Health Sciences Review 5 (2022) 100060

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Health Sciences Review

journal homepage: www.elsevier.com/locate/hsr

Effective health education methods to improve self-care in older people

with chronic heart failure: A systematic review
Sriyanti Mansyur a,b, Andi Masyitha Irwan c,∗, Rosyidah Arafat d, Yudi Hardianto e
a
H Padjonga Dg.Ngalle General Hospital, Takalar, South Sulawesi 92211, Indonesia
b
Post Graduate Nursing Program, Faculty of Nursing, Hasanuddin University, Perintis Kemerdekaan Street KM.10, Tamalanrea, South-Sulawesi, Makassar 90245,
Indonesia
c
Gerontological Nursing Department, Faculty of Nursing, Hasanuddin University, Perintis Kemerdekaan Street KM.10, Tamalanrea, South-Sulawesi, Makassar 90245,
Indonesia
d
Medical Surgical Nursing Department, Faculty of Nursing, Hasanuddin University, Perintis Kemerdekaan Street KM.10, Tamalanrea, South-Sulawesi, Makassar 90245,
Indonesia
e
Physiotherapy Study program, Faculty of Nursing, Hasanuddin University, Makassar, South Sulawesi, Indonesia

a r t i c l e i n f o a b s t r a c t

Keywords: Objective: Health education is proven to be able to improve self-care behavior, reduce hospital readmission,
Health education hospitalization or death in the older people with chronic diseases. Strategies in delivering education can make it
Older people easier for the older people to understand the learning provided. The aim of this systematic study was to identify
Self-care behavior
effective health education methods to improve self-care behavior in older people with Chronic Heart Failure.
Chronic heart failure
Methods: We performed literature searching in seven databases (Pubmed, Cochrane, Ebscohost, Proquest, DOAJ,
CHF
Science direct, and Clinical Key) to identify studies published in the last five years (2015–2020) that review the
health education methods in older people with CHF. Articles that meet the inclusion criteria will be assessed
using critical appraisal skills program (CASP) tool from the Joanna Brigg’s Institute, and the Cochrane of risk
bias tools to assess the risk of bias of the articles.
Results: Eight studies met the inclusion criteria. Health education methods included individualized with telephone
follow-ups, lectures, and face-to-face deliveries. The duration of education started from 30 min to 3 h. Health
education can significantly improve self-care behavior in older people, although some do not have a positive
effect after the intervention.
Conclutions and clinical implications: This review describes several health education methods for the older people
in changing the self-care behavior of CHF patients. Although there are a variety of methods that we found, we
can provide an overview of effective educational methods in the older people with CHF from the quality of the
results of the studies we reviewed. This review is that only a few studies have focused on older people. Health
education needs to be provided by a nurse to reduce the morbidity and mortality of older people with CHF.

1. Introduction results of the 2018 Basic Health Survey (Ministry of Health Research
and Development Agency Republic of Indonesia, 2018), the prevalence
Chronic Heart Failure (CHF) is the inability of the heart to pump ade- of heart disease according to a doctor’s diagnosis is 1.5% [5]. With ag-
quate blood to meet the tissue needs for oxygen and nutrients [1]. Based ing, the number of people with heart failure is also predicted to increase
on a World Health Organization (WHO) report in 2016, heart failure is [6]. Patients with CHF have a poor quality of life because of the unpre-
the leading cause of death in older people worldwide [2]. The Centres dictable risk of decompensation and reduction, concomitant symptoms,
For Disease Control and Prevention (CDC) in 2017 also reported that high cost of care, high hospitalization rates, and poor prognosis [7]. The
heart failure is one of the most chronic diseases affecting older people high number of older people with CHF can lower their survival rate if
in the United States [3]. In line with this report, the New York Heart not treated properly.
Association (NYHA) report showed that more than 5.7 million people Accumulating evidence shows that self-care behavior can reduce
live with heart failure in America, and 600.000 people are diagnosed morbidity and mortality and improve the quality of life in older peo-
with heart failure annually [4]. Meanwhile, in Indonesia, based on the ple. However, currently, self-care in older people with CHF disease is
still far from satisfactory [8]. This condition is also in line with the re-

