There is a particular article to back up this research question.
1. Research the importance of the topic and write an introduction that includes these main points:
· Relevant background information from a credible source to explain the importance of your topic
· A purpose statement (“The purpose of this paper is…”).
This is the topic: What are the benefits of physical activity after a heart attack base on the article?
2. Write a study synopsis that includes these main points:
· research design and setting
· sample: sampling method; number of subjects; inclusion/exclusion criteria; attrition, loss to follow up, or response rate (if any); and important characteristics of the sample
· how the study was conducted (explain how the data was collected—including measurement instruments–and, if the study involves an intervention, how the intervention was carried out)
3. Appraise the article in narrative format by answering the following questions.
· What is known and not known about the topic? What gap in knowledge does this study address?
· Was the sampling method appropriate for this study? Why or why not?
o If inclusion and exclusion criteria were noted in the report, did the criteria control for extraneous variables? Why or why not?
· Were the measurement instruments reliable and valid? Why or why not?
o If the study was experimental, was the intervention performed consistently? Why or why not?
· Were the conclusions of the study supported by the results? Why or why not?
· Were the study limitations identified and explained? If so, was the explanation sufficient? Why or why not?
4. Write a conclusion that states the nursing implications based on the findings of the study, taking statistical significance into account. (DO NOT just list the implications to nursing from the article; provide your analysis.)
Submit your article in pdf format and your appraisal and synopsis in Word format.
IT IS MOST BE IN APA 7TH EDITION FORMAT.
Cent Eur J Nurs Midw 2019;10(2):1026–1034
doi: 10.15452/CEJNM.2019.10.0010
© 2019 Central European Journal of Nursing and Midwifery 1026
ORIGINAL PAPER
EDUCATIONAL PROCESS IN PATIENTS AFTER MYOCARDIAL INFARCTION
Jakub Doležel1,2, Darja Jarošová1
1Department of Nursing and Midwifery, Faculty of Medicine, University of Ostrava, Czech Republic
2Department of Cardiovascular Diseases, University Hospital Ostrava, Czech Republic
Received November 20, 2018; Accepted January 28, 2019. Copyright: This is an open access article distributed under the terms of the Creative
Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/
Abstract
Aim: The study aimed to determine the effect of education on the prevalence of risk factors and adherence to lifestyle measures
in post-myocardial infarction
patients.
Design: A clinical, interventional, explanatory study. Methods: The sample (n = 165)
comprised consecutive patients hospitalized for acute myocardial infarction. The interventional, explanatory study followed
changes in two cohorts: intervention (n = 68) and control (n = 97). The intervention (prospective) group consisted of patient s
educated by a nurse using a previously developed nursing standard. The control (retrospective) group comprised patients who
received no education on myocardial infarction provided by nurses. Results:
After one-year follow-up, patients in the intervention
group had statistically better knowledge about their condition (p < 0.001) and used their medication more regularly (p < 0.001)
than controls. At one year, systolic blood pressure and total cholesterol decreased by a mean of 2.5 mmHg and 0.3 mmol/l,
respectively, in intervention group participants. As early as after one month, patients in this group increased their physical activity
by a mean of 35 minutes per week. Conclusion: Post-myocardial infarction patients educated according to the developed nursing
care standard were shown to better adhere to their pharmacological therapy and lifestyle
changes.
Keywords: education, intervention, myocardial infarction, nurse, patient, secondary prevention.
Introduction
Over the last 25 years, cardiovascular mortality has
declined in Europe; yet the prevalence of coronary
artery disease remains high in the Czech Republic
(Čapková et al., 2016). The Czech middle-aged
population was found to have a high prevalence of the
main cardiovascular risk factors (Cífková et al., 2011).
Also data from several European Countries including
the Czech Republic continue to show that
cardiovascular disease preventive care is not
adequately provided. Many post-myocardial
infarction patients do not adhere to a healthy lifestyle,
do not know the risk factors and do not receive the
proper treatment (Kotseva et al., 2016).
The core of cardiovascular disease prevention has
shifted from drug therapy to preventive care through
non-pharmacological interventions. Drug therapy
should be initiated only after non-pharmacological
interventions fail (Magnani et al., 2018). A systematic,
comprehensive and multidisciplinary approach is
needed that is focused on lifestyle and risk factor
Corresponding author: Jakub Doležel, Department of Nursing
and Midwifery, Faculty of Medicine, University of Ostrava,
Syllabova 19, Ostrava, Czech Republic; e-mail:
jakub.dolezel@osu.cz
management by physicians, nurses and other health
workers (Piepoli et al., 2016). Nurses play a key role
in educating patients after myocardial infarction.
