Source Content Special Considerations To be Effective Mode Evaluation
CACR [19] (Canada) Topics: - Risk factor target and risk factor modification (weight reduction, smoking cessation, dietary and nutrition habits) - Dietary habits to increase fibre, alpha-linolenic acid, fruits, nuts, vegetables, whole grains, monounsaturated fats, polyunsaturated fats, omega 3s, plant-based proteins and reduce saturated fats, simple carbohydrates and sodium) - Adherence to life-enhancing and/or life-prolonging prescription and non-prescription drugs. (e.g. aspirin, clopidogrel, beta blockers, statins, ACE inhibitors and/or angiotensin receptor blockers) - Health behaviour interventions including optimal dietary, physical activity strategies and weight control - Develop self-management techniques (problem solving, decision making, resource utilization, partnership formation, action planning (SMART goal setting) and self-tailoring) - Elderly-cognitive function may be impaired; instructions need to be clear, concise and may need to be written down and frequently reviewed (often with family members) -Hearing impaired-clear description by video -Visually impaired-clear description by audio -Heart failure-education (and counselling) to help them adjust to the psychological, physical and social effects of living with heart failure.  Importance of weighing themselves daily and how to adjust diuretic usage in response to weight gain. -Diabetes-foot care, proper footwear, medication adherence to diabetes meds, blood sugar monitoring and prevention/treatment of hypo and hyperglycemia. - Sexual health- expert education and counselling in patients with congenital heart disease, heart failure or patients who have received information about their sexual health in relation to their cardiovascular condition. - Voluntary participants - Mutual respect - Time for critical reflection of material - Empowered to become self-directed learners - Discuss specific health goals - Is personalized - Explains the risks of not changing, the benefits of changing - Seeks to influence outcome beliefs regarding the outcome efficacy of interventions or behavioural changes - Often emphasizes proximal risks and benefits over distal ones - Seeks to heighten self-efficacy concerning possible effective self-regulation of specific behaviours - May seek 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. - Individual or group - Collaborative learning activities - Internet-based cardiac rehab education - Efficacious dietary interventions include case management and group interventions combined with individual counselling - Education outcomes are considered a core component of cardiac rehab - Documentation of the education plan and progress.
AACVPR [64] (USA)   Topics: - Improving cardiac risk (through a low-fat diet, blood pressure management, lipid management, smoking cessation, diabetes management, depression/stress management and physical activity habits) - Managing cardiac emergencies (angina, possible heart attack, pain or discomfort during exercise Understanding the disease process (atherosclerosis, high blood pressure, diabetes) - Maintaining psychosocial health (addressing sexual function, social relationships, depression, anger, hostility - Adapting to limitations imposed by the disease process (changing roles in the family, jobs at work, hobbies and recreational activities) Materials should be: - Consistent with national guidelines - Developed by health care professionals - Developed from behaviour and education programs with documented success - Reviewed and commented on by patients and families - Approved by the appropriate institutional administrative structure - Dependent upon the needs and preferences of patient and families - At appropriate reading level of patient and family - Large print on nonglossy paper is more readable Translated into different languages Elderly-address impaired senses(e.g., printed instruction for hearing impaired large-type print for poor vision), offer daylight times, small amounts of information repeated often and individualized to each person, involve family/care givers to reduce social isolation, emphasize nutrition principles adapted for this age group, identify barriers to learning) Multicultural-plan education sessions to last longer than usual, use simple sentences when giving instruction, speak clearly and avoid technical terms, sequence the material, have patient give a return demonstration on any skill you teach, include one or more significant family members, partner with faith-based organizations whenever possible, use health care providers from the patient’s culture where possible, respect the patient’s health beliefs or practices Transplant patients-medications, symptoms, specific diet changes (diet low in fat, cholesterol and sodium to prevent weight gain and hypertension), importance of regular exercise Diabetes-medications, exercise safety, diet, complications, blood sugar monitoring, prevention/treatment of hypoglycemia, foot care. - Should be dependent upon the needs and preferences of the patient and family - Individual or group - Telephone, internet based, books, audiotapes, videotapes, CD-ROMs, interactive computer programs (computer assisted instruction)   All programs should have written plans for providing education and a method for documenting implementation and patient progress.
