Abstract
Introduction
Illness perception (IP) significantly influences recovery and self-care in patients undergoing percutaneous coronary intervention (PCI), particularly in managing post-intervention complications. Although effective education is acknowledged as a way to enhance IP, using novel technologies such as mobile apps in this area has received less attention. This study aimed to evaluate the impact of education delivered through mobile apps on IP in patients undergoing PCI.
Materials and methods
A randomized controlled trial was conducted with 110 patients undergoing PCI at Shahid Rajaee Hospital in Karaj, Iran, in 2023. Patients were enrolled consecutively and assigned through block randomization to either an intervention group (n = 55) or a control group (n = 55). The intervention group received educational content derived from the five dimensions of Leventhal’s Common-Sense Model of Illness Perception through a mobile app. The control group received routine hospital care. Data were collected using a demographic characteristics form and the Illness Perception Questionnaire-Brief (IPQ-B) at baseline and four weeks after the intervention. The collected data were analyzed with SPSS version 21, using descriptive and inferential statistical tests. Statistical significance was established at P < 0.05.
Findings
The two groups were homogeneous regarding age, gender, body mass index, occupation, education level, smoking status, family history of coronary artery disease, presence of stents, underlying diseases, and balloon angioplasty (P < 0.05). The results indicated no significant differences between the experimental and control groups regarding IP mean score and the median scores of its dimensions (consequences, timeline, control, treatment, identity, concerns about the illness, emotional responses, and concerns about IP) at baseline (P > 0.05). A statistically significant improvement in IP score and its dimensions was observed in the intervention group compared to the control group (P < 0.05). More specifically, the experimental group displayed a significantly lower mean score of IP and median scores of its dimensions than the control group after the intervention (P = 0.001).
Conclusion
Mobile app-based education can enhance IP in patients undergoing PCI. Thus, these findings support the integration of mobile apps into routine nursing care to enhance IP in patients undergoing PCI.
Clinical trial registration
The study was registered with the Iranian Registry of Clinical Trials (IRCT) with the following details:
Registration code
IRCT20110912007529N27.
Registration date
January 23, 2023.
Keywords: Education, Mobile app, Illness perception, Percutaneous coronary intervention
Background
According to the World Health Organization, cardiovascular disease (CVD) is responsible for approximately 17.9 million deaths annually, representing 31% of all global deaths [1]. This renders CVD the leading cause of mortality on a global scale [2]. Coronary artery disease (CAD) accounts for 32.7% of CVD and is the leading cause of premature death globally [3, 4]. CAD management involves risk factor modification, lifestyle changes to slow disease progression, pharmacotherapy, and coronary revascularization to alleviate symptoms and improve prognosis [5].
Percutaneous coronary intervention (PCI) is typically recommended as the first-line treatment for CAD. It is a non-surgical procedure to reduce coronary artery stenosis or occlusion and improve blood flow to the ischemic tissue [6]. This intervention has exhibited significant efficacy in enhancing symptoms among patients with stable angina and improving the prognosis in acute coronary syndromes, particularly in the emergency treatment of patients with ST-elevation myocardial infarctions. The procedure is performed through a small intra-arterial sheath. A balloon is used to dilate the coronary stenosis, and a stent is placed to serve as a vascular scaffold [7].
PCI has grown in popularity thanks to its high success rate, low cost and risks, shorter hospital stays, and faster return to daily activities [8]. Importantly, however, this procedure has potential complications such as atherosclerosis and restenosis [9], although patients often ignore these possibilities. As a result, the majority of patients undergoing PCI are hesitant to change their lifestyles following treatment and tend to overlook their underlying disease [10].
One possible explanation for this behavior is a lack of an accurate perception of their illness. Illness perception (IP) includes both knowledge of the disease and personal beliefs about its treatment [11]. IP influences how patients perceive and respond to their illness. Leventhal’s Common-Sense Model of Illness Perception offers a solid foundation for investigating these perceptions. According to this model, patients actively seek to understand their illnesses through cognitive and emotional processes, which eventually influence their behaviors, emotional responses, and health outcomes [12]. Within this framework, patients process illness-related information and attempt to manage their condition by regulating their emotions and adopting coping strategies. A key component of the model is the cognitive representation of illness, which includes patients’ beliefs about the identity of the illness, its causes, duration, consequences, and controllability [13].