∗
Corresponding author.
E-mail address: citha_ners@med.unhas.ac.id (A.M. Irwan).

https://doi.org/10.1016/j.hsr.2022.100060
Received 29 August 2022; Accepted 3 October 2022
2772-6320/© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
S. Mansyur, A.M. Irwan, R. Arafat et al. Health Sciences Review 5 (2022) 100060

sults of previous studies, which show that the score of self-care behavior 2.4. Selection process
in older people is still low [9]. Thus, intervention is needed to improve
self-care behavior in older people. Self-care is an activity that leads to The first author (SM) conducted the searching process in the selected
internal and external aspects. databases and filtered studies that met the eligibility criteria. Two other
Internal self-care links to knowledge and skills, while external one authors (AMI and RA) independently reviewed the studies against the
includes obtaining health from the environment [10]. However, the gen- eligibility criteria. The final decision regarding the inclusion and ex-
eral obstacle to self-care practice is inadequate knowledge and skills clusion of studies was made after going through a discussion process
about the disease [11]. This situation is where nurses’ role as educators between the three authors. Based on the process, eight studies were el-
can help patients increase their knowledge so that behavior changes igible for review. The process of assessing the quality of articles and
can occur after a health education program. Educational methods fa- data extraction was conducted by writer SM and reviewed by AM and
cilitate understanding of older people when given instruction. The ed- RA. while for the writing of the script is done by as a writer D.
ucational method is a way of selecting, combining, and designing ed-
ucation to achieve learning objectives [12]. Educating patients about
self-care behavior using appropriate health education methods helps in- 2.5. Quality assessment
crease patient knowledge and skills and make the practice easier. Older
people experience a decrease in physical and cognitive functions (such Included studies were assessed for their quality using the Criti-
as forgetfulness, fatigue, and difficulty in understanding new informa- cal Appraisal Skill Program (CASP) from Joanna Briggs Institute (JBI)
tion) that can hinder the learning process [13]. Therefore, they need a 2017 [15], their level of evidence with the Center for Evidence-Based
health education method that can facilitate their understanding of given Medicine (CEBM) [16], and their risk of bias with the Cochrane Risk of
information. Bias Tool [17]. Risk can be determined based on data extraction cover-
Previous reviews discussed mHealth technology-based educational ing 6 aspects including: (a) assessing the risk of bias in terms of sampling
methods, re-teaching methods, and educational programs that summa- technique, (b) limited research sample during the experimental proce-
rize various foot care educational methods. However, these studies were dure, (c) Reporting bias, does the author only inform certain results that
limited to one type of educational intervention, did not assess self-care, may result in a high risk of bias, (d) Variable bias, where studies with
were carried out in the adult to older people population, and were con- low risk are studies that recognize confounding factors, (e) Measurement
ducted not in patients with CHF . Several educational methods have bias by instruments assessing literacy and numeracy outcomes, reliabil-
been offered from these articles. However, no review summarizes the ity and validity of instruments, (f) Assessor bias, does the examiner know
various educational techniques for older people with CHF . Based on which students are included in the comparison or intervention group.
those findings, the authors set a research question: what educational
methods effectively increase self-care in older people with CHF disease?
This systematic review explicitly reviews the literature covering health
education methods and media, duration and frequency of education, 3. Results
and instruments used to assess self-care.
3.1. Study selection
2. Methods
Search articles on 7 databases, identified 1142 articles, including
2.1. Design Pubmed 9 articles, Cochrane 103 articles, Proquest 549 articles, Eb-
scohost 34 articles, DOAJ 6 articles, Science Direct 232 articles, Clin-
The writing protocol in this systematic review followed the ical Key 207 articles and secondary search 2 articles. Forty-one articles
PRISMA checklist 2020 [14]. The systematic guide can be accessed at that matched the research question were examined, thirty-three of them
http://www.prisma-statement.org/. This systematic review was regis- were excluded because they were not in accordance with the desired re-
tered to the International Prospective Register of Systematic Reviews sults and research objectives so that leaving 8 articles to be included in
(PROSPERO) with ID 223860. the review.

