Vol.6, No.5, 364-373 (2014)
http://dx.doi.org/10.4236/health.2014.65053

HealthAssessment of a portfolio as an effective tool topromote self-management among patients withischemic heart diseases: A preliminary trial
Haruka Otsu1, Michiko Moriyama2, Yuasa Yuka3, Toyonori Omori4
1

Graduate School of Health Sciences, Hirosaki University, Hirosaki, Japan; h_otsu@cc.hirosaki-u.ac.jp
Division of Nursing Science, Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan;
morimich@hiroshima-u.ac.jp
3
Hiroshima University Hospital, Hiroshima, Japan; riyuasa@hiroshima-u.ac.jp
4
National Institute of Health and Nutrition, Shinjuku, Japan; green_omori@yahoo.co.jp
2

Received 7 January 2014; revised 4 February 2014; accepted 11 February 2014
Copyright © 2014 Haruka Otsu et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In accordance of the Creative Commons Attribution License all Copyrights © 2014 are reserved for SCIRP and the owner of the intellectual
property Haruka Otsu et al. All Copyright © 2014 are guarded by law and by SCIRP as a guardian.

ABSTRACTPortfolio has been used as an approach to promoting self-learning in the field of education andits effectiveness was reported in school education. The purpose of this study was to assess
effectiveness of portfolio as a tool for educating
patients with ischemic heart diseases as selfmanagement behavior in terms of applicability
and efficacy. Subjects of this study were seventeen patients who had myocardial infarction or
angina. They were assigned to collect information about their themes chosen from diet, exercise, alcohol intake, smoking cessation, andstress management and gathered in files. Thirty
minutes face-to-face educational interviews
were conducted by a nurse for once per monthover three months. Self-management, self-efficacy, and physiological data were evaluated forbaseline and 3 months. Two participants
dropped within two months (completion rate is
88.2%). The results showed that portfolio was
effective as a self-management education toolon patients who were willing to participate, but
did not improve physiological data if they did
not continuously implement lifestyle change.
Moreover it was dangerous when the patientsacquired incorrect information on diseases. For
these patients, health education by health professionals is required prior to conduct portfolio.
Attributes fit for portfolio were assessed. Effectiveness of portfolio related to high self-efficacy
and high self-management, but did not relate to
Copyright © 2014 SciRes.

living status, having job, educational background,and health locus of control.

KEYWORDS
Portfolio; Ischemic Heart Diseases;
Self-Learning; Self-Management; Self-Efficacy

1. INTRODUCTION
Patient education is a key to prevent recurrences andexacerbation of myocardial infarction. The purpose of
the secondary prevention is to enhance recognition of
disease condition, provide knowledge and skills for lifestyle modification, and emphasize the importance ofproper and continuous medical intervention [1]. With thegoal of achieving behavior modification, patient education based on principles of adult learning (learning fromexperience) has proved more effective than informative
learning administered in a didactic manner by healthcare
professionals [2,3].
A number of cognitive behavioral theories also showhigh quality evidence of developing self-efficacy througha method consisting of small steps in goal-setting typeeducation [4,5]. Group guidance using group dynamics
through peer support, individualized education utilizing
cardiac rehabilitation, distant education through internet
and telephone, self-monitoring using a journal kept by
the patient, methodology using visual materials such asDVDs, as well as traditional face-to-face interviews arereported as methods of patient education [2,6]. However,a little payment is made for patient education under theJapanese health insurance system, therefore most patient
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education is provided in just one session of no more than
one hour using booklets that are available nationwide [7].
Booklets, brochures, and DVDs are easy-to-use approaches in the comparative efficacy of patient education,
but patients tend to become passive and it is more difficult to modify their behavior than to be educated throughface-to-face education, counseling, and support groups[6]. Booklets and brochures, on the other hand, also havedisadvantages because it is difficult to correct wrong understandings among patients and to teach them to adjust
to individual situations [8]. Individual face-to-face education is the most effective approach in order to obtain
efficacy of implementation when ease of use is not considered [6].
Portfolio has been used as an approach to promoting
self-learning in the field of education [9,10] and its effectiveness was also reported in postgraduate and undergraduate education for nursing and medical professionals[11]. If this education method is useful for fostering selflearning, it might be applicable to the education on patients who need to acquire self-management skills. We,
therefore, consider the portfolio as a tool for educating
patients with ischemic cardiac disease with the aim oflifestyle modification. There are some studies on portfolio which were applied to patient education, but thesewere for patients with schizophrenia and type 2 diabetes.
In these studies, portfolio was reported to be effective;
however, participants were limited to only one to threecases [12-14]. Hence, we investigate effectiveness of theportfolio as a tool for educating patients with ischemic
heart diseases to promote self-management behavior interms of applicability and efficacy.

