The effect of a smartphone-based application on the self-efficacy of heart valve surgery patients and their family caregivers` burden: a randomized clinical trial

The prevalence of cardiovascular diseases (CVD) (comprising CHD, HF, stroke, and hypertension) in adults aged 20 years and older was determined to be 48.6% (127.9 million) in a 2023 statistical update; this prevalence increases with age in both males and females [1].

Cardiovascular diseases are one of the leading causes of death worldwide [2]. Every year, more than 17 million people die due to cardiovascular diseases [2]. In Iran, 45% of deaths are due to cardiovascular diseases, and it is considered to be the first cause of death among adults [3]. Meanwhile, heart valve diseases are of great importance due to their chronic and progressive nature. Heart valve surgery is considered the last line of treatment for this disease [3]. In Iran, 23.8% of heart surgeries are related to heart valve repair or replacement [4]. Breathing problems, heart palpitations and atrial fibrillation, sleep problems, bleeding, changes in daily activities, risk of thromboembolism, endocarditis, and valve dysfunction are among the most critical complications of post valve surgery [5]. These complications weaken the quality of life of cardiac patients and require high self-efficacy to manage them [6, 7].

Self-efficacy is a broad psychosocial concept that is usually used in connection with the management of chronic diseases. It also plays a vital role in health-related behaviours and adherence to preventive programs [8]. Self-efficacy increases the patient's motivation, self-care, and quality of life. Since self-efficacy improves the patient's quality of life, it has attracted the attention of researchers and specialists in various fields [9]. Improving self-efficacy can help maintain health and well-being, increase patient compatibility, and reduce disability and treatment costs [8].

On the other hand, family is one of the important sources of support for patients undergoing heart valve replacement after returning home and going through post-surgery critical conditions [10]. Family caregivers play an important role in patients' physical and psychological support. They are considered one of the main pillars of the care system and contribute the greatest to patient care [11]. Managing chronic diseases at home is a complex issue that requires multidimensional care and services. Caring for chronic patients is associated with a high psychological burden for caregivers [12]. The term "care burden" is generally used to describe different aspects of stress and pressure that result from an imbalance between care demands and access to resources to meet them [13]. In this situation, family caregivers need rehabilitation nursing to help them meet the demands of the patients they care for [14]. Therefore, in line with holistic care, rehabilitation care is provided on a family-centred basis to the patient's family and the patient himself, considering the family's important role in the patient's rehabilitation [15].

Education is one of the most important methods to reduce the care burden [13], improve self-efficacy [16]. Therefore, providing various educational interventions emphasizing patient needs increases the patients' knowledge and helps them adapt to post-surgery conditions. Teaching communication and problem-solving skills to increase patients' ability to take care of themselves can also help reduce complications related to surgery and improve the knowledge of family caregivers, which is also considered a necessity [16]. Appropriate training and teaching approaches compatible with the patient's condition are also among the important interventions [15]. The World Health Organization defines digital health as " digital health is the field of knowledge and practice associated with the development and use of digital technologies to improve health." [17]. In recent years, the increasing use of smartphones and other technological tools and applications shows that health education through smartphones will be a significant force in health care [18].

Recently, the number of studies in this area has been increasing. The results of one study showed that a mobile-based health intervention led to significant improvements in self-care of patients with heart failure [19]. A systematic review and meta-analysis also found that multiple behaviors such as self-managements and cardiovascular risk factors can be modified in the short-term using mobile apps. The authors of the mentioned study stated that evidence for effectiveness requires larger, controlled studies with longer durations [20]. Another study also evaluated the impact of a self-management mobile phone application on patient adherence to hypertension treatment. The study showed that the application can be used as a successful tool for self-management of hypertension in patients attending public hospitals in developing countries [21]. Although mobile phone-based studies are frequently conducted in other patients with CVD, they have had very limited application in patients undergoing valve surgery.

Given the significance of readily available, ongoing education for cardiovascular patients and the proliferation of smartphone technology, and in the absence of prior research on designing and evaluating a smartphone application for educating patients undergoing heart valve surgery, we conducted a study aimed to evaluate the effects of a smartphone-based educational application on the caregiving burden of family members and the self-efficacy of patients who haveundergone heart valve surgery.

This study is reported based on the Consolidated Standards of Reporting Randomised Controlled Trials (RCTs) of Social and Psychological Interventions (CONSORT-SPI) 2018 [22].

The results showed that the self-efficacy of patients undergoing heart valve surgery in the two intervention and control groups was not significantly different from each other before the intervention, but after the intervention, the self-efficacy of patients in the intervention group had significantly increased. Comparing the self-efficacy scores of patients before and after the intervention in the intervention group showed a significant difference between the pre-test and post-test scores. But in the control group, this difference was not significant.

In this regard, the research of Elsayed et al. (2024) suggested a deficiency in self-efficacy within the cardiac surgery patient population [28]. Dawa et al. [29] study indicated a heightened risk of burden among caregivers due to their responsibilities. Furthermore, the study’s findings indicated a high prevalence of caregiving burden among post-cardiac surgery patients [29]. The findings of a study conducted in 2019 by Bjørnnes et al. demonstrated the willingness of informal caregivers to assist in the postoperative care of their patients after cardiac surgery. Nevertheless, caregivers experience insecurity and a sense of being overwhelmed due to insufficient and unclear discharge instructions and inadequate follow-up support in the early post-discharge period at home [30].

