Depression and Adherence to Healthy Lifestyle Among Patients with Coronary Artery Diseases

Background: It is well-established in the literature that coronary artery disease (CAD) is a risk factor for depression and that depressive symptoms inversely affect the development and progression of CAD. No published studies have examined the relationship between depression and adherence to healthy lifestyle behaviors among patients with CAD in Jordan. Therefore, the purpose of this study is to investigate the impact of depression on adherence to healthy lifestyle behaviors among CAD patients in Jordan. Methods: A convenience sample of 130 patients with CAD was recruited from out-patient cardiac clinics in a university-aliated hospital and government-operated hospital in Northern Jordan. Data were collected using self-administered questionnaires on depression and adherence to healthy lifestyle behaviors among CAD patients. Results: Our data showed that 41% of the participants were non-adherent to healthy lifestyle behaviors, especially in the areas of physical activity (6.2%), maintaining a healthy diet (24.6%), and weight loss (26.15%). Gender, smoking status, and number of cardiac catheterization procedures were found to be signicant predictors of patient adherence to healthy lifestyle behaviors. Although depressive symptoms were present in 56.9 % of the participants, depression was not found to be a signicant predictor of adherence to healthy lifestyle behaviors among our sample. Conclusion: Our study provides valuable data regarding the levels and predictors of adherence to healthy lifestyle behaviors among CAD patients with CADs. Implications for future research and practice are addressed.

from depression [12]. In a study conducted by Hamdan-Mansour and colleagues [13], 27.5% of Jordanian patients with chronic diseases such as CAD reported that they had moderate to severe depressive symptoms, and about 31% of them had mild depression. Depression affects the adherence of patients to self-care practices [14] and healthy lifestyle behaviors, which predisposes them to developing CAD.
Several studies have also demonstrated that patients who suffer from depression show less adherence to lifestyle changes and medication, which negatively impacts their health outcomes [15,16,17]. Moreover, depression is associated with increased rates of smoking and decreased chances of smoking cessation [5,18], increased physical inactivity [5,17,18], increased alcohol intake [5], and increased dietary fat intake [18]. In comparison, patients who suffer from CAD but display positive affect have higher survival rates as a result of their increased physical activity [19,20]. Furthermore, the increase in positive affect over time is associated with increased patient adherence to healthy lifestyle behaviors [20]. This inverse relationship between depression and healthy living indicates the importance of eliminating the symptoms of depression in order to foster adherence to healthy lifestyle habits and thereby decrease the risk of CAD incidence.
Whilst previous studies have explored the relationship between depression and adherence to healthy lifestyle behaviors among patients with CAD, there appear to be no published studies which have focused on CAD patients in Jordan speci cally. Therefore, the aim of this study is to bridge that gap in the literature by investigating the impact of depression on adherence to healthy lifestyle behaviors among CAD patients in Jordan. Speci cally, the objectives of this study are as follows: 1) to assess the levels of depression and adherence to healthy lifestyle behaviors among patients with CADs, 2) to examine the relationship between depression and adherence to healthy lifestyle behaviors among CAD patients in Jordan, 3) to examine the relationship between adherence to healthy lifestyle behaviors and certain sociodemographic characteristics among patients with CAD, and 4) to determine the signi cant predictors of adherence to healthy lifestyle predictors among patients with CAD.

Study Design
This study is a descriptive, cross-sectional study designed to assess the relationship between depression and adherence to healthy lifestyle behaviors among CAD patients in Jordan. The study was conducted on a convenience sample recruited from outpatient cardiac clinics in a university-a liated hospital and government-operated hospital in the north of Jordan. One hundred and thirty patients participated in the study. The inclusion criteria were as follows: a) patients diagnosed with CAD for at least 6 months, b) patients aged over 18 years, and c) patients who are mentally and physically competent to give consent.

