The Effect of a Mobile Application on Treatment Adherence, Self-Management, and Quality of Life in Patients With Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention
Phase: NA
Conditions: Acute Myocardial Infarction (AMI), Mobile Health Technology (mHealth), Quality of Lifte, Treatment Adherence, Self Care
Sponsor: Trakya University

02.06.2025 
 
The Effect of The Mobile Application on Treatment Adherence, Self-Management, and 
Quality of Life in Patients with Acute Myocardial Infarction Undergoing Primary 
Percutaneous Coronary Intervention 
Ezgi KINICI DIRIK, Eylem PASLI GURDOGAN,  
 
Ezgi Kinici Dirik, Msc, RN, Research Assistant (Corresponding author) 
Department of Nursing, Trakya University Faculty of Health Sciences, Edirne, TURKIYE 
Orcid No: 0000-0002-5106-6013 
e-posta: ezgi.knc@hotmail.com 
 
 
Eylem Pasli Gurdogan, PhD, Msc, RN, Associate Professor  
Department of Nursing, Trakya University Faculty of Health Sciences, Edirne, TURKIYE 
Orcid No: 0000-0003-0711-2112 
e-mail: e.gurdogan@gmail.com 
 
Adress for Correspondence:  
Ezgi KINICI DIRIK, Msc, RN, Research Assistant 
Adress: Department of Nursing, Trakya University Faculty of Health Sciences, Edirne, 
TURKIYE, 22000 
Tel. number: 0 284 213 30 42 
Fax number: 0 284 212 61 07 
e-mail: ezgi.knc@hotmail.com 
 
 
 
 
 
 
 

Background and Aim: Acute myocardial infarction is a clinical condition with high mortality 
and morbidity rates. Ensuring patient adherence to treatments and lifestyle recommendations 
after discharge is crucial for effective post-acute myocardial infarction management. This study 
aimed to determine the impact of the mobile application on treatment adherence, self-
management, and quality of life in patients with acute myocardial infarction undergoing 
primary percutaneous coronary ıntervention. 
 
Study’s Methods 
Study design and sample 
The study was conducted as a prospective (6-month follow-up), two-group (control and 
intervention), randomized controlled, experimental study.  
 
The universe of the study consisted of patients who had their first time ST segment 
elevation MI (STEMI) undergoing PPCI in the Cardiology Clinic of a university hospital in 
Edirne, Turkey, between 01.11.2021 and 10.07.2024. In determining the sample of the study, 
power analysis was performed with reference to the study of Turan Kavradım and Özer (68). 
The effect size of the study was found to be 0.92 and considering this effect size, it was 
determined that it was sufficient to include a total of 54 patients, 27 in each group, at 95% 
power and 0.05 significance level. However, considering a 20% loss rate during the study 
period (30), it was aimed to reach a total of 66 patients, 33 patients for each group. Patients who 
volunteered to participate in the study were determined in accordance with the inclusion criteria. 
The selection of patients to the intervention and control groups was made using the simple 
randomization method. According to the randomization list, the groups were matched based on 
the time of discharge from the clinic of the patients. For patients who were discharged on the 
same day, the matching was based on their hospitalization times. The inclusion criteria were as 
follows: the patients who (1) had first time STEMI undergoing PPCI, (2) are over 18 years of 
age, (3) have a smartphone, (4) have internet access, (5) have orientation to place, time and 
situation, (6) have no problems with vision, hearing and speech, (7) are at least literate, (8) 
regularly come in for the doctor’s check up, and (9) volunteer to participate in the study. Among 
the volunteers participating in the study, those who wanted to leave the study (2 patients) and 
those who didn’t come in for the doctor’s check up (3 patients) were excluded from the follow-
up. Therefore, the study was completed with 61 patients, 30 in the intervention group and 31 in 

the control group. The study design and implementation were based on the principles in the 
CONSORT (Consolidated Standards of Reporting Trials) list  (Figure 1). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 1. Flow chart of design and recruitment of participants according to CONSORT 
statement 
 
