, including medication adherence, exercise, dietary modifications, stress management, and smoking cessation, align with the American Heart Association's (AHA) guidelines (6).The adoption of such health-promoting behaviors is crucial for reducing hospital admissions and mortality among MI survivors.Evidence suggests that comprehensive management of risk factors, through lifestyle changes and evidence-based medical therapies, is vital for enhancing survival rates and preventing recurrent cardiovascular events in individuals suffering from acute myocardial infarction (AMI) (7,8,9).It has been shown that managing risk factors effectively can lead to longer life spans, fewer recurrences, and improved quality of life for MI survivors (10).The dawn of the twenty-first century witnessed significant advancements in the diagnosis and treatment of cardiovascular diseases, fundamentally transforming patient care (11,12).Concurrently, there has been a substantial increase in governmental healthcare expenditure on treating these conditions.Despite these advancements, challenges remain, such as the observation that the decrease in early mortality rates from myocardial infarction has not translated into a reduction in the overall mortality rate from cardiovascular diseases (13).As such, preventive measures are increasingly recognized as the most effective approach to mitigate the epidemiological risk associated with cardiovascular diseases.These measures include assessing and managing cardiovascular risk factors with the goal of reduction or elimination (14,15).Presently, adopting a healthy lifestyle is considered essential for the preservation and enhancement of public health (16).Therefore, understanding the factors influencing health-promoting behaviors among patients with myocardial infarction is of paramount importance, leading to the initiation of research aimed at identifying these determinants.

MATERIAL AND METHODS
The study, employing a cross-sectional descriptive design, was conducted from September 2022 to June 2023 at a tertiary care hospital in Pakistan.It aimed to examine health-promoting behaviors in patients diagnosed with myocardial infarction, encompassing both ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (non-STEMI).The research population comprised patients who had been diagnosed with myocardial infarction, from which a sample of 255 individuals was selected through purposive sampling, based on specified inclusion criteria.These criteria included patients who were at least 18 years old, had been diagnosed with myocardial infarction for at least one year, and were capable of understanding and responding to the questionnaire.Exclusion criteria ruled out patients who were mentally unstable, immobilized, or unwilling to participate in the study.The recruitment process began in the outpatient department (OPD), where potential participants were introduced to the study's objectives and procedures in a face-to-face manner.Following the evaluation for eligibility based on the inclusion criteria, informed consent was obtained from each participant, ensuring their agreement to partake in the study voluntarily.This consent process was conducted in accordance with the ethical standards of the Declaration of Helsinki, ensuring the protection of participants' rights and well-being throughout the study.Data collection encompassed demographic information and health behavior data.Demographic data included variables such as age, gender, education level, co-morbidity, marital status, body mass index (BMI), and smoking history.Health behaviors were assessed using the Song-and-Lee Health Behaviors Checklist, a validated and reliable instrument featuring five dimensions and 21 items, rated on a scale from 1 (never) to 4 (routinely), and boasting a Cronbach alpha of 0.83 (16).The analysis of the collected data was performed using the Statistical Package for the Social Sciences (SPSS) version 25.This encompassed both descriptive and inferential statistical methods to examine the data thoroughly.Independent t-tests and ANOVA (Analysis of Variance) were employed to identify differences within the groups.Furthermore, multiple linear regression analysis was utilized to explore the impact of various factors on health-promoting behaviors among the study population.This comprehensive approach to data analysis aimed to uncover significant insights into the factors influencing health behavior among myocardial infarction patients, contributing valuable information to the field of cardiovascular disease management and prevention.