1.1. Operational Definition of the Term
Portfolio: Portfolio is one methodology for promoting
self-learning in patients. Patients can review their progress
and the efforts which they have made in learning information by using the portfolio, and an instructor (a nurse)
evaluates the information in the portfolio. Basically, thisis a process of developing patient perception and giving
support to properly acquired self-management behavior.

1.2. Framework of the Concept in This Study
The framework of the concept in this study is shownin Figure 1.

specific experiences
practical attempt

implementation of portfolio
reflecting observationinteraction with a nurse

abstract ideas

plan for implementation
advice and evaluation by a nurse

3651) Process of modifying patients’ behavior by using
portfolio
Kolb [15], who developed a theory of experiential
learning, stated that learning in adulthood has a learning
cycle with 4 different stages: 1) doing or initiating related to a new experience (concrete experience), 2) skillsof observation and reflection through the perspective of
the new experience (reflective observation), 3) analyticalability based on reflective observation to produce an integrated concept (abstract conceptualization) and 4) skills
in decision-making which permit the use of this newconcept for implementation and problem solution (active
experimentation). We added a plan for implementation to
the cycle of learning and intervention from a nurse topromote this cycle. Figure 1 demonstrates the process of
how learning effects appear among patients in this learning cycle.
In particular, patient attitude towards assignments is
affected by circumstances such as ease of access to source
material and specific experiences. During portfolio implementation, they are proactive in collecting the necessary information through a system of trial and error, andreflect on their usual behavior in comparison with thosein collected information from a variety of angles (reflective observation). Moreover, they consider future desirable behavior (abstract conceptualization), plan strategies
for implementation (implementation of the plan), andcarry out these strategies (active experimentation). Finally, new modified behavior becomes meaningful throughevaluation by a nurse. Thus, it is considered that theportfolio implementation contributes to adult learning
through this process.
2) Portfolio effects: setting evaluation indicators
Self-efficacy will be achieved in the beginning if adultlearning is promoted. After that, self-management behavior will be achieved as a result and finally physiological data will improve.

2. METHOD
2.1. Participants
Inclusion criteria: Participants were patients diagnosed with myocardial infarction or angina pectoris in
the past 6 months, who made regular (once per month)
hospital visits in a general hospital and agreed to participate in this study.

improvement ofself-efficacy

promotion ofself-management

improvement ofphysiological data

Figure 1. A framework of the concept in this study.

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Exclusion criteria: Patients who have cognitively impaired or physical difficulties for portfolio implementation, and who have serious diseases such as cancer orbrain disease and mental disabilities were excluded.
We asked a physician to introduce patients who filled
the criteria, and we informed gist of this study to the patients and obtained their consent.

2.2. Period of the Study
Enrollment of participants was conducted from June 1
to 30, 2010. Intervention was carried out from July 1 to
October 31, 2010.

2.3. Study Design
A pre-post comparison design within the intervention
group was used as applicability on participants who wasbeing examined for the first time.

they learned. Next, the nurse evaluated it and praised thepatient, with asking them where they collected the information and what they had noted in comparison with
their lifestyle habit. After the patient and the nurse discussed this, the nurse asked about implementation ofself-management, reasons for non-implementation, results, improvements, and what participants had noticed
and learned after 2 months. If the patients had insufficient knowledge, the nurse corrected this and provided
them with accurate information. In addition, the nurse
asked about data collection sources and gave advice aboutfinding them.
Meanwhile, we set the intervention period as threemonths because participants with myocardial infarction
were assumed to be able to continue self-management if
they keep high self-efficacy for 3 months after discharge
from a hospital. Behavioral modification also occurred
immediately after receiving instruction and significant
difference was observed after 3 months [16].

