EDUCATIONAL INTERVENTION IN THE POST-OPERATIVE PERIOD OF CARDIAC SURGERY: A MIXED METHODS STUDY GUIDED BY THE HEALTH BELIEF MODEL

INTERVENCIÓN EDUCATIVA EN EL POSTOPERATORIO DE CIRUGÍA CARDÍACA: MÉTODOS MIXTOS GUIADOS POR EL MODELO DE CREENCIAS

ABSTRACT

Objective:   to analyze the contribution of educational intervention to health literacy and knowledge of coronary artery disease in adults in the late postoperative period of cardiac surgery; and to understand the factors which affect behavior change based on a theoretical model.

Methods:   this is a mixed-methods study with educational intervention based on the health belief model, conducted with 25 people undergoing cardiac surgery living in Western Paraná, Brazil. Data were collected from June 2021 to October 2022. A sociodemographic-clinical questionnaire and the Coronary Artery Disease Education Questionnaire Short-Version and Eight-item Health Literacy Assessment Tool instruments were used in the quantitative stage, analyzed using descriptive and inferential statistics. Then, a semi-structured interview was conducted in the qualitative stage, investigated by content analysis. A joint display approach based on the belief model was chosen for data integration.

Results:  the intervention enabled an increase in health literacy (p=0.035) and knowledge about the disease (p=0.007). The qualitative analysis generated the following categories: before the intervention: “Susceptibility”, “Severity” and “Perceived severity”; after the intervention: “Perceived benefits” and “Barriers encountered in rehabilitation”. Data integration enabled identifying perceptions before and after the intervention, modifying factors, benefits and barriers encountered.

Conclusion:  there was an increase in knowledge about the disease and health literacy through developing self-management skills. The use of tools to assess knowledge about the disease and health literacy enabled planning educational actions to fill existing gaps.

DESCRIPTORS:
Cardiovascular diseases; Health education; Cardiac surgery; Clinical management; Health literacy; Health belief model; Adult health

RESUMO

Objetivo:   analisar a contribuição de intervenção educativa na literacia em saúde e no conhecimento da doença coronariana em adultos no pós-operatório tardio de cirurgia cardíaca; compreender os fatores que afetam a mudança de comportamento baseado num modelo teórico.

Método:  estudo de métodos mistos com intervenção educativa baseada no modelo de crenças em saúde, realizado com 25 pessoas submetidas à cirurgia cardíaca residentes do Oeste-Paranaense, Brasil. Os dados foram coletados de junho de 2021 a outubro de 2022. Na etapa quantitativa, utilizou-se um questionário sociodemográfico-clínico e os instrumentos Coronary Artery Disease Education Questionnaire Short-Version e Eight-item Health Literacy Assessment Tool, analisados mediante estatística descritiva e inferencial. Na qualitativa, realizou-se entrevista semiestruturada, investigada por análise de conteúdo. Para a integração dos dados, optou-se por abordagem de exibição conjunta baseada no modelo de crenças.

Resultados:  a intervenção possibilitou aumento da literacia em saúde (p=0,035) e conhecimento sobre a doença (p= 0,007). A análise qualitativa gerou as categorias: antes da intervenção: “Susceptibilidade”, “Severidade” e “Gravidade percebida”; após a intervenção: “Benefícios percebidos” e “Barreiras encontradas na reabilitação”. A integração dos dados permitiu identificar percepções antes e após a intervenção, fatores modificadores, benefícios e barreiras encontradas.

Conclusão:  Houve aumento do conhecimento sobre a doença e da literacia em saúde mediante desenvolvimento das habilidades para autogestão. O uso de ferramentas para avaliar o conhecimento da doença e literacia em saúde propiciou o planejamento de ações educativas para suprir lacunas existentes.

