https://doi.org/10.15218/ejnm.2019.16 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article Effect of a Health Educational Program on Patients Knowledge regarding Heart Failure: A Quasi-Experimental Study ABSTRACT INTRODUCTION Heart failure (HF), a state in which the heart muscle is unable to pump enough blood throughout the body, is considered a worldwide problem in the 21st century with increasing effect on healthcare sys- tems [1]. Prevalence of HF is rising in both industrialized and developing countries, according to the American Heart Association (AHA), about 1 in 5 over age 40 years suffer from HF [2].Heart failure is one causes of hospitalization of patients over 65 years old, it costs around 2% of the entire budget of health care in many devel- oped countries [3]. The disease has a sub- stantial effect on physical ability, quality of life, public health and the cost of healthcare. This can happen to many Backgrounds and objective: Heart failure is a major public health problem in the world with a significant load of disease on population and the individual, this burden of disease can be measured in terms of mortality, readmission rate, and healthcare costs. Adequate knowledge about the disease is an effective strategy to prevent further disease complica- tion. The study aimed to determine the effect of a health education program on heart fail- ure patients regarding their disease through a pre-post-test approach. Methods: A quasi-experimental study with the application of pre and post-test approach for both the study and control group at Hawler Teaching Hospital, Rizgary Teaching Hospi- tal and Rojhalat Hospital on patients with heart failure. A non-probability purposive sam- pling technique used on 400 heart failure patients chosen to include in the study. The study samples were divided into two groups; 200 patients as a study group and exposed to the health education program, and the other 200 patients were not exposed to the health education program and considered as the control group. The measurement of the effec- tiveness of a health education program through the knowledge assessment includes six main domains like General information, risk factors, causes, clinical manifestation, diagno- sis, and management of heart failure. Statistical data analysis achieved through descriptive and inferential data analysis. Results: The results indicated that a health education program was effective among pa- tients regarding management heart failure. It also indicates that there is good improve- ment with highly significant differences in study group between pre and post-test, in over- all items. Conclusion: The study concluded that the educational program is an appropriate and effective way to improve the patient's knowledge about heart failure. Keywords: Health educational program; Knowledge; Heart failure; Mortality Younus Khudhur Baeez; Department of Nursing, College of Nursing, Kirkuk University, Kirkuk , Iraq. (Correspondence: : yuns34@yahoo.com ) Yousif Mohammed Younis; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 125 Erbil Journal of Nursing & Midwifery Received: 17/7/2019 Accepted: 12/9/2019 Published: 30/11/2019 mailto::%20yuns34@yahoo.com https://doi.org/10.15218/ejnm.2019.16 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article patients being readmitted to the hospital every year, which cause a continuous growing burden of HF on society [4,5]. Pa- tients may have many medical conditions, along with many medications, no social support, and other factors limiting the suc- cess of some treatment options. In addi- tion, patients with HF may have low knowledge about their medication, weight and sodium management, and activity modification. For this, patients need healthcare and increased knowledge about HF to produce changes in health behaviour [6,7]. Nurses have an important role in the reassessment of heart failure disease, con- trolling the hemodynamic function and management of HF[8]. Nursing implications help to minimize patient suffering from HF, the patients who are provided with care acquired from programs show a significant effect on morbidity and mortality reduc- tion. Hence, the nurse should become ade- quately prepared as an educator to man- age a patient with HF [9]. Most heart fail- ure management program’s goals are to make patient receive ideal medical care by assessing needs and implementing medical management, device therapy teaching, self -care, follow-up, and psychosocial health care [10]. Advancing patients on self-care management can help in behavioural rein- forcement and accompanied with effective outcomes, including subjective symptoms, weight observation, low salt diet, improve exercise, medication intake, and a plan for management in case of symptoms agita- tion. Additional knowledge is important in improving patients’ results and to maintain patient condition in the