chronic heart failure ( hf ) is a significant health and social problem . in the united states alone , nearly 6 million people suffered from hf in 2008 , and this disease is becoming increasingly prevalent   with more than 550,000 new cases diagnosed each year .
half of hf patients die within 5 years of the first onset of symptoms , and half ( 50%60% ) of the patients diagnosed with severe hf do not live longer than a year .
hf is the most common cause of hospitalization in those over the age of 65 years , and 54% of the patients are readmitted to hospital within 6 months of discharge .
hf also results in significant morbidity and disability , thereby generating permanent and high health care costs .
heart disease is the leading cause of mortality in iran ; unfortunately , further accurate statistics describing the burden of hf are not available .
optimal medical management following a cardiovascular event remains underprescribed , and even more so in developing countries .
similarly , nonpharmacological management and interventions are infrequently recommended , and patient adherence to lifestyle modifications remains poor .
recent european research suggests that the control of cardiovascular risk factors , including tobacco use , obesity , hypertension , hypercholesterolemia , and diabetes , is far below an acceptable level [ 9 , 10 ] .
the nature and severity of hf symptoms greatly depend on the patient 's knowledge , cooperation , and active participation in their health management .
however , improving health and preventing hf from progressing by adopting self - care skills , adhering to complex treatment regimens , and changing lifestyle behaviours is particularly challenging . according to orem 's self - care theory , effective self - care activities can reduce the need for hospitalization .
this theory postulates that nurses interact with patients in three ways according to the patient 's ability to participate in their care : total compensation , partial compensation , and supportive - educational systems .
patients in the supportive - educational system are capable of engaging in self - care but require education about the different aspects of therapeutic self - care behaviours .
nurses are optimally positioned to identify existing and potential health issues and to provide supportive - educational interventions where appropriate .
postdischarge support in the form of patient education is one of the most effective interventions to improve self - care abilities and behaviours among hf patients , which ultimately improves prognosis and reduces hospital readmission rates .
the main objective of education for hf patients is to improve the patient 's management of their disease , thereby reducing the onset of complications and morbidity .
patient education is generally delivered within the framework of a comprehensive discharge program and covers information about fluid and sodium intake restriction , diet , exercise , adherence to pharmaceutical treatment , monitoring symptoms , and seeking health care when symptoms worsen . according to a recent systematic review
, large studies have demonstrated the efficacy of therapeutic education programs in changing cardiac patients ' lifestyles and ultimately improving morbidity and cost - effectiveness . yet
, there are no recommendations or standardized guidelines about methods to deliver information and education .
strmberg   found that most hf patients do not have a clear understanding of recommended self - care behaviours despite receiving related education .
rather , hf patients require further assistance to learn self - care behaviours and adapt to living with a chronic illness . providing education and training based on individual patient needs and desires
therefore , a thorough assessment of hf patients ' educational needs and preferences , as well as their beliefs and abilities related to medical and lifestyle recommendations , can provide the foundation for personalizing educational efforts .  
interventions to promote self - care behaviours among hf patients , and corresponding research , must take into account culture , which greatly influences diet , exercise , lifestyle , and attitudes toward medical therapy .
the few intervention studies conducted in iran did not evaluate supportive - educational interventions nor did they measure self - care behaviours [ 1719 ] .
the purpose of this research was to evaluate the effect of a supportive - educational intervention on self - care behaviours of iranian hf patients .
the research council of the tabriz university of medical sciences gave ethical approval for this randomized control trial .
consecutive patients admitted to shahid madani hospital with a diagnosis of hf and who met the inclusion criteria were recruited into the study .
a sample size of 80 ( 40 individuals in the intervention group and 40 in the control group ) was deemed sufficient based on a preliminary analysis of self - care scores of 5  hf patients .
the following parameters guided the present study ; the optimal self - care behaviour score in the study was 70 , the mean and standard deviation of self - care behaviours scores were estimated ( mean = 25 , sd = 6.15 ) ,  = 0.05 and power = 0.9 were chosen , and no attrition during followup was anticipated .
the participants were randomized into the control and experimental groups using random number software ( figure 1 ) .
participants who were included were of 18 years age and older , diagnosed with new york heart association class iii or iv hf , had an ejection fraction less than 40% , agreed to predischarge education and follow - up care , and would be available by phone after discharge .
