The majority of the participants in the current study were male, married, and unemployed. Most of the participants suffered from coexisting chronic illnesses and had been diagnosed with CAD for at least one year, and nearly half of the participants had undergone at least one to two catheterization procedures in the past. As for the participants’ healthy lifestyle practices, most of the participants were either current smokers or ex-smokers, and the majority exercised rarely. Approximately one third of the sample described their psychological health as being "good", and depressive symptoms were present in 56.9% of the participants.
Our data also indicated that many of the participants were non-adherent to healthy lifestyle behaviors, especially in the areas of physical activity, maintaining a healthy diet, and weight loss. The two most commonly adopted lifestyle changes were quitting smoking and medication compliance. Meanwhile, the lifestyle change that was the least commonly adopted and least adhered to was physical activity.
The findings of our study also revealed that smoking status, gender, and number of previous catheterization procedures were the only predictors of adherence to healthy lifestyle behaviors. Being male, having undergone a high number of catheterization procedures, and being a non-smoker were found to predict the participants’ adherence to healthy lifestyle behaviors. Interestingly, even though depressive symptoms were present in more than 50% of our sample, this variable was found to be an insignificant predictor of adherence.
These findings on the levels of adherence among our sample are similar to the findings reported by studies conducted in other Eastern countries [24, 25, 26]. For example, Ghaddar and colleagues [25] reported that patients with CAD had low adherence to physical activity (10.8% − 14.7%) and weight loss (33.3% − 61.3%) but had satisfactory adherence to taking medications (83% − 89.9%). On the contrary, high adherence rates to healthy lifestyle behaviors have been reported by studies conducted in Western countries. For example, in the study of Griffo and colleagues [27], 89.9% of the patients showed good adherence to treatment, 72% to maintaining a healthy diet, 51% to following exercise recommendations, and 74% to quitting smoking. These differences between the findings of Eastern studies and the findings of Western studies may be attributed to the influence of culture on patients’ attitudes towards adopting healthy lifestyle behaviors. For example, studies conducted in Eastern countries have found that non-adherence to healthy lifestyle behaviors may be due to patients having busy schedules, an unwillingness to adopt healthy lifestyle behaviors, the presence of comorbidities, and patients placing more emphasis on attending social gatherings than on adhering to a healthy lifestyle [24, 26].
Our findings on the gender-based differences in the participants’ adherence to healthy lifestyle behaviors are consistent with other studies conducted in Jordan, which have found that men are more adherent to healthy lifestyle behaviors than are women [28, 29, 30, 31]. For example, in the study of Ammouri and colleagues [28], Jordanian men were found to be significantly more physically active than Jordanian women. Maintaining a healthy lifestyle may be challenging for women in Jordan due to several factors, which include problems in transportation, low social status, low self-efficacy, and lack of spousal support [32]. Vari and colleagues [33] also explained that gender behaviors, including the adoption of healthy lifestyle behaviors, are defined by sociocultural expectations. In Jordan, women are expected to place great emphasis on family-oriented tasks and caring for the family, which may mean that they pay insufficient attention to adopting healthy lifestyle behaviors such as physical activity. Future studies are needed to further investigate the other factors which may contribute to gender-based differences in adherence to healthy lifestyle behaviors in the Middle Eastern context. It is noteworthy that in the present study, no gender-based based differences in adherence to healthy lifestyle behaviors were identified by the t-tests; however, the regression models indicated that males had higher adherence than did females. The difference between the findings of the two statistical models may be attributed to the fact that regression analysis estimates the significance of a variable on an outcome after controlling for the effect of other variables, while t-test does not control for such an effect [34]. Therefore, estimates based on regression models can be more reliable than the estimates of t-tests.
A positive association was found between adherence to healthy lifestyle behaviors and the number of previous cardiac catheterization procedures, indicating that the participants are aware of the importance of adopting healthy lifestyle behaviors in order to prevent further CAD episodes or complications. Kayaniyil and colleagues [35] explained that knowledge of diagnostic tests and interventional procedures allows patients to clearly understand their condition and enables them to make educated decisions regarding their health.
Smoking status was also found to predict adherence among the participants in this study. Participants who had never smoked had better adherence to healthy lifestyle behaviors than current smokers or ex-smokers. In the study of Sharma and Agrawal [36], knowledge of the harmful effects of smoking on CAD was found to increase patients’ adherence to healthy lifestyle behaviors. Another interesting explanation is provided by Masiero, Lucchiari, and Prave ttoni [37], who reported that smokers and ex-smokers might have a cognitive distortion called “optimistic bias”. This group of patients tend to overestimate the impact of their decisions and are too optimistic towards their future and their capacity to monitor their health consequences.
Studies in the literature have reported contradictory findings regarding the impact of depressive symptoms on adherence to healthy lifestyle behaviors among CAD patients. Although the majority of studies have reported that depressive symptoms predict poor adherence to healthy lifestyle behaviors among CAD patients [38, 39, 40], one study [41] suggested no such relationship, which is consistent with our findings. Although many of the participants in the present study reported having depressive symptoms, this does not necessarily mean that they are clinically depressed. According to Fogel [42], depression had the most significant impact on adherence among cardiac patients during hospitalization. Therefore, the fact that our participants were recruited from outpatient cardiac clinics may justify the weak relationship between depressive symptoms and adherence to healthy lifestyle behaviors indicated by our results.