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A Study to Assess the Knowledge and Quality of Life of Pacemaker Patients

with a view to Develop an Information Booklet

Article  in  Asian Journal of Nursing Education and Research · January 2017

DOI: 10.5958/2349-2996.2017.00022.2

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 Asian J. Nursing Edu. and Research 7(1): January- March 2017

ISSN 2231-1149 (Print) www.anvpublication.org

2349-2996 (Online) www.ajner.com

RESEARCH ARTICLE

A Study to Assess the Knowledge and Quality of Life of Pacemaker Patients

with a view to Develop an Information Booklet

Swaty Chapagai1, G Rachel Andrews1, Nitish Naik2

1
College of Nursing, All India Institute of Medical Sciences, New Delhi, India
2
Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
*Corresponding Author Email: [email protected]

ABSTRACT:
Background: Pacemaker is the recommended therapy for treating the conduction system disorders. As
permanent pacemakers are meant for life time use, a negligence and lack of knowledge can cause life threatening
complications so subsequent evaluation of knowledge among the patients is the first step towards maintaining
optimal quality of life. Objective: the main purpose of this study was to assess the knowledge and quality of life
of pacemaker patients during early and later phase after implantation of pacemaker with a view to develop an
information booklet. Methods: A descriptive cross-sectional study was undertaken using purposive sampling
among 100 patients (50 early and 50 later phase) following permanent pacemaker implantation from a Tertiary
care Hospital, India. Data was collected from June 2014 to December 2014 by means of a validated self-
developed pretested structured knowledge questionnaire and WHOQOL-BREF. Results: The Mean knowledge
score in later phase patients was higher than early phase patients (p = 0.008). Early phase patients had lower
quality of life in social relationships (p = < 0.0001) and environment domain (p = 0.014) when compared to later
phase. There was weak positive correlation of knowledge with quality of life in physical health (r = 0.32, p =
0.0206) and social relationships domain (r = 0.38, p = 0.0052) during early phase of pacemaker implantation.
Conclusion: Knowledge and quality of life was not optimal during early phase after pacemaker implantation.
Thus, development of an information booklet for these patients will help them to improve their self-care
activities while preventing further complications.

KEYWORDS: Knowledge, Quality of Life, Pacemaker Patients, Information Booklet.

INTRODUCTION:
Implantation of a cardiac pacemaker is the treatment of Other indication for cardiac pacing include hypertensive
choice in severe and/or symptomatic bradycardia. Sinus carotid sinus syndrome, neurocardiogenic syncope
node dysfunction is the most common indication for (vasovagal syncope), long QT syndrome, and sleep
permanent pacing, followed by AV node dysfunction1,2. apnea. Cardiac pacing today is an accepted and common
High-degree atrioventricular block and sick sinus treatment for patients with bradycardia, with almost
syndrome remain the major indications for implantation 600,000 pacemakers being implanted worldwide
of a cardiac pacemaker. annually3. Currently around 15000 pacemakers are
being implanted annually in India, in various centers
around the country. About 4000 pacemakers are being
implanted per year in All India Institute of Medical
Sciences (AIIMS), New Delhi. Currently, artificial
electrical cardiac pacing is no longer just a way to save
Received on 10.10.2016 Modified on 15.11.2016 patients' lives with atrioventricular blocks, becoming a
Accepted on 15.12.2016 © A&V Publications all right reserved
Asian J. Nur. Edu. and Research.2017; 7(1): 108-114. way to correct heart rhythm disturbances and
DOI: 10.5958/2349-2996.2017.00022.2 atrioventricular synchrony4. However, the implantation