 
 
 
Study Protocol 
Randomized (n=66) 
Allocated to intervention 
(n=33) 
Allocated to control (n=33) 
1st month 
follow-up 
3th month 
follow-up 
6th month 
follow-up 
Individual who wants to 
leave the study (n=1) 
Allocation 
Individual who didn’t come in 
for the doctor’s check up (n=1) 
Individual who wants to 
leave the study (n=1) 
Individual who didn’t come in 
for the doctor’s check up (n=1) 
No lost (n=0) 
Individual who didn’t come in 
for the doctor’s check up (n=1) 
Analyzed 
 (n=31) 
Analyzed 
(n=30) 
Analysis 

Education booklet 
In the study, firstly, an education booklet was created by the researchers to be used as an 
education material to provide self-management in patients with AMI. During the development 
phase of the education booklet, expert opinions were obtained from a total of 9 people, 
including 3 cardiologists, 4 academic nurses and 2 cardiology nurses. In line with the expert 
opinions, the necessary arrangements were made and an 18-page “Education Booklet for 
Patients Having Heart Attack” was created. 
Mobile application and web page control panel 
After the creation of the education booklet, the development process of the mobile application 
began. In the first stage, the content of the application was determined based on the education 
booklet and sample mobile application studies in the literature (30,66,71,73,74). In order to 
evaluate the content of the mobile application, expert opinions were obtained from 3 
cardiologists, 4 academic nurses and 2 cardiology nurses. 
 
In the second stage, a software company was contacted and the interface and logo of the 
mobile application called “MEDIFOLL” was designed. The interface of the application 
includes “Medication Information”, Blood P. & Pulse”, ‘Notifications’, ‘Lifestyle’ and 
‘Contact’ sections. In the “Medication Information” section, medication entries are made. When 
it is time to take each medication, the mobile application sends a medication reminder 
notification to the user. “Blood P. & Pulse” section includes the screen where blood pressure 
and pulse are entered. The “Notifications” section displays personalized reminders sent by the 
researcher to the users via the web page control panel. Personalized reminders are information 
provided by the researcher to patients regarding the things to be considered in the post-discharge 
process, which are included in the education booklet. The “Lifestyle” section has been created 
for situations where the education booklet is lost or cannot be accessed in their environment 
where they are located. This section contains the information contained in the booklet under the 
heading lifestyle changes. The “Contact” section allows users to communicate with the 
researcher. In this way, patients can send their questions to the researcher via message. 
 
In the third stage, a web page control panel was created that allows the mobile 
application to be controlled remotely, patient information to be viewed, data to be monitored, 
lifestyle information to be uploaded and viewed in the mobile application, personalized 
reminders 
to 
be 
sent 
to 
patients, 
and 
to 
becommunicated 
with 
patients 
(https://www.medifoll.com/,  https://www.medifoll.com/brave/login). 

 
In the fourth phase, the application was purchased from Google Play Store and App 
Store. In the fifth stage, the mobile application and website were tested by experts for 1 week 
to determine usability of them and errors. Finally, a pilot study was conducted with 4 patients 
and the patients were allowed to use the application for a month. Patients who participated in 
the pilot study were not included in the study. 
 
After the pilot study was completed, the Patient Information Form was filled out with 
all patients in the patient room before discharge. The researcher provided training to the patients 
in both groups in line with the educaiton booklet and it was delivered to the patients. 
MEDIFOLL application was downloaded to the mobile phones of the patients in the 
intervention group and user registration was made. Information was provided to them on how 
to use the application and how to enter data such as blood pressure and pulse rate. The times of 
the use of medications prescribed during discharge were planned together with the patients and 
they were provided with the opportunity to enter their medications into the application.  
 