2.4. Procedures
The procedures for this study are shown in Figure 2. 1)
At the first interview, participants received files, sticky
notes, and a pen. A nurse explained the purpose of thisportfolio, implementation methods, and enhancement
details. 2) Participants selected one theme in which they
were interested from diet, exercise, reduction of alcoholintake, smoking cessation, and stress management on selfmanagement of myocardial infarction and angina pectoris, and they collected information about these themes
and kept it in their files. Furthermore, if they noticed
anything in particular, they were required to write it on a
sticky note. 3) Face-to-face interviews were conducted
one, two and three months after intervention commenced.
These were conducted by a nurse in a private room for 30
minutes during hospital visits. First, participants showed
the collected information to the nurse and explained what

2.5. Evaluation Indicators and Evaluation
PointsSelf-management and self-efficacy were evaluated as
primary endpoints, and physiological data were evaluatedas secondary endpoints.
1) A questionnaire to evaluate the self-management
behavior of patients with ischemic heart disease [17](hereinafter referred to as “scale of self-management behavior”)
This is a specialized scale for evaluating self-management behavior in ischemic heart disease, which consists of 32 items with answers ranging from “never (1point)” to “always (4 points)”. High scores are indicatedas excellent self-management behavior.
2) The scale of self-efficacy on health behavior in
Chronic Disease Patients [18]patients

nurse
Figure 2. A portfolio method in this study.
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This scale consists of 25 items and has two sub-concepts, which are positivity of copying behavior with respect to the disease, and feelings of control with respect
to health. Answers are ranging from “not applied at all (1point)” to “well applied (4 points)” by degree of performance. The highest score is 96, and a high score indicates high self-efficacy.
3) Physiological data
Weight, body-mass index (BMI), abdominal circumference, blood pressure (systolic and diastolic pressure),
HDL-cholesterol, LDL-cholesterol, and triglycerides (TG)were collected.
4) Descriptive evaluation of portfolio implementation
This includes whether the portfolio had been implemented, the process of behavior modification, and evaluation after implementation. It also includes whether
information was collected and the contents of it were
descriptively evaluated.
Scales of self-management and self-efficacy were administered to the participants, and physiological data
were collected from their medical records before the firstintervention and immediately after it (3 months). Weight,
abdominal circumference, and blood pressure were measured by the nurse at each interview.

2.6. Attributes Affecting Portfolio
Implementation
Demographic profiles, such as age, sex, marital andliving status, occupation, academic background as a basic attribute, diagnosis, experience of lifestyle education
by medical professionals, and lifestyle habits of alcohol-intake and smoking were evaluated at the beginningof intervention. Locus of control was evaluated with thefollowing scales.

2.7. Japanese Version of the Health Locusof Control Scale [19] (JHLC)
This scale measures causal attribution with respect tohealth and disease (locus of control) on the basis of individual belief systems. This scale modified the original
health locus of control scale [20] to fit Japanese belief
system. The factors in health and disease tend to be attributed to the following 5 factors: Internal (oneself),
Family, Professional (medical professionals), Chance (accident), Supernatural (key player beyond oneself such as
Shinto and Buddhist deities and spirits). Each subscale isevaluated and a high score indicates a strong tendency.

2.8. Data Analysis
The contents of portfolio implementation by participants were described in the learning process from theviewpoints of changes in cognition and behavior. BeCopyright © 2014 SciRes.

367

cause based on the nurse’s report, we found two types ofparticipants: voluntary participate and involuntary participate, we divided the participants into two groups andcompare with them. Participants who felt reluctant tocollect information and/or quit portfolio activity wereplaced as involuntary group; whereas participants who
felt interesting in collecting information and voluntarily
involved in portfolio activity were placed as voluntarygroup.
Chi-square test was conducted on baseline comparisonof participants’ attributes. Analysis of Variance (ANOVA) was used on baseline comparison of scales andphysiological data. Repeated measure of two-way ANOVA and analysis of covariance (ANOCVA), when baseline comparison had significant differences, were applied
for evaluating chronological changes of all indicators. To
examine influence of gender during implementation,
chisquare test was utilized between both sexes. To evaluate change in abdominal circumference between thetwo groups and time, repeated measure of two-way
ANOVA was conducted.