2.2. Search strategy

3.2. Study characteristics
We performed the literature searching on seven databases (PubMed,
Cochrane, EBSCOhost, ProQuest, DOAJ, Science Direct, and Clinical Eight studies were selected based on established inclusion criteria
Key). We also performed a secondary search on the references to the among them Five studies were RCTs [7,8,18–20] and three studies were
included articles. The keywords used in the search process were “older quasi-experiments [21–23]. All studies were conducted in various coun-
adult OR geriatric OR senior OR AND CHF OR CHF” AND “Health educa- tries: Iran, Korea, United States, Taiwan, and China. The characteristics
tion OR health promotion OR health teaching OR health learning” AND of each study are summarized in Table 1. One article did not blind in-
“control group” AND “self-care”. We filtered the search results based on tervention providers [8]. Two articles did not randomize their sampling
articles published in the last five years (2015–2020) and English and [21,22]. Performance bias, a question regarding whether the sample was
issued duplicates and not in full text. The searching process is presented blinded from information on intervention in either the control or inter-
in the flowchart (Fig. 1). vention groups, one article did not blind research-related information
on its participants. One article had an “unclear” answer because it did
2.3. Eligibility criteria not explain whether the assessment of the results was done blindly. On
the bias friction regarding incomplete data results, all articles have com-
We included studies that met our inclusion criteria: (1) studies that plete data although there are some respondents who dropped out at the
were conducted on older people with CHF, (2) studies that compared time of follow-up, but the researcher can handle and explain the rea-
two or more groups, (3) studies that investigated health education in- sons for drop out. Furthermore, for selective reporting, One article only
terventions, and (4) studies that had self-care as one of the measured describes the results of the objectives to be achieved. while for other
outcomes. We did, however, exclude review studies, protocol studies, bias risks, all articles have a low risk of bias. Meanwhile, the level of
and case reports. The searching identified 41 articles that were eligible evidence for each article is shown in Table 1. while the risk of bias for
to be examined for inclusion in reviewed studies. each article is included in Table 4.

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S. Mansyur, A.M. Irwan, R. Arafat et al. Health Sciences Review 5 (2022) 100060

Table 1
Characteristics and Levels of Evidence of the studies.

Educational Levels of Grade of Recom-

Author/ Year Country Design Number of Subjects location Education methods evidence mendation

Siabani et al. (2015) Western Iran RCT 184 people: Homes and Face-to-face methods 1b A
Control hospitals
Group:
- n: 55
Intervention group :
- FHP n: 67
- CHV n: 62
Sun et al. (2019) China RCT 100 people Hospital Individual methods 1b A
with phone follow-up
Wang et al. (2017) China RCT 62 people Hospital Lecture methods 2b B
Chen et al. (2018)[20] China RCT 62 people Hospital Individual methods 1b A
with phone follow-up
Clark et al. (2015) The United States RCT 50 people Home Individual methods 1b A
of America with phone follow-up
Seraji and Rakhshani. Iran Quasi-experimental 140 people Hospital Film combination 2b B
(2018) speech method
Moon, M. K., et al. Korea Quasi-experiments 38 people Hospital Face-to-face with 2b B
(2018) Intervention group: 18 counseling and
Control Group 20 education over the
phone
Liou et al. (2015) Taiwan Quasi-experimental 131 people Hospital Individual methods 2b B
Control Group 75 with phone follow-up
Intervention group: 56

Table 2
Health education procedures.