By delivering accurate, comprehensible, and interactive content, mobile app–based education can enhance this cognitive representation. The emotional representation of illness plays a key role in shaping psychological responses. Anxiety and fear associated with illness and treatment may reduce motivation and adherence to care [14]. Research has shown that health applications can help reduce emotional distress and improve patients’ experience by providing supportive messages and a platform for interaction with healthcare providers or peer patients [15]. Another important process in the model is coping and behavioral regulation. Continuous and interactive educational applications, such as guidance on post-PCI care, medication management, nutrition, and physical activity, can promote self-care and enhance adherence to medical recommendations [16]. These educational interventions help patients incorporate health-promoting behaviors into their daily lives, thereby preventing potential complications [17].
Muhammad et al. (2017) noted that PCI outcomes, particularly diagnostic outcomes, may be associated with patients’ IP after this interventional procedure [18]. Other studies have found that low IP is associated with decreased physical activity, nutritional difficulties, sleep disturbances, poor overall health, low medication adherence, increased stress and depression, and higher mortality rates among PCI patients [19–21]. Therefore, providing educational interventions to patients undergoing PCI is critical to improving their health beliefs, IP, and self-care behaviors. A clear perception of illness and self-efficacy are key components of self-care that contribute to improved patient outcomes [22]. PCI patients stay in hospitals for a relatively short period, which limits nurses’ opportunities to provide necessary information and education to patients and their families [23]. Therefore, it is vital to deliver these educational interventions in a time- and place-independent manner.
Recent digital advancements allow for the direct delivery of medical and health information, as well as disease management, to patients regardless of time or location. This is accomplished through software algorithms that run on advanced digital devices such as smartphones. Notably, smartphones have several features that make them useful learning tools, including audio capabilities, graphical displays, SMS functionality, downloadable apps, and mobile internet browsers [24]. The unique features of mobile applications—such as 24/7 accessibility, multimedia content, personalization, and instant feedback—have made them an effective tool for patient education [25]. These capabilities enhance patient engagement and interaction in the educational process, ultimately contributing to improved clinical outcomes [26].
Another advantage of mobile applications lies in their high degree of interactivity and content personalization. Patients can receive tailored educational materials based on their individual characteristics, health literacy, and disease condition. Unlike traditional brochures, which are static and generic, mobile apps can deliver multimedia content (videos, audio, images, infographics) and self-assessment quizzes, thereby strengthening concept comprehension and promoting active patient participation in the learning process [27]. From an economic perspective, app-based education is also more cost-effective. The use of mobile applications reduces the need for in-person training, printed brochures, and telephone follow-ups, thereby decreasing the workload for healthcare personnel and lowering the costs of educational delivery [28]. Mobile phone-based education has emerged as an effective method for modifying health behaviors [29]. Mobile apps enable users to access reliable scientific information anytime and anywhere. Therefore, numerous health-focused smartphone apps can aid patients in understanding their illnesses, thereby enhancing disease management, encouraging healthier behaviors, and supporting the attainment of therapeutic goals [30].
As a result, mobile apps may prove helpful in providing education to patients undergoing coronary artery interventions, thereby improving their understanding of the disease. Nurses can utilize evidence-based interventions to maximize the effectiveness of their care in light of two issues. Firstly, they play a crucial role in enhancing the quality of life and facilitating ongoing treatment and self-care for patients with cardiac conditions. Secondly, they have a higher frequency of interactions with patients compared to other healthcare professionals [31]. Given the importance of IP in the recovery process and self-care of patients undergoing PCI, as well as the growing role of innovative educational technologies, this study was conducted based on two hypotheses: first, mobile app-based education improves IP in these patients; and second, such education leads to significant improvements in various dimensions of IP compared to routine care. A thorough literature search revealed no studies investigating the impact of mobile educational apps on IP among patients undergoing PCI. Accordingly, the primary objective of this study was to assess the impact of mobile app-based education on IP in patients undergoing PCI.
Methods
Design
A randomized controlled trial with a pretest/posttest design was conducted. The study involved 110 participants who were referred to the cardiac care units and cardiology outpatient clinic of Shahid Rajaei Hospital in Karaj, Iran, between July and September 2023. The study methodology and reporting adhered to the Consolidated Standards of Reporting Trials (CONSORT) guidelines [32].
Sampling
Out of 115 individuals evaluated for eligibility, 110 met the inclusion criteria and were enrolled in the study. Eligible participants were recruited through consecutive sampling, a type of non-probability method. Subsequently, they were provided with a detailed explanation of the study’s objectives and procedures. Those who signed informed consent forms were recruited and completed baseline questionnaires.
