Review
A systematic review of patient education in cardiac patients: Do they increase knowledge and promote health behavior change?

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Abstract

Objective

(1) To investigate the impact of education on patients’ knowledge; (2) to determine if educational interventions are related to health behavior change in cardiac patients; and (3) to describe the nature of educational interventions.

Methods

A literature search of several electronic databases was conducted for published articles from database inception to August 2012. Eligible articles included cardiac patients, and described delivery of educational interventions by a healthcare provider. Outcomes were knowledge, smoking, physical activity, dietary habits, response to symptoms, medication adherence, and psychosocial well-being. Articles were reviewed by 2 authors independently.

Results

Overall, 42 articles were included, of which 23 (55%) were randomized controlled trials, and 16 (38%) were considered “good” quality. Eleven studies (26%) assessed knowledge, and 10 showed a significant increase with education. With regard to outcomes, educational interventions were significantly and positively related to physical activity, dietary habits, and smoking cessation. The nature of interventions was poorly described and most frequently delivered post-discharge, by a nurse, and in groups.

Conclusions

Findings support the benefits of educational interventions in CHD, though increase in patients’ knowledge and behavior change.

Practice implications

Future reporting of education interventions should be more explicitly characterized, in order to be reproducible and assessed.

Introduction

Cardiovascular diseases (CVDs) are the leading cause of mortality worldwide [1], and are a significant contributor to morbidity and health-related costs [2]. Coronary artery disease (CAD) – the most common type of CVDs – is considered a chronic condition and, therefore, requires a careful medical management with multiple recommendations for patients to achieve optimal secondary prevention [3], [4], [5]. As a consequence, patient education is a necessary first step to promote patient understanding of the recommended therapies and behavior changes, as well as to follow them [6], [7], [8], [9].

Patient education has been formally defined as “the process by which health professionals and others impart information to patients that will alter their health behaviors or improve their health status” [10]. Research is beginning to demonstrate a positive effect of cardiac patient education on behavior change, including 4 reviews [11], [12], [13], [14]. Of these, 3 demonstrated educational interventions produce a positive effect on behavior change. Although these reviews may be less subject to bias as they included only randomized controlled trials, they included a small number of trials and focus on outcomes, failing to describe the interventions in depth and aiming only to assess psycho-educational strategies. It is important to gain a clear picture of how these interventions are structured and how they impact not only behavior, but also knowledge. To our knowledge, such a synthesis has not been published previously.

Cardiac rehabilitation (CR) is a comprehensive risk reduction program, of which patient education is considered a core component [15]. Thus, American and Canadian Cardiovascular Societies include education as a quality indicator of CR [16], [17]. According to the Canadian Association of CR Guidelines [3], patient education should: be personalized; be led by a professional staff, with regular contact between staff and patients; be delivered in individual or group settings; discuss specific health goals; and seek to influence outcomes beliefs, to elicit positive emotions, to increase optimism about the possibility of change, and to heighten the salience of personal experience or other evidence supporting self-efficacy. However, the nature of education delivery is not fully specified, and the impact of the education has not been often considered.

The first objective of this systematic review was to investigate the impact of education on patients’ knowledge about health and disease. The second objective was to determine if educational interventions are related to health behavior change in CAD patients, namely smoking, physical activity, dietary habits, response to cardiac symptoms, and medication adherence, as well as psychosocial well-being. Finally, the third objective was to describe the nature of the educational interventions offered, as per the Workgroup for Intervention Development and Evaluation Research (WIDER) reporting guideline [18].

Section snippets

Search methods for identification of studies

Literature published from database inception until August 2012 was searched using the MEDLINE, PsycINFO, CINAHL, EMBASE and EBM computerized databases, in conjunction with a subject librarian. Search results were downloaded into bibliographic software. The search strategy incorporated 3 concepts: (1) condition, which was divided into cardiac and rehabilitation aspects (e.g. coronary disease, myocardial infarction, and rehabilitation); (2) education (e.g. health education or patient education);

Results

Initial searching yielded 6476 records, and 3 records were identified through the snowball hand-search. After the screen, 343 full-articles were assessed for eligibility. Overall, 42 articles were included in this systematic review. A flow diagram depicting the search results, reasons for exclusion, and study selection is presented in Fig. 1.

Discussion

This systematic review investigated the impact of education on patients’ knowledge and health behavior change in CAD patients and described the nature of educational interventions delivered. Overall results of this review suggest that educational interventions within cardiac care increase patients’ knowledge and facilitate behavior change. All studies assessing knowledge but one reported an increase in patients’ knowledge, in areas including appropriate responses to cardiac symptoms and

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