DESCRITORES:
Doenças cardiovasculares; Educação em saúde; Cirurgia cardíaca; Gerenciamento clínico; Literacia em saúde; Modelo de crenças em saúde; Saúde do adulto

RESUMEN

Objetivo:   analizar la contribución de la intervención educativa a la alfabetización en salud y al conocimiento de la enfermedad coronaria en adultos en el postoperatorio tardío de cirugía cardíaca; Comprender los factores que afectan el cambio de comportamiento basándose en un modelo teórico.

Método:  estudio de métodos mixtos con intervención educativa basada en el modelo de creencias de salud, realizado con 25 personas sometidas a cirugía cardíaca residentes en el Oeste de Paraná, Brasil. Los datos fueron recolectados de junio de 2021 a octubre de 2022. En la etapa cuantitativa se utilizó un cuestionario sociodemográfico-clínico y los instrumentos Coronary Artery Disease Education Questionnaire Short-Version y Eight-item Health Literacy Assessment Tool, analizados mediante estadística descriptiva e inferencial. En el aspecto cualitativo se realizó una entrevista semiestructurada, investigada mediante análisis de contenido. Para la integración de datos, se eligió un enfoque de visualización conjunta basado en el modelo de creencias.

Resultados:  la intervención permitió un aumento de la alfabetización en salud (p=0,035) y del conocimiento sobre la enfermedad (p=0,007). El análisis cualitativo generó las categorías: antes de la intervención: “Susceptibilidad”, “Severidad” y “Severidad percibida”; Después de la intervención: “Beneficios percibidos” y “Barreras encontradas en la rehabilitación”. La integración de datos nos permitió identificar percepciones antes y después de la intervención, factores modificadores, beneficios y barreras encontradas.

Conclusión:  hubo un aumento del conocimiento sobre la enfermedad y la alfabetización en salud a través del desarrollo de habilidades de autogestión. El uso de herramientas para evaluar el conocimiento de la enfermedad y la alfabetización en salud permitió planificar acciones educativas para llenar las brechas existentes.

DESCRIPTORES:
Enfermedades cardiovasculares; Educación para la salud; Cirugía cardíaca; Gestión clínica; Alfabetización en salud; Modelo de creencias de salud; Salud del adulto

INTRODUCTION

Ischemic heart disease (IHD) was the leading cause of death in Brazil between 1990 and 2019, increasing from 1.48 million in 1990 to 4 million in 2019¹. One of the most effective treatments for IHD is coronary artery bypass grafting (CABG). A total of 20,674 CABG surgeries were performed in Brazil during the pre-pandemic period in 2019².

CABG is a complex procedure that requires intensive care to ensure a good recovery³. Therefore, it is necessary for people to have adequate management of modifiable risk factors related to lifestyle⁴ to avoid complications resulting from the surgical procedure. Managing care requires actions such as case management led by a nurse, with a view to planning, monitoring and evaluating health needs, and a social support network aiming to promote individual and family empowerment in the rehabilitation process. It can be used as a tool that contributes to care in various complex disease situations⁵, such as in the recovery of people undergoing CABG. However, its use in the postoperative period of complex surgeries still lacks more evidence.

One of the factors that contributes to care autonomy is health literacy (HL). In this study, we use the term health literacy according to the translation and validation of the instrument applied. HL is understood as skills and competencies limited to different levels and domains used by people to access, understand, evaluate and give meaning to health information, with the aim of taking care of their own health or that of others⁶.

Inadequate HL is recognized as a barrier to maintaining health and preventing coronary artery disease (CAD); it is associated with the absence of self-care behaviors for managing the disease⁷, as they are built throughout life and can impact the rehabilitation process. The concept of health and related behaviors are constructed from personal experience and are intertwined with beliefs, values, and feelings which can influence adherence or non-adherence to treatment and lifestyle changes⁸. Therefore, it is believed that the Health Belief Model (HBM) can help identify factors that influence behavior and rehabilitation.

HBM is one of the first models designed to explain how to change health behaviors and the psychological processes involved in such changes; it is based on the expectancy-value theory and provides information about motivation for healthy behaviors⁹. Therefore, HBM assesses people’s perceptions and beliefs regarding strategies to reduce disease and its occurrence. Perceived benefits, perceived barriers, perceived susceptibility, perceived severity, and self-efficacy are the main constructs of the HBM¹⁰.