Patients in the intervention and control groups were interviewed in the outpatient clinic 
1 month, 3 months and 6 months after discharge, and the Patient Information Form, İUBÖ ve 
MIDAS scales were filled out. The flow chart of the research is presented in Figure 2. 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determination of the content of “Educational Booklet for Patients Who Have Had a Heart 
Obtaining expert opinion for the educationnal booklet and developing the booklet 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   Figure 2. The flow chart of the research 
 
Data collection tool 
Determination of the mHealth content (MEDIFOLL) and obtaining expert opinion 
Creation of the logo and user interface for the mHealth 
Creation of a web page control panel 
Uploading the mHealth to Google Play and App Store 
Testing the usability of the mHealth and the website 
Filling out the “Patient Information Form” to patients in the intervention and control 
groups 
Providing training to the both groups in accordance with the educational booklet 
Downloading the mHealth to the mobile phones of the patients in the intervention group 
and teaching how to use it to them. 
Filling out the Patient Information Form, MARS and MIDAS to the patients in the 
intervention and control groups at 1st month after discharge 
Filling out the Patient Information Form, MARS and MIDAS to the patients in the 
intervention and control groups at 3th month after discharge 
Filling out the Patient Information Form, MARS and MIDAS to the patients in the 
intervention and control groups at 6th month after discharge 

Patient Information Form: It, developed by the researcher through a literature review 
(15,18,30,36,59,67), consists of questions about the socio-demographic, the lifestyle, and the 
disease characteristics of the participants. 
Medical Adherence Report Scale (MARS): The scale was developed by Horne and Hankins to 
determine medication adherence in individuals with chronic diseases. The Turkish validity and 
reliability of the scale was performed by Şen et al. (21). The scale has 5 items, one sub-
dimension and 5-point Likert type.  The total score obtained from the scale varies between 5 
and 25. A high total score indicates adherence to medication treatment, while a low score 
indicates non-adherence to medication treatment. The Cronbach alpha value of the scale was 
found to be 0.78 in the study of Şen et al. (21) and 0.68 in this study. 
Myocardial Infarction Dimensional Assessment Scale (MIDAS): The Turkish validity and 
reliability of the scale, developed by Thompson et al., was performed by Yılmaz et al. (71). The 
scale is used to determine the HRQoL of individuals with MI and consists of 35 items and 7 
sub-dimensions (physical activity, insecurity, emotional reaction, dependency, diet, concerns 
over medication, and medication side effects). This 5-point Likert-type scale is scored between 
0-4. Scores that can be obtained from the scale and its sub-dimensions vary between 0-100. The 
score is calculated with the formula: (Total score obtained from the sub-dimension/highest 
score that can be obtained from the sub-dimension) x100. As the scores obtained from the scale 
increase, the perceived HRQoL worsens. In the study of Yılmaz et al. (71), the Cronbach alpha 
value of the sub-dimensions of the scale was found to be between 0.79-0.90. In this study, it 
was found to be 0.93. 
Ethical Consideration 
The study was conducted in accordance with the Declaration of Helsinki. The study protocol 
was approved by the Scientific Research Ethics Committee of XXX University Faculty of 
Medicine (xxx), and written permission was obtained from the institution where the study was 
to be conducted (xxx). Necessary written consents were obtained from the patients. 
Data Analysis 
The data were evaluated using the IBM SPSS 22.0 (Statistical Package for Social Sciences 22.0) 
package program. The data to a normal distribution was examined by the Kolmogorov–Smirnov 
test. The number and percentage distribution were used to evaluate categorical data, and 
meanstandard deviation was used to evaluate continuous data. In the analysis of the data, Mann 
Whitney U test was used to compare the mean scores that did not show normal distribution 
between the groups and Student's t test was used to compare the mean scores that showed 
normal distribution. Pearson chi-square test and Fisher-Freeman-Halton Exact test analysis 

were used to determine the relationship between groups for nominal variables. The statistical 
significance limit value was accepted as p<0.05.