Curr Heart Fail Rep DOI 10.1007/s11897-014-0200-1
SELF-CARE AND HEALTH OUTCOMES (T JAARSMA, SECTION EDITOR)
Education Material for Heart Failure Patients: What Works and What Does Not? Mary Boyde & Robyn Peters
# Springer Science+Business Media New York 2014
Abstract Patient education is an important element of care, but evidence with regard to education material is not always apparent, as it is intertwined with educational strategies as components of heart failure management programs. Difficulties have arisen in determining the effectiveness of particular education strategies, as multiple strategies are commonly bundled together and packaged within research protocols. To further complicate this issue, the bundles are diverse, lack precision in describing their components, and report different outcomes. Despite these difficulties, clinicians can utilise a number of proven commonalities to deliver effective education: assessment of learning needs and style, verbal interaction with a healthcare professional, and a selection of multimedia patient education materials. Keywords Heart failure . Patient education . Education materials
Introduction Heart failure (HF), a chronic and progressive clinical syndrome, imposes a significant human and economic burden on the community. Hospital readmissions significantly contribute to the economic burden [1], with evidence that 30– 50 % of patients are readmitted within six months [2, 3]. Contributing factors include patients’ inability to perform M. Boyde (*) : R. Peters Cardiology Department, Princess Alexandra Hospital, The University of Queensland, School of Nursing and Midwifery, Third Floor, Building One, Ipswich RoadWoolloongabba Brisbane QLD, 4102, Australia e-mail: [email protected] R. Peters e-mail: [email protected]
self-care activities as well as failure to adhere to their medical regime, suggesting that at least some of these admissions are preventable [4]. Heart failure management programs (HFMPs), which apply multidisciplinary interventions within a specialist framework of care, have evolved to become the gold standard of treatment in evidenced-based guidelines [5, 6]. The effectiveness of HFMPs in reducing hospital readmissions has been confirmed in several systematic reviews and meta-analyses [7–11], with patient education identified as the most commonly applied intervention within these programs [12•, 13•]. For patients living with HF, the day-to-day symptom burden can vary depending upon the stage of their illness. These symptoms are insidious, with an illness trajectory that is unpredictable [14]. This cohort of predominantly elderly patients may have difficulty adapting to the demands of daily self-care management due to comorbidities, reduced cognition, poor health literacy, poor social support, and polypharmacy. HFMPs have been proven beneficial in assisting HF patients in overcoming these difficulties, with patient education identified as an essential component of care in this cohort by key organisations including the European Society of Cardiology, the American College of Cardiology/ American Heart Association, and the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand [5, 15, 16]. This article provides a review of the current evidence with regard to education material for people living with HF in an effort to identify practice improvement opportunities in the delivery of patient education.
Educational Strategies Well-designed educational strategies grounded in theory and utilising contemporary evidence are essential in improving
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patient outcomes such as readmissions, mortality, self-care abilities, knowledge, and quality of life. Historically, healthcare professionals have utilised a variety of educational strategies within HFMPs [13•, 17•], often supplemented by written patient education materials [18].Videos/DVDs and interactive systems such as telemonitoring and computer applications have been applied as well. The timing and frequency of educational strategies have varied considerably, and materials may have been presented in single sessions or on multiple occasions [13•, 17•]. Descriptions of implemented educational programs and interventional procedures often lack detail and transparency, creating difficulties in comparing interventions or conducting further analysis [12•, 17•, 19, 20, 21•]. Analyses from studies often lack detail with respect to the impact of a theoretical framework on the development of educational strategies [17•, 19]. In addition, the literature has reported a broad variety of outcome parameters, impeding the development of educational strategies based on scientifically sound evidence [20]. In a recent review, Albano and colleagues identified the primary issue for comparisons, reproducibility, and generalisation of results as the lack of precise descriptions of programs and consistent reporting of standardised outcomes [21•]. Despite these difficulties, however, there is some evidence that knowledge, behaviour, and symptom experience improve when content is individualised using combined media and provided in multiple one-on-one sessions [22], although the methods best suited for education of HF patients have not been clearly defined [23]. Education of HF patients is complex and multifaceted, and to date there is no definitive gold-standard approach. Various educational strategies and materials have been packaged together in an attempt to achieve incremental benefits. Implementing several interventions simultaneously to address complex problems is often referred to as bundling [12•], and this approach can compromise efforts to determine the effect of any singular strategy [24]. In-hospital teaching sessions and printed education materials have been bundled with various follow-up strategies post-discharge, with a range of results. Importantly, research has shown that educational nursing intervention, supplemented with an HF manual, is effective in improving the knowledge of HF and self-care in all patients, regardless of telephone follow-up [25]. Similarly, no change in clinical outcomes was identified when a single-session educational strategy, supplemented with a literacy-sensitive workbook, was compared to a more intensive approach consisting of additional education and self-care training along with follow-up via telephone [26]. Another study demonstrated no difference in outcomes between group counselling sessions and telephone follow-up when all participants received the same printed education materials in the form of 18 tip sheets [27]. Other bundled approaches, including the use of telemonitoring, interactive voice response reminder
systems, and computer-aided learning, have produced varying results [28–33].