2.9. Ethical Attention
The study was carried out with the approval of ethicalcommittees of a hospital. Participants agreed to participate in this study after receiving an explanation andsigned in the consent form.

3. RESULTS
3.1. Completion Rate of This Study
Seventeen outpatients agreed and were referred to thisstudy; however, two dropped out; one (male, age 53,
living with a family, having a spouse, works as a carpenter, drinks beer 1.5 L/day, smoke 1 pack of cigarette/day)
dropped out within one month due to time constraints;
the other (male, age 50, living with a family, having a
spouse, a company employee, stopped drinking and smoking after the attack) dropped out after two months due toa health problem. Finally, 15 completed three times interviews and were analyzed (completion rate is 88.2%).

3.2. Participants’ Situation Concerning
Basic Attributes
Average age was 60.1 ± 11.7 (range from 33 to 79; in
30’s 1, in 40’s 1, in 50’s 3, in 60’s 7, in 70’s 3). There
were 11 male (73.3%) and four female (26.7%); four
lived alone (26.7%) and 11 lived with their families. Ten
had jobs (66.7%), of which three were female and seven
were male. Two graduated from junior high school, eightfrom high school (53.3%), and three from university.
Seven (46.7%) had experienced lifestyle education suchas diet, exercise, and smoking cessation from medical
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professionals. Two (13.3%) smoked and four took alcohol (26.6%). Seven were diagnosed as acute myocardiac
infarction, and eight as angina pectoris.

3.3. Evaluation of Portfolio Implementation
Participant implementation status
Fourteen participants (93.3%) collected information in
the portfolio in the 1st month, 11 (73.3%) in the 2ndmonth, and eight (53.3%) in the 3rd month. Six (40.0%)
implemented the portfolio in the 1st month, nine (60.0%)
in the 2nd month, and six (40.0%) in the 3rd month. The
contents of collected information by participants included
ischemic cardiac disease explanation such as “myocardial
infarction and other diseases”, “the most recent medical
therapy for myocardial infarctions”, “low sodium dietand hypercholesterolemic diets”, and “main points of exercise”. During three month, eleven participants (73.3%)
collected information more than once, six (40.0%) morethan twice, and four (26.7%) more than three times.
Participants who implemented the portfolio involuntarily (Table 1)
Nine out of 15 participants (60%) implemented theportfolio involuntarily because they could not find information by themselves, and stopped collecting information or showed negative behavior, and could not change
their behavior. Five of them self-reported that they did
not have any experience of having education from medical professionals. Their information sources were mainly
newspapers, but one participant collected information

other than newspapers when he could not find any information in newspapers. Only one participant used theinternet.
Newspapers mainly provided information about disease explanation and its medical therapy, as a result, participants gave up the assignment because they could not
find any useful information for them. They implemented
general advice from colleagues, friends, and families. This
information, however, included misleading information,
and as a result, they implemented the wrong health behavior.
As summary, participants could not obtain necessary
information, even though they read an article, and feltthat the information in newspapers was not suited tothem. Therefore, they gave up collecting information andcarried out the general advice of their colleague regardless of whether it was suited for their health or not. Someof them asked for support from their families, but they
could not find out accurate information.
Participants who implemented the portfolio voluntarily (Table 2)Six participants implemented the assignment voluntarily, and their lifestyle habits changed effectively after
three months interventions. Four out of six participants
did not have any experience of being educated at healthcare facilities regardless of their educational level.
They did not show emotional difficulties in collecting
information and enjoyed doing it from the beginning.
They took pleasure in obtaining new information and

Table 1. Participants’ behavior in those who implemented the portfolio involuntarily.
Resource of Portfolio
Only newspapers

n=9
6

Only newspapers, but could not search by themselves, asked family for help (family helped to cut out newspaper articles)2