Instruments
The questionnaire consisted of three parts: a) sociodemographic and health characteristics of the participants; b) the Cardiac Depression Scale (CDS) [21]; and c) the Adherence Scale [22], used to determine the levels of adherence to healthy lifestyle behaviors in patients with CAD. Firstly, the sociodemographic and health-related data section included items related to age, gender, marital status, work status, income, health insurance, presence of chronic illnesses, previous cardiac catheterization procedures, smoking, number of cigarettes per day, number of years since CAD diagnosis, exercise habits, adherence to medication, health assessment, psychological health, previous diagnosis with depression, and sexual in uence.
The Cardiac Depression Scale (CDS), which is a 26-item self-rated questionnaire [21], was used to assess the levels of depression among the participants. The scale was developed by Hare and Davis in 1996 [21] and has been validated among the Jordanian population [3]. Responses are scored on a 7-point Likert scale, with higher scores indicating an increased number of depressive symptoms [21]. The Cronbach's alpha in the original study was 0.9. The correlation of CDS with Beck Depression Inventory (BDI) was 0.73, and with clinical assessment was 0.67 [21]. The original CDS was developed to have two dimensions and seven subscales, namely sleep, anhedonia, uncertainty, mood, cognition, hopelessness, and inactivity [21]. The participants were asked to rate how they felt regarding each question, and each item was then rated on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).
Seven of the 26 items are worded in a positive direction, and the total score is calculated by summing the scores of all of the items after reversing the positively worded items, with the total possible score ranging from 26 to 182.
The participants' levels of adherence to healthy lifestyle behaviors were assessed using the Adherence Scale, which is a 0-9 ordinal scale developed by Alm-Roijer, Stagmo, Ude´n, and Erhardt [22]. According to the scale, adherence to lifestyle changes and attainment of the treatmnet goals was de ned as the patient's changes in self reported dietary, smoking habits, and physical activity, reduction in weight, stress management and reduction in lipid, blood glucose, and blood pressure levels. Eleven items are used to measure adherence to lifestyle changes, whilst lifestyle modi cation to achieve treatment goals is assessed using questions with responses ranging from 0 ("I have not made any lifestyle changes") to 9 ("I have made a lot of lifestyle changes"). The total score is obtained by summing the scores of all of the items. The total possible score ranges from 0-99, with higher scores indicating a higher degree of adherence to lifestyle modi cations. The items were tested for internal consistency reliability using Cronbach's alpha coe cient, which has been reported to be around 0.73 in previous studies [22].
Since the participants of this study are mainly speakers of Arabic, the Cardiac Depression Scale and the Adherence Scale were translated from English into Arabic. The scales were then translated back into English by bilingual experts in the Arabic and English languages. The experts also approved the scales for face validity, and the Cronbach's alphas for the CAD and the Adherence Scale in our study were 0.90 and 0.71, respectively.

Data Analysis
The Statiscal Package for the Social Sciences (SPSS) for windows version 25.0 was used for data analysis. Descriptive statistics were used to describe the charcteristics of the sample and the main study variables. Hireracheal multiple regression was used to determine the signi cant predictors of the participants' adherence to healthy lifestyle behaviors.

Ethical Considerations
Institutional Review Board (IRB #2014/274) approval was obtained from Jordan University of Science and Technology (JUST) and the hospitals where the study was conducted. Patients who met the inclusion criteria were invited to participate in the study, and patients who agreed to participate were asked to sign an informed consent form.

Results
A total of 130 patients with CAD participated in this study. The mean age of the participants was 56.15 years (SD = 10.83). The majority of the participants (55.4%) were male, 81.5% were married, approximately 36% were educated to secondary level or below, and 31.5% were employed and had an average income of 558.24 JOD (SD = JD 437) (See Table 1).
As with regards to the clinical characteristics of our study sample, the majority of the participants (85.4%) had coexisting chronic conditions, and 65.4% had previously undergone cardiac catheterization. Meanwhile, 39.2% of the participants reported good general health, and 33.1% reported good psychological health.
Shi, Stewart, and Hare [23] suggested a cut-off point for the CDS of > 95. Based on that, 56.9% of the participants in the present study were found to have depressive symptoms, and 9.2% had a previous diagnosis of depression (See Table 2).
Our data also showed that the average adherence to healthy lifestyle behaviors among the participants was (M = 58.98, SD = 1.75, range = 0-99), whilst 41% of the participants were found to be non-adherent to healthy lifestyle behaviors. High adherence rates were associated with taking medications (68.5%) and quitting smoking (47.7%), while low adherence was attributed to physical activity (6.2%), followed by healthy nutrition (24.6%), and weight loss (26.15%). The relationship between depressive symptoms and adherence to healthy lifestyle behaviors was found to be weak, as indicated by r = .067. The t-test and one-way ANOVA statistics showed no signi cant differences in adherence based on sociodemographic variables (i.e., gender, age, marital status, education, and work status), as all p values were above .05.
A hierarchal multiple regression analysis was conducted to predict the participants' levels of adherence to healthy lifestyle behaviors. Missing data were treated using the expectation-maximization algorithm, and data were missing completely at random. The tests for multicollinearity using bivariate correlation table and VIF values indicated no multicollinearity between the variables. Independence and homoscedasticity were also tested. The scatterplot for the dependent variable showed that the values fell between 2 and 3 for the regression standardized predicted value and regression standardized residuals. The P-P plot of regression standardized residuals showed linearity of the residuals. Normality of the continuous variables was tested using the Kolmogorov-Smirnov test, and the variables were normally distributed.
The predictors of adherence were entered into three successive blocks as follows: (a) sociodemographic variables (including gender, age, income, and level of education), (b) clinical variables (including presence of co-existing chronic illnesses, previous cardiac catheterization procedures, smoking status, and previous depression diagnosis), and (c) depression variable of the CDS.  Table 3).