hospital and the outpatient [11]. Studies have shown that half of the patients with heart failure who have been re-admitted to hospital can be prevented from re-entering the hospital if they continue with the prescribed treat- ment [12].Patients, as well as their caretak- ers, level of knowledge, is significantly related to their level of adherence to rec- ommended care regimens [13].Patients knowledge is an essential component for the treatment of their disease [14]. Heart failure requires a strong focus on the edu- cation of patients and their families to improve their knowledge of self-care and compliance [15]. A quasi-experimental study was carried out through with the application of pre and post-test approach for both case and control group, The study was conducted at Intensive Care Unit (ICU) and Medical Ward at Hawler and Rizgary Teaching Hospital, as well as Rojhalat Emergency Hospital. A non-probability purposive sampling technique used on 400 heart failure patients chosen to include in the study, the sample size were determined through the formula " Sample size= Z2pq/ d2 ". The samples of the study were divid- ed into two groups; 200 patients as a case group were exposed to the health educa- tion program and the other 200 patients are not exposed to the health education program, considered as the control group. The two groups have the same demographic characteristic. The educa- tional program is designed and based on the patients need assessment and from reviewing the relative scientific literature, and previous studies. The content of the program is evaluated by experts in differ- ent fields, revision is made on the content of the program from based on these ex- perts recommendation and suggestions. To evaluate the effectiveness of the edu- cational program on patient knowledge, the researcher constructs a questionnaire interview form for the purpose of data collection, which contains six main do- mains:General information 10 items, risk factors 10 items, causes 5 items, clinical manifestation 8 items, diagnosis 4 items, 126 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2019.16 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article The study showed that most of the case group were at age group of (75-79) years old with mean of age and standard devia- tion 76.68 ± 6.67, while the majority of the control group were at age (70-74) years old with mean of age and standard deviation 75.44 ± 6.32, these findings agree with the result of cross-sectional study done by Gianluigi and Lars, on 199 heart failure patients and they concluded that the majority of the patients age was above 70 years old [16]. Moreover, the result of the present study agrees with the study on heart failure, the finding of their study revealed that the mean of age and slandered deviation was 75.2. ± 6.18 [17]. According to the cases group main domains knowledge along pre-post peri- ods, the results showed that the GMS of patients knowledge regarding heart fail- ure in the study group has been improved after exposure to a health education pro- gram, and this was indicated by the sig- nificant difference between pre-test and post-test of the results. Moreover, regard- ing the control group main domains knowledge along pre-post periods, the study indicated that changes in the case group were significantly higher than that of the control group. The study comes along Mahramus et al, who founded in his study that there is a significant improve- ment in patients' knowledge regarding heart failure after imparted the study samples with a health education program [18]. Furthermore, the study in agreement with Sundel, who stated that providing heart failure education classes to patients can be successful in increasing their knowledge [19].For summarizing the over- all knowledge assessment along pre-post periods in case-control groups, it could be concluded that suggested educational program could be applicable for case and management of HF 4 items. The con- tent validity of the program and study in- struments are determined by a panel of experts, reliability of the tools was deter- mined through the use of test-retest ap- proach obtained through evaluating 20 patients selected from above hospitals with interval period of two weeks. The re- sult of the reliability coefficient was 0.91 for patients knowledge related to heart failure. The statistical data analysis ap- proaches were used in order to analyze and assess the results of the study under the application of the Statistical Package (SPSS) ver. 22.0: Descriptive data analysis: Frequencies, Percentages, Mean of the score (MS), Grand mean of scores (GMS), Standard Deviation (SD), Relative Suffi- ciency (RS%), as well as inferential data analysis: The Independent-Samples t-test to compares means for two groups of cas- es, and Matched Paired-Samples t-test (MP t-test) to computes the differences