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. 2017 Oct 30;23(1):76–88. doi: 10.1177/1744987117728314

Prevalence of depression and its associated factors in patients post-coronary artery bypass graft surgery

Issa M Hweidi 1,✉, Besher A Gharaibeh 2, Salwa M Al-Obeisat 3, Ahmed M Al-Smadi 4
PMCID: PMC7932255  PMID: 34394410

Abstract

This research aimed to determine the depression level and its correlation experienced by post-coronary artery bypass graft patients after being discharged from cardiac intensive care units. A cross-sectional design was employed for assessing variables. The Self-rating Depression Scale, as proposed by Zung, was used by the researchers on a convenience sample of Jordanian patients (N = 143) who were approached soon after their discharge from the targeted units. The results suggested that the level of depression among Jordanian patients was relatively high (M = 62.7, SD = 5.6). Moreover, depression was significantly higher among female, unmarried and unemployed patients. Patients who received their information about coronary artery bypass graft surgery from nurses had a lower level of depression. Age, length of stay in the cardiac intensive care unit and hospital type significantly predicted the level of depression. The research concluded that the post-coronary artery bypass graft patients who experienced an early onset depression required more attention to highlight the importance of supportive interventions.

Keywords: cross-sectional, depression, early discharge, Jordan, post-CABG patients

Introduction

Coronary artery bypass graft (CABG) surgery has become an increasingly dominant treatment modality for coronary artery diseases (CADs), the leading cause of worldwide mortality and responsible for 30% of total deaths globally (World Health Organization, 2011). However, CABG is providing beneficial results that enhance quality of life and promote and minimise mortality and morbidity among CAD patients (Coskun et al., 2005; Diez et al., 2007). Nevertheless, CABG surgeries are accompanied by significant immediate and long-term potential physical and psychological complications (Blumenthal et al., 2003; Coskun et al., 2005; Diez et al., 2007; Hollenbeck et al., 2000; Olsen et al., 2002). Most recently, more attention has been paid to psychological responses, particularly depression, following CABG surgeries because depression influences the recovery process and poses life-threatening complications that can endanger health and drain health care resources (Connerney et al., 2010; Ghoneim and O’Hara, 2016; Katon and Ciechanowski, 2002; Krannich et al., 2007).

Depression is an ailment or condition that has an influence on a person’s mood. A person who experiences depression seems to feel angry, unhappy, guilty or annoyed (Cooper, 2014; Wang et al., 2014). Depression not only affects a person in terms of their mental condition, but also results in changing the human body physically, causing people to suffer from higher levels of pain and other health-related issues (Roy, 2005). Depression predominates remarkably among post-CABG patients and has been regarded as a significant predictor of cardiac morbidity and mortality (Baker et al., 2001; Borowciz et al., 2002; Burg et al., 2003; Frasure-Smith et al., 2000; Krannich et al., 2007; Seymour and Benning, 2009; Tully et al., 2008). Studies found that moderate to severe depression post-CABG triples the risk of death, particularly in the early period after discharge, and could quadruple the cardiac mortality over the first week after CABG surgery (Kendel et al., 2010). The increase in morbidity and mortality has been attributed to a reduction in adherence to the therapeutic regimen and to lifestyle changes following surgery (Burg et al., 2003; Topol et al., 2007). Approximately 800,000 patients undergo CABG surgery worldwide annually (Krannich et al., 2007) of which 20–45% experience depression shortly afterwards (Rymaszewska et al., 2003). Because depression increases the risk of cardiac complications post-CABG surgery, major interventional and rehabilitative strategies are required to counteract such adversities, which may include delirium, low immunity and higher rates of infection (Borowciz et al., 2002; Burg et al., 2003; Ghoneim and O’Hara, 2016; Rymaszewska et al., 2003). Despite therapeutic advancements in managing post-CABG patients, health care providers still face the challenges of both early identification of clinical depression and overcoming the negative consequences of depression post-CABG (Baker et al., 2001; Borowciz et al., 2002; Burg et al., 2003).