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 Asian J. Nursing Edu. and Research 7(1): January- March 2017

procedures may cause uncommon but potentially life- The study has been approved by Institute Ethics
threatening infective complications, with an incidence Committee for Postgraduate Research, AIIMS, New
rate ranging from 0.5% to 5.2%5-7. In recent years the Delhi.
importance of health related quality of life (HRQoL) as
an outcome measure has increasingly been recognized. Data Collection Tools and Techniques:
This has particular relevance in cardiac pacing because Demographic Profile and Clinical Profile of the patients
the goal of therapy for most patients with chronic disease was collected using a self-developed pretested
is improvement in function, not cure. These measures questionnaire.
should be incorporated as one of the primary measures Knowledge Questionnaire:
of outcome in the evaluation of new therapies in chronic Self-Developed, validated, Structured Knowledge
diseases including cardiac pacing. Doing so, clinicians, questionnaire comprising of 31 questions was used to
patients, policymakers, health care providers, and assess the knowledge with regard to pacemaker among
HRQoL researchers gain experience with these the patients with permanent pacemaker implantation.
measures8. The minimum maximum possible KQ (Knowledge
questionnaire) score ranges between 0 – 53 where, total
The term quality of life (QOL) has many definitions. knowledge score was classified into 2 categories; Less
According to the World Health Organization, quality of than adequate (0 – 26) and Adequate (27 – 53). The
life is the "individual's perception of their position in life reliability was tested using test retest method.
within the cultural context and values that he lives as Cronbach’s alpha: 0.93. This tool was translated in Hindi
well as in relation to their goals, expectations, standards and translated back to English by Hindi Section, AIIMS.
and concerns"9. Several studies have shown deleterious
quality of life after implantation depending on duration Quality of Life Assessment:
of time and other aspects such as gender, age, co WHOQOL-BREF was used for Health related QOL
morbidities, psychological and sociocultural aspects. assessment. This is an abbreviated 26-item version of the
Also the pacemaker patients has been seen more prone to WHOQOL-100 which is Scored in four domains:
depressive disorder and anxiety disorder and there are domain 1: physical health, domain 2: psychological,
also physical complications related to implantation domain 3: social relations and domain 4: environment;
procedure10. Since limited researches has been done and separate items related to overall perception of
regarding knowledge and quality of life of pacemaker quality of life and general health. Higher scores denote
patients in India, the present study has been undertaken higher quality of life. Permission to use the tool was
related to the concerned issues like inappropriate taken from WHO prior data collection.
knowledge, misconception and their effects on quality
of life (QOL) of patients with pacemaker implantation. Data collection Procedure
The purpose of this study is to assess the knowledge with
regard to pacemaker and quality of life among
pacemaker patients during early phase (the time period
up to three months after pacemaker implantation ) and
later phase (the time period more than six months after
pacemaker implantation) with a view to develop an
information booklet.

METHODS:
A descriptive, Cross sectional survey was applied to
assess the knowledge and quality of life of patients after
permanent pacemaker implantation who were
registered/admitted in Cardiology wards/ Pacemaker
Clinic (CN center OPD), during the period from June to
December 2014, Department of Cardiology, AIIMS,
New Delhi. A total of 100 patients with 50 in each phase
of age group > 18 years and those who can understand
Hindi or English were enrolled using Purposive
sampling whereas patients with NYHA Class IV, COPD,
Chronic Liver disease, Chronic Kidney disease and
Neurological disorders and Patients in intermediate
phase (the time period between three – six months after
pacemaker implantation) were excluded from the study. Figure 1: Data Collection Procedure
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Statistical Analysis: STATA 11.2 version. A probability of (p<0.05) was

Descriptive statistics i.e. mean, median, percentage and accepted as significant.
standard deviation were used for selected socio-
demographic and clinical variables. Inferential statistics RESULTS:
i.e. Chi – square test / Fisher’s exact test was used to The total of 100 patients (50 in each phase) were
compare the categorical variables. Two Sample enrolled in the study where the mean age of patients was
independent t- test, was used to compare the knowledge 57.0 ± 14.1 years in early phase and 53.9 ±13.6 years in
score and QOL scores between early and later phase. later phase. Most of the patients were diagnosed with
Pearson correlation was used for association between complete heart block. The demographic and clinical
knowledge score and QOL domain scores. Data analysis profile of patients are shown in table 1 and 2
was done using BREF Syntax and statistical package respectively.