Mobile devices are currently one of the most widely used technologies in the medical industry. The use of new educational methods such as smartphones can be effective in controlling diseases and their complications, especially in the elderly [31]. A comparative study conducted in 2016 by Voutilainen et al. demonstrated that e-learning achieved higher scores than conventional teaching methods [32]. In addition, research published in 2021 by Chen et al. suggested that mobile learning can enhance clinical nursing education [33]. Similar results were observed regarding the effectiveness of mobile phone-based interventions in improving self-efficacy in patients with thalassemia and gestational diabetes, such that these interventions were significantly associated with improving self-efficacy in this group of patients [34, 35]. Cai et al.`s study (2022) showed a significant increase in the physical activity, exercise self-efficacy and aerobic capacity of participants. Their study also showed a significant increase in the adherence to rehabilitation programs in the intervention group compared to the control group [36]. Ebrahimi et al. in their study showed that after the intervention, participants` self-efficacy improved in all dimensions, including personal responsibility for health, physical activity, nutritional behaviors, mental and spiritual growth, interpersonal relationships, and stress control [37]. The results of Cho and Lee`s (2021) study also showed that, using the smartphone application strategy was an effective way to promote self-efficacy and safe behaviors in patients attending outpatient clinics [38]. By conducting a single-group study on the elderly, Seo announced that the intervention and use of smartphone App was significantly effective in improving the quality of life, self-efficacy and psychological well-being of the elderly [39]. Aminuddin et al. [40] in a systematic review study conducted stated that, self-management interventions based on smartphones seem to have beneficial effects on self-efficacy, self-care behaviors and health-related outcomes of patients with type 2 diabetes. However, they argued that more research with appropriate design is needed to evaluate the effectiveness of smartphone-based self-care interventions for these patients [40]. From the researcher's point of view, the main reason for similar results of this study and other studies is the nature of education and the advantages of remote educational methods such as smartphone. In the current study, an up-to-date educational method was used that made it easy for individuals to access educational materials in a short period of time, eliminate the cost of transports and most importantly, not interfering with their life plan. There are many differences between the present study and the aforementioned studies, which is one of the strengths of this study. The present study’s participants were only patients undergoing a single type of cardiac surgery, a key differentiating factor. Also, in the present study, a smartphone educational App was designed by cooperations of the researchers, a cardiologist, a physiotherapist, several nurses (working in cardiac department, CCU and heart clinic), and five nursing professors who were experts in cardiac care. Since we could find no study to show that education through smartphone does not affect the self-efficacy of patients, it can be said that the hypothesis of present study is confirmed and the designed educational App for smartphones is effective in increasing the self-efficacy of patients while reducing care burden for their caregivers. In this regard, Bahadri et al. (2023) conducted a study with the aim of comparing the impact of face-to-face and smartphone-based rehabilitation trainings on the care burden of caregivers of patients with chronic obstructive pulmonary disease, and found that rehabilitation training with smartphone was more effective than face-to-care training [41]. Research by Alhawiti indicated that implementing tele-nursing in elderly care during the COVID-19 pandemic resulted in substantial improvements in the knowledge and performance of caregivers, concurrently diminishing their perceived caregiving burden [42]. González-Fraile et al. (2021) acknowledged that remotely delivered interventions including support, education or both, with or without information, may slightly reduce caregivers’ burden and improve their depression symptoms, but not compared to conventional treatment, waiting list or attention control. These interventions appear to make little or no difference in health-related quality of life [43]. Bani Ardalan et al. (1401) announced that intervention through training and telephone follow-up can be an effective and low-cost method in reducing the care burden of caregivers of elderly patients diagnosed with stroke [44]. Teaching the patients and their caregiver is one of the most basic responsibilities of nurses, which can have a significant impact on the disease prevention and treatment [45]. The researcher believes that the main reason for the alignment of these studies and acquisition of similar results is the nature of education and the benefits of remote educational method such as smartphone Apps. Providing accurate information through any means can have an impact on people's knowledge and attitude, and can help family caregivers of patients, while getting to know more about the disease, learn how to care for the patients and increase their self-efficacy and resilience. This can also clear up ambiguities in their minds and make difficult tasks easier for them. In the current study, an up-to-date method was used, which made it easy for the individual to access educational materials at any time and place. It also provided the caregivers with more free times to do their personal work, eliminate the cost of travel and, most importantly, not interfering with their life plans. Caregivers could study the materials at times when their patients did not require care. This education method also helped the caregivers to, in addition to gaining more skills in caring for patient, they will learn about how to direct patient towards greater independence.

One of the limitations of present study was the researcher's lack of control over the participants' study of educational materials, as they could only trust the participants' statements regarding the complete study of educational materials. Another limitation of this study was that it was conducted in a university-affiliated hospital. In this study, blinding was not applicable to educators, patients, and their caregivers. However, we tried to blind the analyst. Only one post-test was conducted in this study. Further follow-ups may be necessary to assess the impact of this educational intervention. Also, the current study was conducted on 18–65 years old literate people, so it can not be generalized to the whole society. The design and implementation of smartphone application in more advanced versions of devices required programming and online support, which was very costly for a senior student, so there was a limitation in designing a more advanced application.

The findings of present study, while confirming the research hypotheses, showed that the use of an educational program based on smartphone is effective in improving the self-efficacy of patients undergoing heart valve surgery, and also reducing the care burden of their family caregivers. This means that the use of this App, as one of the simple, cheap, applicable and effective nursing interventions, can be useful to improve self-efficacy of patients undergoing heart valve surgery, while reducing the care burden of their caregivers. Although in this study, self-care training was given to patients in all sessions, it seems that it was not enough, so it is better to use this method along with other new educational methods to achieve better results. Future research studies are suggested to include larger sample sizes and an educational intervention based on the use of comprehensive educational applications. Additionally, comparing different teaching methods helps us identify the most cost-effective form of education.