Nurses’ educational activities contribute to improving
the health status of both individuals and communities,
leading to reduced cardiovascular risk and fewer
rehospitalizations (Lachman et al., 2015).
The aim of the study was pilot implementation
of a nursing care standard called Education of Post-
Myocardial Infarction Patients. The nursing standard
was developed by a multidisciplinary working group.
The first step in the development of the standard was
to formulate the basic STANDARD definition
in accordance with Standard nursing care: an asset
(Danasu, 2007). Subsequently, activities were defined,
measured and selected using the Dynamic Standard
Setting System (Kitson, 1990). To justify the nursing
processes in the standard, an analysis from a literature
search was used. The final standard consists of nine
nursing processes complemented by justification,
references to relevant studies and levels of evidence.
Aim
The study aimed to determine the effect of education
on the prevalence of risk factors and adherence to
lifestyle measures in post-myocardial infarction
patients.
Doležel J, Jarošová D. Cent Eur J Nurs Midw 2019;10(2): 1026–1034
© 2019 Central European Journal of Nursing and Midwifery 1027
Methods
Design
A clinical, interventional, explanatory study was
conducted.
Sample
Included in the study were consecutive patients
(convenience sampling) hospitalized for acute
myocardial infarction (Figure 1). Data were collected
at the Department of Cardiovascular Diseases,
University Hospital Ostrava. The sample (Table 1)
comprised a total of 165 participants divided into two
groups, intervention (n = 68) and control (n = 97).
The inclusion criteria were patients after acute
ST-elevation myocardial infarction, after
percutaneous coronary intervention, aged 30–85
years. Excluded were patients in cardiogenic shock,
after cardiopulmonary resuscitation, with serious
complications or life-threatening comorbidities.
The intervention (prospective) group consisted
of patients consecutively admitted for acute
myocardial infarction in 2016. Their mean age was 58
years (SD = 11.4). The patients were educated by
a nurse using the above nursing standard, with a
follow-up at one, six and
twelve months.
The control (retrospective) group comprised patients
hospitalized for acute myocardial infarction in 2015,
with a mean age of 61 years (SD = 11.1). They were
approached by telephone twelve months after their
heart attack. The controls received no education
on their condition (i.e. myocardial infarction).
Figure 1 Patient selection process
INTERVENTION GROUP
361 patients eligible
CONTROL GROUP
329 patients eligible
258 patients excluded
death (n = 25)
inclusion criteria (n = 112)
exclusion criteria (n = 29)
other (n = 92)
PRIMARY ANALYSIS
103 patients included
68 PATIENTS
included in the final analysis
SAMPLE
690 post-myocardial infarction patients eligible
232 patients excluded
death (n = 24)
inclusion criteria (n = 101)
exclusion criteria (n = 30)
other (n = 77)
PRIMARY ANALYSIS
97 patients included
97 PATIENTS
included in the final analysis
35 patients excluded
death (n = 2)
loss to follow-up (n = 33)
Doležel J, Jarošová D. Cent Eur J Nurs Midw 2019;10(2): 1026–1034
© 2019 Central European Journal of Nursing and Midwifery 1028
Table 1 Patient characteristics
Description of the intervention
Interventions were provided in accordance with the
standard. The nurse educated the patient within three
days of myocardial infarction, during their stay at the
Department of Cardiovascular Diseases, University
Hospital Ostrava. Educational sessions were repeated
after one, six and twelve months in an outpatient ward
of the department. The date of the first follow-up
session was set during the hospital stay; the other dates
were agreed on during the preceding sessions in the
outpatient ward. The education session duration was
30–60 minutes. In each patient, a nursing assessment
was carried out based on an educational history and an
educational plan was developed. Patients were
educated individually through motivational
interviewing.
During the initial session, patients were informed
about their condition (myocardial infarction), warning
signs, therapeutic regimen, use of medication and
lifestyle changes. The latter included
recommendations on an adequate diet, proper physical
activity, smoking cessation and blood pressure
control. At the end of the session, the nurse determined
whether the goals were met and assessed the
effectiveness of education.