The HBM has been used to address challenges of various health behaviors in different contexts^9,11-12. However, we did not identify the use of this theoretical model in developing health education actions to prevent and control complicating factors in the rehabilitation process in CABG. Considering the complexity of these factors, a complex mixed methods research design was used herein, with qualitative research conducted in conjunction with the application of the intervention. This allows us to understand complex mixed methods research issues which encompass the participants’ experience on certain aspects of the proposed intervention, without subjectively inferring the effects of the intervention on the analyzed variables^12-13.

In view of the above, this study aimed to analyze the contribution of an educational intervention to health literacy and knowledge of coronary disease in adults undergoing late postoperative CABG and to understand the factors which affect behavior change based on the HBM.

METHOD

This is an experimental mixed-methods study with single-group educational intervention based on the Health Belief Model (HBM), which combines quantitative and qualitative approaches (QUAN+QUAL)^13-14. In intervention or experimental studies with mixed methods, it is up to the researcher to strategically define the qualitative data collection moment, which can occur before, during or after the intervention, according to the study’s exploratory objectives. This strategy enables deeper understanding of the quantitative findings and gives greater ecological validity to the intervention¹⁴.

Collecting qualitative data before and after the intervention was necessary to understand and monitor the needs of the participants, as well as to identify possible barriers related to the proposed intervention, without interfering in the evaluation of the results on health literacy and knowledge about the disease¹⁴. The criteria established by the Consolidated Criteria for reporting qualitative research (COREQ)¹⁵, Consolidated Standards of Reporting Trials (CONSORT)¹⁶ and Mixed Methods Appraisal Toll (MMAT)¹⁷, translated into Brazilian Portuguese, were considered.

The study was conducted at the homes of participants living in a city located in the western region of Paraná, Brazil, between June 2021 and October 2022. The sample size calculation was based on population data from the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística - IBGE)¹⁸ for the year 2019 of the city where the study was conducted, and on the incidence of CABG², considering a 95 % confidence level and a sampling error of 10 %. The qualitative sample was composed of the same participants as in the quantitative stage.

The inclusion criteria were: having suffered an acute myocardial infarction (AMI) and undergoing CABG; age ≥18 years; reaching the minimum score on the Mini-mental (13 points for illiterate participants, and 18 for low and medium education levels); and residing in the city where the study was conducted. The exclusion criteria were: having comorbidities and/or complications that made communication impossible. Thus, a total of 43 participants were selected, 18 were excluded due to moving to another city after hospital discharge, and the remaining 25 comprised the effective sample. However, two participants died and two dropped out of the study during the intervention, resulting in a final sample of 21 participants.

The study protocol was conducted according to the following steps:

1) Participant selection: performed in two referral hospitals in cardiology. All hospitalized patients who met the inclusion criteria were invited, regardless of the type of health insurance. Then, three days were waited after discharge for the first home visit, where clinical conditions were assessed and eligibility confirmed. Participants who agreed to participate in the study signed the Informed Consent Form (ICF).

2) Initial assessment: performed at the patient’s home with collection of sociodemographic and clinical data, application of the Coronary Artery Disease Education Questionnaire - Short Version (CADE-Q SV)¹⁹ and Health Literacy Assessment Tool (HLAT-8)²⁰ instruments, in addition to a semi-structured interview based on the HBM²¹. The CADE-Q SV, validated for Brazilian Portuguese, consists of 20 items distributed in five domains (medical condition, risk factors, physical exercise, nutrition and psychosocial risk), with a total score of 0 to 20 points. The HLAT-8 was adopted to measure the HL level, which consists of eight Likert-type questions with a total score of 0 to 37, with a score ≥19 points being considered satisfactory.

Qualitative data collection was conducted through semi-structured interviews, conducted individually in a private environment, according to the participant’s choice. The scripts were constructed based on the theoretical framework of HBM²¹, considering the domains of perceived susceptibility, severity, benefits, barriers and self-efficacy.