Novel Approaches With the increasingly widespread use of the Internet, Webbased components have begun to be incorporated within educational strategies. A small study of two remote Webbased educational strategies demonstrated overall improved knowledge scores, with significantly higher scores in the group exposed to additional sessions [34]. The proliferation of healthcare information on the Internet, however, has caused researchers to question its credibility and readability. Disappointingly, a recent investigation of HF informational material on Internet websites found that a biomedical approach was most common, information was often written in the thirdperson, and it was presented in an authoritarian manner using technical language [35]. Less evident was a partnership approach that provided information about living with heart failure, which was generally written in the second-person and focused on the experience of HF. An evaluation of 15 websites revealed only five that included all required areas of content, together with a readability score at or near the appropriate level for most patients [36]. The challenge for healthcare professionals is identifying websites that are credible, are reader-friendly, and provide quality material, so that patients do not feel overwhelmed by the plethora of Internet information [36]. Research investigating the use of an iPad app to support self-care and monitoring is currently underway, with some initial promising results [37].
Topics for Patient Education Patients continue to demonstrate poor knowledge of the nature and cause of HF as well as its pharmacological and behavioural management [38]. Lack of knowledge has been independently associated with poor HF self-care behaviours [39], while increased HF-specific knowledge has been associated with improved self-care [40]. The majority of patients want more information about self-management, with a preference for material that is easy to understand [41]. Overall, patients tend to identify four top-ranked topics – signs and symptoms, prognosis, risk factors, and medications – as their learning needs [42], a trend that has been consistently demonstrated in studies [43–47]. Evidence suggests that within HFMPs, clinicians have provided a broad range of information, including understanding HF, beneficial lifestyle changes, adherence to pharmacological and non-pharmacological therapies, symptom monitoring, and self-care behaviours [12•, 13•]. However, in order to engage patients in their own learning and thus
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improve patient outcomes, educational content must be individualised to the learning needs of each person [42, 48].
Patient Education Materials Printed education materials consist of booklets specifically designed to provide information for patients about health promotion, disease prevention, treatment modalities, and self-care regimens [49]. These resources allow patients to absorb information over time at their own pace [50], and they are an important source of supplementary information [51]. Studies have demonstrated improved knowledge among patients with the use of printed materials compared to verbal information alone [52]. Other beneficial outcomes attributed to effective and well-written education materials include improved ability to adhere to post-discharge instructions, reduced hospital readmissions, enhanced patient confidence, reduced anxiety, and decreased recovery times [53]. Written educational materials are able to target specific patient populations, can provide a reference for information, are suitable for patients who identify as having a read/write learning style, and are widely acceptable to the general population [53–55]. The literature suggests that written materials are most commonly utilised to supplement verbal interaction with a healthcare professional [18]. Traditionally, programs for patients have focused on educational needs identified by healthcare providers [56]. Education is more effective, however, when it is based upon an assessment of the participant’s existing knowledge, skills, and preferred learning style [53]. While an initial verbal interaction delivered together with written materials by a healthcare professional is acknowledged as common practice, the assessment of learning styles and preferences prior to implementation of an educational strategy is often lacking. Our group conducted an investigation into the learning styles, needs, and preferences of people with HF, which informed the development of a patient-centred HF manual and DVD [42]. We found that HF patients preferred multimodal learning, with information premised on the experiences of others relative to the patient’s own experiences, presented by reliable healthcare professionals, in a format that they could then maintain as a reference [57]. Decisions regarding content, presentation, and style of the manual were guided by the principles of andragogy, together with instructional design aimed at enhancing readability and patient engagement (Table 1) [54, 55, 58, 59]. The DVD used visual role-modelling to demonstrate self-care behaviours, as visual representation of scenarios has been found to stimulate learning and aid in transfer of knowledge [60]. Utilising these patient-centred resources, we conducted a pilot study, which demonstrated improved patient knowledge and self-care abilities [61]. Importantly, older patients with the lowest level of education showed