A sample size of 53 participants per group (experimental and control) was calculated using the formula for the difference between two independent means, assuming an alpha level of 0.05 and a power of 80%, based on a previous study [33]. Nonetheless, 55 participants were recruited per group to account for a potential 5% attrition rate. Data collection continued until each group had the required number of participants.
α = 0.05.
β = 0.2.
µ1 = 134.87.
σ1 = 10.37.
µ2 = 129.35.
σ2 = 9.63.
n1 = 53 n2 = 53.
Dropout rate = 5%.
n1 = 55 n2 = 55.
Randomization
In order to avoid selection bias, participants were assigned to different groups using a concealed randomization procedure. Each sequence was written randomly on a card and placed in an opaque envelope. Sealed envelopes were only opened at the time of group allocation. A block randomization with a block size of four was employed. The randomization list was generated in consultation with a statistician using an online randomization tool (https://www.sealedenvelope.com/simple-randomiser/v1/lists).
There were two groups of participants: an intervention group (app-based training) and a control group. A research assistant distributed questionnaires to participants for completion. Random group assignment is expected to control for potential confounding variables.
Blinding
The study was conducted as a randomized, single-masked clinical trial. Due to the nature of the educational intervention, participants were not blinded, as they were aware of whether they had received the app or not. However, all outcome assessors and data analysts were masked to group allocations.
Eligibility
Inclusion criteria included: age between 18 and 60 years, ability to read and understand Persian, capability for effective communication through hearing and vision, possession of a smartphone, first experience receiving PCI, non-participation in other studies, absence of chronic or malignant diseases, and provision of informed consent to participate in the study.
Exclusion criteria: unwillingness to continue, physician’s objection to continued participation, inaccessibility, referral to other medical centers, severe cognitive impairment, significant orthopedic or musculoskeletal complications that hindered physical activity, the need for non-emergency PCI, or the need to repeat PCI.
Measures
Data was collected using the patient demographics form and the Illness Perception Questionnaire-Brief version (IPQ-B).
Demographic characteristics form
This form included the following variables: age, gender, education, marital status, employment status, current diagnosis, stent implantation, primary source of information about current illness, body mass index, smoking history, underlying disease(s), family history of CAD, and type of medications currently in use.
Illness perception questionnaire-brief (IPQ-B)
Broadbent et al. (2006) developed the IPQ-B to assess cognitive and emotional representations of illness rapidly. It consists of nine items, each examining a different aspect of IP. The first five items focus on cognitive perceptions of the illness, including its impact on life (item 1), the timeline of the illness (item 2), personal control (item 3), treatment control (item 4), and the identity of the illness (item 5). Items 6 and 8 assess emotional aspects such as concern about illness and a multifaceted question about mood. Item 7 measures emotional responses to the illness (emotional representations). The final item is open-ended, asking respondents to rank the three most important causes of their illness, using prompts such as stress, heredity, and lifestyle.
The first eight items on this questionnaire are rated on a 10-point Likert scale (0–1: none or very little; 2–3: low; 4–6: moderate; 7–8: severe; 9–10: very severe). For the ninth item, all responses are categorized and analyzed quantitatively. The total score reflects the degree to which the patient perceives their illness and may range from 0 to 83, with 0–27 indicating high IP, 28–55 indicating moderate IP, and 56–83 indicating low IP [34, 35]. The reliability of this questionnaire, reported by Broadbent et al. (2006), was initially assessed using test-retest reliability and ranged from 0.42 to 0.75 across its dimensions [34]. Bagheriansararoodi et al. (2009) conducted a study in which 15 experts evaluated the content validity of the Persian version of this questionnaire as satisfactory. Cronbach’s alpha was 0.84, and test-retest reliability after a 3-week interval was 0.68 [36]. Masaeli et al. (2017) conducted content and construct validity analyses on this questionnaire. Its reliability was determined using test-retest reliability, with Cronbach’s alpha ranging from 0.59 to 0.73 for the questionnaire and its dimensions [37].
Intervention
Members of the intervention group received a custom-designed mobile app before discharge. The researchers personally installed the app on the patients’ smartphones, provided detailed instructions on its use, and addressed any questions or concerns. Patients were encouraged to use the app at least twice a week. Additional guidance was provided to ensure all app features were used to their full potential. The researcher developed the offline app in collaboration with an IT professional. The app’s design prioritized user-friendliness with well-matched fonts and color palettes. Multimedia elements, including images, videos, and instructional text, were created using credible sources to enhance user engagement. In order to mitigate information leakage from the application to the control group, participants were randomized into the intervention group, and each individual was assigned a unique access code. This code was sent to each participant in the intervention after discharge. As a result, even if members of the control group installed the application, they were unable to access the educational content until the end of the study.
