Iran Journal of Nursing

Introduction
Cardiovascular diseases are responsible for 30% of all deaths worldwide. Several methods are used to diagnose cardiovascular diseases. Coronary angiography is a method to confirm or reject coronary artery diseases and is a gold method for gathering information to decide on the need for drug therapy, angioplasty or bypass surgery. Diagnostic methods, including coronary angiography, are a stressful experience for patients undergoing angiography, which can cause anxiety in these patients. A high level of patient anxiety is directly related to patient dissatisfaction. Satisfaction creates patient cooperation and accelerates the treatment process. Nurses use pharmacological and non-pharmacological methods to control anxiety and improve the physiological indicators of these patients. Despite the therapeutic effects of drugs, due to their side effects, nowadays the pharmacological methods are less used for these patients and non-pharmacological methods are used as complementary or alternative treatments. Education and increasing the awareness of patients is one of non-pharmacological methods. Education using virtual social networks provides the possibility for patients to experience a new type of communication and care. The present study aims to evaluate the effect of education using multimedia materials and texts and presented by a social network platform (WhatsApp) on the anxiety and satisfaction of candidates for coronary angiography.

Methods
This is a quasi-experimental study with pretest-posttest design using a control group that was conducted from May to July 2021. After obtaining the ethical code and permission from Iran University of Medical Sciences and referring to Imam Khomeini Hospital in Ahvaz, Iran, the candidates for elective coronary angiography who met the inclusion criteria were selected and a full explanation about the study objectives was presented to them. Then, their informed consent was obtained. They were divided into two groups of intervention and control. They had an active WhatsApp account and Internet access. Data were collected using a demographic form, the Beck anxiety inventory (BAI) and the visual analog scale (VAS) for measuring satisfaction. The minimum required sample size at 95% confidence level for each group was determined 38, by considering an 80% test power and assuming that the effect of education on anxiety of patients undergoing coronary angiography in the intervention group compared to the control group should be 3 units to be considered statistically significant. Then, by considering a 20% sample drop in each group, it was increased to 46. Three patients from the intervention group (two patients due to having incomplete questionnaires and one patient due to the need for emergency surgery before angiography) and 3 patients from the control group (two due to withdrawal from the study and one patient due to not completing the questionnaires) were excluded from the study. After assigning the samples to the intervention (n=43) and control (n=43) groups, the pre-test assessment by the BAI was done in both groups. In the intervention group, in addition to the usual training in angiographic care department, patients received educational materials such as videos, pictures and texts through the WhatsApp. The control group received routine hospital education. Two groups completed the BAI one hour before angiography as the post-test assessment. Then, the VAS was completed before discharge by two groups. Data analysis was performed in SPSS version 16 using descriptive and analytical statistics including independent t-test, paired t-test, chi-square test, and Fisher’s exact test.

Results
The results showed that both groups were homogeneous in terms of demographic characteristics at baseline and there was no significant difference in anxiety scores between the intervention and control groups before the intervention (P=0.229). The results of independent t-test showed a significant difference in the mean anxiety score before and after intervention in two groups (P<0.001), indicating the effect of intervention on reducing their anxiety levels. The results of independent t-test showed that the satisfaction in the intervention group was significantly higher than in the control group (P<0.001). The effect size of education on anxiety was 0.9 and the effect size on satisfaction was 1.88, which shows the high effect of the educational intervention.

Conclusion
The use of mobile social networks for education is effective in reducing anxiety and improving satisfaction in patients undergoing coronary angiography. Therefore, this interventional method can be used by nurses as an effective method in medical centers.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee of Iran University of Medical Sciences (Code: IR.IUMS.REC.1399.1314).

Funding
This study was funded by Iran University of Medical Sciences.

Authors' contributions
Conceptualization and supervision: Fathemeh Mohaddes; Methodology: Tahereh Najafi Ghezeljeh; Investigation and writing: Mehri Bozorgnejad; Data collection: Mohamadreza Zarei; Data curation: Fariba Jalalinejad; Data analysis: Shima Haghani.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the personnel of Imam Khomeini Hospital in Ahvaz city and all the patients participated in this study for their cooperation.