Depression was found to be influenced by various factors such as level of education, source of teaching information regarding the surgery, length of stay, hospital type, and gender, as well as where higher level of education, longer hospital stay, public hospitals and female patients were associated with higher level of depressive manifestations; whereas receiving teaching from nurses was associated with lower level of depression (Al-Hassan and Sagr, 2002; Connerney et al., 2010; Dijkstra et al., 2006; Wenham and Pittard 2009). In addition, studies that addressed depression post-CABG surgery studied its level and consequences over different periods of time. These time periods were classified as early period (1–2 weeks), recovery period (>2 weeks to 2 months), mid (>2 months to 6 months) and late (>6 months) (Ravven et al., 2013). However, there is a scarcity of studies that have addressed depression and its associated factors post-CABG surgery during hospitalisation or during times as early as discharge from the cardiac intensive care unit (CICU). In addition, the literature addressing depression post-CABG surgery is predominantly from Western culture. So the purpose of this study was to identify levels of depression among Jordanian post-CABG patients, to investigate whether certain CABG patients’ characteristics affect depression levels and to identify the predictors of depression among post-CABG patients in Jordan in the initial period after CICU discharge.

Methods

Design and sample

A descriptive cross-sectional design was selected to identify levels of depression based on the fact that post-surgical depression among CABG patients is associated with poor health outcomes (Krannich et al., 2007; Poole et al., 2017). Sample size was calculated using G* Power software (Faul et al., 2007). The following determinants were used: a power level of 0.95, an alpha level of 0.05, a moderate effect size of 0.15 for the regression analysis, and the nine predictors entered into the regression equation (age, income, gender, employment, marital status, education, hospital type, length of stay in CICU and source of teaching information). From this, the minimum estimated sample size was 74. We added 25% to the total number of participants in order to overcome the problem of missing or incomplete questionnaires. Thus an additional 19 participants were added, resulting in 93 participants. A total of 150 questionnaires was distributed and 143 completed questionnaires were returned, indicating a response rate of 95%.

Eligibility criteria were Jordanian patients who had undergone CABG surgery, were 18 years of age or older and were able to understand Arabic. Those with a concurrent surgical procedure (e.g. valve replacement or other surgery), redo CABG surgery, cerebrovascular accidents during or post-CABG surgery, or active neurological or psychiatric diagnosis that might influence the distortion of the subjects were excluded from the study. Subjects were excluded on the basis of the data gathered from their medical records.

Procedure

The study was conducted in three major referral hospitals located in the capital city and another major city in Jordan. These hospitals provide care for patients from different parts of the country, particularly for CABG surgery. The private and the university-affiliated hospital are Joint Commission International accredited, while the public hospital is not. These three hospitals provide structured cardiac rehabilitation programmes that deliver standard perioperative teaching to their patients. These structured teaching programmes are carried out and officially documented by either nurses or physicians and include reading and discussing a cardiac surgery brochure and reviewing a compact disc (CD) in groups of five to six patients. The CD explains how patients should prepare themselves for surgery and how they should deal with the rehabilitation period.

After obtaining permission from the Institutional Review Board committee at Jordan University of Science and Technology and the three targeted hospitals, the researcher distributed instrument packages to the participants 2 days after their transition from the CICU to the intermediate units, assuming that the health status of patients would be more stable here than when they were in the CICUs. The package contained a summary of the study, the participants’ rights, the researchers’ contact information, a consent form, a characteristics sheet and the Arabic version of the Self-rating Depression Scale (SDS). The Arabic version was developed by the authors of this study after translating the original SDS (Zung, 1972). The primary strategy of data collection was the drop-and-collect technique. This technique involves the hand delivery and subsequent recovery of self-completion questionnaires (Brown, 1987). Participants took around 20 minutes to complete the distributed package. For those who were illiterate, a structured interview strategy (reading of the scales’ questions and demographic items) was employed by the second author for the purpose of data collection.

Instruments

The SDS developed by Zung (1972) is a Likert type scale that quantifies the severity of current depression. Item scores range from 1 to 4 where 1 = little or none of the time and 4 = most of the time. Item scores were added to form a total ranging from 20 to 80. The raw score is converted to an index by multiplying by 1.25, producing a range from 25 to 100 with higher scores indicating increasing depression levels. The SDS measures affective, somatic, psychomotor and psychological dimensions of depression with a score of 49 or less indicating a normal value, a score between 50 and 59 indicating mild depression, a score between 60 and 69 representing moderate depression and a score of 70 or more signifying severe depression (Zung, 1965, 1972).