between values of the two variables for each case and tests whether the average differs from zero. Respect to study socio-demographical characteristics in table (1), results show that study groups had recorded no signifi- cant differences at P>0.05, except in age groups, and levels of education, which represented significant different at P<0.05, rather than most of the studied group's individuals distribution concerning age, and levels of education were very similar. In regards to age, the majority of study groups were at the age group of (75- 79) years old with mean of age and stand- ard deviation 76.68 ± 6.67, while the ma- jority of the control group were at age (70 -74) years old with mean of age and stand- ard deviation 75.44 ± 6.32. 127 Erbil Journal of Nursing & Midwifery RESULTS DISCUSSION https://doi.org/10.15218/ejnm.2019.16 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article group, since the absence of significant differences between the two groups 128 Erbil Journal of Nursing & Midwifery Socio-demographical characteristics. Classes Study group Control group P-value No. (%) No. (%) Age < 65 8 (4) 0 (0) 0.015 (S) 65 – 69 23 (11.5) 32 (16) 70 – 74 45 (22.5) 64 (32) 75 – 79 64 (32) 58 (29.9) 80 – 84 38 (19) 33 (16.5) 85 – 89 14 (7) 9 (4.5) 90 > 8 (4) 4 (2) Mean ± SD 76.68 ± 6.67 75.44 ± 6.32 Gender Male 105 (52.5) 104 (52) 0.920 (NS) Female 95 (47.5) 96 (48) Levels of Education Illiterate 101 (50.5) 139 (69.5) 0.001 (HS) Read and write 31 (15.5) 15 (7.5) Primary 16 (8) 14 (7) Intermediate 13 (6.5) 11 (5.5) Preparatory 11 (5.5) 12 (6) Institute graduate 11 (5.5) 4 (2) College graduate 17 (8.5) 5 (2.5) Occupation Before disease Employed 33 (16.5) 24 (12) 0.107 (NS) Unemployed 33 (16.5) 42 (21) House wife 78 (39) 93 (46.5) Self- employed 23 (11.5) 22 (11) Retired 33 (16.5) 19 (9.5) Occupation After disease Returned to work 12 (6) 13 (6.5) 0.836 (NS) Out of work 188 (94) 187 (93.5) Marital Status Married 134 (67) 132 (66) 0.832 (NS) Widowed 66 (33) 68 (34) Residential Area Urban 179 (89.5) 185 (92.5) 0.295 (NS) Rural 21 (10.5) 15 (7.5) regarding knowledge of patients with heart failure. Table 1: Socio-demographical characteristics of the samples https://doi.org/10.15218/ejnm.2019.16 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article 129 Erbil Journal of Nursing & Midwifery Table 2: Cases group main domains knowledge along pre-post periods Main Domains Group No. GMS SD SE t-test P-value General Information Pre 200 0.563 0.193 0.014 -20.14 < 0.001(VHS) Post 200 0.782 0.128 0.009 Risk factors Pre 200 0.223 0.178 0.013 -34.60 < 0.001(VHS) Post 200 0.620 0.157 0.011 Causes Pre 200 0.354 0.208 0.015 -22.69 < 0.001(VHS) Post 200 0.692 0.191 0.014 Clinical Manifestation Pre 200 0.636 0.170 0.012 -20.66 < 0.001(VHS) Post 200 0.854 0.120 0.008 Diagnosis Pre 200 0.393 0.317 0.022 -17.34 < 0.001(VHS) Post 200 0.770 0.249 0.018 Management Pre 200 0.386 0.212 0.015 -16.77 < 0.001(VHS) Post 200 0.719 0.259 0.018 (*) HS: Highly Significant at P<0.01; NS: Non-Significant at P>0.05; Testing based on Matched Paired t-test; GMS=Grand mean of score Table 3: Control group main domains knowledge along pre-post periods Main Domains Group No. GMS SD SE t-test P-value General Information Pre 200 0.566 0.170 0.012 -7.79 < 0.001(VHS) Post 200 0.623 0.153 0.011 Risk factors Pre 200 0.195 0.164 0.012 -5.70 < 0.001(VHS) Post 200 0.257 0.207 0.015 Causes Pre 200 0.353 0.180 0.013 -6.42 < 0.001(VHS) Post 200 0.415 0.221 0.016 Clinical Manifestation Pre 200 0.630 0.159 0.011 -5.74 < 0.001(VHS) Post 200 0.661 0.159 0.011 Diagnosis Pre 200 0.400 0.321 0.023 -5.45 < 0.001(VHS) Post 200 0.465 0.325 0.023 Management Pre 200 0.373 0.226 0.016 -4.93 < 0.001(VHS) Post 200 0.429 0.249 0.018 (*) HS: Highly Significant at P<0.01; NS: Non-Significant at P>0.05; Testing based on Matched Paired t-test; GMS=Grand mean of score https://doi.org/10.15218/ejnm.2019.16 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article In conclusion, the current study data showed that implementing an education program regarding heart failure in Erbil city had increased patients' knowledge about their disease as well as improved their health status. We would like to express thanks to all heart failure patients who participate in the study and thank their families for their collaboration. We would like also to thank all health staff in the Hawler teaching hos- pital, Rizgary teaching hospital and Rozha- lat emergency hospital for their facilities and cooperation over the periods of the study. Before starting the research procedures, official approval was obtained from the re- search ethics committee at the college of nursing from Hawler medical university. Written permission was obtained from the Directorate of the health of Erbil city in or- der to facilitate data collection, after that, informed consent was obtained from the HF patients who engaged in the study prior to data collection. The authors declare that there is no con- flict of interest. [1] Anne M, Jette R, Karsten M, Charlotte S, and Klas K. Patients with heart failure as co- designers of an educational website: Impli- cations for medical education. International Journal of Medical Education. 