Extended Abstract

Introduction
Acute coronary syndrome (ACS) occurs following coronary artery thrombosis and embolism, resulting in a sudden decrease in blood flow and oxygen supply to the heart muscle. ACS accounts for approximately 60% of deaths in individuals over 65 years of age. In Iran, about 30% of deaths occur annually due to this phenomenon. The persistence of this disease is associated with numerous complications and life-threatening risks, such as cardiac arrhythmias, and severe metabolic and electrophysiological changes.
Non-adherence to treatment regimens is a significant factor contributing to the persistence of cardiovascular diseases, leading to increased disability, high mortality rates, and rising healthcare costs. Adherence to the treatment regimen in patients with heart disease involves adherence to both drug and non-drug therapies. One of the most important reasons for treatment failure is poor adherence, and evidence suggests that patient education and follow-up after discharge play a crucial role in patient’s rehabilitation and adherence to treatment. Developing an educational program tailored to the needs, experiences, and interests of patients remains a significant challenge for healthcare workers. Mobile phones, like other communication technologies, have found their way into education and healthcare, and have been introduced as mobile phone-based education. Given the varying and sometimes contradictory evidence, or single-group designs, regarding the effectiveness of telephone services as an educational and follow-up method in diseases and studies based on the effect of education without the delivery of educational booklets, as well as the lack of studies using the method of education and follow-up with short message services (SMSs), this study was conducted to compare the effect of two educational methods with and without SMS reminder on adherence to the treatment regimen in patients with ACS.
Methods
This clinical trial was conducted on 111 patients with ACS, divided into three 37-people groups: A control group (receiving routine education), the first intervention group (receiving education and a booklet), and the second intervention group (receiving education, a booklet, and SMS reminders).
Inclusion criteria included a diagnosis of ACS by a cardiologist, age range of 25-75 years, ability to speak and understand Persian, ability to read and write, ability to use a mobile phone, having an active mobile phone and SMS, an adherence to treatment score of less than 50%, and no sensory or intellectual impairment.
The intervention consisted of adherence to treatment-based education and reminder SMS. The first intervention group received pre-discharge education along with a booklet, while the second intervention group, in addition to education along with a booklet, received SMS reminder for two months after discharge. The control group only received routine education of the ward before discharge.
A demographic information checklist and the Treatment Adherence Perception Questionnaire (TAPQ), psychometrically validated by Kamrani et al. with confirmed reliability and validity, were used. This questionnaire includes three domains: Dietary regimen, medication regimen, and exercise and activity.
For the first intervention group, pre-discharge adherence to treatment-based education was provided individually and face-to-face by the researcher. The education setting was the ward and patient hospitalization room, and the education time was in the morning or afternoon shift in a one-hour session. In addition to the routine pre-discharge education, patients and their companions received adherence to treatment education based on an educational booklet in three dietary regimen, medication regimen, and exercise and activity, and the educational booklet was finally delivered to the patients and their companions by the researcher.
The second intervention group, in addition to receiving adherence to treatment-based education similar to the first intervention group, also received SMS reminders for two months after discharge. During the face-to-face education session with the patients, the researcher coordinated with the patients about sending SMSs to follow up and continue education after discharge, as well as the time and frequency of sending SMSs. One day after discharge on odd days of the week at 9 AM for 8 weeks, a reminder SMS about adherence to treatment (a total of 24 SMS reminders) was sent by the researcher. The content of each reminder SMS was based on the booklet educated during hospitalization. To ensure that the SMSs were received by the patients or their companions, the researcher’s mobile delivery section was activated.
The TAPQ was completed in two stages: Once at the beginning of the study in the ward as face-to-face by the researcher, and the second time two months after discharge, as face-to-face at home or at the heart clinic by the researcher.
Results
The mean scores of adherence to dietary regimen in both the first intervention group (education and booklet delivery) and the second intervention group (education, booklet delivery, and reminder SMS) showed a statistically significant increase after the intervention (P<0.001).
The mean score of adherence to dietary regimen in the second intervention group significantly increased by a 31.86 units after the intervention (P<0.001). After the educational intervention, the level of adherence to dietary regimen in the second intervention group was 5 times higher than the first intervention group and 6 times higher than the control group.
The mean score of adherence to medication regimen in the education and reminder SMS group increased significantly by approximately 6.45 units after the intervention (P<0.001). Also, in the control group, the mean score of adherence to medication regimen increased by 1.51 units at the beginning and at the end (P<0.001).
The mean score of adherence to exercise and physical activity in patients in the education and reminder SMS group increased by approximately 11.10 units after the intervention (P<0.001).
In all three groups, adherence to exercise and physical activity increased after the educational intervention; however, this increase was approximately 4 times higher in the second intervention group compared to the first intervention group and the control group, which is clinically significant.
Before the intervention, there were no statistically significant differences between the three groups in the areas of usual food consumption, medication regimen, and exercise and physical activity; however, the frequency of food consumption was significantly different. After the intervention, there were statistically significant differences between the three groups in terms of usual food consumption, medication regimen, and exercise and physical activity (P<0.001).
Conclusion
Based on the results of this study, the educational intervention had a significant statistical effect on adherence to treatment of ACS patients in both the intervention group receiving education (the first intervention group) and the group receiving education combined with reminder SMS (the second intervention group). This increase in adherence to treatment was greater in patients in the second intervention group compared to the first intervention group, indicating the effect of the educational intervention combined with reminder SMS. This increase was significantly greater in all three domains of adherence to treatment, namely dietary regimen, medication regimen, and physical activity, in the education/reminder SMS group compared to the education group and the control group.
It is noteworthy that in the present study, both before and after the intervention, there were significant differences in the results between the different intervention and control groups, and there were also significant differences between the intervention and control groups after the intervention. These results suggest that over time, the diversity and types of mobile phones and their efficiency and capabilities have led to increased use and attractiveness, allowing patients to receive messages better and more easily. Perhaps this impact is partly due to the increased use of these devices by individuals.
Ethical Statement
This study was approved by the Research Ethics Committees of Golestan University of Medical Sciences (IR.GOUMS.REC.1397.102) and the Iranian Registry of Clinical Trials (IRCT20180911041002N1).
Funding
This article has been extracted from the master’s thesis of Ms. Zoleikha Ghoreishi, a graduate of the School of Nursing and Midwifery, Golestan University of Medical Sciences, in the field of Critical Care Nursing and is also the result of an approved research project (No. 179356) at the Nursing Research Center, Deputy of Research and Technology.
Conflicts of Interest
No conflict of interest.
Acknowledgement
We would like to thank the Nursing Research Center of Golestan University of Medical Sciences for their financial support. We also sincerely appreciate all nurses, patients, and their families, as well as the staff of the hospitals investigated in the study. We would like to thank Dr. Amrollah Sharifi, a nutritionist, and Dr. Aref Salehi, a cardiologist, for their help with the educational content.

Key message: The use of educational and providing a booklet, along with reminder SMS, for ACS patients discharged from the hospital significantly increases adherence to treatment, with higher adherence observed in the intervention group receiving reminder SMS.