 References

1. Tammeh MA, Akhondzadeh K, Ehsani SR, Shamsi MA, Mohammadnejad E. The concept of spiritual well-being from the viewpoint of nurses caring for heart disease patients. Int J Humanit Cult Studies. 2356-5926, 2016; 3(1):2109-16. [Link]
2. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, et al. [2016 European Guidelines on cardiovascular disease prevention in clinical practice (Polish)]. Kardiol Pol. 2016; 74(9):821-936. [DOI:10.5603/KP.2016.0120] [PMID]
3. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics-2012 update: A report from the American Heart Association. Circulation. 2012; 125(1):e2-e220. [PMID]
4. Uzun S, Vural H, Uzun M, Yokusoglu M. State and trait anxiety levels before coronary angiography. J Clin Nurs. 2008; 17(5):602-7. [DOI:10.1111/j.1365-2702.2007.02018.x] [PMID]
5. Nekouei ZK, Yousefy A, Manshaee G, Nikneshan S. Comparing anxiety in cardiac patients candidate for angiography with normal population. ARYA Atheroscler. 2011; 7(3):93-6. [PMID]
6. Afzali S, Masoudi R, Etemadifar S, Moradi M, Moghaddasi J. [The effect of progressive muscle relaxation program (PMR) on anxiety of patients undergoing coronary heart angiography (Persian)]. J Shahrekord Univ Med Sci. 2009; 11 (3):77-84. [Link]
7. Habibzadeh H, Milan ZD, Radfar M, Alilu L, Cund A. Effects of peer-facilitated, video-based and combined peer-and-video education on anxiety among patients undergoing coronary angiography: Randomised controlled trial. Sultan Qaboos Univ Med J. 2018; 18(1):e61-e67. [DOI:10.18295/squmj.2018.18.01.010] [PMID] [PMCID]
8. Lieber AC, Bose J, Zhang X, Seltzberg H, Loewy J, Rossetti A, et al. Effects of music therapy on anxiety and physiologic parameters in angiography: A systematic review and meta-analysis. J Neurointerv Surg. 2019; 11(4):416-23. [DOI:10.1136/neurintsurg-2018-014313] [PMID]
9. Buzatto LL, Zanei SS. Patients’ anxiety before cardiac catheterization. Einstein (Sao Paulo). 2010; 8(4):483-7. [DOI:10.1590/s1679-45082010rw1517] [PMID]
10. Basar C, Beşli F, Keçebaş M, Kayapınar O, Turker Y. The effect of audio-visual education prior to coronary angiography on the state anxiety. Anxiety. 2015; 1(8):176-8. [Link]
11. Atashi V, Sheikh Abumasoudi R, Moghimian M, Hashemi MS, Karimi T, Kashani F, et al. [The effect of E-learning on the quality of life of patients with stroke (Persian)]. J Health Care. 2017; 19(1):30-8. [Link]
12. Farajzadeh M, Karimi L, Mirjavadi SA, Azimi AV, Chaharshahi SG, Farjam SN, et al. Survey of the patients’ satisfaction with services provided in an Iranian Naval Hospital in 2019: A cross-sectional study. Rom J Mil Med. 2021; 124(4):452. [DOI:10.21203/rs.3.rs-29151/v1]
13. Zafari E, Rokhafroz D, Dashtebozorgi B, Maraghi E. [The effectiveness of based-mobile education on anxiety of patients candidate coronary angiography (Persian)]. J Critic Care Nurs. 2019; 12(2):35-41. [Link]
14. Khezerloo S, Habibzadeh H, Rasouli D, Rahmani A, Ahangarzadeh rezai S. [Effect of video information on anxiety level and hemodynamic parameters of patients undergoing coronary angiography (Persian]. Nurs Midwifery J. 2018; 16(4):295-302. [Link]
15. Gökçe E, Arslan S. Possible effect of video and written education on anxiety of patients undergoing coronary angiography. J Perianesth Nurs. 2019; 34(2):281-8. [DOI:10.1016/j.jopan.2018.06.100] [PMID]
16. Molazem Z, Shahabfard Z, Askari A, Kalyani MN. Effects of a peer-led group education on fear, anxiety and depression levels of patients undergoing coronary angiography. Invest Educ Enferm. 2018; 36(1):e13. [DOI:10.17533/udea.iee.v36n1e13] [PMID]
17. Torabizadeh C, Rousta S, Gholamzadeh S, Kojouri J, Jamali K, Parvizi MM. Efficacy of education delivery through multimedia and text messaging on the psychological parameters of patients scheduled for coronary angiography: A single-blind randomized controlled clinical trial. BMC Cardiovasc Disord. 2021; 21(1):3. [PMID] [PMCID]
18. Kolivand P, Ali Hakami M, Eghbali F, Monjamed Z, Sharifi F. [Patient satisfaction of the quality of patient teaching in Khatam Alanbia hospital (Persian)]. Neurosci J Shefaye Khatam. 2015; 3(3):25-31. [DOI:10.18869/acadpub.shefa.3.3.25]
19. Ruffinengo C, Versino E, Renga G. Effectiveness of an informative video on reducing anxiety levels in patients undergoing elective coronarography: an RCT. Eur J Cardiovasc Nurs. 2009; 8(1):57-61. [DOI:10.1016/j.ejcnurse.2008.04.002] [PMID]
20. Ferguson LA. Implementing a video education program to improve health literacy. J Nurs Pract. 2012; 8(8):17-22. [DOI:10.1016/j.nurpra.2012.07.025]