The first script was composed of 17 questions and applied at the pre-intervention stage (T₀) with the purpose of exploring the participants’ perception of their heart condition, as well as identifying beliefs related to vulnerability to the disease and its perceived severity. The second script had seven questions and was applied at the end of the intervention (T_final), aiming to understand the perceived benefits of the surgery and the barriers faced during the rehabilitation process, including emotional, social and structural aspects.

The interviews were audio-recorded with informed consent, and lasted an average of 60 minutes. The approach enabled collecting fundamental information to elaborate individualized care plans based on the needs expressed by the participants themselves, in addition to supporting the integrated analysis of quantitative and qualitative data. The qualitative collection and analysis process was conducted in accordance with COREQ¹⁵ criteria, ensuring methodological rigor, transparency and scientific validity.

3) Educational Intervention: lasting five months and divided into three stages: nursing consultation, agreement on care goals, and home and remote monitoring. The nursing consultation included a physical examination (blood pressure, pulse oximetry and heart rate, abdominal circumference, body mass index (BMI), lung auscultation, and assessment of the surgical wound), in accordance with the guidelines of the Brazilian Society of Cardiology²² and Resolution 358/2099 of the Federal Nursing Council²³. This stage lasted an average of 90 minutes. Participants received guidance on the disease, treatment, and complications.

Follow-up occurred every 30 days with home visits, supplemented by biweekly contacts via mobile application (WhatsApp) for educational reinforcement, clarification of doubts, and monitoring of clinical progress. The behaviors and variables of interest were recorded in a specific research instrument (vital signs, anthropometry, nursing diagnosis, behaviors, and agreed goals). The information was recorded for later evaluation of the data and scheduling of the next activities to be developed.

4) Final assessment: a new home visit was performed at the end of the five months, with reapplication of the CADE-Q SV and HLAT-8 instruments and a new semi-structured interview (T_final) aiming to assess the intervention effectiveness. The participants were instructed on the end of the study and referred for continued care with the health network and the cardiology outpatient clinic of the municipality.

The numerical variables were analyzed by measures of central tendency (mean and standard deviation), and the nominal variables with simple (n) and relative ( %) frequency. The comparison of the sociodemographic categories with the CADE-Q SV and HLAT-8 instruments was performed using the Student’s t-test or ANOVA, and were considered significant when p<0.05.

The differences between T₀ and T_final in the CADE-Q SV score were analyzed using the Wilcoxon test. The HLAT-8 score used the paired t-test to verify the differences between T₀ and T_final. Spearman’s correlation was used to analyze the relationship between the HLAT-8 domains and the CADE-Q SV areas, while Pearson’s correlation was used for linear parametric analysis. The chi-squared test and McNemar’s test were used to analyze the qualitative variables.

The content analysis proposed by Creswell and Creswell¹³ was used for the qualitative phase. The statements were read and transcribed in full, and entered into the Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires software (IRAMUTEQ_0.6-alpha3^®).

The classes were identified and named by similarity in two moments: 1) Before the intervention, through the analysis of the individual perceptions of the participants in relation to the susceptibility and perceived severity of the illness, and the perceived severity after the surgery. 2) After the intervention, in relation to the probabilities of actions in relation to the benefits perceived in the preventive action and barriers encountered during rehabilitation or that interfered with therapeutic adherence.

Interpretation and understanding of the data were performed based on the HBM. Data was integrated through investigating and interpreting the quantitative and qualitative results, presented at three distinct moments: 1) Before the intervention - qualitative data (individual perceptions); 2) Intervention - modifying factors based on quantitative data (HLAT-8 domains and CADE-Q SV areas); 3) After the intervention - perceived benefits and barriers encountered (qualitative data). We chose to use a joint display approach (Join displays) including the theory that guided the study²⁴, as shown in Figure 1.