The SDS has proven to be a reliable and valid measure of depression among patients post-CABG surgery (Edéll-Gustafsson and Hetta, 1999). For the purpose of this study, the original SDS scale was translated into Arabic and back translated by a panel of four experts who were competent bilingually. No major changes were suggested by the experts, except some rewording of sentences. Back translation is usually considered an acceptable norm for translating a research questionnaire (Kim et al., 1995). Cronbach’s α of the translated version of the SDS was 0.78 in this study, which suggested the reliability was at an acceptable level of internal consistency.

Statistical analysis

For the analysis of data, the Statistical Package of Social Sciences (SPSS) version 19 was employed. Descriptive statistics were used to describe the patients’ depression levels and their demographic characteristics. Analysis of variance (ANOVA) and the t-test were used to test for statistical differences in level of depression in terms of selected patients’ characteristics. An α-level of 0.05 was set as a level of significance for all statistical procedures executed in this study. Stepwise regression analysis was employed to assess for significant predictors of depression.

Results

Characteristics of the sample

Altogether, 143 post-CABG patients were surveyed or interviewed in the targeted hospitals. Patients’ mean age was 64.11 with a range of 47 to 86 years (SD = 10.8). Of the total sample, 53.1% were male (n = 76) and 46.9% were female (n = 67). In terms of their marital status, the results revealed that 49.7% were married (n = 71) and 50.3% were unmarried (n = 72). Monthly income ranged from JD180 to JD920 (JD1 = US$1.3) with a mean of JD485.18 (SD = 198.5). Data also revealed that 36.4% were illiterate (n = 52), 23.8% had basic education (n = 34) and 39.9% had university education (n = 57); 39.9% were employed (n = 57), and 60.1% were unemployed (n = 86). All sample subjects received information regarding CABG surgery (N = 143). Approximately 55% of the total sample received teaching information regarding surgery from physicians (n = 79) and 44.8% received information from nurses (n = 64). The results revealed that the length of stay in the CICU ranged from 5 to 8 days with a mean of 6.4 (SD = 1.16) (see Table 1).

Table 1.

Sample characteristics.

Variable Range M SD N %
Age (years) 47–86 64.1 10.80
Gender
 Male 76 53.10
 Female 67 46.90
Marital status
 Married 71 49.70
 Unmarried 72 50.30
Monthly income (Jordanian dinar) 180–920 485.18 198.53
Educational level
 Illiterate 52 36.40
 Basic education 34 23.70
 University education 57 39.90
Working status
 Employed 20 13.70
 Unemployed 130 86.30
Length of stay in CICU (days) 5–8 6.4 1.16
Primary source of information
 Physician 79 55.20
 Nurse 64 44.80
Hospital type
 Private 66 46.20
 University affiliated 41 28.60
 Public 36 25.20
Total depression score 48–73 62.7 5.638
 Psychological dimension 27.62 2.51
 Somatic dimension 23.02 3.73
 Psychomotor dimension 7.02 0.87
 Affective dimension 5.04 1.0
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CICU: Cardiac Intensive Care Unit.

Prevalence of depression and its level post-CABG surgery

The level of depression among Jordanian post-CABG patients admitted to intermediate care units (N = 143) was moderate, with a mean of 62.7 (SD = 5.6) within the potential score range of 25–100. Within the study sample, only three subjects reported no depression (2.1%) while 46 participants (32.2%) reported mild depression. The majority of the sample (n = 86; 60.1%) reported moderate depression and only eight participants (5.6%) reported severe depression. The psychological dimension of the depression scale had the highest mean score, followed by the somatic dimension, then the psychomotor dimension. The affective dimension had the lowest mean score (see Table 1).