Table 1 Guidelines for developing printed education materials Design Use a short title Ensure that the purpose of the printed material is clear to the intended reader Use at least a 12-point type font Write in the active voice Aim for year/grade 5 to 6 reading level Content Keep content clear, simple, and concise Use common language Include a table of contents Outline the learning objectives Use topic headings Use one- and two-syllable words understood by the intended reader Use short sentences, with one idea to a sentence Use short paragraphs and discuss important ideas first Ensure that the content is focused on what the reader should do Provide examples Include questions Avoid jargon and define medical terminology Ensure that content is based on the information needs of the target audience Ensure that content is evidenced-based Ensure currency by including a publication date Acknowledge sources of information Layout Use a structured format with clear and obvious headings Use bold print to highlight headings Use subheadings Use bullet points Use upper- and lower-case letters for ease of reading Presentation Use adequate spacing, with adequate white space Use dark print on light background Use illustrations that are recognisable, clearly labelled, informative, and complementary to the written text
significantly improved knowledge. These promising results are currently being investigated in a randomised controlled trial. Similarly, the practice of mailing an evidence-based DVD and booklet to patients with HF demonstrated a statistically significant increase in daily weight monitoring compared to a control group [62]. This broad-based, relatively inexpensive educational strategy has shown promise as a component of a comprehensive HFMP.
Health Literacy Inadequate health literacy has a negative impact on learning and is associated with adverse health outcomes [63]. A
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consensus statement from the Heart Failure Society of America on health literacy for patients with HF identified that, while the literature is limited, clinicians should focus on these five steps: recognising the consequences of low health literacy, identifying and then screening patients at risk, documenting literacy levels and learning preferences, and integrating effective strategies to enhance patient understanding [63]. Patient education is more effective when strategies are tailored to level of health literacy and patient preferences for learning [61, 64]. Written education materials specifically designed for patients with inadequate health literacy, when coupled with appropriate teaching and follow-up strategies, have demonstrated beneficial effects on patient outcomes. An intervention specifically designed for HF patients with low literacy implemented an initial one-to-one education session, guided by the principles of pedagogy, coupled with a picturebased booklet and management plan [65]. A more recent study by the same author, which included the use of a literacy-sensitive manual, found that multi-session interventions were more effective than single sessions for individuals with low literacy [26]. Improvements in HF symptoms can be achieved when education materials are written with specific attention to the instructional design to ensure relevance for people with inadequate health literacy [66].
Cognition Cognitive impairment is a contributing factor to poor health outcomes for patients with HF, as it impacts on the patient’s ability to participate in education and to implement appropriate self-care behaviours [23, 67]. Davis and colleagues [68] demonstrated a significant increase in HF knowledge, with a trend towards improved self-care, using an individualised strategy incorporating a workbook containing pictograms, which was tailored to individuals with cognitive impairment. Incorporation of appropriately designed written materials within tailored educational strategies can enhance outcomes for patients who are cognitively impaired.
Evaluation of Patient Education Materials Healthcare professionals must ensure that all patient education materials meet the learning needs of HF patients and are suitable for the intended audience. Evaluation is an essential element in gauging the appropriateness of the content with regard to suitability and readability. The readability of written materials refers to how easy the content is to read [53]. Ease of readability and reading grade level can easily be assessed on word-processing programs such as Microsoft Word (Microsoft Corporation, USA). Another instrument is the Tool to Evaluate Materials Used in Patient Education (TEMPtEd)
developed by Clayton [69]. An evaluation of 18 written patient education materials for HF patients using the suitability of materials (SAM) and Fry readability formula found that only two had the optimum suitability score of 70 % or higher and fifth grade or lower readability level [70]. Gwadry-Sridhar and colleagues have developed two instruments to facilitate patient evaluation of education materials—the educational material acceptability (EMA) and the knowledge acquisition questionnaire (KAQ)—which healthcare practitioners can utilize to measure patient satisfaction [71]. There appears to be a prevalence of poorly prepared education materials that are written beyond the reading level of most patients, which may diminish the effectiveness of educational strategies.