Table 1: Demographic characteristics of patients in early and later phase of pacemaker implantation n= 100
Variables Early phase (n=50) Mean ± SD Later phase (n=50) Mean ± SD p-value
Age$ 57.0 ± 14.1 53.9 ± 13.6 0.26
Frequency (%) Frequency (%)
2
Gender χ Male 38 (76) 34 (68) 0.37
Female 12 (24) 16 (32)
Place of stay χ2 Rural 20(40) 24 (48) 0.42
Urban 30 (60) 26(52)
2
Marital status χ Single 5 (10) 7 (14) 0.53
Currently married 45 (90) 43(86)
Types of Family χ2 Nuclear 18 (36) 23 (46) 0.30
Joint 32 (64) 27(54)
2 th
Education status χ Up to 10 16 (32) 13(26) 0.73
Up to 12th 13(26) 11(22)
Graduate 16 (32) 18(36)
Postgraduate 5(10) 8 (16)
2
Occupation χ Employed 22 (44) 19 (38)
Unemployed 14 (28) 18 (36) 0.68
Retired 14 (28) 13 (26)
Profession ¤ Student 0 (00) 1 (2)
House wife 9(18) 10(20)
Government Service 16(32) 17 (34)
Private Service 4(8) 6(12) 0.29
Business 612) 1 (2)
Farmer 8 (16) 4(8)
Others 7(14) 11 (22)
Monthly income (Rs.) ¤ <1000 5 (10) 6(12)
1000 – 5000 15 (30) 17(34) 0.15
5000 – 10000 8(16) 15 (30)
>10000 22 (44) 12(24)
$= Two Sample independent t test χ2= Chi square test; ¤ = Fisher’s exact test p<0.05

Table 2: Distribution of patients according to clinical characteristics during early and later phase of pacemaker implantation n = 100
Variables Early phase (n=50) Later phase (n=50) p-value
Frequency (%) Frequency (%)
Diagnosis ¤ 1 heart block 0 (00) 2(4) 0.05
2 AV block 4(8) 7 (14)
CHB 30(60) 24 (48)
LBBB 4 (8) 9 (18)
RBBB 3 (6) 6 (12)
SSS 9 (18) 2(4)
NYHA Class ¤ Class I 19(38) 17 (34)
Class II 26(52) 30 (60) 0.64
Class III 5 (10) 3 (6)
2
Modes of Pacing χ Single Chamber 11 (22) 18 (36)
0.12
Dual Chamber 39 (78) 32 (64)
χ = Chi square test; ¤ = Fisher’s exact test p<0.05
2

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 Asian J. Nursing Edu. and Research 7(1): January- March 2017

70% Both the early and later phase were found comparable in
< adequate 64% terms of physical health domain, psychological domain,
60%
60% Adequate overall quality of life and general health of WHO QOL-
BREF whereas there had been a significant difference
50% observed among both the phases in social relationships
40% domain and environmental domain of WHO QOL-
40% 36% BREF (figure 3).
30%

20%

10%

0%
Early Later
Figure 2: Knowledge level in Early and Later phase of Pacemaker
implantation

Knowledge level was found to be more in later phase

than the early phase of pacemaker implantation as shown
in figure 2. A significant difference was observed in the
mean knowledge score of patients early phase (24.8 ±
9.5) and later phase (29.8 ± 8.6) of pacemaker
implantation at p= 0.008 (table3). Figure 3: QOL of patients during Early and Later Phase of
pacemaker implantation
Table 3: Comparison of Knowledge regarding pacemaker in early
and later phase of pacemaker implantation n=100 There was a weak positive correlation of knowledge with
Variables Min – Max Early Later p-value physical health domain (p = 0.0206) and social
possible phase phase
score (n=50) (n=50) relationships domain (p = 0.0052) in early phase as
Mean ± Mean depicted in Table 4 .
SD ± SD
Total 0 – 53 24.8 ± 29.8 ± 0.008
Knowledge 9.5 8.6
Score
Two Sample independent t test,  p<0.05

