ABSTRACT
Background and Aims
Coronary artery disease is one of the chronic diseases that contribute to a significant number of deaths worldwide. The prevention and management of coronary artery diseases are greatly influenced by the lifestyle of patients suffering from these disorders. On the contrary, as the personality types of individuals have the potential to influence lifestyle modifications, this study was conducted to ascertain the relationship between type D personality characteristics and self‐efficacy in patients with coronary artery disease with type A personality.
Methods
This Cross‐sectional Descriptive Study was conducted among 150 Patients diagnosed with coronary artery disease with type A personality. The data collection tools Included items on demographics, Friedman‐Rosenman Personality types questionnaire, Persian version of the type D personality scale and self‐efficacy scale. Data were analyzed using descriptive and inferential statistics (multiple linear regression analysis and Spearman Correlational Test). The data analysis was conducted using the 16th edition of the Statistical Product and Service Solutions (SPSS16).
Results
Most of participants were male (57.4%), and the average age was 59.12 ± 11.83 years. The analysis showed lower self‐efficacy significantly correlates with type D personality characteristics (p < 0.001, r = −0.367). According to the linear regression test, if other variables are held constant, for a one‐unit increase in the type D personality characteristics score, the self‐efficacy score decreases by 0.293 (R 2 = 0.19, p < 0.001).
Conclusion
It is crucial to offer training that focuses on boosting self‐efficacy in individuals diagnosed with coronary artery disease who exhibit traits of type A and type D personalities.
Keywords: cardiovascular diseases, coronary artery disease, self‐efficacy, type D personality characteristics
1. Introduction
Along with the advancement of medical science and the control of infectious diseases, chronic and debilitating diseases have been identified as factors affecting people's health and longevity [1]. Cardiovascular diseases are among the chronic diseases that account for a large proportion of deaths worldwide and millions of people die every year from these diseases [2]. According to statistics from the World Health Organization, chronic diseases are responsible for 70% of deaths. Among these diseases, coronary artery disease ranks first at 21% and is the most important cause of death [3]. The World Health Organization has predicted that one out of every three deaths will be related to coronary artery disease by 2030 if no action is taken to improve the health of coronary artery patients [4]. Factors such as personal experiences, behavioral habits, lifestyle, personality type, social isolation, lack of social support, and life stresses can play a role as risk factors for cardiovascular disease [1].
One of the risk factors affecting the prevalence of cardiovascular diseases is personality type, which refers to a set of dynamic and organized characteristics that uniquely affect one's cognitions, emotions, motivations, and behaviors in different situations [5]. Epidemiological research has identified a strong relationship between type A personality and the incidence of cardiovascular disease [6]. Type A personality traits are characterized by being ambitious, rigidly organized, highly status‐conscious, and impatient [7]. People with a type D personality are more likely to express negative emotions (discomfort, irritability, and sadness) and do not share their emotions and thoughts with others due to fear of opposition [1]. In addition, personality types are a very important psychological factor that can improve lifestyle and be effective in the health of patients with coronary artery disease [8]. Kuper and Denollet's (2018) study showed that type D personality is associated with an increase in the burden of death and prevalence of coronary artery diseases [9]. Moreover, a study by Manoj et al. (2020) showed that there is a positive and significant relationship between type D personality and occurrence of myocardial infarction (MI) [10]. In addition, previous studies have shown that type D personality is related to a lower quality of life and mortality among patients with and without heart diseases [11, 12, 13]. People with heart failure and type D personality are more likely to report poor health‐related quality of life, more depressive symptoms, and higher cardiac mortality than patients with heart failure without type D personality [14, 15]. Recent studies have shown that health behaviors depend not only on the social environment but also on human personality characteristics. Therefore, personality patterns can be influential in the occurrence of health behaviors related to a person's health [16].