At the beginning of each follow-up session, the
patient’s knowledge was tested. Based on the
assessment, topics to be covered during the follow-up
sessions were defined. The assessment of knowledge
included all topics covered by the initial session using
the following scale: 0 – topic not understood;
1 – mostly not understood; 2 – mostly understood;
3 – completely understood. The points were assigned
based on questions asked to patients. Those receiving
0–2 points were repeatedly educated about that
particular topic. If they received 3 points, they were
not educated again.
Patients also received educational materials on heart
anatomy and physiology, basic facts about myocardial
infarction, recognizing myocardial infarction
symptoms, calling for professional help,
cardiopulmonary resuscitation, myocardial infarction
treatment, recovering from myocardial infarction and
lifestyle changes following myocardial infarction.
Data collection
In both the intervention and control groups, the
following items were compared one year after heart
attack: adherence to lifestyle changes (dietary habits,
physical activity, use of medication), prevalence
of risk factors (smoking, total cholesterol level, blood
pressure values, body mass index), knowledge of the
condition (myocardial infarction) and need for
rehospitalizations. To analyze changes in the
variables, biomedical data were collected and
a structured interview was conducted. Biomedical
data collection included anthropometric
measurements, clinical examination, biochemistry
tests and data from medical records.
Adherence to dietary measures was assessed using our
classification of eating habits that was based on the
food pyramid and nutritional recommendations for the
Czech population (Dostálová, Dlouhý, Tláskal 2012).
Physical activity (walking, household work,
exercising and other leisure activities) was recorded
in minutes per week. Physical activity assessment also
took into account the participants’ occupations.
The physical intensity of their jobs was categorized
based on job classes (Nařízení vlády č. 361/2007, Sb.).
Use of medication was recorded on a Likert scale.
Participants were asked about regular use of drugs
(0 – not at all; 1 – somewhat no; 2 – somewhat yes;
3 – yes).
Data analysis
The sample was characterized using descriptive
statistics (median, arithmetic mean, standard
deviation, frequency tables). For quantitative
variables, normality of data distribution was assessed
with the Shapiro-Wilk test; based on that, parametric
or nonparametric tests were used. Differences between
the intervention and control groups were analyzed
with the nonparametric two-sample Mann-Whitney U
test, chi-squared test and two-sample t-test. In the
intervention group, pre-education values were
compared to those obtained during the follow-up at
Intervention
group
Control
group
n (%) n (%)
Gender
male 37 (54) 50 (52)
female 31 (46) 47 (48)
Age
30–39 years 3 (4) 1 (1)
40–49 years 11 (16) 12 (12)
50–59 years 29 (43) 29 (30)
60–69 years 14 (21) 26 (27)
70–79 years 8 (12) 25 (26)
80–85 years 8 (4) 4 (4)
Education
primary 5 (7) 10 (10)
vocational 37 (54) 59 (61)
secondary 19 (28) 19 (20)
tertiary 7 (10) 9 (9)
Body mass index
under 25 24 (35) 23 (24)
25 to 29.9 31 (46) 43 (44)
30 or more 13 (19) 31 (32)
Doležel J, Jarošová D. Cent Eur J Nurs Midw 2019;10(2): 1026–1034
© 2019 Central European Journal of Nursing and Midwifery 1029
one, six and twelve months. Differences were tested
with the following paired tests: chi-square test,
Wilcoxon test and t-test. The level of statistical
significance was set at 5% (p < 0.05 – H0-rejected;
p ≥ 0.05 – not rejected). The Stata version 13 software
was used.
Results
In the study, the following variables were compared:
number of rehospitalizations, knowledge of the
condition (myocardial infarction), use of medication,
blood pressure values, body mass index, total
cholesterol level, smoking status, physical activity and
dietary habits (Table 2).