Discussion
The majority of the participants in the current study were male, married, and unemployed. Most of the participants suffered from coexisting chronic illnesses and had been diagnosed with CAD for at least one year, and nearly half of the participants had undergone at least one to two catheterization procedures in the past. As for the participants' healthy lifestyle practices, most of the participants were either current smokers or ex-smokers, and the majority exercised rarely. Approximately one third of the sample described their psychological health as being "good", and depressive symptoms were present in 56.9% of the participants.
Our data also indicated that many of the participants were non-adherent to healthy lifestyle behaviors, especially in the areas of physical activity, maintaining a healthy diet, and weight loss. The two most commonly adopted lifestyle changes were quitting smoking and medication compliance. Meanwhile, the lifestyle change that was the least commonly adopted and least adhered to was physical activity.
The ndings of our study also revealed that smoking status, gender, and number of previous catheterization procedures were the only predictors of adherence to healthy lifestyle behaviors. Being male, having undergone a high number of catheterization procedures, and being a non-smoker were found to predict the participants' adherence to healthy lifestyle behaviors. Interestingly, even though depressive symptoms were present in more than 50% of our sample, this variable was found to be an insigni cant predictor of adherence.
These ndings on the levels of adherence among our sample are similar to the ndings reported by studies conducted in other Eastern countries [24,25,26]. For example, Ghaddar and colleagues [25] reported that patients with CAD had low adherence to physical activity (10.8% − 14.7%) and weight loss (33.3% − 61.3%) but had satisfactory adherence to taking medications (83% − 89.9%). On the contrary, high adherence rates to healthy lifestyle behaviors have been reported by studies conducted in Western countries. For example, in the study of Griffo and colleagues [27], 89.9% of the patients showed good adherence to treatment, 72% to maintaining a healthy diet, 51% to following exercise recommendations, and 74% to quitting smoking. These differences between the ndings of Eastern studies and the ndings of Western studies may be attributed to the in uence of culture on patients' attitudes towards adopting healthy lifestyle behaviors. For example, studies conducted in Eastern countries have found that nonadherence to healthy lifestyle behaviors may be due to patients having busy schedules, an unwillingness to adopt healthy lifestyle behaviors, the presence of comorbidities, and patients placing more emphasis on attending social gatherings than on adhering to a healthy lifestyle [24,26].
Our ndings on the gender-based differences in the participants' adherence to healthy lifestyle behaviors are consistent with other studies conducted in Jordan, which have found that men are more adherent to healthy lifestyle behaviors than are women [28,29,30,31]. For example, in the study of Ammouri and colleagues [28], Jordanian men were found to be signi cantly more physically active than Jordanian women. Maintaining a healthy lifestyle may be challenging for women in Jordan due to several factors, which include problems in transportation, low social status, low self-e cacy, and lack of spousal support [32]. Vari and colleagues [33] also explained that gender behaviors, including the adoption of healthy lifestyle behaviors, are de ned by sociocultural expectations. In Jordan, women are expected to place great emphasis on family-oriented tasks and caring for the family, which may mean that they pay insu cient attention to adopting healthy lifestyle behaviors such as physical activity. Future studies are needed to further investigate the other factors which may contribute to gender-based differences in adherence to healthy lifestyle behaviors in the Middle Eastern context. It is noteworthy that in the present study, no gender-based based differences in adherence to healthy lifestyle behaviors were identi ed by the t-tests; however, the regression models indicated that males had higher adherence than did females. The difference between the ndings of the two statistical models may be attributed to the fact that regression analysis estimates the signi cance of a variable on an outcome after controlling for the effect of other variables, while t-test does not control for such an effect [34]. Therefore, estimates based on regression models can be more reliable than the estimates of t-tests.
A positive association was found between adherence to healthy lifestyle behaviors and the number of previous cardiac catheterization procedures, indicating that the participants are aware of the importance of adopting healthy lifestyle behaviors in order to prevent further CAD episodes or complications. Kayaniyil and colleagues [35] explained that knowledge of diagnostic tests and interventional procedures allows patients to clearly understand their condition and enables them to make educated decisions regarding their health.
Smoking status was also found to predict adherence among the participants in this study. Participants who had never smoked had better adherence to healthy lifestyle behaviors than current smokers or exsmokers. In the study of Sharma and Agrawal [36], knowledge of the harmful effects of smoking on CAD was found to increase patients' adherence to healthy lifestyle behaviors. Another interesting explanation is provided by Masiero, Lucchiari, and Prave ttoni [37], who reported that smokers and ex-smokers might have a cognitive distortion called "optimistic bias". This group of patients tend to overestimate the impact of their decisions and are too optimistic towards their future and their capacity to monitor their health consequences.
Studies in the literature have reported contradictory ndings regarding the impact of depressive symptoms on adherence to healthy lifestyle behaviors among CAD patients. Although the majority of studies have reported that depressive symptoms predict poor adherence to healthy lifestyle behaviors among CAD patients [38, 39, 40], one study [41] suggested no such relationship, which is consistent with our ndings. Although many of the participants in the present study reported having depressive symptoms, this does not necessarily mean that they are clinically depressed. According to Fogel [42], depression had the most signi cant impact on adherence among cardiac patients during hospitalization. Therefore, the fact that our participants were recruited from outpatient cardiac clinics may justify the weak relationship between depressive symptoms and adherence to healthy lifestyle behaviors indicated by our results.