Following discharge, the intervention group received educational materials via the app. The content was developed based on the five dimensions of Leventhal’s IP model and addressed a wide range of issues, including CVD definitions and concepts, symptoms, risk factors, CVD treatment types, management strategies, rehabilitation, patient abilities, nutrition education, and physical activity guidelines tailored to individual patient conditions. Patients were reminded to review the educational content through weekly follow-up calls and text messages. Four weeks after the intervention, both groups received the IPQ-B during their monthly clinic visits. To follow ethical principles, the control group was given access to the app after the study was completed.
Control group
Patients in the control group received standard hospital care, which comprised identical and minimal education at discharge. The intervention group received this training as well.
Ethical considerations
The study was approved by the ethics committee of Shahed University, with the ethics code IR.SHAHED.REC.1401.102. The present study was conducted in accordance with the revised Declaration of Helsinki, which outlines ethical principles guiding physicians and other researchers in medical studies involving human subjects. All participants were informed of the voluntary nature of their participation, the commitment to confidentiality and anonymity of their data, and their right to withdraw at any time without consequences. Prior to data collection, all participants (both control and intervention groups) signed informed consent forms that outlined the study’s purpose and their roles and rights. Only those who agreed to participate voluntarily signed the consent form. Upon conclusion of the study, participants in the control group were provided with the mobile application containing educational materials.
Statistical analysis
Data were analyzed using SPSS version 21. The Shapiro-Wilk test was used to determine whether the data from the experimental and control groups were normally distributed. Fisher’s exact and chi-square tests were subsequently employed to investigate associations within the IP qualitative data. The Wilcoxon signed-rank test and paired t-test were employed to evaluate within-group differences in IP scores and their dimensions for continuous data, whereas the Mann-Whitney U test and independent samples t-test were utilized to examine between-group differences in IP scores. A significance level of 0.05 was set for all statistical analyses. Cohen’s d was employed to estimate effect size for normally distributed continuous data. The correlation coefficient (r) was applied for continuous data that did not follow a normal distribution. Cramer’s V was employed as the effect size measure for categorical data. All assumptions for parametric tests were assessed prior to analysis, including normality and homogeneity of variance.
Results
The study phases followed the CONSORT flow diagram (Fig. 1).
Fig. 1.
CONSORT flow diagram with response rates
All 110 patients undergoing PCI were analyzed, with 55 participants assigned to each of the intervention and control groups. No cases were excluded.
Demographic characteristics
The demographic characteristics of participants were comparable between the two groups, with no statistically significant differences observed in age, gender, BMI, educational level, occupation, or clinical history (P > 0.05). This indicates successful randomization and baseline group equivalence (Table 1).
Table 1.
Comparison of demographic characteristics between intervention and control groups
| Variable | Group | P-value | ||
|---|---|---|---|---|
| Control group Mean ± SD |
Experimental group Mean ± SD |
|||
| Age (years) | 52.45 ± 6.30 | 53.75 ± 4.83 | P = 0.453 * | |
| Body mass index (kg/m2) | 28.68 ± 1.83 | 29.43 ± 2.15 | P = 0.051 ** | |
| Characteristic | n (%) | n (%) | P -value | |
| Gender | Male | 32 (55.2) | 26 (44.8) | P = 0.340 *** |
| Female | 23 (44.2) | 29 (55.8) | ||
| Occupation | Homemaker | 16 (48.5) | 17 (51.5) | P = 0.920 **** |
| Employed | 20 (48.8) | 21 (51.2) | ||
| Retired | 19 (52.8) | 17 (47.2) | ||
| Education level | Elementary | 27 (62.8) | 16 (37.2) | P = 0.060 **** |
| High school | 13 (36.1) | 23 (63.9) | ||
| University | 15 (48.4) | 16 (51.6) | ||
| Smoking | Yes | 28 (60.9) | 18 (39.1) | P = 0.081 *** |
| No | 27 (42.2) | 37 (57.8) | ||
| Family history of coronary heart disease | Yes | 28 (53.8) | 24 (46.2) | P = 0.567 *** |
| No | 27 (46.6) | 31 (53.4) | ||
| Having stent | Yes | 44 (50.6) | 43 (49.4) | P = 0.999 *** |
| No | 11 (47.8) | 12 (52.2) | ||
| Underlying disease | Yes | 36 (48.6) | 38 (51.4) | P = 0.839 *** |
| No | 19 (52.8) | 17 (47.2) | ||
| Having balloon angioplasty | Yes | 38 (48.1) | 41 (51.9) | P = 0.672 *** |
| No | 17 (54.8) | 14 (45.2) | ||
*Mann-Whitney Test **Independent t-test ***Fisher’s Test ****Chi-square Test
As displayed in Table 2, within-group analysis using the Wilcoxon signed-rank test revealed a significant reduction in both the overall IP score and its dimensions in the intervention group four weeks after the educational app-based intervention (P = 0.001). Effect sizes indicated a moderate-to-strong impact. In contrast, the control group showed minimal or no change in IP scores, with the exception of the “disease control” dimension, which showed a non-significant increase.