Only newspapers, due to no information found, then asked friends/colleagues

2

Only newspapers, due to no information found, then asked a doctor/nurse

1

Due to no information found in newspapers, read magazines

1

Newspapers, TV, and internet, but was not able to find information needed1

Response to information
Articles were all about disease and medical treatment. not relevant to them (confused, difficult)8

Articles described patients’ experiences (story) were useful3

Newspaper articles did not fit their condition/situation (confused)1

Colleagues gave advice (most of them were misleading and incorrect)

1

Doctors did not give examples suitable to his lifestyle

1

Quit searching because of stress1

Action taken (final results)
No information possible to implement, so followed general advice by others (mostly incorrect)

5

Quit portfolio. Listened the nurse’s advice, but did not implemented

5

Quit portfolio, gave up everything “nothing helpful”

2

Continued to search for articles, but could not find nor implement

1

Serched articles, boasted to his colleagues what he found, but did not appliy to him

1Multipule answers

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369

Table 2. Brief overview of changes in patients who implemented the portfolio voluntarily.
IDbasic attributes

attitude

key person

sources of portfolio

Age: 68, male
lives with family
no job

loved reading
newspapers and was
unbothered by reading it

familycollected not only from newspapers but also magazines and pamphlets

Change process1

Collected articles on the disease and implemented diet and exercise. Based on the nurse's advise, corrected misunderstandings. Continued to do
diet and exercise properly. His collection grew larger to include articles about stress.
Evaluation of portfolio

His work benefited him and felt satisfaction. Cut back on eating mayonnaise and eggs. Lost weight and kept improving.

Age: 57, male lives withvolunteers for good causesfamily no job

wife and son

got necessary information from dietician, and borrowed
or bought books, compiled information in notebook

2 Collected information on the theme of diet and implemeted it. The nurse was impressed with his behavior and encouraged him to continue,
telling him the proper amounts and criteria to combat his self-imposed strict constraints. His consciousness changed as well.
Got to know about cholesterol-rich food. His family also changed. Changed to a low-sodium diet and felt that food was salty when he ate out.
Felt good and his stress decreased. Understood himself well because he obtained new knowledge and hoped to continue like this.
takes things easy
usually reads newspaper,
when finds something
relevant, clips it

Age:33, male
lives with his familybusiness position3

nomainly read newspaper and clipped relevant information.
read pamphlets relevant to health

Clipped newspaper articles as always when caught his attention. The nurse advised him to use the information step by step taking a look at his
lifestyle. When he faild to collect any new information, the nurse encouraged him with advice. Found importance in having peers.
Acquired sufficient knowledge, though his knowledge was unclear before. Accepted his disease as it was and took resonsibility for prevention.
Age:70, female lives
alone sales position

wants to live with hersister with good healthsisterborrowed or bought books about diseaseor medical therapy and also read newspapers

Found that she did not know about her disease at all, so started to think about getting an understanding of her disease. Tentatively started diet,exercise, and self-monitoring. The nurse approved her behavior change and advised her to continue them. The nurse connected the things that
4 this patient realised in daily life to the contents of a textbook. The nurse advised her to keep working hard and to take time and not get upset if
her weight plateaued. Started to watch out for various things and continued to improve. Reviewed her implementation in the context of theoutcome of her lab data.
Felt the need to learn and got into reading various things daily things. Her consciousness changed and she realised that her implementation leadto good results. Her lifestyle habits changed such as diet, low-stress, more regular lifestyle, and she continued to measure her weight.
Age:66, male lives withfamily no job

always love to lookfor new informationwife

read newspaper and internet, searchedwebsite if did not understand newspaper articles

First researched on wrong information, then gradually reached to right information by the nurse's advoice. The nurse approved his collection
5 and advised him to focus on topics. Reviewed his dietary life and told his wife where wanted to make changes. The nurse approved his approach and advised him to continue.
The portfolio was beneficial. Intensive learning during this time was useful because could reconsider his daily habits and could also pass onwhat he learned to his wife.
Age:61, female
lives alone
restaurant businesswants to review her lifestyle

nobodyno information in newspapers, went to bookstores, but could not get
good information, then hospital leaflets advised by the nurse