Limitations Of The Study
One of the limitations of the present study is that the use of a self-report questions for data collection may have led to social desirability bias. Further, the participants were recruited from two outpatient cardiac clinics, which may limit the generalizability of our ndings to other CAD patients in other care settings. Finally, this study was unable to assess the causal relationships between depression and the factors that contribute to adherence to healthy lifestyle behaviors among CAD patients in Jordan.

Implications
Our study has shown that CAD patients in Jordan have low adherence to certain healthy lifestyle behaviors, including physical activity, maintaining a healthy diet, and weight loss. Signi cant genderbased differences in adherence were identi ed, whereby females were found to be less adherent than males to healthy lifestyle behaviors. Our ndings also showed that being a smoker negatively impacts adherence to healthy lifestyle behaviors among CAD patients. Therefore, future studies are needed to investigate the factors which contribute to low adherence to healthy lifestyle behaviors among CAD patients in Jordan and to determine whether gender-based differences in adherence exist among larger samples. Further studies are also needed to investigate the barriers to adopting and adhering to healthy lifestyle practices among female CAD patients in Jordan. Furthermore, future studies are needed to examine the factors that hinder CAD patients from adopting healthy lifestyle behaviors such as quitting smoking. Finally, further studies are needed to investigate the effect of depressive symptoms on adherence to healthy lifestyle behaviors among CAD patients in Jordan using more speci c measures of depression and taking into account any differences between patients in inpatient and outpatient cardiac settings.

Conclusion
Effective and exible strategies are needed to help patients with CAD adjust their lifestyle behaviors in order to improve their overall health and reduce the risk factors of CAD. Nurses play a major role in assessing CAD patients' lifestyle practices on a regular basis and spreading awareness among patients regarding the importance of adopting healthy lifestyle behaviors. Nurses can support patients in making healthy choices and adhering to them.