Table 4: Correlation between Knowledge score and QOL domain score in early and later phase of pacemaker implantation n = 100
QOL Domains Early phase (n=50) Later phase (n=50)
Knowledge Knowledge
Overall quality of life r = 0.01 p = 0.89 r = - 0.03 p = 0.79
General Health r = - 0.04 p = 0.76 r = - 0.01 p = 0.94
Physical Health r = 0.32 p = 0.0206 r = 0.17 p = 0.22
Psychological r = 0.25 p = 0.07 r = - 0.02 p = 0.89
Social relationships r = 0.38 p = 0.0052 r = 0.01 p = 0.94
Environment r = 0.14 p = 0.31 r = 0.22 p = 0.10
Pearson correlation test, *p< 0.05

Table 5: Association between General health of quality of life and selected variables of patients during early and later phase of
pacemaker implantation n = 100
Variables Categories Scores of General health
Early phase (n=50) Later phase (n=50)
Mean ± SD p value Mean ± SD p value
Type of family Nuclear 58.3 ± 27.1 0.0377 65.2 ± 18.0 0.92
Joint 71.8 ± 17.6 65.7 ±20.9
Two Sample independent t test, p<0.05

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Table 6: Association between QOL in Physical Health domain and selected variables of patients during early and later phase of
pacemaker implantation n = 100
Scores of quality of life in physical health domain
Variables Categories Early phase (n=50) Later phase (n=50)
Mean ± SD p value Mean ± SD p value
Place of stay$ Rural 58.5 ± 12.3 0.67 58.1 ± 11.3 0.0275
Urban 60.3 ± 15.6 65.5 ± 11.4
Type of family$ Nuclear 52.5 ±10.5 0.0075* 60.0 ± 10.8 0.29
Joint 63.6 ± 14.7 63.6 ±12.6
Median (min – max) Median (min – max)
NYHA class€ I 64.2(21.4 – 92.8) 0.0396 60.7(42.8 – 92.8) 0.84
II 64.7(32.1 – 78.5) 60.7(25 – 78.5)
III 46.4 (35.7 –60.7) 64.2(46.4 – 71.4)
€ = Kruskal Wallis Test; $= Two Sample independent t test, p<0.05

Table 7: Association between QOL in Psychological Domain and selected variables of patients during early and later phase of pacemaker
implantation n= 100
Variables Categories Scores of quality of life psychological domain
Early phase (n=50) Later phase (n=50)
Mean ± SD p value Mean ± SD p value
Gender Male 61.9 ± 13.9 0.0299* 62.0 ± 10.0 0.44
Female 51.7±13.3 56.5 ±18.1
Place of stay Rural 57.7 ± 11. 6 0.47 53.2 ± 15.1 0.0092
Urban 60.6 ± 15.9 63.9 ± 12.5
Two Sample independent t test, p<0.05

Table 8: Association between QOL in Environment domain and selected variables of patients during early and later phase of pacemaker
implantation n= 100
Variables Categories Scores of quality of life Environment domain
Early phase (n=50) Later phase (n=50)
Mean ± SD p value Mean + SD p value
Place of stay$ Rural 46.2 ± 12.4 0.72 47.2 ± 11.0 0.0018
Urban 47.5 ± 12.3 59.6 ±14.8
$
Type of family Nuclear 43.4 ± 13.3 0.12 49.3 ±12.2 0.0476
Joint 49.0 ± 11.4 57.4 ±15.3
Occupation¥ Employed 46.0 ± 12.1 0.36 46.0 ± 11.8 0.0318
Unemployed 44.6 ±12.2 52.4 ± 14.9 0.030b
Retired 50.8 ± 12.5 62.2 ± 14.4
Median (min – max) Median (min – max)
Marital status# Single 40.6(21.8 – 46.8) 0.0475* 46.8(40.6 – 59.3) 0.30
Currently married 53.1(18.7 -65.6) 56.2 (28.1 -84.2)
Education status€ Up to 10th 40.6(18.7 – 62.5) 46.8(28.1 – 84.3)
Up to 12th 50.0(31.2 – 59.3) 56.2(40.6 – 75) 0.0153
Graduate 53.1(18.7 – 65.6) 0.10 46.8(28.1 – 78.1) 0.0072∞
Postgraduate 62.5(34.3 – 62.5) 65.6(56.2 – 84.3 0.0074£
# = Wilcoxon ranksum test; € = Kruskal Wallis Test; $= Two Sample independent t test; ¥ = One way Anova corrected with Bonferroni test,
p<0.05 (b = employed vs retired; ∞= up to 10th vs Postgraduate; £ = graduate vs postgraduate)