Researched in newspapers but no helpful information. But wanted to go forwarded, the nurse advised her to use the leaflets available at the
6 hospital as a reference. Read a booklet at a hospital and found the necessary information. After that, she became more aware of her lifestyle
habits.
Started by doing whatever she could and ate a lot of vegetables, reduced sodium and weight, and started paying attention to meals overall.
Bought a blood pressure machine and started measuring it. Started walking. Made sure to research unclear points until understood them. As aresult, her aches and pains disappeared and wants to continue with the portfolio.

knowledge. They researched newspaper articles, went tolibraries, researched on the internet, and then found out
information from health professionals. They mainly collected information about the disease in the first month
Copyright © 2014 SciRes.

and then gradually focused on specific themes according
to the nurse’s advice and then they were about to collectthe necessary information. They particularly looked backon their lifestyle habits and after that set specific goals
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H. Otsu et al. / Health 6 (2014) 364-373

and incorporated them into their lifestyle.

group as we expected after three months of intervention.
Improvement of self-management scores was statisticallysignificant within the group (p = 0.004) (Table 5).

3.4. Attributes Affecting the Portfolio
Implimentation
The attributes that were compared between voluntaryand involuntary participants with respect to portfolio
implementation are shown in Table 3. Any attribute did
not specifically contribute to voluntary activity. Age, living arrangement, and having job did not affect; however,more people with a spouse were in involuntary group,and more people with financially satisfied and higher
educational background were in the voluntary group.
Self-management and self-efficacy were higher in thevoluntary group, but it was no statistically significant.
No differences in health locus of control, internal andexternal (chance, supernatural) were found. The ratio of
portfolio implementation of collecting information overthree months was significantly higher in females than inmales (p = 0.033) (Table 4).

3.5. Changes in Primary Endpoints
Self-management and self-efficacy in the voluntarygroup were higher than those in the involuntary group in
the baseline, and the scores improved in the voluntary

3.6. Changes in Secondary Endpoints
The baseline comparison of physiological data wasshown in Table 3, and the chronological changes wereshown in Table 5. The results showed no significant
changes in any indicators. As shown in Table 6, thegroup of continuous implementation of contents collectedin the portfolio for 3 months was significantly improvedin comparison with the group of continuous implementation of contents collected in the portfolio for less than 2months (p = 0.036).

4. DISCUSSION
4.1. Applicability of Portfolio as a Tool for
Patient Education for Patients with
Ischemic Heart Disease
All participants consented by themselves; however,nine implemented the portfolio involuntarily. Moreover,they could not collect proper information and as a result
they had incorrect information or could not judge which

Table 3. Baseline comparison between the groups.
voluntary group n = 6

involuntary group n = 9

p-valuesex (male)

4 (66.7%)

7 (77.8%)

1.000

a

age (years old)60.7 ± 11.0

59.2 ± 13.7

0.817

b

living alone

2 (33.3%)

2 (22.2%)

1.000

a

person with a job

4 (66.7%)

6 (66.7%)

1.000

a

elderly person (age 65 over)

3 (50.0%)

3 (33.3%)

0.622

a

marital partner (yes)3 (50.0%)

7 (77.8%)

0.329

a

high school graduate (or higher)

5 (83.3%)

7 (77.8%)

1.000

a

financial situation (satisfied）

5 (83.3%)

5 (55.6%)

0.580

a

self-management (score)

103.8 ± 13.5

100.6 ± 11.5

0.622

b

self-efficacy (score)

81.5 ± 12.7

77.9 ± 9.6

0.541

b

Internal

22.3 ± 4.2

21.8 ± 3.9

0.798

b

Family22.5 ± 5.5

18.7 ± 3.8

0.134

b

Professional

19.2 ± 5.6

20.4 ± 3.7

0.600

b

HLC (score)aChance15.2 ± 5.6

16.7 ± 6.9

0.665

b

Supernatural

13.3 ± 3.3

13.9 ± 3.4

0.760

b

weight (kg)66.4 ± 5.7

68.7 ± 15.8

0.748

b

BMI

24.6 ± 2.2

24.5 ± 3.9

0.961

b

abdominal circumference (cm)