participants who were excluded were those who experienced significant worsening of their disease and transfer to the intensive care unit , were hospitalized for greater than 1 month , had a chronic disease other than hf , or were diagnosed with a mental illness . according to orem 's self - care theory , the supportive - educational system is the only system in which patients require assistance in relation to decision - making , behaviour control , and acquiring knowledge and skills .
some patients are capable of carrying out self - care behaviours but are in need of guidance and support , while others only require education .
the supportive - educational intervention in the present study was tailored to address the appropriate level and type of assistance / care as per the participant 's need .
those who needed guidance and support were encouraged to continue to carry out current self - care behaviours , and additional information and support were provided related to reducing salt in the diet , restricting fluids , and increasing physical activity for example .
participants requiring education were given information about how to create new self - care behaviours .
hf participants randomized to the intervention group received a two - part intervention aimed at improving self - care behaviours . the first phase consisted of a one - hour , nurse - led , in - person hf education session that was customized by the nurse according to the participant 's level of education .
an individualized education booklet was reviewed with literate patients , while for illiterate patients this booklet was reviewed with the participant as well as a family member .
the intervention was also customized according to the participant 's prior knowledge and learning needs , which was assessed with a learning need inventory .
the following information was reviewed : the definition and symptoms of hf , strategies to prevent the worsening of hf symptoms , explanations about medications , and recommendations about dietary changes ( i.e. , reducing salt intake ) , exercise , and smoking cessation .
these participants were given a booklet at the time of discharge that was based on heart failure society of america ( hfsa ) 2010 guideline executive summary .
the objective of this phase was to reiterate and review information covered during the initial education session and improve the participant 's ability to cope with the disease , as well as enhance self - care behaviours .
the first followup telephone call was made by a nurse two days after hospital discharge to verify participant information and determine the next date of contact .
the nurse then contacted the participant by phone every two weeks for 3 months . during these phone
calls the nurse asked the participant whether they were experiencing any signs or symptoms that would suggest worsening hf .
the nurse also reviewed the recommended self - care behaviours and provided support in the form of advice and encouragement when deemed necessary .
the participants were also advised to contact the nurse if any question or an acute medical issue arose related to preventing or managing their hf .
participants who were randomized to the control group received usual care provided by the hospital and attending physician ( nonsystematic and informal teaching ) .
sociodemographic characteristics were gathered through individual interviews and medical data were extracted from medical records .  
the educational needs of participants in the intervention group were assessed with a self - report questionnaire , which was filled out independently with pen and paper or with the assistance of a nurse during a face - to - face interview .
the education needs assessment instrument   is specific to hf patients and consists of 42 items , with 7 subscales to assess learning needs in the areas of anatomy , physiology , diet , activity , cognitive factors , risk factors , and pharmaceutical information .
this instrument uses a five - point likert scale ( ranging from least important to know = 1 to most important to know = 5 ) .  
baseline self - care behaviour data were collected with the pen and paper method or during face - to - face interviews using the self - care of heart failure index ( schfi ) .
subsequent self - care behaviour data were collected with this instrument by telephone at 1 , 2 , and 3 months following hospital discharge .
the maintenance self - care behaviours scores includes 10 questions , the self - care management the scores includes six items , and the self - care confidence the scores includes seven questions .
all items are scored on a four - point likert scale from 1 ( poor self - care behaviour ) to 4 ( optimal self - care behaviour ) , and summative scores are standardized on a scale of 0 to 100 . a cutoff point of 70 on each schfi scale
is used to judge self - care adequacy . to ensure the accuracy of the farsi translation of these instruments , they were reviewed by three professors ( two with english language m.a .
the instruments were reviewed for content validity by 12 faculty members of tabriz university of medical sciences ( 9 with an m.s . and 2 with a ph.d . in nursing ,
the reliability was determined through test - retest methods , wherein the instruments were given to 10 hf patients twice , 2 days apart .
measures of central tendency mean , standard deviation , and percentage were used to describe participant characteristics at baseline .
the control and intervention groups ' self - care behaviours were compared at baseline , 1 , 2 , and 3 months using t - tests .
a repeated - measures anova was used to determine time effects and the impact of group on different aspects of self - care behaviours .
a total of 200 hf patients were screened for inclusion from july to september 2011 .
80 hf patients with an ejection fraction above 40% were excluded , 20 patients with severe hf were transferred to another hospital unit , and 20 patients declined to participate .
the 80 remaining patients were enrolled in the study and randomized into the control ( n = 40 ) or intervention ( n = 40 ) groups . of the 40 individuals assigned to the intervention group , two did not complete the study ; one participant required pacemaker implantation , and another became a heart transplant candidate . at study completion
, 38 individuals remained in the intervention group and 40 in the control group .  