One of the factors affecting the management and control of health behaviors in patients with coronary artery disease is self‐efficacy [17]. According to Bandura's theory which was later renamed social cognitive theory (SCT), self‐efficacy includes a person's trust and confidence in being able to perform self‐care tasks optimally, in such a way as to achieve desired results [18, 19]; In this way, improving self‐efficacy can lead to increasing motivation in patients to perform self‐care behaviors [20, 21]. Feelings of self‐efficacy can affect all aspects of life. People with higher self‐efficacy believe that they can effectively control their life events. Therefore, people with better self‐efficacy often show better participation in health‐enhancing behaviors and a better understanding of health‐related behaviors [22, 23]. In addition, it provides self‐efficacy for health care, in which the patient plays a central role in improving the level of health, disease prevention, and successful control of his disease [24]. Higher self‐efficacy is associated with better disease management, higher mental health, and better quality of life [25, 26, 27]. However, poor self‐efficacy reduces emotional balance, the ability to deal with stressful factors, and physical and mental health by reducing self‐care [28, 29]. Therefore, identifying the factors affecting self‐efficacy is important.
We know that higher self‐efficacy is associated with positive health outcomes in coronary patients. On the other hand, the personality type A is a risk factor for coronary artery diseases due to its role in lifestyle modification [5]. By knowing the possible relationship between type D personality characteristics and the self‐efficacy of coronary artery patients with type A personality, we can move towards improving the self‐efficacy of the above patients by implementing targeted interventions to correct the weak points of personality types. Therefore, first it is necessary to determine the probable relationship between type D personality characteristics and self‐efficacy in coronary artery disease patients with type A personality. Secondly, we aimed to determine the predictive factors of self‐efficacy in coronary artery disease patients with type A personality.
2. Methods
2.1. Study Design and Setting
This Cross‐sectional Descriptive study was conducted among patients diagnosed with coronary artery disease and admitted to the cardiac departments of Valiasr Hospital and Razi Hospital affiliated with Birjand University of Medical Sciences, Iran.
2.2. Participants
Patients expressing willingness to participate in the research and currently hospitalized in the cardiac departments of Valiasr and Razi hospitals were selected using convenience sampling. Inclusion criteria comprised individuals who: (1) provided informed consent for study participation; (2) have personality type A; (3) received a definitive diagnosis of coronary artery disease confirmed by a qualified cardiologist; and (4) demonstrated capability in independently managing aspects of self‐care, specifically in areas such as dietary management, activity patterns, and drug therapy. Patients who were excluded from the study were those: (1) who demonstrated evident cognitive impairments impeding comprehension of the informed consent procedure or rendering them unable to respond to questionnaires; and (2) who had advanced disease stages affecting self‐care, such as kidney diseases or advanced cancer. In line with a descriptive correlational study, the initial sample size was determined to be 130 individuals using the formula: n = (zs/d)2 [30]. However, with 15% attrition rate the sample size was increased to 150.
2.3. Scales
The data collection tools included demographic, Rosenman and Friedman questionnaire, Persian version of the type D personality scale and self‐efficacy questionnaires. The demographic questionnaire included information such as age, gender, job, place of residence, marital status, income, disease duration, education, current smoking, and family history.
The Rosenman and Friedman questionnaire was used to identify the A, B, and C personality types. This questionnaire has 25 questions, and the subject answers each question as yes or no. A score greater than 13 indicates a tendency towards type A personality, and less than 13 indicates a tendency towards type B personality. If a person scores exactly 13, he is considered personality type C. In Shakerinia et al.'s (2010) study, the reliability and validity of the questionnaire were investigated, and Cronbach's α coefficient was calculated as 0.89 [31].
The Persian version of the type D personality scale was used to determine the type D personality characteristics. This Scale includes two subscales, Negative Affectivity (NA) and Social Inhibition (SI). Each of these contains 7 items. These items are answered on a 5‐point Likert scale from 0 (false) to 4 (true) giving maximum scores of 28 apiece for NA and SI. A predetermined cut‐off of ≥ 10 on both subscales determines those with a type D personality. In the study by Bagherian (2011), the test–retest reliability of the NA and the SI subscales were reported 0.86 and 0.77, respectively [32].