91.1 ± 6.7

90.5 ± 9.0

0.894

b

*

b

systolic blood pressure (mmHg)

119.7 ± 14.2

138.7 ± 17.6

0.046

diastolic blood pressure (mmHg)

71.7 ± 7.1

77.1 ± 13.6

0.386

b

HDL (mg/dl)

44.7 ± 8.2

50.9 ± 11.4

0.211

b

LDL (mg/dl)

93.2 ± 26.9

98.4 ± 19.6

0.637

b

TG (mg/dl)

123.3 ± 29.2

133.6 ± 49.0

0.672

b

Chi-square test, bANOVA. Upper: baseline attributes, Lower: physiological data *p < 0.05.

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371

Table 4. Duration of contents implementation of participant by gender (n = 15).
male

femalep-value

implementation more than 1 month

8 (72.7%)

3 (75.0%)

0.635

implementation more than 2 months

3 (27.3%)

3 (75.0%)

0.235

implementation more than 3 months

1 (9.1%)3 (75.0%)

0.033**

p < 0.05.

Table 5. Chronological changes of the groups (n = 15).
voluntary group n = 6

self-management

self-efficacy

weightBMI

ACsystolic BP*

diastolic BP

HDL

LDL

TG

baselinemonth 1month 2103.8 ± 13.5--

81.5 ± 12.7--

Footpace: F-value,
lower stand: p-value

involuntary group n = 9month 3baselinemonth 1month 2month 3113.7 ± 11.0100.6 ± 11.5--

104.4 ± 11.8

83.5 ± 7.7 77.9 ± 9.6--

77.3 ± 9.0Interaction

66.4 ± 5.7 66.4 ± 5.8 66.4 ± 6.0 66.4 ± 6.0 68.7 ± 15.8 68.0 ± 15.5 69.0 ± 15.3 67.9 ± 15.1

24.6 ± 2.2 24.6 ± 2.0 24.6 ± 2.0 24.6 ± 2.1 24.5 ± 3.9 24.3 ± 4.0 24.7 ± 3.9

91.1 ± 6.7 91.6 ± 5.5 91.8 ± 5.3 90.5 ± 5.5 90.5 ± 9.0 90.7 ± 9.8 89.8 ± 8.9

24.3 ± 3.9

89.4 ± 9.7

119.7 ± 14.2 121.0 ± 11.6122.0 ± 12.0121.0 ± 12.4138.7 ± 17.6125.3 ± 11.1131.8 ± 16.3125.8 ± 16.0

71.7 ± 7.1 69.9 ± 5.8 69.2 ± 10.7 70.2 ± 9.2 77.1 ± 13.6 74.7 ± 10.6 75.3 ± 14.9 72.1 ± 11.2

44.7 ± 8.2--

47.7 ± 8.1 50.9 ± 11.4--

52.1 ± 9.0

93.2 ± 26.9--

89.0 ± 24.4 98.4 ± 19.6--

104.9 ± 18.5

123.3 ± 29.2--

132.3 ± 66.7133.6 ± 49.0--

153.1 ± 71.2

Between Withingroups groups

2.248

1.099

11.978

0.158

0.314

0.004**

0.868

0.962

0.277

0.369

0.345

0.607

0.869

0.089

0.951

0.465

0.770

0.059

0.788

0.006

0.678

0.508

0.937

0.571

1.716

0.072

4.790

0.180

0.793

0.680

1.795

2.355

3.777

0.164

0.149

0.467

0.238

0.871

0.514

0.869

0.368

0.905

0.292

1.214

1.722

0.599

0.292

0.214

1.488

0.907

0.071

0.246

0.360

0.794

0.109

0.343

0.804

0.747

0.569

0.388

AC: abdominal circumference, BP: blood pressure. *Systolic BP was curriculated by analysis of covariance, rest of the data were curriculated by repeated mearue of two-way ANOVA. **p < 0.01