In the early phase, male had higher knowledge than type of family (p = 0.0075) and NYHA class (p =
female (p = 0.0343), also knowledge had association 0.0396), psychological domain with gender (p = 0.0299)
with occupation (p = 0.0224) and education status (p = and environment domain with marital status (p = 0.0475)
0.0093) whereas in later phase, knowledge showed during early phase of pacemaker implantation. During
association with gender (p = 0.0445), place of stay (p = later phase, place of stay had an association with
0.0176) and occupation (p = 0.0174). The finding physical health (p = 0.0275), psychological (p = 0.0092)
reported that higher the age higher the QOL in and environment domain (p = 0.0018). Again, type of
psychological (p = 0.0018) and environment domain (p = family (p = 0.0476), occupation (p = 0.0318) and
0.0024) during later phase of pacemaker implantation. In education status (p = 0.0153) had association with
terms of QOL, the overall quality of life was associated environment domain of QOL.
with monthly income (p = 0.0134), general health with
type of family (p = 0.0377), physical health domain with
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 Asian J. Nursing Edu. and Research 7(1): January- March 2017

Development of an Information Booklet: pacemaker can be done. 2) Development of educational

Based on the study findings, an informational booklet intervention and discharge counselling services for
was developed which focuses mainly on general pacemaker patients regarding home care management
information about pacemaker, components of and follow up teaching session in OPD can be organized
pacemaker, lifestyle modifications and self-care by nurses to prevent the complications thus improving
activities. It was developed under the guidance of guide the QOL of patients. 3) Institution should emphasize the
and co guides, validated by experts and translated to development of competent nurse practitioner with
Hindi with the help of experts from Hindi section, specific focus on pacemaker care. 4) Video teaching
AIIMS. After development of booklet, it was given to programme based on study findings can be developed
the patients to establish their understanding and and displayed in the OPD. 5) Further, research can be
usefulness of information and was found to be undertaken with large sample size, in a multi – centered
acceptable and useful. setting or on a different demographic and geographic
areas.
DISCUSSION:
This study revealed a significant difference in CONCLUSION:
knowledge score of pacemaker patients in early and later Quality of life assessment of patients after permanent
phase of implantation where majority (60%) had less pacemaker implantation in clinical practice can help
than adequate knowledge in early phase and most of the nurses to understand better the disease and treatment
patients (64%) had adequate knowledge in later phase. effect on one’s life, and to understand the preferences,
This finding is supported by other similar studies (11-14). expectations and requirements associated with the
In the present study, the early phase patients had low disease. Knowledge among the patients affect their
QOL in social relationships domain and in environment quality of life after pacemaker implantation. The study
domain. Mean QOL score of patients was higher in later findings support the need to have an educational
phase when compared to early phase in social intervention for patients in order to improve their
relationships domain and environment domain. The knowledge with regard to pacemaker resulting into
QOL in the physical domain was improved in both the positive self-care attitude and improvement of quality of
phases. These findings are supported by another study life. Thus, development of an information booklet for
which states quality of life in people with pacemaker is these patients will help them to improve their self-care
reported to be higher with longer duration after activities while preventing further complications.
implantation as reported by Vellone E et al15. Findings
also supported in a study by Van Eck JWM et al 16, FUNDING:
where it is concluded in most patients receiving a Nil.
pacemaker, HRQoL increased in the first year after
pacemaker implantation. In this study, there was CONFLICT OF INTEREST:
improved quality of life in social relationships domain in None declared.
later phase which is similar with the results reported by
Kurucová R et al17 but it is in contrast to the same study ACKNOWLEDGEMENT:
which showed that patients reported lowest quality of Authors thanks the WHO for providing permission to
life in psychological and spiritual domains while there use WHOQOL-BREF Questionnaire for the purpose of
was an improved QOL in psychological domain in the the study.
present study. In this study, Knowledge had a weak
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