Procedure
Author/ Year Methods of education
Intervention groups Control group

Siabani et al. face-to-face/individual Intervention group 1 (CHV) was taught individually at The control group received
(2015) methods their home by volunteers for 2 h each day within three regular treatments such as
days. Intervention group 2 (FHP) was taught in one class in prescribed medications and
the hospital by a cardiologist for 3 h with a break of some advice on how to take
30 min each day within three days. the drug.
Sun et al. Individual methods with The patient received individual health guidance about the The control group received
(2019) phone follow-up disease and its treatment and a three-day self-care plan by routine nursing care
the nursing staff. After discharge, the nurse sent
educational messages via internet-based platforms and
follow-up calls every week for three months, every two
weeks in the fourth month, and every month in the fifth
and sixth months.
Wang, Q., Lecture methods Patients receive nine sessions of education each week with NA
et al. (2017) lecture techniques for two months. For three months, every
two weeks, the patient is followed up while receiving
health promotions and reporting their self-care behavior.
Clark et al. Individual methods with Seven educational sessions were delivered individually to The control group received a
(2015) phone follow-up patients by expert nurses every 10–14 days for three book containing information
months. The following three months telephone follow-up is on health promotion
conducted every 3–4 weeks for 5–15 min to promote and
develop disease symptom management decisions.
Seraji and Videos combined with The patient’s first session was given lecture education NA
Rakhshani. lecture method through a media booklet and a film then a CD on self-care
(2018) behavior was given to the patient. The second session was
held the day after the first session to summarize the
questions related to the educational booklet and CD
contents and provide answers to the questions.
Moon, M.K., Face-to-face methods The first training session was conducted face-to-face using The control group received
et al. (2018) accompanied by counseling the educational media booklet, after one week of an education booklet related
and education by phone consultation and education every week for one month. to heart failure information.
Liou et al. Individual methods with Teaching sessions were given individually for one day after The Control group received
(2015) phone follow-up one week in the hospital. After the session ended, booklets, advice on treatment
self-care videos, and daily notes on blood pressure, diet, compliance
and symptoms were recorded as being administered. Then
the follow-up call by the care provider was done at
intervals of 1 week, one month, and three months to get
feedback related to self-care compliance.
Chen, et al. Individual methods with Patients were individually educated upon discharge by a Standard care includes phone
(2018) phone follow-up cardiologist. After two weeks, the patient got a home visit calls by nurses
to check for changes in signs and subsequent symptoms.
Every two weeks, telephone follow-up was conducted to
encourage the patient to comply with treatment. Intensive
education was also conducted at 3 and 6 months.

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S. Mansyur, A.M. Irwan, R. Arafat et al. Health Sciences Review 5 (2022) 100060

Fig. 1. Article search flowchart.

3.3. Findings group taught at a hospital. Education was carried out for three days the
same week [21]. The study of Clark et al. (2015) used a duration of
3.3.1. The health education method 1–1.5 h given every 10–14 days for three months; then follow-up calls
Of the eight included studies, five studies used the individualized were carried out every 3–4 weeks for 5–15 min in the following three
method with telephone follow-up [8,18,19,21,22]. The media used were months [18]. In the study by Wang et al. (2017) using 1–1.5 h, edu-
booklets [22] and modules [18]. Two studies used the lecture method cation was given weekly for two months [7]. Rakhshani’s study (2018)
with booklets and self-care films [21,23], while other studies used fly- used 45 min given two meetings with a break of 1 day between the
ers, slides, and films [7]. One study used the face-to-face method, which first and second meetings [23]. Moon et al. (2018) study used 30 min
was carried out in two intervention groups: the home-based educational given only once and continued by telephone every week for a month
intervention group using healthy volunteers and the formal education [22]. The study of Liou et al. (2015) provided one-time education, then
intervention group taught at a hospital [20]. The study did not explain follow-up education by telephone at intervals of 1 week, one month, and
the media used. The procedures of the educational method are summa- three months [21]. The study of Sun et al. (2019) provided education for
rized in Table 2. three days while being hospitalized. Then education was continued on
discharge via an internet-based platform every week for three months,
every two weeks after 3–4 months, and once after 5–6 months [8]. Chen
3.3.2. The duration and frequency of education
et al. (2018) study provided education with one meeting when an ex-
The duration and frequency of education varied with each study.
pert doctor discharges the patient. The patient got a home visit by the
The study of Siabani et al. (2015) used 2 h for the intervention group
nursing staff two weeks after discharge to check the patient’s condi-
taught at home and 3 h (rest 30 min in the middle) for the intervention