Table 2 Comparison of values of the studied variables
Item
Intervention group Control group
before education after one year before education after one year
1. number of rehospitalizations – 034.0 – 027.0
2. knowledge of the condition 013.7 017.5 – 014.2
3. use of medication – 091.2 – 084.5
4. systolic blood pressure 127.2 124.7 130.4 129.3
5. diastolic blood pressure 074.5 070.2 074.1 072.2
6. body mass index 026.9 026.4 028.3 028.4
7. total cholesterol 005.3 005.0 004.6 004.7
8. number of smokers 042.6 020.6 035.0 023.7
9. number of cigarettes smoked 014.9 008.8 016.4 016.2
10. physical activity 597.0 633.0 634.0 610.0
11. regular eating 073.5 082.4 060.8 063.3
12. recommended diet 022.1 035.3 006.2 009.3
1. numbers of rehospitalized patients expressed as relative frequency; 2. mean number of points obtained in knowledge assessment; 3. numbers of patients
reporting regular use of medication expressed as relative frequency; 4. mean systolic blood pressure; 5. mean diastolic blood pressure; 6. mean body mass
index; 7. mean total cholesterol; 8. numbers of smokers expressed as relative frequency; 9. mean number of cigarettes smoked by smokers; 10. mean number
of minutes of physical activity per week; 12. numbers of patients reporting regular eating expressed as relative frequency; 13. numbers of patients reporting
eating the recommended diet expressed as relative frequency
After one-year follow-up, patients in the intervention
group showed statistically significantly higher rates
of rehospitalization for coronary artery disease than
controls (p = 0.035). In that respect, the intervention
(education) was not successful.
Patients in the intervention group had, after one year,
statistically better knowledge about their condition
than controls (p < 0.001). Their knowledge at all time
intervals (one, six and twelve months after myocardial
infarction) was also statistically significantly better
(p < 0.001) compared to that before education.
Compared to controls, patients in the intervention
group used their medication statistically significantly
more regularly (p < 0.001). At all time intervals (one,
six and twelve months), the rates of intervention group
participants regularly taking their drugs increased.
After one-year follow-up, systolic blood pressure was
statistically significantly lower in patients in the
intervention group than in controls (p = 0.0146).
In intervention group participants, systolic blood
pressure dropped by a mean of 2.5 mmHg. After one-
year follow-up, there was no statistically significant
difference in diastolic blood pressure between the two
groups (p = 0.2783).
One year after myocardial infarction, patients in the
intervention group had statistically significantly lower
body mass index values than controls (p = 0.0013).
On average, their body mass index decreased by 0.5
points (Figure 2).
Prior to education, total cholesterol levels were
statistically significantly higher in patients in the
intervention group than in controls (p < 0.001). After
one-year follow-up, the difference between the groups
was no longer statistically significant (p = 0.1326).
In intervention group participants, total cholesterol
decreased by a mean of 0.3 mmol/l.
There were no statistically significant differences
in the numbers of smokers between the two groups,
either before (p = 0.323) or after (p = 0.623) the
follow-up. At one year, smokers in the control group
smoked more cigarettes than their counterparts in the
intervention group.
Controls showed a statistically significant decrease
in the mean number of minutes of physical activity per
week at one year after myocardial infarction
(p = 0.0003). By contrast, intervention group
participants statistically significantly (p = 0.0001)
increased their physical activity at all time intervals
(Figure 3). As early as after one month, patients in the
intervention group increased their physical activity by
a mean of 35 minutes per week.
After one-year, patients in the intervention group ate
Doležel J, Jarošová D. Cent Eur J Nurs Midw 2019;10(2): 1026–1034
© 2019 Central European Journal of Nursing and Midwifery 1030
Figure 2 Differences in patients’ body mass index
Figure 3 Patients’ physical activity before and one year after education
statistically significantly more regularly than controls
(p = 0.010). There was also a statistically more
significant shift to a healthier diet in intervention
group participants than in controls (p < 0.001).
Discussion
Nurses who work in health facilities, particularly
in inpatient settings, adhere to local professional
standards and providing nursing care based on current
scientific evidence confirmed by research and practice
(Jarošová, Zeleníková, 2014). Therefore, prior to its
implementation, the standard was tested in clinical
practice using a correlational study.
Nurses and other health professional should ensure
follow-up of educated post-myocardial infarction
patients (Piepoli et al., 2016). To achieve permanent
lifestyle changes and adherence to therapy, continued
support in the form of repeated sessions is needed
(Rydén et al., 2013). That is why patients included in
the study were educated within three days
of myocardial infarction and then after one, six and
twelve months.
One in five patients suffering cardiovascular or
cerebrovascular events needs rehospitalization within
one year and even one in three patients over a period
Doležel J, Jarošová D. Cent Eur J Nurs Midw 2019;10(2): 1026–1034
© 2019 Central European Journal of Nursing and Midwifery 1031
of three years (Alberts et al., 2009). Therefore the
present study focused on rehospitalization rates. After
one-year follow-up, patients in the intervention group
needed statistically significantly more
rehospitalizations than controls.