Table 2.
Determination and comparison of changes in dimensions of illness perception between control and intervention groups before and 4 weeks after intervention
| Dimensions of illness perception | Intervention group | Control group | Significance level P-value |
|
|---|---|---|---|---|
| Median (Q1-Q3) |
Median (Q1-Q3) |
|||
|
Disease Outcome (out of 10) |
Before Intervention | 7 (5–9) | 7 (6–9) | 0.451* |
| 4 Weeks After Intervention | 6 (5–7) | 7 (6–8) | 0.004* | |
| P-value | 0.005** | 0.694** | ||
| Effect Size*** | r = 0.43 | r = 0.06 | ||
|
Duration of Illness (out of 10) |
Before Intervention | 6 (4–8) | 6 (3–8) | 0.451* |
| 4 Weeks After Intervention | 5 (3–7) | 6 (4–7) | 0.054* | |
| P-value | 0.006** | 0.481** | ||
| Effect Size*** | r = 0.40 | r = 0.11 | ||
|
Personal Control (out of 10) |
Before Intervention | 6 (5–7) | 6 (4–7) | 0.460* |
| 4 Weeks After Intervention | 4 (2–5) | 6 (4–7) | 0.001* | |
| P-value | 0.001** | 0.891** | ||
| Effect Size*** | r = 0.85 | r = 0.02 | ||
|
Treatment Control (out of 10) |
Before Intervention | 3 (1–4) | 2 (1–4) | 0.494* |
| 4 Weeks After Intervention | 1 (1–2) | 3 (2–4) | 0.001* | |
| P-value | 0.001** | 0.040** | ||
| Effect Size*** | r = 0.66 | r = 0.29 | ||
|
Symptom Perception (out of 10) |
Before Intervention | 5 (3–7) | 6 (4–7) | 0.258* |
| 4 Weeks After Intervention | 5 (1–4) | 6 (4–7) | 0.001* | |
| P-value | 0.001** | 0.479** | ||
| Effect Size*** | r = 0.73 | r = 0.10 | ||
|
Concern (out of 10) |
Before Intervention | 8 (6–9) | 8 (7–9) | 0.626* |
| 4 Weeks After Intervention | 5 (3–7) | 8 (6–9) | 0.001* | |
| P-value | 0.001** | 0.784** | ||
| Effect Size*** | r = 0.73 | r = 0.04 | ||
|
Understanding (out of 10) |
Before Intervention | 8 (5–9) | 7 (5–8) | 0.156* |
| 4 Weeks After Intervention | 2 (1–4) | 7 (6–8) | 0.001* | |
| P-value | 0.001** | 0.885** | ||
| Effect Size*** | r = 0.84 | r = 0.02 | ||
|
Emotional Response (out of 10) |
Before Intervention | 7 (5–8) | 7 (5–8) | 0.576* |
| 4 Weeks After Intervention | 3 (2–5) | 7 (6–7) | 0.001* | |
| P-value | 0.001** | 0.796** | ||
| Effect Size*** | r = 0.87 | r = 0.04 | ||
| Overall Illness Perception (Quantitative) (out of 80) | Intervention group | Control group | Significance Level**** | |
| Mean ± SD | Mean ± SD | |||
| Before Intervention | 46.29 ± 9.19 | 46.69 ± 9.25 | 0.821 | |
| 4 Weeks After Intervention | 30.53 ± 6.30 | 47.13 ± 7.08 | 0.001 | |
| Significance Level***** | 0.001 | 0.598 | ||
| Cohen’s d Effect Size****** | 1.89 | -0.07 | ||
*Mann-Whitney, **Wilcoxon
***Effect size (r): 0.1–0.3 small, 0.3–0.5 medium, above 0.5 large effect
****Independent t-test
*****Paired t-test
******Effect size: 0.3–0.5 small, 0.5–0.7 medium, above 0.7 large effect
Between-group comparison using the Mann-Whitney U test revealed no significant differences in baseline scores (P > 0.05). However, post-intervention analysis demonstrated a significantly greater improvement in the intervention group compared to the control group across all IP dimensions (P < 0.05).