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S. Mansyur, A.M. Irwan, R. Arafat et al. Health Sciences Review 5 (2022) 100060

Table 3
Results of health education effects.

Authors Findings
P-value Instrument
Control Intervention Intervention
Variable Group group I group II

Siabani et al. (2015) • Self-care maintenance - 26.2 ± 12.69 29.5 ± 11.87 P = 0.12 SCHFI
• Self-care management 2.7 ± 8.99 - 29.5 ± 11.87 P <0.001
• Self-care confidence 2.7 ± 8.98 26.2 ± 12.69 - P <0.001
- 29.4 ± 10.85 31.3 ± 11.80 P = 0.41
10.2 ± 9.51 - 31.3 ± 11.80 P <0.001
10.2 ± 9.51 29.4 ± 10.85 - P <0.001
- 9.5 ± 16.55 18.1 ± 16.69 P = 0.004
−0.3 ± 10.88 - 18.1 ± 16.69 P <0.001
−0.3 ± 10.88 9.5 ± 16.55 - P <0.001
Sun et al. (2019) • Self-care maintenance 30.04 ± 8.22 38.21 ± 7.43 - P = 0.000 SCHFI
• Self-care management 50.76 ± 8.13 55.47 ± 12.08 - P = 0.024
• Self-care confidence 36.30±10.44 43.75 ± 14.37 - P = 0.00
Wang, Q., et al., • Knowledge 5.02 ± 1.11 9.24 ± 1.03 - P = 0.004 EHFScBs9
(2017) • Attitude 6.94 ± 4.70 2.71 ± 2.72 - P = 0.000
• Self-care behavior 24.55 ± 3.93 16.87 ± 3.34 - P = 0.000
Chen et al., (2018) • Self-care behavior 24.5 (3.9) 16.9 (3.0) – P< 0.001 EHFScBs9
Clark et al., (2015) • Knowledge - - - P = 0.000 SCHFI
• Self-care maintenance - - - P < 0.001
• Self-care management - - - P = 0.001
• Self-care confidence - - - P = 0.006
Seraji and • Knowledge 03.2 ± 10.1 32.2 ± 93.2 - P< 0.001 _
Rakhshani, (2018) • Practice self-care 64.3 ± 33.4 44.3 ± 04.6 - P< 0.001
Moon, M.K., et al., • Self-care behavior 19.15±4.83 16.06 ± 4.83 – P < 0.001 EHFScBs9
(2018)
Liou et al., (2015) • Knowledge 70.8 ± 17.4 75.8 ± 16.8 - P < 0.05 SCHFI
• Self-care maintenance 66.7 ± 10.8 68.3 ± 12.5 - P < 0.001
• Self-care management 65.5 ± 12.2 72.5 ± 11.3 - P < 0.01
• Self-care confidence 70.5 ± 13.7 73.7 ± 14.6 - P < 0.01

Table 4
Risk of Bias Tools.