The project was approved by the Research Ethics Committee, developed in accordance with Resolution 466/2012 of the National Health Council. All instruments used in the study were authorized by their respective authors. The information was validated with the participants at the end of the interview in a summarized manner, and they were asked if they would like to make any additions to the reports.

RESULTS

Quantitative phase

Regarding sociodemographic and clinical data, the participants were predominantly male (12; 57.1 %), married (15; 71.4 %), with one to three children (13; 61.9 %), and had a low education level (12; 57.1 %). The mean age was 62.5±11.2 years. Systemic arterial hypertension (SAH) stood out among the chronic diseases (12; 57.1 %), along with a sedentary lifestyle and smoking among the main risk factors. The mean per capita income was R$2,977.50.

Table 1 presents the results related to HL and knowledge about CAD before and after the educational intervention. An increase in the overall score was observed, which demonstrates that the intervention was effective in increasing HL (T₀ -18.4 ± 5.7; T_final - 20.8 ± 5.1; p-0.035) and knowledge about CAD (T₀ -39±6.7; T_final- 44.7±6.6; p-0.007) among participants.

When analyzing the score before and after the intervention according to the sociodemographic and clinical variables, it was observed that the intervention was effective in improving knowledge about CAD, with a significant difference in the variables: male gender; married or in a consensual union; one to three children; education between nine and 12 years; retired; ex-smokers, sedentary, people with DM associated with SAH and without comorbidities. It was effective in improving HL, with a significant difference in the variables: male gender, people without DM and without DM associated with SAH, as shown in Table 1.

Table 1 -
Comparison of Health Literacy Assessment Tool -8 and Coronary Artery Disease Education Questionnaire - Short Version scores before and after the intervention, according to the sociodemographic and clinical profile of the participants. Curitiba, PR, Brazil, 2023 (n=21).

Variable	CADE-Q SV					HLAT-8
		T0	T final	p-value‡		T0	T final	p-value‡
All participants n( %)	General score M*±SD†	39±6.7	44.7±6.6	0.007	Escore geral M±DP†	18.4 ± 5.7	20.8 ± 5.1	0.035
	Insufficient knowledge	0(0.0)	0(0.0)	0.042	Unsatisfactory	10 (47.6)	9 (42.9)	0.823
	Little knowledge	1(4.8)	0(0.0)		Satisfactory	11 (52.4)	12 (57.1)
	Acceptable	9(42.9)	5(23.8)
	Good	11(52.4)	10(47.6)
	Excellent	0(0.0)	6(28.6)
Gender	Female	42±5.9	44±5.8	0.527	21 ± 4.0	21 ± 5.0	0.709
	Male	37±6.8	46±7.3	0.006	16 ± 6.1	21 ± 5.3	0.002
Civil status	Married or in a common-law union	37±6.3	44±5.6	0.002	18 ± 4.9	20 ± 5.0	0.053
	Separated or divorced	45±3.0	47±12.1	0.750	22 ± 4.4	25 ± 0.6	0.423
	Single	42±0.0	54±0.0	1.000	7 ± 0.0	18 ± 0.0	-
	Widowed	47±2.1	42±4.2	1.000	23 ± 8.5	20 ± 9.9	0.205
Number of children	0	30±0.0	36±0.0	1.000	17 ± 0.0	25 ± 0.0	-
	1 to 3	39±4.6	46±7.1	0.002	17 ± 5.8	19 ± 4.1	0.183
	More than 3	41±9.4	43±5.2	0.892	21 ± 5.9	23 ± 6.4	0.220
Education	<9	38±7.8	42±4.7	0.183	18 ± 5.9	20 ± 5.9	0.285
	9 to 12	41±5.1	48±7.4	0.022	18 ± 5.9	22 ± 3.2	0.080
	>12	42±0.0	51±0.0	1.000	24 ± 0.0	25 ± 0.0	-
Occupation	Retired	38±7.3	45±6.7	0.006	17 ± 4.9	19 ± 5.8	0.132
	Active	42±0.0	50±5.2	0.174	17 ± 7.9	21 ± 3.8	0.192
	On sickness benefit	35±4.6	44±6.9	0.250	20 ± 3.6	23 ± 3.2	0.567
	Housewife	48±0.0	39±0.0	1.000	29 ± 0.0	27 ± 0.0	-
	Unemployed	48±0.0	36±0.0	1.000	24 ± 0.0	24 ± 0.0	-
Arterial hypertension	No	40±5.2	46±7.5	0.068	18 ± 7.1	22 ± 4.1	0.062
	Yes	38±7.7	44±6.1	0.052	19 ± 4.8	20 ± 5.7	0.327
Diabetes mellitus	No	39±6.9	45±6.9	0.029	18 ± 6.1	22 ± 5	0.024
	Yes	39±6.8	44±6.8	0.147	19 ± 5.5	19 ± 5.2	0.749
Arterial hypertension/Diabetes mellitus	SAH + DM	38±6.2	45±6.8	0.035	17.4 ± 4	18 ± 4.5	0.629
	One of the two	40±10	42±5	0.892	22±6.2	23±6.5	0.523
	None	39±4.7	47±7.5	0.022	17±6.2	21±3.8	0.041
Smoking	No	40±6.0	43±4.8	0.416	19 ± 6.2	22 ± 6.9	0.141
	Quit	37±7.4	46±7.6	0.006	17 ± 5.8	19 ± 3.7	0.271
	Yes	43±4.6	45±7.9	1.000	22 ± 2.9	24 ± 0.6	0.321
Practice physical activity	No	38±7.0	44±5.8	0.024	17 ± 5.3	20 ± 4.5	0.079
	Yes	41±6.2	46±8.4	0.206	21 ± 6.3	22 ± 6.2	0.294