Research Implications While there have been a variety of educational strategies implemented within HFMPs, due to the heterogeneity of these interventions it has been difficult to formulate evidencedbased guidelines. During the development and implementation phase of educational strategies, appropriate methodologies should be employed to evaluate written education materials and multimedia resources. Future research should systematically delineate the singular and bundled components of educational strategies in order to enable comparison, reproducibility, and generalisation. Detailed descriptions of educational strategies, with standardised format for reporting outcomes, will enhance the ability to assess the effectiveness of particular strategies as they are implemented.
Clinical Implications An appropriate theoretical approach and an understanding of the learning needs and style of the individual patient will help to facilitate the effective transfer of knowledge and the development of self-care skills. Healthcare professionals must ensure that education is individualised and is implemented with a partnership approach. Well-written education materials allow patients to learn at their own pace, and can be retained as an ongoing reference. In addition, a selection of multimedia resources will provide a patient-centred learning environment to accommodate unique learning styles. Reiteration of information through repeated visits, telephone contact, or telemonitoring has shown promising results.
Future Approaches Approaches to patient education are constantly evolving. Healthcare professionals are challenged to develop welldesigned, detailed educational strategies utilising new
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technologies such as Web-based applications. Comprehensive reporting of these strategies, together with systematic evaluation of patient outcomes, will allow us to build an evidence base to guide future patient educational programs.
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Conclusions Education of chronically ill HF patients is a multifaceted effort, leading healthcare professionals to bundle together a number of different strategies and resources. This approach has hindered our ability to clearly identify the most effective patient educational strategy and appropriate materials to improve patient outcomes. Commonalities have been found within these disparate approaches, however, which can provide the framework for a comprehensive strategy that includes assessment of learning needs and style as well as verbal interaction with a healthcare professional, supplemented with a selection of multimedia education materials.
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Compliance with Ethics Guidelines
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Conflict of Interest Mary Boyde and Robyn Peters declare that they have no conflict of interest.
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Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
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References Papers of particular interest, published recently, have been highlighted as: • Of importance
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SELF-CARE AND HEALTH OUTCOMES (T JAARSMA, SECTION EDITOR)
Education Material for Heart Failure Patients: What Works and What Does Not? Mary Boyde & Robyn Peters
# Springer Science+Business Media New York 2014
Abstract Patient education is an important element of care, but evidence with regard to education material is not always apparent, as it is intertwined with educational strategies as components of heart failure management programs. Difficulties have arisen in determining the effectiveness of particular education strategies, as multiple strategies are commonly bundled together and packaged within research protocols. To further complicate this issue, the bundles are diverse, lack precision in describing their components, and report different outcomes. Despite these difficulties, clinicians can utilise a number of proven commonalities to deliver effective education: assessment of learning needs and style, verbal interaction with a healthcare professional, and a selection of multimedia patient education materials. Keywords Heart failure . Patient education . Education materials
Introduction Heart failure (HF), a chronic and progressive clinical syndrome, imposes a significant human and economic burden on the community. Hospital readmissions significantly contribute to the economic burden [1], with evidence that 30– 50 % of patients are readmitted within six months [2, 3]. Contributing factors include patients’ inability to perform M. Boyde (*) : R. Peters Cardiology Department, Princess Alexandra Hospital, The University of Queensland, School of Nursing and Midwifery, Third Floor, Building One, Ipswich RoadWoolloongabba Brisbane QLD, 4102, Australia e-mail: [email protected] R. Peters e-mail: [email protected]
self-care activities as well as failure to adhere to their medical regime, suggesting that at least some of these admissions are preventable [4]. Heart failure management programs (HFMPs), which apply multidisciplinary interventions within a specialist framework of care, have evolved to become the gold standard of treatment in evidenced-based guidelines [5, 6]. The effectiveness of HFMPs in reducing hospital readmissions has been confirmed in several systematic reviews and meta-analyses [7–11], with patient education identified as the most commonly applied intervention within these programs [12•, 13•]. For patients living with HF, the day-to-day symptom burden can vary depending upon the stage of their illness. These symptoms are insidious, with an illness trajectory that is unpredictable [14]. This cohort of predominantly elderly patients may have difficulty adapting to the demands of daily self-care management due to comorbidities, reduced cognition, poor health literacy, poor social support, and polypharmacy. HFMPs have been proven beneficial in assisting HF patients in overcoming these difficulties, with patient education identified as an essential component of care in this cohort by key organisations including the European Society of Cardiology, the American College of Cardiology/ American Heart Association, and the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand [5, 15, 16]. This article provides a review of the current evidence with regard to education material for people living with HF in an effort to identify practice improvement opportunities in the delivery of patient education.