Random Blinding of Blinding of

sequence Allocation participants and outcome Incomplete Selective
generation concealment personnel assessment outcome data reporting Other sources of
Author/ Year (Selection bias) (Selection bias) (performance bias) (detection bias) (attrition bias) (Reporting bias) bias (other bias)

Siabani et al., (2015) + + + + + + +

J. Sun et al., (2019) + + + + + + +
Wang et al., (2017) + + + + + + +
Y. Chen et al., (2018) + + + + + + +
Clark et al., (2015) + + + _ + + +
Seraji & Rakhshani, (2018) + + + ? + + +
Moon et al., (2018) _ + _ + + _ +
Liou et al., (2015) _ + + + + + +

tion and environment. The patient also gets a call every two weeks by of self-care confidence than the home-taught intervention group [20].
the cardiologist to encourage the patient to comply with medication, The study by Liou et al. (2015) also showed higher results on self-care
monitor physical exercise, and strengthen education. The patient also confidence among the components of self-care after the intervention
received intensive education by the head nurse every three months and compared to before the intervention, and the intervention group was
six months to provide additional information about heart failure and higher than the control group. Another variable measured was knowl-
self-care [19]. edge of heart failure, where the intervention group was higher than the
control group [21]. According to the study by Sun et al. (2019), self-
3.3.3. The self-care instrument care behavior scores did not show a significant difference on admission
Two instruments were used to assess self-care in the studies: The between the two groups (P> 0.05). However, at 3 and 6 months after
Self-care Heart Failure Index (SCHFI) and the European instruments hospital discharge, the total scores of self-care maintenance, self-care
Heart Failure Self-care Behaviour Scale 9-item (EHFScBs9). Four studies management, self-care confidence, and self-care behavior in the inter-
used the SCHFI [8,18,20,21] and three studies used EHFScBs9 [7,19,22]. vention group were significantly higher than in the control group (P
Meanwhile, one study did not mention the name of the instrument used <0.05) [8]. Similar results were found in the study by Clark et al. (2015)
[23]. Instrument details can be seen in the Table 3. for self-care scores in both groups increased over time. The interven-
tion group increased more than the control group over time to the first
3.3.4. The effects of health education interventions three months, the second 3 months, and the third three months follow-
All the results reported in the studies show positive results for the up. Two-fold improvement in self-care management in the intervention
self-care behavior of older people after being given health education. group compared to the control group (12.22 vs. 6.78). This study also
The study of Siabani et al. (2015) showed significant results after the assessed the significantly increased knowledge over time (P = 0.000)
intervention on the self-care component (p <0.001). However, between and the variables of quality of life and self-confidence, which increased
the two intervention groups, the hospital-taught group had higher levels over time (P = 0.018; P = 0.028) [18].

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S. Mansyur, A.M. Irwan, R. Arafat et al. Health Sciences Review 5 (2022) 100060