• Legend: *M - mean; †SD - standard deviation; ‡Value obtained through Paired T-Test comparing before (T₀) and after (T_final) the intervention.

Regarding the participants’ knowledge about CAD in relation to the CADE-Q SV domains before and after the intervention, it was found that there was an improvement in almost all CADE-Q SV domains, although with statistical significance only in the areas related to “exercise” (p-0.008) and “diet” (p-0.029).

The “risk factors” area presented the lowest overall score: an increase in the average score was observed before (5±1.7) and after (6±1.1) the educational intervention, but without a statistically significant difference between the groups. The “psychosocial risk” area did not present significant changes after the intervention.

Qualitative phase

The qualitative analysis was conducted inductively and guided by the HBM²¹ theoretical framework. The categories were based on the theoretical framework itself which guided identification of the narratives in terms of content.

The “Susceptibility” category exemplified the perception of the risk of illness or becoming ill, as illustrated by a statement regarding the lack of knowledge about the illness process and difficulty in understanding its severity:

[...] I never had symptoms, I didn’t have a headache, I wasn’t tired, I wasn’t short of breath. I think it's due to age. My mother died of a heart attack at 55, it could be (N1).

Then in the “Perceived severity” and “Barriers encountered in rehabilitation” categories, it was observed that the perception of the severity of the disease was intrinsically related to having a comorbidity, be it hypertension or DM. The absence of a chronic disease interfered with the understanding of the risk factors that triggered the illness, as evidenced in the statement:

[...] I never thought I would have to have surgery. I was sick for several nights. I got sick. I didn't treat my blood pressure and cholesterol before (N9).

The “Perceived severity” category is related to the biological, emotional, social and financial consequences that can interfere with rehabilitation. These factors can create barriers for patients to make the necessary changes or even reduce the severity of the event or the inability to make decisions, as evidenced in the testimony of N19:

[...] our diet hasn’t changed much. We haven’t changed, because we can’t even buy things, but we’ve reduced it. I find it difficult because I can’t do the things I used to do. I used to make bread, but now I have to depend on others to knead the bread for me (N19).