Educational Strategies Well-designed educational strategies grounded in theory and utilising contemporary evidence are essential in improving
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patient outcomes such as readmissions, mortality, self-care abilities, knowledge, and quality of life. Historically, healthcare professionals have utilised a variety of educational strategies within HFMPs [13•, 17•], often supplemented by written patient education materials [18].Videos/DVDs and interactive systems such as telemonitoring and computer applications have been applied as well. The timing and frequency of educational strategies have varied considerably, and materials may have been presented in single sessions or on multiple occasions [13•, 17•]. Descriptions of implemented educational programs and interventional procedures often lack detail and transparency, creating difficulties in comparing interventions or conducting further analysis [12•, 17•, 19, 20, 21•]. Analyses from studies often lack detail with respect to the impact of a theoretical framework on the development of educational strategies [17•, 19]. In addition, the literature has reported a broad variety of outcome parameters, impeding the development of educational strategies based on scientifically sound evidence [20]. In a recent review, Albano and colleagues identified the primary issue for comparisons, reproducibility, and generalisation of results as the lack of precise descriptions of programs and consistent reporting of standardised outcomes [21•]. Despite these difficulties, however, there is some evidence that knowledge, behaviour, and symptom experience improve when content is individualised using combined media and provided in multiple one-on-one sessions [22], although the methods best suited for education of HF patients have not been clearly defined [23]. Education of HF patients is complex and multifaceted, and to date there is no definitive gold-standard approach. Various educational strategies and materials have been packaged together in an attempt to achieve incremental benefits. Implementing several interventions simultaneously to address complex problems is often referred to as bundling [12•], and this approach can compromise efforts to determine the effect of any singular strategy [24]. In-hospital teaching sessions and printed education materials have been bundled with various follow-up strategies post-discharge, with a range of results. Importantly, research has shown that educational nursing intervention, supplemented with an HF manual, is effective in improving the knowledge of HF and self-care in all patients, regardless of telephone follow-up [25]. Similarly, no change in clinical outcomes was identified when a single-session educational strategy, supplemented with a literacy-sensitive workbook, was compared to a more intensive approach consisting of additional education and self-care training along with follow-up via telephone [26]. Another study demonstrated no difference in outcomes between group counselling sessions and telephone follow-up when all participants received the same printed education materials in the form of 18 tip sheets [27]. Other bundled approaches, including the use of telemonitoring, interactive voice response reminder
systems, and computer-aided learning, have produced varying results [28–33].
Novel Approaches With the increasingly widespread use of the Internet, Webbased components have begun to be incorporated within educational strategies. A small study of two remote Webbased educational strategies demonstrated overall improved knowledge scores, with significantly higher scores in the group exposed to additional sessions [34]. The proliferation of healthcare information on the Internet, however, has caused researchers to question its credibility and readability. Disappointingly, a recent investigation of HF informational material on Internet websites found that a biomedical approach was most common, information was often written in the thirdperson, and it was presented in an authoritarian manner using technical language [35]. Less evident was a partnership approach that provided information about living with heart failure, which was generally written in the second-person and focused on the experience of HF. An evaluation of 15 websites revealed only five that included all required areas of content, together with a readability score at or near the appropriate level for most patients [36]. The challenge for healthcare professionals is identifying websites that are credible, are reader-friendly, and provide quality material, so that patients do not feel overwhelmed by the plethora of Internet information [36]. Research investigating the use of an iPad app to support self-care and monitoring is currently underway, with some initial promising results [37].
