Background
Over 23 million people worldwide suffer from heart failure (HF) [
1]. Already at epidemic proportions, this significant global public health problem is predicted to escalate exponentially over the next decade [
1]. For example, currently in the United States HF affects over five million people [
2] and it is expected that by 2030 eight million will be diagnosed with HF [
3]. Heart failure is now one of the most common reasons for hospital admissions in older people, resulting in a substantial economic drain on healthcare resources [
4].
One way to redress the burden of HF is through implementation of multidisciplinary chronic disease models of care that have been shown to yield significant benefits, compared with usual care, in reducing readmissions and associated costs and improving patient quality of life [
5]. Identified as a key component of these programs is patient education specifically directed at promoting self-care behaviours [
6]. Most studies investigating HF patient education have been conducted in Europe [
7‐
10], Australia [
11‐
13] and North America [
14‐
17]. This leaves a significant knowledge gap regarding the efficacy of such programs in Asia, for example Thailand.
The Thai Acute Decompensated HEart Failure REgistry (Thai ADHERE) has recognised HF as a major cardiovascular health problem and economic burden [
18]. Thai ADHERE epidemiological data were collected from 18 cardiovascular health centres across Thailand. Thai ADHERE found 2,041 HF admissions among 1,612 HF patients during 2006 to 2007. A large proportion of re-hospitalisations were admitted via the emergency department (77%), of which one quarter (25%) required a critical care bed. The absence of HF education programs was identified as a significant factor leading to the high numbers of Thai HF readmissions [
18]. Evidence presented from studies conducted in Western countries has demonstrated that many HF readmissions are preventable through patient education targeting self-care [
6,
19].
Patient education aims to improve knowledge and skills in order to positively influence attitudes and behaviours, thereby resulting in improved health outcomes [
20]. Knowledge can improve an individual’s confidence and sense of control, and with respect to understanding the disease trajectory of HF, can motivate patients to adhere to treatment and lifestyle changes and necessary adaptations [
21]. The evidence-base in support of patient education improving HF health outcomes is compelling [
5,
6,
22], and has resulted in the inclusion of educational strategies as a key non-pharmacological component within evidenced-based HF practice guidelines [
4,
23,
24].
The situation-specific theory of HF self-care provides a framework for understanding and evaluating the competencies of HF patients [
25]. Self-care refers to a naturalistic decision-making process involving the choice of behaviours patients adopt in order to maintain physiological stability and responses executed when they occur [
26]. Appropriate engagement in HF self-care has the potential to reduce HF readmissions and health care costs, and improve health-related quality of life [
27]. In light of this, evidence has also revealed that patients with HF demonstrate difficulties in complying with the recommended self-care regimen [
28]. Recently, and importantly, patient knowledge and social support from informal carers are fast being recognised as key to successful self-care [
29‐
32].
The informal carer can be defined as a spouse/partner, family member, friend or neighbour who performs caring without pay, assisting the care recipient with daily activities and/or medicine administration [
33]. The role of carers is crucial in HF self-care. A recent systematic review found that the social well-being of HF patients is strongly linked with carers’ support in performing HF self-care [
29]. Social support has been found to be a vital resource for patients with HF and used as part of their everyday coping strategies [
32]. Patient health outcomes, including health-related quality of life (HRQoL), rehospitalisation, adherence to HF treatment, and optimal engagement in self-care, are strongly associated with the existence of carers [
34]. International guidelines now specify that carers be included in the educational processes that promote HF self-care [
35‐
37], though the number of intervention studies that have focused on informal carers of HF are limited [
38].
Although the evidence is compelling as to the importance of patient education promoting self-care, most studies investigating patient education have been conducted in Europe, Australia and North America where the characteristics of the population and the culture are often quite different from that in Asia, including Thailand, and especially in rural communities. In Thailand only one published randomised trial of education (coaching by telephone) in HF has been conducted [
39], and only two other published studies have explored the notion of education improving knowledge, self-care and HF symptoms [
40,
41]. However, limitations of these studies include the use of quasi-experimental designs, small samples, differing theoretical frameworks for developing the educational strategies, and varied settings - home-based to outpatient clinic settings – for conducting them. Moreover, none of these studies included carers, or delivered the education program in the community, nor examined changes in HRQoL in both the patient and carer as an outcome of the education. In light of the incomplete body of knowledge regarding the effectiveness of an education-based intervention for HF patients and carers in Thailand, and the increasing prevalence of HF in Thailand, further research is warranted.
Cultural perspectives become paramount when adapting a Western-based intervention into an Asian country. For example, in Thailand the role of carer is crucial, and the Buddhist concept of karma strongly influences Thai people’s beliefs and their way of thinking and living. Although demographic and socio-economic aspects have changed dramatically in Thailand over recent decades, family members remain the pillar of support for elderly people [
42]. Living with older parents, showing respect and taking care of them are considered a normal way of family life and are highly valued in Thailand. Therefore, providing an education program that involves both the patient and carer has the potential to enhance the quality of life for the patient with HF, and for their supporting family [
43].
Aim
The aim of this research is to develop and evaluate a family-based education program for HF patients and their carers residing in rural Thailand.
Hypothesis
We hypothesise that a family-based education program is effective in improving HF knowledge, self-care behaviour and HRQoL for patients, and perceived control, HF knowledge and HRQoL for their carers living in rural Thailand.
Discussion
This trial will test the effectiveness of a family-based education program for HF patients and their carers residing in rural Thailand. Patient education is rapidly becoming recognised as a key component of HF management. Unfortunately, most trials of such programs have been undertaken in Western countries which have considerable differences to Asian countries in terms of, for example, patient characteristics, settings, interventions, and outcome measures. This is the first trial of such a program in rural Thailand taking into account cultural and societal factors.
The trial will not only provide evidence pertaining to the effectiveness of education programs for Thai HF patients, but it will be the first to include family members. We hypothesise that a family-based education program will improve HF knowledge, self-care and HRQoL in patients and carers in rural Thailand. This will be assessed via the implementation of a HF manual and DVD specifically developed to meet the knowledge requirement of HF patients and carers.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
NS, JC, CSF and DRT were involved in the conception and design of study and drafting of the manuscript. All authors read and approved the final manuscript.