In turn, the “Perceived benefits” category is intrinsic to the actions performed by people; it is influenced by beliefs, norms and social pressures, both in relation to the effectiveness of the knowledge they have or believe in and in executing the strategies necessary for self-management of the disease. The barrier identified in the speech is related to understanding the surgical procedure and rehabilitation, as well as health education (HL), which interfered with understanding the illness and adherence to lifestyle changes:

[...] I was afraid of going up or down the stairs, a very big fear, but after we talked (researcher and patient/educational action), and he told me to go slowly, go down, walk, take some walks, then I lost my fear and became more confident (N2).

The results are presented as pragmatic opportunities to address HL and CADE-Q SV in people undergoing HBM-based CABG. Figure 1 illustrates the integration of qualitative and quantitative data and the correlation with the HBM model.

Figure 1 -
Relation of the Health Belief Model before and after the educational intervention in relation to Health Literacy Assessment Tool -8 and Coronary Artery Disease Education Questionnaire - Short Version. Curitiba, PR, Brazil, 2023. (n=21)

DISCUSSION

This study evaluated individuals undergoing late CABG after AMI using a mixed method, and measured HL and knowledge about CAD after an educational intervention based on the health belief model.

No statistically significant differences were observed between education level, HL and knowledge about CAD. However, this study demonstrated a significant probability of knowledge about ways to prevent CAD in men who have a support group (stable marital relationship and children) and retirees.

Care continuity works best when there is involvement of care around the patient, involving families, shared decision-making and personalized multidisciplinary education and care which allows a more coordinated holistic approach to care^25-26. Furthermore, in relation to HL, male participants and those without chronic diseases (DM or SAH) demonstrated significant improvement after the intervention in individual and social skills to deal with lifestyle changes resulting from late CABG.

Studies have shown that lifestyle interventions generally cause small changes in cardiovascular risk factors or total mortality in the population. Thus, when monitored and involved in health education program, in order to motivate, support and empower them to manage signs and symptoms, it improves quality of life and delays complications²⁷.

The data mix allowed us to identify factors which can interfere with care and therapeutic adherence. The participants presented unsatisfactory HL and acceptable to good knowledge about CAD before the intervention. This result is consistent with the study carried out by Costa et al.⁷, which also identified inadequate HL in patients with CAD. Another study carried out in Brazil with 357 adults with and without arterial hypertension, also identified inadequate HL in 70 % of the hypertensive patients investigated²⁸.

However, it is worth noting that HL is a multidimensional concept. Having knowledge and understanding health information does not necessarily mean changing lifestyle and therapeutic adherence, since it depends on personal, family and environmental factors⁷. This has also been observed in other studies which show high HL levels, but low therapeutic adherence^29-30.

Evidence from a study conducted in Iran based on the the HBM with 228 oil industry workers on the prevention of CVD showed a low level of susceptibility and perceived severity in relation to the disease. The participants did not recognize CVD as a potentially fatal disease, which resulted in unhealthy attitudes and habits¹⁰.

The participants demonstrated a lack of knowledge about the illness process and difficulty in understanding the severity of the disease. The perceived severity of the disease was intrinsically associated with the fact of having or not a comorbidity (SAH or DM), meaning another relevant aspect in relation to the “Risk Factors”, which presented lower averages even after the intervention. However, the participants knew how to identify the factors which cause illness, such as stress, smoking and sedentary lifestyle, but minimized their importance in the illness.

In addition, an experimental study of educational intervention based on the HBM in Iran over five weeks demonstrated that the intervention was effective, despite its short duration. An improvement in the scores for risk factors, psychological and behavioral factors for CVD was observed, both in terms of severity and in the identification of the benefits and barriers present in implementing prevention measures and behavior change⁹, similar to the present study.

A significant increase in HL and knowledge about CAD was observed during the educational intervention according to the participants’ statements about the benefits perceived with the treatment, change of habits and physical activities, compared to other knowledge areas related to CAD.

Although the knowledge area about “Risk Factors” regarding the CADE-Q SV had a lower score even after the intervention, the participants reported changes in lifestyle. Identification of facilitators and barriers (social, cultural and epidemiological) in developing and implementing educational strategies focused on the individual’s reality with planning and redefining new care methods³⁰ is essential for agreeing to goals and therapeutic adherence.