RESULTS
In this study, a total of 318 participants diagnosed with myocardial infarction were analyzed to understand the factors affecting health-promoting behaviors.The gender distribution was nearly equal with 157 males (49.4%) and 161 females (50.6%), indicating a balanced representation of both genders in the study population (Table 1).The majority of participants fell into the age group of 56-65 years (55.7%),followed by those aged 66 and above (22.6%)and 45-55 years (21.7%),highlighting a higher prevalence of myocardial infarction among the older population.Remarkably, all participants were married, reflecting a specific demographic characteristic of the sample.Educational levels varied, with 47.2% of participants having no education, 39.3% completing matriculation, 5% having intermediate education, and 8.5% holding a bachelor's degree, suggesting a significant portion of the population had limited educational background (Table 1).Body Mass Index (BMI) data showed that a substantial majority of participants were categorized as healthy (81.1%), with a smaller segment being overweight (17.0%) and a minimal percentage (1.9%)classified as obese.Smoking status revealed that 22.3% of the participants were smokers, while a significant majority (77.7%) did not smoke.Co-morbid conditions were prevalent, with 65.1% of participants suffering from hypertension (HTN), 8.5% with diabetes mellitus (DM), and 9.7% experiencing both HTN and DM.Notably, 30.5% of the participants had a history of hospitalization (Table 1).The analysis of differences within groups concerning health behaviors revealed significant findings.A slight but statistically significant difference was observed between genders in their health behaviors, with females showing marginally higher scores (2.15 ± 0.23) than males (2.14 ± 0.18), as indicated by a P-value of 0.044.Age groups did not show a significant difference in health behaviors, suggesting that age may not be a critical factor in influencing health-promoting behaviors in this population.19 BMI categories also did not reveal significant differences, although obese participants had a slightly higher mean score (2.30), which was not statistically significant (P-value=0.188).Smoking status and comorbid conditions, specifically the presence of hypertension and diabetes, showed no significant difference in health behavior scores, highlighting that these factors might not distinctly influence health-promoting behaviors in myocardial infarction patients (Table 3)..050Further analysis using multiple regression identified several factors impacting health behaviors.Gender was a significant predictor, with males exhibiting slightly lower health behavior scores than females (B=0.067,P-value=0.017).Smoking negatively influenced health behaviors, with smokers having lower scores (B=-0.103,P-value=0.002),suggesting that smoking status significantly affects the engagement in health-promoting behaviors.Other variables, including age, education, BMI, comorbid conditions, and hospitalization history, did not show a significant impact on health behaviors, indicating that these factors might not play a critical role in influencing health-promoting behaviors among myocardial infarction patients (Table 4).

DISCUSSION
This investigation set out to identify factors influencing health-promoting behaviors (HBs) among myocardial infarction (MI) patients.The study found an average overall HB score of 2.14 ± 0.21 among participants, slightly above the median, indicating a moderate engagement in health-promoting activities.This result contrasts with findings from a South Korean study, which reported a higher mean HB score of 2.66 ± 0.41 among cardiovascular patients (17), and another study on adolescents with cardiogenic heart disease, which also documented higher health-promoting habits (18).Interestingly, our participants exhibited a greater focus on eating behaviors (2.26 ± 0.34), potentially attributed to dietary adjustments commonly practiced within the family systems of Khyber Pukhtunkhwa, emphasizing low-salt and low-sugar diets for managing hypertension and diabetes respectively.This observation aligns with other research highlighting the significance of a healthy diet in HB scores (20), including a study that reported a particularly high mean score for a healthy diet among arthritis patients (19).Conversely, health responsibility garnered the lowest mean score (2.00 ± 0.40), suggesting a possible resignation towards health management in later adulthood among the study's demographic.This is in contrast to other studies that identified physical activity (17) and smoking cessation (20) as the lowest-scoring domains, underscoring the varied prioritization of health behaviors across different populations.The importance of physical activity as a primary prevention measure to reduce mortality from cardiovascular disease has been well-documented, further emphasizing the need for targeted interventions to enhance engagement in physical exercise and other health-promoting activities following MI (21,22).Gender and smoking status emerged as significant determinants of HBs, with female participants displaying better scores than males, and nonsmokers engaging more in health-promoting behaviors than smokers.These findings are supported by literature emphasizing the critical need for smoking cessation among cardiac patients to reduce future morbidity and mortality risks (23).The study, however, is not without its limitations.The generalizability of the findings is constrained by the sample's degree of representation, and the analysis was limited to a narrow set of variables to examine health-promoting behaviors.Furthermore, the cross-sectional design precludes the determination of causality between identified factors and HBs.

CONCLUSION
In conclusion, the investigation revealed an average level of engagement in health-promoting behaviors among MI patients, with significant variances observed in relation to gender, dietary habits, and smoking status.The pivotal role of a healthy diet and the negative impact of smoking on HBs highlight areas for targeted interventions.The findings advocate for the implementation of comprehensive nursing strategies, encompassing medication education, post-discharge support programs, and enhanced nurse-led healthcare services, to bolster health-promoting behaviors in cardiovascular patients.Future research should aim to broaden the scope of variables examined and include longitudinal studies to better understand the dynamics of health-promoting behaviors postmyocardial infarction, enabling the development of more effective, evidence-based interventions to support patient recovery and well-being.

Table 1 :
Demographic Characteristics of Participants Regarding health behaviors, the study observed a range of scores across different dimensions, including health responsibility, physical activity, eating behaviors, stress management, and smoking habits.The mean scores varied slightly, with eating behaviors scoring the highest (2.26 ± 0.34) and health responsibility the lowest (2.00 ± 0.40).The overall mean score for health behaviors was 2.14 ± 0.21, indicating a moderate level of engagement in health-promoting activities among the participants (Table2).

Table 2 :
Health Behaviors Among Participants

Table 3 :
Differences Within Groups Regarding Health Behaviors

Table 4 :
Factors Affecting Health Behaviors of Study Participants