53.8% were men , and 72.5% were married and lived with their spouse and children .
ischaemic heart disease ( 36% ) and hypertension ( 36% ) were the main causes of participant 's hf .
there was no statistically significant difference between sociodemographic characteristics of the participants in the control and intervention groups .
the control and intervention groups did not differ in self - care scores at baseline , prior to delivery of the intervention .
each of the self - care scores was significantly higher in the intervention group than the control group at 1 , 2 , and 3 months ( table 2 ) .
the anova results showed significant differences in self - care between the control and intervention groups ( tables 3 and 5 ) .
the results also showed significant difference in self - care behaviours over the three months , such that as time progressed self - care scores among participants in the intervention group continued to increase ( table 4 ) .
this study provides evidence that a supportive - educational intervention can strengthen and establish new self - care behaviours among hf patients in iran .
this intervention , informed by orem 's self - care theory , provided patient education about self - care behaviours to assist in the management of hf , as well as support in the form of telephone followups .
this improvement in self - care behaviours is consistent with previous research , wherein self - care skills among hf patients were improved following one educational session and an eight - month followup with a nurse educator .
strmberg and colleagues   found that the readmission rate and healthcare costs also decreased with educational interventions that included follow - up support for hf patients .
this provides support for including education about self - care activities , including nonpharmaceutical interventions , as a part of standard management of hospitalized hf patients .
this educational training ought to begin when patients are initially hospitalized and continue following discharge . in the present study
, improvements in self - care among participants in the intervention group were not only maintained , but continued to improve over the three months .
this finding lends support to comments made by evangelista   that education alone does not lead to positive outcomes , and that using behavioural strategies , such as reinforcing behaviours through a follow - up program , can help optimize self - care .
however , it is unknown how long beyond the 3-month followup the improvements made in self - care in the present study lasted among participants in the intervention group .
there is evidence that the effect of educational interventions on self - care behaviours is not maintained over time [ 2224 ] .
it was likely that the participants gave incorrect answers to the self - report questions .
however , by gaining their trust and explaining the confidential nature of the study , we attempted to control false reporting .
patient education is currently an essential part of treating chronic diseases such as hf , but , in the busy day - to - day practice of caring for hf patients , education often is not a priority .
we recommend that time and resources are to be allocated to enable health care professionals to adequately promote patients ' self - care behaviours through supportive - educational interventions .
the present research also suggests that further knowledge about factors that limit or promote effective patient education is needed to improve their quality and effectiveness .
findings of this study indicated that patients with hf not only need pharmaceutical management by physicians and nurses , but they also require support to enhance their self - care behaviours and non - pharmaceutical management ( e.g. , reducing salt in the diet , restricting fluid intake , daily weighing , and monitoring the symptoms ) . according to the results of the present study , implementing personalized , theoretically driven , supportive - educational programs based on nonpharmacological management strategies might be a useful tool to develop , maintain , and change self - care behaviours of hf patients .
this study confirmed that postdischarge supports are very effective in improving self - care activities and reaching optimal behaviours .
 
 background . chronic heart failure is a major health and social problem . 
 the promotion of self - care behaviours can potentially assist patients to effectively manage this chronic condition and prevent worsening of the disease . 
 formal personalized educational interventions that provide support and take into consideration the cultural context are needed . 
 objective . 
 the objective of this research was to evaluate the effect of a supportive - educational intervention on self - care behaviours of heart failure patients in iran . 
 methods . 
 this research was a prospective , randomized trial of a supportive - educational intervention . 
 eighty heart failure patients were randomly assigned to receive the supportive - educational intervention or usual care . 
 the intervention consisted of a one - hour , nurse - led , in - person education session and postdischarge followup by telephone over three months . 
 data were collected at baseline , one , two , and three months . 
 results . the control and 
 intervention groups did not differ in self - care scores at baseline ( p > 0.05 ) . 
 each of the self - care scores was significantly higher in the intervention group than the control group at 1 , 2 , and 3 months ( p < 0.001 ) . 
 there were significant differences in self - care behaviours over the three months , among participants in the intervention group . 
 conclusion . 
 this study provides support for the effectiveness of a supportive - educational intervention to increase self - care behaviours among iranian patients suffering from chronic heart failure . 
1. Introduction
2. Methods
3. Results
4. Discussion
5. Limitations and Suggestions
6. Conclusion