Seraji and Rakhshani’s study (2018) showed that, on average, self- techniques are repeated with large writing sizes in each teaching mod-
care knowledge related to heart failure has a significant difference be- ule. Geragogy is a term used to describe the process that helps parents
tween before and after education in the intervention group (p <0,001), in learning [28]. The previous study has also applied geragogy learning
as well as in the control group. Besides, the mean scores of self-care techniques. The results show that this technique can significantly im-
practices differed in the two groups before and after the intervention. prove and maintain knowledge, attitudes, and practice of reducing salt
The increase was higher in the intervention group (63.4%) than in the in patients with hypertension [29].
control group (5.4%) [23]. Meanwhile, the score of research self-care Another educational method found is through lecture techniques
behavior by Moon et al. (2018) increased by 7.56 ± 3.90 in the inter- [7,24]. This method uses booklets and films about self-care. Patients
vention group and the control group by 0.75 ± 3.80 [22]. are given self-care booklets and CDs to take home after the teaching
The study by Wang et al. (2017) assessed the PRECEDE construc- session ends. This method can stimulate older people’s interest in learn-
tion: predisposing (knowledge and attitudes), supporting factors, and ing because it is presented in an audiovisua form. This method is also
reinforcing factors, while self-care behavior was assessed using differ- prevalent in health services. A well-designed education such as using
ent measuring tools. The score of self-care behavior in the experimental booklets and teaching films about self-care enables service providers to
group before the intervention was higher than after the intervention and provide evidence-based education [23]. One of the advantages of book-
the control group [7]. let media as a learning tool can be made according to the reading level
The study by Chen et al. (2018) score of self-care behavior at 3 and 6 of older people. These findings are consistent with the study results by
months compared at baseline was significantly different in the interven- Reid et al. (2019) [29] that adding educational videos to education sig-
tion group. While the control group change from baseline to 3 months nificantly increases knowledge and maintenance of patient self-care.
and 6 months. Besides, with self-care scores from baseline to 6 months, Similar to the lecture education method, this method is also carried
the total improvement in the intervention group was 33%, and the con- out face-to-face, but the difference is that this educational method is
trol group was 8%. Meanwhile, the other measured outcome was that carried out in patients’ homes. Of the 50 volunteers, only ten were se-
the quality of life increased by 37% from baseline to 6 months after the lected and trained by a general practitioner in 3 workshops. Selected
intervention [19]. A summary of the results related to the effectiveness volunteers were rated the most experienced in health education, par-
of health education is shown in Table 3. ticipated effectively in health programs during the previous year, and
had conversational skills. Selected volunteers attended three workshop
4. Discussion activities held in one day to educate about self-care activities and how
to present information to patients. The educational content includes all
4.1. The health education method information about CHF patient self-care, including adherence to ther-
apy, disease management (recognizing CHF symptoms, assessing symp-
The educational method used in each article is reported to improve toms, applying the appropriate medication, and evaluating treatment for
self-care behavior of parents with CHF. Health education can consis- symptoms), healthy lifestyle (e.g., adequate daily exercise), and dietary
tently improve patient knowledge and self-care behavior. These factors recommendations. (e.g., limiting salt intake and alcohol consumption).
impact reducing the morbidity and mortality rates of older people with Education with home visits can positively improve patient knowledge
CHF due to bad self-care behavior. Older people can apply self-care be- and self-care [30]. The reach of the audience includes families as people
havior based on the knowledge gained to improve better health out- who can help the treatment and care of patients [31]. With this knowl-
comes. Findings in other studies also reveal that self-care management edge, the family can help patient self-care if the patient’s self-care ability
education for the elderly can help reduce readmissions to hospitals [25]. is limited. This practice is related to the self-care theory, where if the
Meanwhile, the condition of the patient, the availability of media and demand for self-care is greater than the patient’s ability to do self-care,
health personnel are important factors in determining the success of ed- it can result in self-care deficits that the patient needs a family who can
ucational interventions [26]. help him in self-care. Another study stated that the level of education
affects a person’s self-care behavior. People with low education tend to
4.2. The duration and frequency of education buy medicine freely for their health. In contrast, parents with higher
education will be careful in consuming medicine as they must be based
Education provided individually with telephone follow-up is better on a doctor’s prescription. People with higher education will easily re-
than simply providing standard care, including providing treatment ad- ceive and digest information [32]. They are more concerned about the
vice, providing books or booklets, routine nursing care, and prescribing dangers and effects caused if it is not under the doctor’s instruction [33].
drugs to health services [8,18,21,23]. This educational method was car- The clinical impact can result from applying self-care to cardiac
ried out by meeting individually with meeting sessions including every function indexes such as NT-proBNP, LV EF, and LVEDP levels. The
10–14 days for three months [18], upon being discharged [19], one day N-terminal pro-brain natriuretic peptide (NT-proBNP) in the interven-
after one week of being hospitalized [21], three days during the patient’s tion group decreased while the control group increased. This condition
stay [8] and one session meeting [22]. In the meeting session, the ed- is attributed to the fact that patients limit their intake of water and
ucators taught about heart failure knowledge, the importance of main- salt, which can be seen from their weight measurement during self-
taining body weight, what to do when facing a bad condition, medica- care. Left ventricular ejection fraction (LV EF) in the experimental group
tion adherence, dietary recommendations, self-care skills, and adequate was higher than the control group. This finding is related to the vari-
physical exercise. Subsequently patients receive further education by able that patients in the experimental group followed the treatment
telephone by nurses and doctors [8,18,19,21,22]. It was conducted to schedule, such as taking anti-diuretic and cardiotonic drugs as recom-
motivate the patient to comply with the treatment, check the health sta- mended. Meanwhile, left ventricular end-diastolic pressure (LVEDP) did
tus, and monitor their self-care behavior [22]. Older people with chronic not change between the two groups [22]. Individual education methods
conditions need supervision in the implementation of self-care consider- accompanied by telephone follow-up can be considered to be used by
ing functional and cognitive decline. The follow-up telephone sessions nurses to provide health education.
supervise patients in carrying out self-care. Recently, the World Health In this review, we found variations in duration and frequency. The
Organization (WHO) has also launched an interactive digital application shortest duration is 30 min with a frequency of meeting only once, then
that provides practical guidance to address priority conditions of older after one week it is followed by consultation and education by telephone
people, including care and social support. This innovation can facilitate for 15 to 30 min and is carried out once a week for four weeks. During
integrated care for older people [27]. One of the five individual educa- both face-to-face and telephone teaching sessions, patients are educated
tional methods applies the theory of geragogy learning, where teaching using booklets, medical records, and symptom checklists [22]. Two stud-

