Journal of Preventive Medicine

Introduction
Cardiovascular diseases are the most important cause of death in the world. One of the most common cardiovascular diseases, which is responsible for the death of millions of people every year, is myocardial ischemia. In addition to having medication regimen, it is very important to adhere to the treatment and self-care to prevent the progression of the disease and the occurrence of repeated heart attacks. Lack of awareness of self-care behaviors and behaviors related to treatment adherence is one of the problems of these patients. To modify and change the self-care behaviors and medication regimen of these patients, there is a need for an intervention to teach patients based on the behavioral models. Behavioral theories are valuable ways for understanding and solving all kinds of behavioral problems. The application of these theories is for investigating the factors affecting the motivations and behaviors of the individuals. One of these theories is the protection motivation theory (PMT). The results of various studies have shown that protection motivation can lead to the improvement of health-related behaviors and self-care in different patients. The PMT first evaluates threats through the constructs of perceived vulnerability, perceived severity, intrinsic and extrinsic rewards; Then, through the constructs of self-efficacy, response efficiency, protection motivation, and response costs, predicts various types of preventive and protective behaviors. Then, it emphasizes the development of adaptation skills. The constructs of this theory are placed in two cognitive mediating processes, including threat appraisal and coping appraisal. Protective behaviors are guided by people’s assessment of threats and how to deal with them. The level of threat appraisal affects people’s goal orientation and coping. Models based on behavioral theories, in addition to predicting intention and behavior, can also be valuable in predicting emotional responses such as adherence to treatment.
Methods
This is a mixed-method (quantitative and qualitative) study. In the first phase, the qualitative approach using grounded theory was used. In the second phase (quantitative), a quasi-experimental study with a pre-test/post-test design and a control group was conducted. The study population included all patients with myocardial ischemia referred to the Payamber-e Azam Hospital in Bandar Abbas, Iran. Using a purposive sampling method, 82 patients were selected. They had no other acute and chronic physical and psychological diseases. They were randomly assigned to the intervention (n=41) and control (n=41) groups. The intervention group received the intervention based on the PMT at 6 sessions of 90 minutes. The data collection tool was Self-Care Questionnaire developed by Miller et al. Two descriptive (mean and standard deviation) and inferential statistics (Shapiro-Wilk test to check the normality of data distribution, Levene’s test to check the equality of variances, and analysis of covariance to examine the study hypotheses) were used to analyze the data in SPSS v. 23 software.
Results
The mean age of patients was 55.50 in the intervention group and 55.66 in the control group. The results have shown that the homogeneity of variances was maintained in the post-test phase for the self-care variable (P>0.05). The results of Box’s M test showed the homogeneity of variance-covariance matrices in the post-test phase (P>0.05). In addition, the results of the Shapiro-Wilk test indicated the normality of data distribution for the self-care variable in both groups and evaluation phases (P>0.05). Finally, by examining the assumption of homogeneity of the regression slope, it was found that the correlation of the pre-test score with the group factor in the post score for self-care variable was not significant (P>0.05).
The intervention based on the PMT was able to lead to a significant difference in the mean scores of the dependent variable (self-care) in the post-test stage (P<0.05). The effect size was 0.65. Moreover, the effect size of the intervention on adherence to dietary regimen, physical activity, use of prescribed medication, and modulating the effect of stressful variables in patients with myocardial ischemia was 0.39, 0.51, 0.61, and 0.36, respectively. The intervention had no effect on smoking cigarettes.
Discussion
The results showed that the intervention based on the PMT was effective in improving self-care and its domains in patients with myocardial ischemia. The intervention helped patients try to consider their disease-related behaviors and activities more seriously by learning protective and adaptive skills, which led to the improvement of their self-care. Overall, it can be concluded that the educational intervention based on the PMT, relying on proper nutrition, self-care skills, increasing awareness, and relaxation exercises, can be used as an efficient intervention to increase self-care of patients with myocardial ischemia.
The study limitations included the assessment of patients only in one hospital in Bandar Abbas, existence of some uncontrolled variables such as family status, financial status, number of children, and social status, not using random sampling methods, and lack of a follow-up phase. Therefore, to increase the generalizability of the results, it is recommended that a similar study be carried out in other cities and regions and communities with different cultures and diseases, by controlling the effect of confounding factors, using a random sampling method, and including a follow-up phase. Moreover, it is recommended that the educational intervention based on the PMT be presented to the consultants and clinical psychologists of the hospitals in the form of a specialized workshop so that they can take a practical step to increase the self-care of patients with myocardial ischemia.

Ethical Considerations
Compliance with ethical guidelines
The current research has a code of ethics license under the number IR.HUMSREC.1399.141 was from Hormozgan University of Science and Medicine.

Funding
The present article was taken from Masoumeh Zakipour's doctoral thesis at Islamic Azad University, International Branch (Kish). This article is not sponsored by any organization or institution and all its financial resources are provided by the authors.

Authors' contributions
The author of the proposal, conducting the intervention and writing: Masoumeh Zakipour; Supervising the research and compiling the package: Kobri Haj Alizadeh; Data analysis: Mohammad Reza Sirfi, Siddiqa Abedini; Editing: Marzieh Nikparvar; Advising on package development: Siddiqa Abedini.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
We are grateful to the officials of Bandar Abbas Hospital of the Prophet (pbuh) for their full cooperation in carrying out the research.


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