To assess self‐efficacy in patients with coronary artery disease, a self‐efficacy questionnaire adapted from the type 2 Diabetes Self‐Efficacy Questionnaire was used [33]. This 10‐item questionnaire asked patients how confident they are that they can perform certain actions or tasks. The items of this questionnaire were graded on a 5‐point Likert scale (range 1–5). Higher scores indicated better self‐efficacy in the study by Baljani et al. (2012), the validity and reliability of this questionnaire were acceptable [22].
2.4. Data Analysis
We used the Rosenman–Friedman questionnaire to identify patients suffering from coronary disease with type A personality. After identifying the desired patients, these patients completed The Persian version of the type D personality scale. Descriptive statistics were employed to analyze the demographic variables (gender, education, marital status, job, income, age, disease duration). The normality of the data distribution was assessed using the Kolmogorov–Smirnov test. The Spearman Correlational Test assessed the correlation between self‐efficacy and type D personality characteristics and Its Subscales. Multiple linear regression (Enter Method) was used to determine predictor variables of self‐efficacy. The data analysis was conducted using the sixteenth edition of SPSS [34]. Collinearity in Multiple linear regression was controlled using variance inflation factor (VIF) and tolerance, ensuring that all variables had a tolerance greater than 0.1 or VIF less than 10. All tests were two‐tailed, and a significance level of 0.05 was considered for all the tests mentioned above.
2.5. Ethical Approval
This study followed the principles outlined in the Declaration of Helsinki, which prioritizes the safety and well‐being of participants. Participants were allowed to withdraw from the study at any point, and their participation was entirely voluntary. Additionally, measures were taken to ensure the confidentiality of their personal information. The confidentiality of information was preserved through coding, rendering the individuals involved unidentifiable. Informed consent was obtained from all participants. Furthermore, the authors of this study aimed to diligently follow the (Committee on Publication Ethics) COPE guidelines while disseminating their findings. The Ethics Committee of Birjand University of Medical Sciences authorized the current study under the code (IR.BUMS. REC.1395.243).
3. Results
3.1. Patients Characteristics
In this study, 150 patients with coronary artery disease hospitalized in the heart departments of Valiasr Hospital and Razi Hospital in Birjand City in 2019 were selected as the research unit. Most participants were male (57.4%), with undergraduate and diploma education (44%), married (93.3%), and city dwellers (60%). More information is given in Table 1. The average age of the studied patients was 59.12 ± 11.83 years and that of the disease duration were 4.24 ± 5.25 years. The other personal characteristics and patient information are shown in Table 2.
Table 1.
Sample characteristics (N = 150).
| Variable | Frequency | Percent (%) | |
|---|---|---|---|
| Gender | Female | 64 | 42.6 |
| Male | 86 | 57.4 | |
| Education | Illiterate | 56 | 37.4 |
| Undergraduate And Diploma | 66 | 44 | |
| Bachelor | 26 | 17.3 | |
| Master's Degree and Above | 2 | 1.3 | |
| Marital status | Single | 1 | 0.7 |
| Married | 140 | 93.3 | |
| Divorced | 1 | 0.7 | |
| Widow | 8 | 5.3 | |
| Job | Unemployed | 9 | 6 |
| Manual Worker | 11 | 7.3 | |
| Employee | 23 | 15.4 | |
| Free | 30 | 20 | |
| Retired | 26 | 17.1 | |
| Housewife | 42 | 28 | |
| Other | 9 | 6 | |
| Income | Less Than enough | 73 | 48.6 |
| Sufficiently | 74 | 49.4 | |
| More Than enough | 3 | 2 | |
| Place of residence | Village | 60 | 40 |
| City | 90 | 60 | |
| Type D personality characteristics | ≥ 10a | 86 | 57.3 |
| < 10b | 64 | 42.7 | |
Greater than or equal to 10 in both dimensions of the scale.
Less than 10 in both dimensions of the scale.
Table 2.
Sample characteristics (N = 150).
| Variable | Mean ± SD | Min | Max |
|---|---|---|---|
| Self‐Efficacy | 39.61 ± 4.33 | 27 | 47 |
| Age | 59.12 ± 11.83 | 24 | 86 |
| Disease Duration | 4.24 ± 5.25 | 1 | 30 |
Abbreviation: SD, standard deviation.