Table 6. Changes in abdominal circumference of the group of continuous implementation of contents in the portfolio for 3 months.
implementation for 3 months

implementation below 2 months

Footpace: F-value, lower stand: p-value

baseline

3 months

baseline

3 months

Interaction

Between groups

Within groups

92.1

90.8

90.3

89.5

0.395

0.102

5.473

±6.7

±6.4

±8.4

±8.8

0.540

0.755

0.036**

p < 0.05.

information was correct, meanwhile they started to follow general advice from colleagues or families regardless of whether the information was accurate or not.
They were also confused because it was difficult forthem to judge whether the information was suitable forthem or not. On the other hands, six participants who
Copyright © 2014 SciRes.

implemented voluntarily did well from the information
obtained, answering “I was glad I participated” and “itwas effective”. Overall, it can be concluded that portfolio
is useful for patients who are willing to get informationand to implement them, and it is dangerous for patients
who cannot find information by themselves.
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H. Otsu et al. / Health 6 (2014) 364-373

4.2. Assessment of Attributes ofApplicability of the Portfolio
Portfolio implementation had less relation to age, family configuration, time-availability (work/non-work), occupation, academic background, previous health education, or economic condition. Even high internal locus ofcontrol, theoretically related to voluntarily behavioral
modification [21], did not related to the implementationof portfolio against our prediction. In terms of sex, bothvoluntary and involuntary groups included two women;
however, gender is considered to be a factor of continuation. Even they did voluntarily or not, more female continued to implement the portfolio and showed physiological effect.
Although it was not statistically significant, it is considered that high self-efficacy and high self-management
were related to implementation of portfolio. Many research studies indicated that high self-efficacy related tohigh self-management [22] therefore, high self-efficacy
might be an indicator to implement portfolio.

4.3. Efficacy of Portfolio as a Tool for Patient
Education for Patients with Ischemic
Heart Diseases
We started this portfolio as an adult education methodology which could promote self-learning, hypothesizing that adult learning increases self-efficacy, then changes in lifestyle habits, following physiological data improvement as shown in Figure 1. As we expected, selfefficacy and self-management increased in voluntarygroup; in contrast, no changes observed in the involuntary group. The portfolio, therefore, is considered to beeffective for participants who prefer independent learning.
Interesting findings are that there was no relationshipbetween physiological changes and voluntary/involuntary implementation of portfolio, in comparison withparticipants’ continuity of behavior. The abdominal circumference of the participants who continued to dietaryand exercise implementation for up to two months decreased. This could be interpreted that regardless of voluntary implementation, the results of physiological data
relate to continuity and correct implementation of behavior. In other words, the portfolio enhances an adultlearning, but it did not have a direct connection tophysiological indicators.
Considering all aspects, portfolio is applicable to patients who are willing to learn with high self-efficacy,
and can be effective for secondary prevention of ischemic heart diseases, when correct and suitable informationfrom health professionals is provided prior to start portfolio. Therefore, we conclude that portfolio is more effective if we use this as a complementary learning tool in
Copyright © 2014 SciRes.

addition to structured learning which provided properbasic knowledge and feedback to their learning by healthprofessionals.

4.4. Limitation of This Study and Future
Implementation
As average age of occurrence of ischemic heart disease is relatively high in Japan, Participants of younger
generation was not much included in this study. In order
to assess applicability and efficacy of portfolio as patient
self-management education, we need to recruit more patients with younger age with various backgrounds. Physiological changes were not observed within three months.
Observation period set by us could be too short to see
improvement. Participants also can be expanded for patients with all kinds of chronic condition which requireself-management.

5. CONCLUSIONS
The following points were suggested in this study.
1) Portfolio is effective as an adult education tool
when it is used with prior structural health education byhealth professionals. However, it does not improvephysiological data if they do not continuously implement
behavioral modification.
2) Portfolio is dangerous if patients do not have ability
to collect correct information. For these patients, healtheducation from health professionals is required prior to
conduct portfolio.
3) Effectiveness of portfolio is assumed to relate tohigh self-efficacy and high self-management, but it does
not relate to age, living status, occupation, educational
background, and health locus of control.

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