Topics for Patient Education Patients continue to demonstrate poor knowledge of the nature and cause of HF as well as its pharmacological and behavioural management [38]. Lack of knowledge has been independently associated with poor HF self-care behaviours [39], while increased HF-specific knowledge has been associated with improved self-care [40]. The majority of patients want more information about self-management, with a preference for material that is easy to understand [41]. Overall, patients tend to identify four top-ranked topics – signs and symptoms, prognosis, risk factors, and medications – as their learning needs [42], a trend that has been consistently demonstrated in studies [43–47]. Evidence suggests that within HFMPs, clinicians have provided a broad range of information, including understanding HF, beneficial lifestyle changes, adherence to pharmacological and non-pharmacological therapies, symptom monitoring, and self-care behaviours [12•, 13•]. However, in order to engage patients in their own learning and thus
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improve patient outcomes, educational content must be individualised to the learning needs of each person [42, 48].
Patient Education Materials Printed education materials consist of booklets specifically designed to provide information for patients about health promotion, disease prevention, treatment modalities, and self-care regimens [49]. These resources allow patients to absorb information over time at their own pace [50], and they are an important source of supplementary information [51]. Studies have demonstrated improved knowledge among patients with the use of printed materials compared to verbal information alone [52]. Other beneficial outcomes attributed to effective and well-written education materials include improved ability to adhere to post-discharge instructions, reduced hospital readmissions, enhanced patient confidence, reduced anxiety, and decreased recovery times [53]. Written educational materials are able to target specific patient populations, can provide a reference for information, are suitable for patients who identify as having a read/write learning style, and are widely acceptable to the general population [53–55]. The literature suggests that written materials are most commonly utilised to supplement verbal interaction with a healthcare professional [18]. Traditionally, programs for patients have focused on educational needs identified by healthcare providers [56]. Education is more effective, however, when it is based upon an assessment of the participant’s existing knowledge, skills, and preferred learning style [53]. While an initial verbal interaction delivered together with written materials by a healthcare professional is acknowledged as common practice, the assessment of learning styles and preferences prior to implementation of an educational strategy is often lacking. Our group conducted an investigation into the learning styles, needs, and preferences of people with HF, which informed the development of a patient-centred HF manual and DVD [42]. We found that HF patients preferred multimodal learning, with information premised on the experiences of others relative to the patient’s own experiences, presented by reliable healthcare professionals, in a format that they could then maintain as a reference [57]. Decisions regarding content, presentation, and style of the manual were guided by the principles of andragogy, together with instructional design aimed at enhancing readability and patient engagement (Table 1) [54, 55, 58, 59]. The DVD used visual role-modelling to demonstrate self-care behaviours, as visual representation of scenarios has been found to stimulate learning and aid in transfer of knowledge [60]. Utilising these patient-centred resources, we conducted a pilot study, which demonstrated improved patient knowledge and self-care abilities [61]. Importantly, older patients with the lowest level of education showed
Table 1 Guidelines for developing printed education materials Design Use a short title Ensure that the purpose of the printed material is clear to the intended reader Use at least a 12-point type font Write in the active voice Aim for year/grade 5 to 6 reading level Content Keep content clear, simple, and concise Use common language Include a table of contents Outline the learning objectives Use topic headings Use one- and two-syllable words understood by the intended reader Use short sentences, with one idea to a sentence Use short paragraphs and discuss important ideas first Ensure that the content is focused on what the reader should do Provide examples Include questions Avoid jargon and define medical terminology Ensure that content is based on the information needs of the target audience Ensure that content is evidenced-based Ensure currency by including a publication date Acknowledge sources of information Layout Use a structured format with clear and obvious headings Use bold print to highlight headings Use subheadings Use bullet points Use upper- and lower-case letters for ease of reading Presentation Use adequate spacing, with adequate white space Use dark print on light background Use illustrations that are recognisable, clearly labelled, informative, and complementary to the written text
significantly improved knowledge. These promising results are currently being investigated in a randomised controlled trial. Similarly, the practice of mailing an evidence-based DVD and booklet to patients with HF demonstrated a statistically significant increase in daily weight monitoring compared to a control group [62]. This broad-based, relatively inexpensive educational strategy has shown promise as a component of a comprehensive HFMP.
