Factors Affecting for Lifestyle Adoption in Patients with Myocardial Infarction

Background Epidemiological transition of acute and infectious diseases to non-communicable ones, aging population, together with rapid lifestyle changes all have given rise to prevalence rate of cardiovascular diseases (CVDs). Thus, it is of utmost importance to reflect on lifestyles especially in this period. The main purpose of this study was to assess lifestyle in patients affected with myocardial infarction (MI). This cross-sectional study was examining health-related lifestyle behaviors in patients with MI in 2019. To this end, a total number of 176 patients were selected using purposive and convenience sampling methods. The research instrument was also the Health-Promoting Lifestyle Profile II (HPLP-II) as a standardized self-report questionnaire. To analyze the data, the IBM SPSS Statistics software (version 22) software and the generalized linear models were used. Moreover, the level of significance was set at 0.05 in this study. The results of Wilks’ lambda distribution revealed that the effect of gender on the linear combination of the dependent variable (i.e. lifestyle) was significant and 11.4% of changes in this variable had resulted from variation in gender. Besides, the results demonstrated that health responsibility scores in men were on average 2.703 lower than those obtained by women. This relationship was also significant and its effect size was by 3.3% (p = 0.016). concluded tool as


Introduction
The prevalence rate of cardiovascular diseases (CVDs) in developing countries is on the rise because of aging population and rapid lifestyle changes, in particular, tobacco use, high-fat food intake, lack of physical activity and exercise, as well as adoption of industrial lifestyle [1]. Nowadays, CVDs are known as the world's leading cause of death. Estimates in 2015 in this respect had also established that 17.7 million people had died from CVDs, accounting for 31% of global mortality. Statistics had further revealed that 7.4 million people had lost their lives caused by coronary artery disease and 6.7 million people had died due to myocardial infarction (MI) [2]. Mortality and recurrent MI are thus considered as the main clinical outcomes following an acute heart attack. Ability to perform daily living activities, level of comfort, and lifestyle behaviors after a heart attack among patients are also taken into account as important factors affecting their survival [3]. Moreover, evidence has demonstrated that lifestyle can shape individuals' health status and longevity [4]. Epidemiological studies have further reported that healthy lifestyle such as proper diet, no tobacco use, healthy weight maintenance, and physical activity can play a role in controlling cardiovascular risk factors [5].
The World Health Organization (WHO) also recognizes the concept of lifestyle based on definable patterns of behavior resulting from interactions between personal characteristics, social relationships, environmental conditions, and socioeconomic situations [6]. In fact, lifestyle refers to routine daily living activities accepted automatically by individuals, so they can affect health status [7]. To pick a lifestyle to maintain and promote one's health and to prevent diseases, individuals take several measures including proper diet adherence, enough sleep, rest, physical activity and exercise, weight control, as well as no tobacco use, and immunization against diseases [8]. It should be noted that health-promoting lifestyle consists of six behavioral aspects of physical activity, nutrition, health responsibility, spiritual growth, interpersonal relations, and stress management [9].
In this line, the results of the study by Manavifar et al. (2019) had found that lifestyle in patients with hypertension referred to clinics affiliated to Islamic Azad University of Mashhad was not at a favorable level. In terms of physical activity, majority of the patients had also answered "never" to items about regular, vigorous, or even moderate exercise. In addition, more than half of the patients had insufficient information about sodium and oil intake with regard to nutrition [9]. The findings reported spiritual growth, interpersonal relations, and stress management) and high blood pressure [11].
On the other hand, epidemiological transition of acute and infectious diseases to non-communicable ones as the leading cause of mortality and health disorders has made the assessment of lifestyle an essential issue especially in this period [12]. Considering the importance of lifestyle and its effect in helping individuals have access to favorable health status, the present study was conducted to assess factors affecting for lifestyle adoption in palliative care of in patients affected with myocardial infarction admitted to Mazandaran Heart Center, Iran, in 2019.