Participants perceived that surgery alone was not effective in restoring health to the level prior to the heart attack, and therefore their levels of hope decreased. Although the study did not find a statistically significant relationship between the psychosocial risk domain, participants reported feelings of sadness, incapacity and increased emotional lability after the intervention related to the absence of work activity, in some cases. Such perceptions may represent a barrier to adherence and to changing lifestyle habits. Other studies can be conducted to analyze psychosocial risk, which may allow its significant demonstration in a larger sample of patients with the same characteristics.

As for study limitations, the first noted is in relation to the sample size resulting from administrative problems (reduction in surgeries due to the bankruptcy of the hospital institution), and the Covid-19 pandemic (reduction in the number of surgeries). Also, regarding the complexity of the sample participants (death during surgery) and change of address after hospital discharge.

CONCLUSION

This study demonstrated that the educational intervention had an effect on the sample studied, improving HL and knowledge about CAD, and emphasizes the need to develop skills aimed at self-management of care, especially in the first months of CABG.

The educational intervention based on the HBM and case management improved knowledge about CAD and HL, helped participants understand their perception of the disease and their adherence to a healthy lifestyle.

Integrating the data enabled us to identify that the increase in health literacy and knowledge about the disease does not occur automatically, but is conditioned by the subjective understanding of the disease process and the barriers perceived in daily life. This understanding was only possible through articulation between the quantitative results and the participants’ narratives, revealing emotional, social and contextual dimensions that would not be captured exclusively by standardized instruments.

Furthermore, this integrated approach made it possible to recognize modifying factors related to susceptibility and perceived severity of the disease, which, when understood on an individual level, can favor therapeutic adherence and contribute to rehabilitation. However, low health literacy levels still represent a significant obstacle, interfering with the ability to recognize the benefits of treatment and modify behaviors associated with risk factors and psychosocial risk.

In view of this, the use of tools to measure HL levels and knowledge about the disease based on understanding the health beliefs which permeate in people can help in developing potentially effective care strategies. Therefore, when case management performed by the nurse during the nursing consultation is planned and individualized, it can strengthen HL, improve self-care and help people become managers of their own care.

ACKNOWLEDGMENT

We are grateful to the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) for the 1C e D productivity scholarship.

REFERENCES

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NOTES

• ORIGIN OF THE ARTICLE
  Extracted from the thesis - O enfermeiro e a Literacia em Saúde na autogestão do cuidado de pessoas pós-cirurgia cardíaca: estudo de métodos mistos, presented to the Postgraduate Program in Nursing of the Universidade Federal do Paraná in 2023.
• APPROVAL OF ETHICS COMMITTEE IN RESEARCH
  Approved by the Ethics Committee in Research of the Universidade Estadual do Oeste do Paraná (Unioeste), opinion no. 5.048.079/2021, Certificate of Presentation for Ethical Assessment (CAAE) no. 37564720.0,0000.0107.
• TRANSLATED BY
  Christopher J. Quinn.
• DATA AVAILABILITY
  The data supporting the findings of this study are available in the doctoral thesis entitled The nurse and health literacy in the self-management of care for people after cardiac surgery: a mixed-methods study, deposited in the Digital Repository of the Federal University of Paraná (UFPR), available at: https://acervodigital.ufpr.br/handle/1884/88566.

Edited by

• EDITORS
  Associated Editors: Glilciane Morceli, Ana Izabel Jatobá de Souza.
  Editor-in-chief: Elisiane Lorenzini.

Data availability

The data supporting the findings of this study are available in the doctoral thesis entitled The nurse and health literacy in the self-management of care for people after cardiac surgery: a mixed-methods study, deposited in the Digital Repository of the Federal University of Paraná (UFPR), available at: https://acervodigital.ufpr.br/handle/1884/88566.

Publication Dates

• Publication in this collection
  06 Oct 2025
• Date of issue
  2025

History

• Received
  20 Dec 2024
• Accepted
  29 Apr 2025