Health Literacy Inadequate health literacy has a negative impact on learning and is associated with adverse health outcomes [63]. A
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consensus statement from the Heart Failure Society of America on health literacy for patients with HF identified that, while the literature is limited, clinicians should focus on these five steps: recognising the consequences of low health literacy, identifying and then screening patients at risk, documenting literacy levels and learning preferences, and integrating effective strategies to enhance patient understanding [63]. Patient education is more effective when strategies are tailored to level of health literacy and patient preferences for learning [61, 64]. Written education materials specifically designed for patients with inadequate health literacy, when coupled with appropriate teaching and follow-up strategies, have demonstrated beneficial effects on patient outcomes. An intervention specifically designed for HF patients with low literacy implemented an initial one-to-one education session, guided by the principles of pedagogy, coupled with a picturebased booklet and management plan [65]. A more recent study by the same author, which included the use of a literacy-sensitive manual, found that multi-session interventions were more effective than single sessions for individuals with low literacy [26]. Improvements in HF symptoms can be achieved when education materials are written with specific attention to the instructional design to ensure relevance for people with inadequate health literacy [66].
Cognition Cognitive impairment is a contributing factor to poor health outcomes for patients with HF, as it impacts on the patient’s ability to participate in education and to implement appropriate self-care behaviours [23, 67]. Davis and colleagues [68] demonstrated a significant increase in HF knowledge, with a trend towards improved self-care, using an individualised strategy incorporating a workbook containing pictograms, which was tailored to individuals with cognitive impairment. Incorporation of appropriately designed written materials within tailored educational strategies can enhance outcomes for patients who are cognitively impaired.
Evaluation of Patient Education Materials Healthcare professionals must ensure that all patient education materials meet the learning needs of HF patients and are suitable for the intended audience. Evaluation is an essential element in gauging the appropriateness of the content with regard to suitability and readability. The readability of written materials refers to how easy the content is to read [53]. Ease of readability and reading grade level can easily be assessed on word-processing programs such as Microsoft Word (Microsoft Corporation, USA). Another instrument is the Tool to Evaluate Materials Used in Patient Education (TEMPtEd)
developed by Clayton [69]. An evaluation of 18 written patient education materials for HF patients using the suitability of materials (SAM) and Fry readability formula found that only two had the optimum suitability score of 70 % or higher and fifth grade or lower readability level [70]. Gwadry-Sridhar and colleagues have developed two instruments to facilitate patient evaluation of education materials—the educational material acceptability (EMA) and the knowledge acquisition questionnaire (KAQ)—which healthcare practitioners can utilize to measure patient satisfaction [71]. There appears to be a prevalence of poorly prepared education materials that are written beyond the reading level of most patients, which may diminish the effectiveness of educational strategies.
Research Implications While there have been a variety of educational strategies implemented within HFMPs, due to the heterogeneity of these interventions it has been difficult to formulate evidencedbased guidelines. During the development and implementation phase of educational strategies, appropriate methodologies should be employed to evaluate written education materials and multimedia resources. Future research should systematically delineate the singular and bundled components of educational strategies in order to enable comparison, reproducibility, and generalisation. Detailed descriptions of educational strategies, with standardised format for reporting outcomes, will enhance the ability to assess the effectiveness of particular strategies as they are implemented.
Clinical Implications An appropriate theoretical approach and an understanding of the learning needs and style of the individual patient will help to facilitate the effective transfer of knowledge and the development of self-care skills. Healthcare professionals must ensure that education is individualised and is implemented with a partnership approach. Well-written education materials allow patients to learn at their own pace, and can be retained as an ongoing reference. In addition, a selection of multimedia resources will provide a patient-centred learning environment to accommodate unique learning styles. Reiteration of information through repeated visits, telephone contact, or telemonitoring has shown promising results.
Future Approaches Approaches to patient education are constantly evolving. Healthcare professionals are challenged to develop welldesigned, detailed educational strategies utilising new
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technologies such as Web-based applications. Comprehensive reporting of these strategies, together with systematic evaluation of patient outcomes, will allow us to build an evidence base to guide future patient educational programs.
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Conclusions Education of chronically ill HF patients is a multifaceted effort, leading healthcare professionals to bundle together a number of different strategies and resources. This approach has hindered our ability to clearly identify the most effective patient educational strategy and appropriate materials to improve patient outcomes. Commonalities have been found within these disparate approaches, however, which can provide the framework for a comprehensive strategy that includes assessment of learning needs and style as well as verbal interaction with a healthcare professional, supplemented with a selection of multimedia education materials.
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Compliance with Ethics Guidelines
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Conflict of Interest Mary Boyde and Robyn Peters declare that they have no conflict of interest.
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Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
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References Papers of particular interest, published recently, have been highlighted as: • Of importance
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