The effects of patients’ socio-demographics on depression

In order to examine the effect of dichotomised selected socio-demographics on depression, a t-test and ANOVA were employed. Results of the t-test analysis indicated that statistically significant differences were detected in gender (t (141) = −5.016, p = 0.001), where female CABG patients reported higher depression scores (M = 65.358, SD = 4.35) as compared with male patients (M = 60.34, SD = 5.620). In addition, the t-test results showed that statistically significant differences existed between employed and unemployed CABG patients (t (141) = −7.273, p = 0.001). Unemployed patients recorded higher total depression scores (M = 65.08, SD = 4.650) than their counterparts (M = 59.08, SD = 5.079). Marital status (t (141) = −7.433, p = 0.001) was found to affect depression scores among Jordanian post-CABG patients, where unmarried patients reported higher total depression scores (M = 65.65, SD = 3.627) than patients who were married (M = 59.69, SD = 5.743). In regard to the source of information about CABG surgery and depression score, results of the t-test revealed that there was a statistically significant difference among Jordanian post-CABG patients (t (141) = 7.352, p = 0.001), where patients who received information from nurses indicated lower levels of total depression score (M = 50.406, SD = 5.838) compared with those who received information from their physicians (M = 65.354, SD = 3.872). A positive significant proportional association existed between the total depression score, patient age (r = 0.645; p = 0.01) and length of stay in a CICU (r = 0.617; p = 0.01). In addition, there was a significant inverse correlation between the total depression score and patients’ monthly income (r = −0.557; p = 0.01) (see Table 2).

Table 2.

Relationship between the patients’ selected socio-demographics and the total depression score using Pearson’s correlation coefficient (r).

Patients’ socio-demographics 1 2 3 4
1. Age −.517a .466a .645a
2. Monthly income −.716a −.557
3. Length of stay in CICU .617a
4. Total depression score
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a

Correlation is significant at the 0.01 level (two-tailed).

CICU: Cardiac Intensive Care Unit.

A one-way ANOVA was used to test for total depression score differences among the three targeted hospitals that participated in the study. Total depression scores were significantly different across the three hospitals (F(2, 140) = 12.736; p = 0.001). Tukey post-hoc comparisons of the three types indicated that the public hospital (M = 63.91, SD = 4.842) scored significantly higher with regard to depression level than the university-affiliated hospital (M = 60.682, SD = 6.282; p = 0.031). All other comparisons using ANOVA showed no statistical difference in the mean depression scores; no statistically significant difference was found between the public and private hospitals (p = 0.83) or the private and university-affiliated hospitals (p = 0.51).

Educational level (F(2, 140) = 12.736; p = 0.001) was found to have a significant effect on the depression level of Jordanian post-CABG patients. Tukey post-hoc analysis revealed that patients with a university education reported higher levels of total depression score (M = 65.368, SD = 4.190) in contrast to illiterate patients (M = 61.269, SD = 5.864; p = 0.001) or patients with a basic education (M = 60.382, SD = 5.726; p = 0.001). Tukey post-hoc comparison demonstrated that no statistical distinction existed among total depression scores of patients with basic education (M = 60.382, SD = 5.726) and illiterate patients (M = 61.269, SD = 5.864; p = 0.722).

Predictors of depression among Jordanian post-CABG patients

Stepwise regression analyses were conducted to determine whether age, income, gender, employment, marital status, education, hospital type, their length of stay in a CICU and source of teaching information contributed significantly to the depression score. The model with age was a significant predictor of total depression scores among Jordanian post-CABG patients and contributed to 41.2% of the variance in the overall model (F = 100.36; p = 0.001).

In the second model, the addition of length of stay in a CICU significantly increased the explained variance in depression by 12.5%. In this model, age and length of stay in a CICU significantly explained approximately 54% of the variance in depression level. Advanced age and increased length of stay in a CICU predicted higher levels of depression (F = 83.28; p = 0.001). In the third model, the addition of hospital type significantly increased the explained variance in depression by 1%. The most significant predictor was age followed by length of stay in a CICU, whereas the hospital type was identified as the least significant predictor. All other remaining variables did not significantly predict the level of depression among the participants (see Table 3).

Table 3.

Significant predictors of depression in Jordanian post-coronary artery bypass graft patients using stepwise regression analysis.

Model Variable B Adjusted R t p
1 Age .645 .412 10.02 .001
2 Age .457 .537 7.07 .001
Length of stay in CICU .404 6.25 .001
3 Age .420 .547 6.34 .001
Length of stay in CICU .422 6.54 .001
Hospital type .120 2.06 .042
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CICU: Cardiac Intensive Care Unit.

Discussion

The findings revealed that Jordanian post-CABG patients experienced a moderate depression level. This result is consistent with the notion that CABG surgery is a life-threatening event that influences life drastically and increases the risk of psychological adversities among those patients. This event is primarily caused by the sudden critical life and health-behaviour modifications required to reduce the cardiac morbidity and mortality risks post-surgery (Connerney et al., 2010; Ghoneim and O’Hara, 2016; Krannich et al., 2007). However, other research studies concluded that post-CABG patients experienced severe levels of depression. This difference in the levels of depression between previous studies and the current study may be attributed to the variations in time span between the discharge from the CICU and the data collection employed in the current study.