2017; 8, 47– 58. doi: 10.5116/ijme.5898.309e [2] Boback Z and Gregg C. Epidemiology and aetiology of heart failure. Nature Reviews. Cardiology.2016;13(6):368–378. doi: 10.1038/nrcardio.2016.25. [3] Wladimir L, Christine K, and Peter K. Cost-of- illness studies in heart failure: a systematic review 2004–2016. BioMedical Central Car- diovascular Disorders, 2018; 18: 74. doi: 10.1186/s12872-018-0815-3 [4] Colleen K, Zubin J, and Larry A. Hospital Re- admissions Reduction Program. Circulation. 2015; 131(20): 1796–1803. doi: 10.1161/ CIRCULATIONAHA.114.010270 [5] Aaron L, Michael R, Maya K, Juan P, Frances S, Katie G, et al. Preventing 30-day hospital readmissions: a systematic review and meta- analysis of randomized trials. Journal of the American Medical Association. 2014; 174 (7):1095–1107.doi:10.1001/ jamainternmed.2014.1608 [6] Kathleen L, Kathleen D, Gemma K, Debra K, Mariann P, Lynne W, et al. Team Manage- ment of Patients With Heart Failure. A State- ment for Healthcare Professionals From the Cardiovascular Nursing Council of the Ameri- can Heart Association. Circulation. 2000;102:2443–2456.https:// doi.org/10.1161/01.CIR.102.19.2443 130 Erbil Journal of Nursing & Midwifery Table 4: Overall main domains knowledge along pre-post periods in case-control groups Groups Group No. GMS SD SE t-test P-value Case Pre 200 0.426 0.106 0.008 -46.4 < 0.001(VHS) Post 200 0.739 0.085 0.006 Control Pre 200 0.419 0.098 0.007 -7.92 < 0.001(VHS) Post 200 0.475 0.128 0.009 (*) HS: Highly Significant. at P<0.01; Testing based on Matched Paired t-test. CONCLUSION ACKNOWLEDGEMENT ETHICAL CONSIDERATIONS CONFLICT OF INTEREST REFERENCES https://doi.org/10.15218/ejnm.2019.16 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article [7] Jessica D, Daniel J, Kris S, and Britta I. Pilot Program to Improve Self-Management of Patients with Heart Failure by Redesigning Care. Coordination. Nursing Research and Practice.2014;836921. doi: 10.1155/2014/836921 [8] Jillian R. The Key Roles for the Nurse in Acute Heart Failure Management. Cardiac Failure Review. 2015; 1(2): 123–127. doi: 10.15420/ cfr.2015.1.2.123 [9] James K, Theodore A, Kathy A, and Dominique L. Diagnosis and treatment of depression in patients with congestive heart failure: A review of the literature. Primary Care Companion for CNS Disorder. 2013; 15 (4), 13- 15. doi: 10.4088/PCC.13r01511 [10] Tiny J, Torben L, Anna S. Practical guide on home health in heart failure patients. Inter- national Journal of Integrated Care. 2013; 13: e043. https://www.ncbi.nlm.nih. gov/ pmc/articles/PMC3821536/ [11] Laura K, Lawrence J, and Chery A. Strategies to Reduce Dietary Sodium Intake. Current Treatment Options in Cardiovascular Medi- cine. 2012; 14(4): 425–434. doi: 10.1007/ s11936-012-0182-9 [12] Nahid A, and Genevieve L. Management of chronic heart failure in the older population. Journal of Geriatric Cardiology. 2014; 11(4): 329–337.doi:10.11909/j.issn.1671- 5411.2014.04.008 [13] Andrew J, Myint A, and Gboyega A. Factors that positively influence adherence to an- tiretroviral therapy by HIV and/or AIDS pa- tients and their caregivers. African Journal of Primary Health Care & Family Medicine.. 2011; 3(1): 196. doi: 10.4102/phcfm.v3i1.196 [14] Saurabh R, Prateek S, and Jegadeesh R. Role of self-care in the management of diabetes mellitus. Journal of Diabetes and Metabolic Disorders.. 2013; 12: 14. doi: 10.1186/2251- 6581-12-14 [15] Tiny J, Jan C, Barbara R, and Anna S. Factors Related to Self-Care in Heart Failure Patients According to the Middle-Range Theory of Self-Care of Chronic Illness: a Literature Up- date. Current Heart Failure Reports. 2017; 14 (2): 71–77. doi: 10.1007/s11897-017-0324-1 [16] Gianluigi S, and Lars H. Global Public Health Burden of Heart Failure. Cardiac Failure Re- view.. 2017 Apr; 3(1): 7–11. doi: 10.15420/ cfr.2016:25:2 [17] Naseer A, Hassan H. Effectiveness of Educa- tional Program on Nurses' Practices toward Cardiac Rehabilitation for Patients with Heart 131 Erbil Journal of Nursing & Midwifery Attack, Kufa Journal of Nursing Science. 2013; 5(1): 3-6. Available from: https:// www.iasj.net/iasj?func=fulltext&aId=99767 [18] Mahramus T, Frewin S. Chamberlain L, Wil- son D, and Sole M. Assessment of an educa- tional intervention on nurses' knowledge and retention of heart failure self-care prin- ciples and the Teach-Back method. Heart Lung. 2014; 43(3):204-12. doi: 10.1016/ j.hrtlng.2013.11.012. [19] Sundel S. An Educational Intervention to Evaluate Nurses' Knowledge of Heart Fail- ure. Journal of Continuing Education in Nursing.. 2018; 49(7):315-321. doi: 10.3928/00220124-20180613-07.