Methods
This study was a descriptive-analytical cross-sectional research assessing health-related lifestyle Research and Technology at Mazandaran University of Medical Sciences and then submitted to the head of Mazandaran Heart Center. After introducing oneself to study samples, the researcher also explained the main research objectives and obtained an informed consent from them. In this study, the designed research instrument was distributed among 176 patients selected via purposive and convenience sampling methods. The patients were further informed that they were free to participate in the project or withdraw. To ensure confidentiality of data, the patients' names were not mentioned on the information forms. The inclusion criteria were willingness to participate in the study, no emergency critical conditions, complete alertness during the study, no mental illnesses, and at least 5 days of being affected with MI. As well, the exclusion criteria were unwillingness to be involved in the study and being in emergency critical conditions. According to the formula for determining sample size, a total number of 176 patients participated in this study. The sample size was correspondingly calculated based on research results by Leifheit-Limson et al. as follows [16]: The main research instruments were a demographic characteristics form (including age, gender, marital status, and level of education) and the 52-item Health-Promoting Lifestyle Profile II (HPLP-II) as a standardized self-report questionnaire, used in the study by Mohseni-Pouya et al., reflecting on six aspects of lifestyle i.e. health responsibility, nutrition, spiritual growth, interpersonal relations (each one with 9 items) as well as physical activity and stress management (each one with 8 items) using a Likert-type scale containing "never (1)", "sometimes (2)", "often (3)", and "always (4)". The total score of lifestyle could also range from 52 to 208. The validity of this research instrument was measured by 10 experts through content validity method. Cronbach's alpha coefficient was also calculated to determine internal validity, which was 0.83 and at a desirable level.
The data were collected based on medical records and through direct interviews with patients in the ward. The data analysis was further conducted using the IBM SPSS Statistics (version 22) software and statistical tests of mean, frequency, and generalized linear models (GLMs). The level of significance was finally set at 0.05 in this study.

Results
The findings illustrated that the mean age in men and women was 56.21 ± 5.31 and 55.14 ± 4.81 respectively. As well, 72.9% of the male patients and 89.2% of the females were married. Among the six aspects of lifestyle, physical activity was the poorest behavior demonstrated by the patients. The results of Wilks' lambda distribution in 0.886, F(6.176) = 3.62, and p = 0.002, as well as partial eta-squared = 0.114 revealed that the effect of gender on the linear combination of the dependent variable (i.e. lifestyle) was significant and 11.4% of the changes in the given variable had resulted from variation in gender. For this purpose, independent T-test was employed to specify the significance source, whose results are outlined in Table 3. The results in Table 3 showed that the score of health responsibility in men compared with women was on average 2.703 lower. So, this relationship was significant and its effect size was reported by 3.3% (p = 0.016). Considering other variables, no statistically significant difference was found between both genders.  The results of this study were also consistent with the findings reported by Abedi et al. (2013) in which a significant relationship had been observed between lifestyle and gender and also men's lifestyle had been poorer than that in women [13]. In the study by Manavifar et al. (2010), women in all age groups had been more active than men, maybe due to their health consciousness behaviors [14]. In the given study, the total score of health-promoting lifestyle behaviors was lower in women than in men, but it was not statistically significant. It seems that this discrepancy might be attributable to the small sample size (i.e. 67 female patients with hypertension) [9]. However, in the study by Babak, the total score of lifestyle in older men had been reported significantly higher than that in women. It looks as if such a difference was the result of factors such as level of education as well as socioeconomic characteristics in men [15].
In the present study, only 27.3% of the patients were women, which could be considered as a limitation; so it was recommended to select a larger sample size of female patients in further research.
In this study, the lowest mean score was related to physical activity, which meant that these patients did not have a good level of health-promoting lifestyle behaviors in this aspect. In the studies by Azadbakht [16], Manavifar [9], Barough [17], and Mansourian [11], majority of the individuals had poor lifestyle with regard to physical activity and exercise. Also, in the study by Sargazi et al. (2012), only 38% of the elderly aged over 65 years had reported moderate to vigorous physical activity [18].
This could be due to factors such as underdevelopment of sports culture in this age group, lack of sports facilities around city, and problems of commuting by older individuals in the city.
In this study, the score of health responsibility in men was on average 2.703 lower than that in women. This relationship was also significant with the effect size of 3.3% (p = 0.016). Health responsibility means that individuals reach a perception of what activities can be performed for being healthy [19]. The results of the present study also demonstrated that men had poor health responsibility than women. The findings of various investigations had further revealed that women had adopted significantly better behaviors than men in terms of health responsibility, nutrition, interpersonal relations, and spiritual growth in health-promoting lifestyle [20]. Research findings by Fuhrer had also shown that women compared with men had healthier lifestyles. For example, men had alcohol consumption by 2.21 times more than women, and they were smoking 16 times more likely than women [21].

Conclusion
The results of the present study implied that the concept of lifestyle could be an analysis tool to better understand differences between genders as an effective variable in adopting a healthy lifestyle, especially in patients with MI. Therefore, there is a need to expand research and education programs about lifestyle in this group of patients and approve appropriate policies in this respect.

Ethics approval and consent to participate
This study was the result of the project approved with the ethical code no.IR.MAZUMS.REC.13971105.
The researcher explained the main research objectives and obtained an informed consent from them.

Consent for publication: Not applicable.
Availability of data and materials: "The dataset(s) supporting the conclusions of this article is (are) included within the article (and its additional file(s))."

Competing interests
The authors declare that they have no competing interests.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

Authors'contributions
HM were supervisors and principal investigators of the study and drafted the manuscript. YJ was an advisor of the study. JY participated in the statistical analysis. AG contributed to the design and assisted in the preparation of the final version of the manuscript. All authors read and approved the final version of the manuscript.