Previous studies revealed that the average length of time from CICU discharge to the data collection time exceeded 12 weeks (Krannich et al., 2007; Seymore and Benning, 2009; Tully et al., 2008) compared with the less than 1 week average in this study. Moreover, in the current study the data were collected while the patients were still hospitalised and receiving specialised and vigorous health care, while the previous studies collected data after hospital discharge when the patients had to care for themselves. In Jordan, there is a lack of structured discharge planning and patient-teaching interventional strategies, which may rationalise the reported levels of depression in this study. Post-CABG patients at this phase lack cognisance of how many modifications in their health habits and lifestyle they need to follow as structured discharge planning and patient teaching are not observed in the health care system in Jordan.

The results of this study revealed that unemployed CABG patients reported higher levels of depression than their counterparts. Employed patients generally have an adequate monthly income, which appeared to be inversely correlated with the total depression scores obtained. This result is congruent with other studies reporting that higher income is associated with low levels of psychological adversities, as a high income allows the patients to feel more secure, less worried about their health consequences on their families, more socially interactive and subsequently less stressed (Hweidi, 2007). In regard to the source of teaching information about CABG surgery, patients who received information from their primary physicians about CABG surgery reported higher depression scores compared with those patients who received information from nurses. This may reflect the satisfaction level of patients with nurses, who are more sensitive to satisfying the learning needs of patients and more accessible than other health care professionals, thereby conveying more confidence and competency in the delivery of health care (Fosbinder, 1994; Kemppainen et al., 2013). In addition, nurses are in close contact with patients and their families and can easily determine their needs and provide patients with appropriate information as required by the patients (Calman, 2006). Moreover, the infrequent exposure time between patients and their physicians, due to the scarcity of Jordanian surgical cardiologists and the subsequent work overload, hinders the interaction process between the two parties. This probably results in reducing the satisfaction level of patients in terms of the quality and quantity of information they receive from their medical care providers, which may heighten their post-surgery psychological adversities.

This study found that the level of depression was also affected by the patient’s level of education and the hospital type. The level of depression was higher among those with higher levels of education, while it was lower among those with lower levels of education. No study was found that explains these findings among patients post-CABG surgery. However, one study that addressed the relationship between depression and level of education found that depression was higher among people with higher levels of education and that depression did not follow a linear pattern with regard to educational level (Akhtar-Danesh and Landeen, 2007). Further research is needed in this regard to explore this complex relationship.

Moreover, patients in public hospitals reported more depression symptoms than those in private and university-affiliated hospitals (see Figure 1). This can be attributed to the fact that Jordanian public hospitals lack the structured cardiac rehabilitation programmes and Joint Commission International Accreditation that emphasise educative counselling and formal cardiac rehabilitation in cardiac care units, which are important for patients’ successful adjustment and recovery (Al-Hassan and Sagr, 2002). These findings raise questions about the efficiency of orientation and teaching programmes conducted in hospitals for newly employed registered nurses, especially in the public sector. Moreover, the higher depression level found in the public hospitals may be attributed to the strict visiting policies executed, where hospitals limit patient visiting to only 2 hours on weekdays, resulting in limited social support for the patient (Al-Hassan and Sagr, 2002; Dijkstra et al., 2006).

Figure 1.

Figure 1.

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Plot of the mean depression scores among the three targeted hospitals participating in the study.

Age, length of stay in a CICU, and hospital type were reported to be significant predictors of depression. Considering age, a study conducted by Connerney et al. (2010) indicated that the elderly might be more vulnerable to cardiovascular reactions evoked by physical and emotional strain than are younger adults, since old age is accompanied by the presence of chronic illnesses that hinder the adjustment process in meeting self-care activities (Surtees et al., 2003). Moreover, as the length of CICU stay increases, CABG patients become more exhausted, irritable and confused since the critical care unit environment is viewed as a leading source of psychological strain, including stress and depression due to an extensive use of sophisticated technology and the complex nature of the health problems (Chan and Twinn, 2007; Wenham and Pittard, 2009). Furthermore, the longer the patient stays in the CICU the more they think about death as a complication of the surgery and the higher the level of depression they suffer (Hermele et al., 2007). Gender, marital status, educational level and receiving previous information about CABG surgery did not significantly predict depression levels of Jordanian CABG patients. Even though gender was not a significant predictor of depression post-CABG, there was a significant difference in the level of depression between males and females. This finding was congruent with those of Connerney et al. (2010).