At baseline, most patients in both groups exhibited moderate levels of IP, with no statistically significant difference (P = 0.84). After the intervention, a significantly higher proportion of patients in the intervention group moved to a high IP level compared to the control group (P = 0.001), with a large effect size (d = 1.89), as detailed in Table 3.
Table 3.
Determination and comparison of changes in overall illness perception (Based on a qualitative criterion out of 80) before and 4 weeks after the intervention between the two groups
| Overall illness perception (Qualitative) | Intervention group | Control group | Significance level* | Effect size** |
|---|---|---|---|---|
| Before the Intervention(out of 80) | P = 0.842 | r = 0.05 | ||
| High(0–27) | 2 (3.6%) | 1 (1.8%) | ||
| Moderate(28–55) | 46 (83.6%) | 47 (85.5%) | ||
| Low(56–80) | 7 (12.7%) | 7 (12.7%) | ||
| 4 Weeks After the Intervention (out of 80) | P = 0.001 | r = 0.40 | ||
| High (0–27) | 15 (23.7%) | 1 (1.8%) | ||
| Moderate (28–55) | 40 (72.7%) | 49 (89.1%) | ||
| Low (56–80) | 0 (0%) | 5 (9.1%) | ||
* Chi-square test
** Effect size interpretation: 0.1–0.3 = small effect, 0.3–0.5 = moderate effect, > 0.5 = large effect
Discussion
This research sought to evaluate the effect of a mobile app on IP in patients undergoing PCI. The analysis of demographic data indicated no statistically significant differences between the intervention and control groups in terms of age, gender, educational level, body mass index, employment status, or underlying diseases. This demographic equivalence reflects successful randomization in the study design and reduces the potential impact of confounding variables on the outcomes. A similar demographic balance has been reported in recent randomized clinical trials evaluating the effectiveness of digital health interventions in patients undergoing CVD. For example, a study by Cruz-Cobo et al. (2024) on mobile app–based cardiac rehabilitation found no significant differences between groups in terms of age, sex, or education level, thereby reinforcing the internal validity of the intervention outcomes [38]. Likewise, these findings are consistent with the results reported by Shi et al. In a 2022 study on post-PCI exercise management, researchers demonstrated demographic homogeneity across groups, allowing for a direct attribution of changes in outcomes to the intervention [39]. These findings underscore the importance of demographic alignment in educational intervention studies, as factors such as age and educational level can directly impact IP and the response to interventions [40].
The results demonstrated that the intervention group experienced a significant improvement in IP scores from baseline to four weeks after the intervention. No significant change in IP scores was observed in the control group during the same period. The findings indicate that the mobile app effectively improved IP levels in patients undergoing PCI. The positive outcomes of the mobile phone intervention among the study participants can be attributed to the fact that behavioral and knowledge-related factors are the primary contributors to decreased IP levels in patients with CVD [41]. The mobile app served as an innovative educational tool, allowing PCI patients to enhance their understanding of their condition and increase their awareness of associated complications. Patients respond to illness signs and symptoms by developing and representing cognitive and emotional responses [42]. Therefore, it is likely that a higher level of IP has resulted from mobile app education, which has elicited and represented cognitive and emotional responses in patients undergoing PCI.
The findings of this study correspond with those of Nikkhah Beydokhti et al. (2023). In their study, patients with myocardial infarction received a six-week multimedia educational intervention via Telegram and WhatsApp (using videos, audio, and images), which resulted in a significant increase in their IP [42]. Despite the distinctions between app-based and multimedia education, both employ text, audio, images, and video as media for information dissemination. This suggests that the approach and format of educational delivery have a significant influence on the improvement of IP in cardiac patients. The research conducted by Goldsworthy et al. (2017) supports our findings, indicating that a mobile app-based educational intervention significantly enhanced IP in cirrhosis patients within a one-month timeframe [43]. The consistency of these studies suggests that app-based educational interventions can significantly improve patients’ awareness of the identity and complications of chronic diseases.