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S. Mansyur, A.M. Irwan, R. Arafat et al. Health Sciences Review 5 (2022) 100060

ies used a similar duration, which was 1–1.5 h with a similar education Clinical implications
frequency. In the first three months, education was conducted every 10–
14 days. Education was conducted by telephone every 3–4 weeks for 5– Appropriate health education methods for older people and clinical
15 min in the next three months. In the last three months, patients were practice have been identified in the evidence summary of this systematic
recommended to communicate with the doctor if they have any ques- review. The recommended educational methods can improve the quality
tions in the third three months. The frequency of other education of the of life and self-care behavior in older people. Important health educa-
same duration was carried out weekly for two months, and then the pa- tion is provided to patients to improve their knowledge and skills and
tient was followed up for three months. During the follow-up period, reduce morbidity and mortality of older people with CHF . Educators
the patient continued to participate in educational promotion programs are required to provide new things in implementing health education
and reported their self-care behavior every two weeks [7,20]. One study programs to improve better health outcomes.
with 45 min duration used two days in education with a break of 1 day
in between. After one month, the group was subjected to a post-test by Statement of interest
visiting the patient’s house. The most prolonged duration of 3 h with a
break of 30 min was conducted for three days in the same week [20]. This research received fund from the Agency for the Development
Based on the theory, seniors take 10 min to focus on learning and have and Empowerment of Health Human Resources, Ministry of Health, In-
to do it repeatedly to maximize their memory [34]. In theory, the du- donesia, number HK.01.07/III/358/2018.
ration of effective education used in older people has not been precise.
However, before providing health education, nurses should discuss the An author statement
time and duration of education for patients.
All authors listed fulfill the authorship requirement according to the
4.3. The Self-care instrument recent guidelines of the International Committee of Medical Journal Ed-
itors, and approved the content before submission.
The instrument used to assess self-care in most studies was the SCHFI
[8,22,23,25,35] compared to the EHFScBs9 [7,19,22]. The SCHFI scale Declaration of Competing Interest
ranges from 0 to 100; a score of 70 or more indicates better self-care and
indicates the adequacy of self-care [20]. The SCHFI measures three main “No conflict of interest has been declared by the authors.”
concepts: (1) maintenance of self-care, which includes monitoring and
compliance of treatment; (2) self-care management, decision-making Acknowledgment
process to recognize and evaluate the symptoms of heart failure; and
(3) confidence in self-care or self-efficacy, which is considered to mod- The author expresses his deepest gratitude to Andi Masyitha Irwan
erate the relationship between self-care and outcomes. The EHFScBs9 PhD and Dr. Rosyidah Arafat for the inputs given during the review
instrument score ranges from 12 to 60 points, and the lower score indi- process.
cates better self-care behavior [7]. The SCHFI is an instrument based on
theory and empirically tested to assess heart failure self-care [36]. The References
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