Study limitations

A relatively small convenience sample was used, therefore this limits the external validity of the results. Furthermore, the study used a cross-sectional design rather than a longitudinal design. A cross-sectional design might not be appropriate to assess depression level over time as patients transition home. In addition, some other factors that may have influenced the level of depression has not been accounted for, such as social support systems.

Conclusion and implications for practice

The results of this study shed light on the depression that Jordanian post-CABG patients experience in the early discharge period from the CICU. The incidence of depression was high. Very few patients reported no depression, whereas, patients post-CABG surgery reported considerable levels of depression after discharge from the CICU. This depression was substantially higher among female, unmarried and unemployed patients. Nurses had a substantial effect on the level of depression in that patients who received their information about CABG surgery from nurses had lower levels of depression. Age, length of stay in the CICU, and hospital type significantly predicted the level of depression. Implementing successful discharge planning alongside effective patient teaching are substantial nursing tasks to reduce the psychological adversities of post-CABG patients, and also to increase patients’ awareness about what is required to aid successful coping and subsequent adaptation in order to mitigate potential psychological consequences of this life-threatening event. Thus, nurses must continue to examine the nature of depression and explore the significant effect of privileged variables on depression.

Professional nurses and health care team members must bear responsibility for the management of depression and execute all possible efforts to combat depression among post-CABG patients. It might also be beneficial to conduct similar studies manipulating a multi-series design to examine the level of depression and its afflictions at different times; this would help in identifying psychological adversities post-CABG patients may encounter at different phases throughout the recovery process.

Key points for policy, practice and/or research

  • Patient-centred teaching and discharge planning for coronary artery bypass graft patients are imperative supportive interventions to counteract the deleterious impact of depression on cardiac outcomes.

  • Nurses must continue to examine the nature of depression and explore the significant effects of privileged variables on depression and its dimensions to facilitate successful adjustment among post-coronary artery bypass graft patients.

  • Health administrators must adopt and implement health policies that ensure utilisation of perioperative assessment of depression by all health care professionals involved.

  • Researchers should consider conducting studies employing a multi-series design for the evaluation of depression level as well as its associated complications at different times.

Acknowledgements

The authors would like to thank Jordan University of Science and Technology for partially funding this study. In addition, the authors would like to thank the targeted hospitals for facilitating the data collection process. Study design: IH; data collection and analysis: BG, SA, IH; and manuscript preparation: IH, AS.

Biography

Issa M Hweidi is a doctoral degree holder with rich experience as a clinical nurse educator in the field of Medical-Surgical Nursing. Dr. Hweidi is an academician in the field of Adult Health Nursing teaching both theory and clinical (undergraduate & graduate) courses, actively participating in professional activities, and has published 12 research studies in refereed, indexed, and international journals. Currently, Dr. Hweidi is a tenured associate professor of adult health nursing at Jordan University of Science and Technology involved in various leadership and managerial tasks in the nursing profession.

Besher A Gharaibeh in 2012, was employed as an Assistant Professor for JUST. Dr. Gharaibeh currently works as a professor at JUST/ Faculty of Nursing and held administrative positions that included Assistant of Dean and Chairperson of the Adult Health Nursing Department. His research activities are focused at adult health nursing and he has many publications in that field.

Salwa M Al-Obeisat (RN, MSN, DNSc), is an Associate Professor of Maternal Child Health Nursing in the Faculty of Nursing, Jordan University of Science and Technology. Her research interest is maternal-child health, adolescent health, health promotion, women health, and infertility. She is currently teaching several undergraduate and graduate courses in the area of maternal-child health nursing, and is an actively participating member of several committees at the university and the national level.

Ahmed M Al-Smadi, PhD, RN, with sixteen years of experience as a nurse and researcher. He earned his bachelor's and master's degrees in nursing from Jordan University of Science and Technology and his PhD in Nursing from the University of Ulster, United Kingdom. Currently he is assistant professor in nursing at the American University of Madaba - department of medical laboratories. His main research interests are cardiac care, refugees' health, and psychological health.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Jordan University of Science and Technology (grant no. 144-2014).

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