Tafaghodi et al. (2022) demonstrated that a smartphone app designed to enhance nutritional awareness effectively improved IP among women with hypertension over a 6-month period after the intervention. Our findings are consistent with the research conducted by Tafaghodi et al., notwithstanding variations in educational topics and study populations. This suggests that mobile apps markedly enhance perceptions of one’s condition among patients with chronic diseases. This is accomplished by positively changing patients’ beliefs about the chronic nature of their disease, increasing their knowledge of the disease, offering solutions to reduce complications, and improving the treatment process [44]. The findings of Mahardika and Widyandari (2023) support our results, demonstrating that a mobile app effectively enhanced IP among type 2 diabetes patients within one month of the intervention [45]. Despite the differences in study populations between our research and that of Mahardika and Widyandari, mobile app-based education for patients with chronic diseases appears to improve knowledge, motivation to learn, and perception while decreasing anxiety associated with learning. These apps can broaden patients’ perspectives on their diseases by transitioning them from passive to active learners [46], thus improving their overall disease perception.
Our study found a significant improvement in IP levels among patients in the intervention group from pre-intervention to four weeks post-intervention compared to the control group. According to the study’s findings, providing educational content to patients via mobile apps improves their psychological and mental well-being, contributing to better treatment outcomes and disease control and management. It is well-established that patients with chronic diseases, such as heart disease, who have higher levels of psychological well-being are more likely to engage in health-related behaviors and follow medical and treatment recommendations [47]. Our study’s findings are consistent with those of Hosseinzadeh et al. (2012), who discovered a significant relationship between prior self-care education and IP among patients with CAD [48]. Likewise, Najafi et al. (2018) studied hospitalized patients with heart failure in a cardiac intensive care unit, noting that a smartphone-based mobile application significantly improved medication adherence, which aligns with the “treatment control” aspect of IP [49]. Additionally, Kitsiou et al. (2021) reported that a patient-centered mobile health intervention had a positive effect on medication adherence in individuals with chronic heart failure, further supporting the treatment control aspect of IP [50].
The findings of Farhane-Medina et al. (2022) are consistent with those of the current study. They reported that delivering education to patients with heart disease via mobile apps over a six-week period resulted in enhanced disease management, improved treatment outcomes, diminished anxiety and psychological distress associated with the condition, better emotional responses to the illness, and an increase in IP [51]. The alignment of our study’s findings with this research suggests that mobile app-based education has the potential to significantly enhance patients’ psychological well-being by alleviating negative psychological emotions, such as anxiety, and fostering healthier emotion regulation. This capacity results from its versatility (encompassing audio, visual, and textual content) and constant accessibility. As a result, heart patients are better equipped to manage their condition and enhance their overall quality of life.
In a similar vein, Salavati et al. (2024) found that mobile apps significantly improve self-care in post-angioplasty patients [52], supporting our findings and underscoring the effectiveness of mobile apps in providing educational content. Furthermore, in alignment with our findings, Fernandes et al. (2019) [53] and certain other studies have shown that mobile app-based education for heart patients results in improved clinical outcomes, enhanced disease control, decreased stress, lower psychological disorders such as anxiety, and increased disease knowledge, with effects lasting for one month post-intervention by minimum. The alignment of our study’s findings with earlier research suggests the effectiveness of mobile app-based educational interventions in helping heart patients better adjust to their condition, adapt to treatment plans, and adopt healthier lifestyles. These improvements, in turn, enhance patients’ psychological well-being, reduce long-term risk factors, and improve overall quality of life [54–57]. Studies have shown that self-care educational applications, featuring reminders, symptom monitoring, and interactive education, directly influence adherence to medications, dietary guidelines, and physical activity. By increasing access to personalized guidance, these tools can facilitate treatment-related behaviors [58]. Conversely, such educational interventions can modify patients’ perceptions of the disease by reshaping their understanding of its nature, symptoms, and risk factors. This enhanced understanding often contributes to a more positive attitude toward disease management; however, it does not necessarily lead to improved treatment adherence [14]. Therefore, it may be interpreted that while the effect of app-based education on treatment adherence is primarily behavioral and practical, its influence on IP is more cognitive and attitudinal in nature. Our findings, consistent with those of similar studies, highlight the significance and enduring effects of mobile app-based educational interventions on various aspects of heart disease management. This evidence provides strong support for the benefits of this educational modality.