These data fail to confirm results of RESPONSE
(Randomised Evaluation of Secondary Prevention by
Outpatient Nurse Specialists) showing that education
of post-myocardial infarction patients by nurses
resulted in fewer repeated hospital stays (Jorstad et al.,
2013). Similarly, our result contradict those reported
by GOSPEL (Global Secondary Prevention Strategies
to Limit Event Recurrence after Myocardial
Infarction). This randomized clinical study concluded
that education programs for post-myocardial
infarction patients reduced both rehospitalization rates
and the risk for cardiovascular diseases (Giannuzzi et
al., 2008).
The Czech Republic is among countries with low
health literacy of the population (Šedová et al., 2016a).
According to a randomized clinical study by Gallagher
et al. (2013), education with a standardized instrument
and adjusted to the patient’s needs is more effective,
leading to their better knowledge about possible
symptoms of acute myocardial infarction and attitude
to recovery over two months from heart attack. These
results were consistent with those in the present study,
with patients in the intervention group having
statistically significantly better knowledge about their
condition than controls.
Similarly, a randomized clinical study by OʼBrien et
al. (2014) found that post-myocardial infarction
participants educated by a nurse had a significantly
higher level of knowledge on their disease and therapy
than controls who received
no education.
A 2016 randomized clinical study (Polsook,
Aungsuroch, Thongvichea, 2016), showed that
subjects educated by a nurse on the use of prescribed
medication adhered to their treatment regimen more
effectively and used their drugs more regularly than
controls. This is consistent with our findings. In the
present study, intervention group participants used
their medication statistically significantly more
regularly than controls.
The effect of education on blood pressure reduction
in post-myocardial infarction patients was also shown
in a randomized clinical study by Campbell et al.
(1998) stating that secondary prevention provided by
nurses to patients with coronary heart disease was
effective. Their results suggested that the incidence
of future cardiovascular events and potential deaths
may be decreased by as much as one-third. This is
consistent with findings in the present study. After
one-year follow-up, patients in the intervention group
had statistically significantly lower blood pressure
than controls. The difference in diastolic blood
pressure between the two groups was not statistically
significant after one year.
In their randomized clinical study, Lachman et al.
(2015) found that after twelve months, post-
myocardial infarction patients educated by nurses on
the need for weight reduction and adequate physical
activity had better quality of life and fewer risk factors
than controls without education. Lower body mass
index values in educated patients were also found
in the present study. After one-year follow-up,
intervention group participants had statistically
significantly lower body mass index values than those
in the control group.
The Czech post-MONICA cross-sectional study
(Cífková et al., 2011) on a representative randomly
selected sample of the middle-aged Czech population
found a high prevalence of major cardiovascular risk
factors contributing to persistently high cardiovascular
mortality in the Czech Republic. These findings were
confirmed by Olišarová et al. (2016) claiming that
education on cardiovascular risk factors provided by
nurses in the Czech Republic is inadequate.
High total cholesterol levels are among major
cardiovascular risk factors. Before education, total
cholesterol levels were statistically significantly
higher in the intervention group than in controls. After
one-year follow-up, the difference between the two
groups was no longer statistically significant.
The positive effect of nurses’ educational activities on
lowering of total cholesterol levels in post-myocardial
infarction patients was also noted in KORINNA
(Coronary Infarction Follow-up in the Elderly). Post-
myocardial infarction patients educated by nurses on
lifestyle changes showed fewer rehospitalizations and
deaths, better hypertension control, lower cholesterol
levels and less depression than controls receiving no
education (Kirchberger et al., 2015).
In post-myocardial infarction patients, smoking
cessation is potentially the most effective secondary
prevention measure (Steg et al., 2012). Similarly,
Svěráková (2012) reported that smoking cessation is a
notable component of lifestyle changes in patients
after myocardial infarction. On the other hand,
smoking cessation was found to be most difficult for
post-myocardial infarction patients (Šedová et al.,
2016b).