3.2. Main Results
The mean and standard deviation of the self‐efficacy score of the studied patients was 39.61 ± 4.33. Using the Rosenman‐Friedman questionnaire, coronary artery patients with type A personality were identified. Using type D personality scale, patients were divided into two groups. patients with type A personality and characteristics of type D personality (57.3%) and patients with type A personality without characteristics of type D personality (42.7%). The Mann–Whitney U test was used to compare self‐efficacy in these two groups. The results of this test showed that self‐efficacy is weaker in patients with type A personality and with characteristics of type D personality (p < 0.001) (Table 3).
Table 3.
The relationship between type D personality characteristics and self‐efficacy in coronary artery disease patients with type A personality.
| Self‐Efficacy | Median (IQR) | p‐value | |
|---|---|---|---|
| Type D personality characteristics | < 10 | 42 (37–44) | < 0.001a |
| ≥ 10 | 38 (36–42) | ||
Abbreviation: IQR, interquartile range.
Mann–Whitney U Test.
The results of the Spearman correlation test revealed a significant negative correlation between Type D personality characteristics, as well as its subscales and self‐efficacy (p = 0.039, p < 0.001 and p < 0.001, respectively) (see Table 4). In other words, increasing the score of type D personality characteristics and its dimensions is Correlated with a decrease in self‐efficacy.
Table 4.
Correlation between type D personality characteristics, and its subscales with self‐efficacy in coronary artery disease patients with type A personality.
| Study Variable | Self‐efficacy | ||
|---|---|---|---|
| p‐value | r | ||
| Type D personality characteristics | Social inhibition subscale | 0.039 | −0.169 |
| Negative emotions subscale | < 0.001 | −0.349 | |
| Total | < 0.001 | −0.367 | |
The following results were obtained after establishing the validity of the assumptions underpinning multiple linear regression. While keeping other variables constant, a one‐unit increase in the score of the Type D personality characteristics, self‐efficacy decreases by 0.293 points. Furthermore, the results indicate that when other variables are held constant, the self‐efficacy score for male patients is 1.724 higher compared to that of female patients and 2.473 for nontobacco users compared to that of tobacco users. Notably, among these variables, smoking demonstrated the highest predictability in influencing patients' self‐efficacy (see Table 5).
Table 5.
Regression analyses of self‐efficacy predictors.
| Predictive variables | B | SE | β | Confidence interval for B | p‐value | Collinearity statistics | |||
|---|---|---|---|---|---|---|---|---|---|
| Lower bound | Upper bound | Tolerance | VIF | ||||||
| Type D personality characteristics | −0.293 | 0.067 | −0.329 | −0.426 | −0.159 | < 0.001 | 0.977 | 1.024 | |
| Smoking | Yes | −2.473 | 0.729 | −0.266 | −3.914 | −1.031 | < 0.001 | 0.911 | 1.097 |
| No | |||||||||
| Family History | Yes | −0.113 | 0.659 | −0.013 | −1.416 | 1.191 | 0.865 | 0.961 | 1.041 |
| No | |||||||||
| Gender | Female | ||||||||
| Male | 1.724 | 0.692 | 0.198 | 0.357 | 3.091 | 0.014 | 0.891 | 1.122 | |
Note: Model Summary: R = 0.44; R 2 = 0.19; Adjust R 2 = 0.17; Durbin‐Watson Statistics = 1.96. Bold values are statistically significant.
Abbreviations: SE, standard error; VIF, variance inflation factor.