Strengths
In summary, the findings of this study suggest that a mobile phone educational app for patients undergoing PCI can enhance their IP by increasing knowledge levels and highlighting the benefits of self-care behaviors to improve disease conditions through the advanced features of mobile apps. This educational modality in nursing significantly enhances the care of patients undergoing PCI, facilitating the provision of services to this patient group irrespective of time and location. Using this educational method decreases the likelihood of readmission to treatment centers for patients undergoing PCI, increases IP, and ultimately enhances medical care while reducing health and care costs for patients.
Practical implications
This study’s findings confirm that a mobile application-based intervention significantly enhances illness perception among patients undergoing PCI, offering actionable implications for practice and policy. For nurses, this evidence supports the integration of mHealth tools into standard care pathways to empower patients in self-management, thereby improving health literacy and potentially reducing hospital readmissions. For healthcare managers and policymakers, these results provide a strong rationale for investing in digital health infrastructure and redesigning care models to alleviate resource constraints and improve efficiency. To facilitate this transition, it is imperative that mHealth competencies are formally embedded within both academic nursing curricula and in-service training programs. This research serves as a foundational step, encouraging future studies to explore the scalability of this model to other chronic diseases, thus paving the way for a more integrated and evidence-based digital healthcare system.
Suggestions for future research
Future studies of a similar nature may extend the follow-up period beyond four weeks to assess the long-term impact of the IP educational app. Furthermore, alternative methods of IP assessment, including observation, are recommended. Future research may also compare the effects of mobile educational apps with other patient education modalities on IP in patients undergoing PCI.
Limitations
A significant limitation of this study was the reliance on standardized self-report questionnaires. Although these instruments have demonstrated validity and reliability, self-report measures are susceptible to response bias, particularly social desirability bias. To minimize this limitation, we implemented several strategies: (1) data collection was conducted in a quiet, private environment without direct research team presence; (2) participants were assured of complete response confidentiality; (3) neutral response instructions were provided, emphasizing that no responses were correct or incorrect; and (4) the data analysis was performed without knowledge of participant group allocation to mitigate analyst bias. The study’s inclusion criteria limit its findings to Persian speakers. Replication with a different population is recommended to broaden the scope of these findings. Moreover, the potential influence of external information sources (such as family, friends, or the media) on participants might be considered a confounding factor.
Conclusions
This study concludes that a mobile phone educational app can enhance IP in patients undergoing PCI. Consequently, interventions that incorporate teaching IP via a mobile phone educational app can improve the health of patients undergoing PCI. Given the positive outcomes of this research, hospitals and healthcare centers should view educational apps as effective tools for enhancing patient health outcomes following PCI. Thus, they are advised to establish the necessary infrastructure and encourage the use of these apps by nurses working in these facilities. Nurses can engage in this field to enhance the care and treatment system for PCI patients and broaden their nursing roles in improving IP among these patients.
Acknowledgements
This study approved by the Ethics Committee of Shahed University (Ethics Code: IR.SHAHED.REC.140.102) and registered in the Iranian Registry of Clinical Trials (IRCT ID: IRCT20110912007529N27) on 2023-01-23. The authors sincerely appreciate the invaluable participation of all patients who contributed to this research. Their cooperation and willingness to share their experiences were essential to the success of this study.
Abbreviations
- PCI
Percutaneous coronary intervention
- CVD
Cardiovascular disease
- CAD
Coronary artery disease
- IPQ-B
Brief Illness Perception Questionnaire
- IP
Illness perception
Author contributions
KS: She was a contributor in writing the manuscript, design of the work, Investigation, and data acquisition. FR: He was a major contributor in analyzing, Supervision, and interpreting the patient data. NR: She was a major contributor in methodology, the design of interventions Reviewing and Editing of the manuscript. All authors read and approved the final manuscript.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Data availability
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The study protocol was approved by the ethics committee of Shahed University with the ethics code IR.SHAHED.REC.1401.102. The present study was conducted in accordance with the revised Declaration of Helsinki, which outlines ethical principles guiding physicians and other researchers in medical studies involving human subjects. All participants were informed of the voluntary nature of their participation, the commitment to confidentiality and anonymity of their data, and their right to withdraw at any time without consequences. Informed consent forms were signed by all participants (both control and intervention groups) prior to data collection. Moreover, the study’s purpose, their role, and their rights were explicated to them. Only those who agreed to participate signed the consent form voluntarily.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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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 datasets used and analyzed during the current study are available from the corresponding author on reasonable request.