In their cohort study, Harbman (2014) showed that
post-myocardial infarction patients educated by nurses
on smoking cessation, hypertension treatment,
sufficient physical activity and diet had lower
coronary heart disease morbidity and mortality rates
than participants in a control group without education.
https://www.ncbi.nlm.nih.gov/pubmed/?term=Aungsuroch%20Y%5BAuthor%5D&cauthor=true&cauthor_uid=27969054
Doležel J, Jarošová D. Cent Eur J Nurs Midw 2019;10(2): 1026–1034
© 2019 Central European Journal of Nursing and Midwifery 1032
Similarly, the present study found a positive effect
of education on patients’ smoking status. After one-
year follow-up, smokers in the control group smoked
more cigarettes than those in the intervention group.
Also a cohort study by Bellman et al. (2009) found that
post-myocardial infarction patients educated by nurses
on the harmfulness of smoking stopped smoking more
frequently than controls with no education. Finally,
Farrell and Keeping-Burke (2014) claim that nurses’
educational activities towards smoking cessation has
repeatedly proved highly effective and should be
further developed in the future.
Regular physical activity is another important feature
of a healthy lifestyle (Rosolová et al., 2013). In 2016,
Kotseva et al. (2016) conducted a cross-sectional
study called EUROASPIRE IV (European Action
on Secondary and Primary Prevention by Intervention
to Reduce Events). The study results suggest that
following their myocardial infarction, most patients
failed to stop smoking, eat unhealthy foods, have
inadequate physical activity and thus suffer from
overweigh or obesity and a high prevalence of diabetes
mellitus.
The effect of education on physical activity was
confirmed by the present study. After one-year follow-
up, controls statistically significantly reduced their
physical activity expressed as minutes per week. By
contrast, there were statistically significant increases
in intervention group patients’ physical activity at all
time intervals.
Positive effects of nurses’ educational activities
on physical activity were also noted in a randomized
clinical study by Yan et al. (2014) showing that post-
myocardial infarction participants receiving repeated
telephone follow-up instructions from nurses had
more positive perceptions of their condition, could
recognize the warning signs, were better at adhering to
lifestyle measures, did more physical activity and had
higher quality of life than their counterparts
in a control group who received no education. Similar
conclusions were reported in a randomized clinical
study by Hanssen et al. (2007) who stated that post-
myocardial infarction patients systematically educated
by nurses were in much better physical condition and
showed more responsible approach to the treatment
of their disease than controls without education.
According to Rosenberg (2014), prevention
of cardiovascular diseases is based on a healthy diet
and lifestyle changes. The present study showed
a positive effect of education on dietary changes. After
one-year follow-up, patients in the intervention group
ate statistically significantly more regularly than
controls. There was also a statistically more significant
shift to a healthier diet in intervention group
participants than in controls.
These results were also confirmed by a cohort study
by Hwang and Kim (2015). The study showed that
post-myocardial infarction patients educated by nurses
on lifestyle measures were considerably more willing
to adhere to their treatment regimen and recommended
dietary changes, perform adequate physical activity
and monitor the warning signs than controls receiving
no education.
Limitation of study
The study has certain limitations. The effectiveness
of nursing care provided would be better assessed by
comparing the intervention and control groups
in a prospective study. Moreover, a multicenter study
would be more appropriate.
Conclusion
Nurses’ educational activities concerning secondary
prevention of coronary heart disease are the key to
better knowledge of the condition, regular use
of medication, blood pressure control, optimal body
mass index, stable total cholesterol levels, smoking
cessation, adequate physical activity and dietary habits
in patients after myocardial infarction.
The study outcomes will serve to improve the quality
and effectiveness of nursing care provided to patients
after myocardial infarction. Post-myocardial
infarction patients educated according to the
developed nursing care standard were shown to better
adhere to their pharmacological therapy and lifestyle
changes.
Ethical aspects and conflict of interest
The study was conducted in accordance with the basic
principles relevant to research involving human
subjects valid for all research phases (Declaration
of Helsinki, 2013). The study was approved by the
Ethics Committee of the University Hospital Ostrava.
Data for the study were collected as part of a project
called Contract for Life (for life after myocardial
infarction) that aimed to develop an education
program for patients after heart attack. The author, as
a member of the Contract for Life project team, was
granted permission to use the data.
The authors declare no conflict of interest; the article
has not been published in any other journal.
Author contribution
Conception and design (JD, DJ), data analysis and
interpretation (JD, DJ), manuscript draft (JD), critical
Doležel J, Jarošová D. Cent Eur J Nurs Midw 2019;10(2): 1026–1034
© 2019 Central European Journal of Nursing and Midwifery 1033
revision of the manuscript (DJ), final approval of the
manuscript (JD).
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