4. Discussion
The results of this study show that self‐efficacy is weaker in patients with type A personality and with characteristics of type D personality. Spearman's correlation test confirmed this result and showed that there is a significant negative correlation between Type D personality characteristics and self‐efficacy. Wiencierz et al.'s (2017) study revealed that individuals with a D personality type exhibited a significantly lower self‐efficacy score compared to those without a D personality type (p < 0.01 and r = −0.41). There was also a significant negative relationship between the subscales of type D personality and self‐efficacy (negative emotions r = −0.43, p < 0.01, and social inhibition r = ‐0.28, p < 0.01) [35]. In Wu et al.'s (2015) study, the results indicate that heart failure patients with the D personality type showed a lower level of self‐efficacy than patients without the D personality type [1]. Cao et al. (2016) investigated the relationship between type D personality and self‐efficacy in patients with heart failure, and the results showed that type D personality is related to low self‐efficacy, even if demographic and clinical variables are constant [36]. In addition, Wongsuriyanan et al.'s (2020) study showed a significant negative relationship between type D personality and medication self‐efficacy in patients with hypertension (p < 0.01 and r = −0.233) [37]. The results of the present study are consistent with those of Molloy et al. (2012) and Shao et al. (2017) [38, 39]. patients with Type D personalities usually have many negative emotions, such as anger, irritability, or anxiety, and suppress their emotions. Therefore, we can assume that self‐efficacy is also affected by these characteristics.
The results of the regression model study showed that gender is a good predictor for self‐efficacy and men showed better self‐efficacy. Furthermore, type D personality characteristics and smoking were key factors in predicting self‐efficacy. The results of the study by Shrestha et al. (2020) showed that age (β = −0.21, p < 0.001) can be effective in predicting the self‐efficacy of cardiac patients; however, sex (β = ‐1.35, p = 0.33) and the use of tobacco such as cigarettes (β = 3.81, p = 0.05) cannot act as predictive factors [40]. On the other hand, Nemer's (2022) study showed that the level of education, social support, and marital status can affect the prediction of self‐efficacy status [41]. After analyzing the findings from earlier research alongside the results mentioned above, it is evident that self‐efficacy is influenced by numerous factors, and further research is necessary to arrive at a conclusive assessment of its predictive capability. We know that self‐efficacy is associated with positive health outcomes such as higher psychological well‐being, improved quality of life, better management of health behaviors, and adoption of healthy lifestyles related to cardiovascular diseases, although low levels of self‐efficacy are closely related to poor self‐care [17]. Since patients with personality types D characteristics are prone to low self‐efficacy, it is necessary to pay more attention to improving self‐efficacy in these patients.
4.1. Limitations and Strengths
The present study is one of the few studies investigating the relationship between personality types D characteristics and self‐efficacy in patients with coronary artery disease. This study was conducted in a special geographical area and a limited population, so it is suggested that these variables be investigated separately for all types of cardiac disorders in other geographical areas. In addition, caution should be taken in generalizing the results of the study to other populations in different regions. Additionally, patients with coronary artery disease typically experience chest pain and a sense of impending death. The stress and anxiety felt by these patients could have led to difficulties in the data collection process. Therefore, patients' companions who had a close relationship with the individual were used to collect data. For future studies, it is suggested to use the standard self‐efficacy questionnaire of cardiac patients. In addition, measuring the relationship of other personality types with the self‐efficacy of patients with coronary artery disease is necessary.
5. Conclusion
There is a significant negative relationship between the characteristics of type D personality in patients with type A personality and the level of self‐efficacy. By knowing more about patients' personalities, self‐efficacy training can be adjusted according to the personality type of patients to increase the probability of compliance with these self‐efficacy instructions, which can play an essential role in Disease management.
Author Contributions
Mahnaz Bahrami: conceptualization, formal analysis. Shahnaz Ahrari: writing – review and editing. Arvin Mirshahi: data curation; writing – review and editing. Mobin Soleimanian Asl: writing – original draft. Mohammad Esmaeelzadeh: writing – original draft, writing – review anf editing; methodology; formal analysis.
Ethics Statement
This study has obtained approval from the Ethics Committee of Birjand University of Medical Sciences under the ethics code (IR.BUMS.REC.1395.243). Informed consent was obtained from all individual participants included in the study.
Conflicts of Interest
The authors declare no conflict of interest.
Transparency Statement
The lead author Mohammad Esmaeelzadeh affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
Acknowledgments
The researchers feel obliged to thank the colleagues of the Medical Information Center of Birjand University of Medical Sciences for their cooperation in data collection. It should be noted that this study did not receive any financial support.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.