The Heart Research Centre [65] (Australia) Medical topics: - Anatomy, physiology and pathology of cardiovascular disease - Coronary heart disease/ischemic heart disease - Acute cardiac events - Investigation and procedures - Symptoms and their management - Cardiac medications Modifiable risk factors: - Smoking, raised lipids, nutrition and dietary fat, high blood pressure, overweight, obesity and diabetes, physical inactivity, other risk factors Non modifiable risk factors: - Older age, male gender, positive family history Behavioural and psychosocial topics: - Behaviour change and adherence to medication and advice - Mood and emotions - Psychosocial risk factors and social support - Impact upon the spouse and family - Sexual activity and activities of daily living - Return to work (this is considered a major aim of cardiac rehab.  This is not consistently done in USA and Canada) Low education levels, increasing age, and heightened anxiety all negatively impacts the cardiac patients’ ability to learn and retain information.     - The patients’ specific needs and their receptivity to information should be considered. - Joint setting of priorities for educational content by the patient and educator is recommended to maximize learning. - Information given needs to be repeated reinforced and be consistent amongst the healthcare providers. Individual or group - Number (%) of patients whose knowledge level is assessed. - Number (%) of patients with improved knowledge.
BACPR [66] (England)   Topics: - Attention to the common unhelpful beliefs and misconceptions about cardiac illness that lead to increased disability - Pathophysiology and symptoms Physical activity, smoking, diet, blood pressure, lipids, weight management and glucose - Psychological issues - Occupational issues - Sexual dysfunction - Cardioprotective drug therapy, surgical interventions and devices - Cardiopulmonary resuscitation        
NHFA & ACRA [67] (Australia) Topics: - Basic anatomy and physiology of the heart, effects of heart disease, the healing process, recovery and prognosis, symptom management, medications, investigations and procedures, cardiac health beliefs and misconceptions, - Risk factors for heart disease and their modification for secondary prevention (e.g. smoking cessation, physical activity, healthy eating, control of blood lipids, weight, blood pressure and diabetes) - Supporting skill development to enable behaviour change and maintenance - Resumption of physical, sexual and daily living activities including driving and return to work (emphasized), - Psychological issues e.g. mood (depression), emotions, sleep disturbance, social factors e.g. family and personal relationships, social support/isolation        
Queensland  Health [68] (Australia) Heart disease: - How the heart works, atherosclerosis, angina, conduction disorders, valvular disease, diseases of the heart muscle, heart attack and the healing process (causes and symptoms, difference between heart attack and cardiac arrest, myths and misconceptions), cardiac symptoms and their management, what to expect during recovery Risk Factors: - Modifiable risk factors (smoking, raised lipids, nutrition and diet, high blood pressure, overweight and obesity, management of type 2 diabetes, physical inactivity alcohol intake, stress) - Non-modifiable risk factors (age, sex, diabetes, positive family history Physical Activity/Exercise: - Definition of physical activity, definition of exercise, type, durations, frequency, intensity, how to monitor the level of exertion, benefits, how to manage angina while doing activity, appropriate clothing and footwear, orthopedic and musculoskeletal problem avoidance-acute and chronic, barriers to exercise, co-morbidity impact on exercise (e.g. CVA, congenital heart disease, very low level of exercise capacity) Activities of Daily Living: - Outline of recovery process and anticipated timeframes, general principles regarding resumption of activity, self-monitoring of exertion and symptoms, how to resume general activities using (principles of energy conservation, principles of work simplification), guidelines for return to self-care, home, work and leisure activities, use of assistive equipment Nutrition: - Healthy weight range, healthy eating, modification of diet to achieve appropriate body weight and maintain micronutrient adequacy, dietary fats-types, role in heart disease, salt, fibre, other nutrients in food, cholesterol, food selection/shopping, eating habits/meal patterns, food preparation/cooking, eating out/takeaway, food labelling, recipe modification, hydration during exercise Smoking Cessation: - Association of smoking and heart disease, benefits of quitting, nicotine dependence, methods of quitting (behaviour change), resources available, medications available for nicotine addiction Medications: - Knowledge and understanding of medications, cost, method of administration, strategies for compliance with medications Psychosocial Issues: - Mood and emotions (anxiety, denial, depression, grief and loss), normalization of event, address areas of concern (job security, sexual activity), psychosocial risk factors, return to normal activities, financial concerns, social support, social isolation, impact on family Stress Management: - Link between stress and heart disease, resources available, stress management strategies (relaxation techniques, time management, setting priorities, balancing work, family and leisure, resources available) Cardiac Investigations and Procedures: - Explanation of test they have had (e.g. ECG, echocardiogram, stress test, blood tests, angiogram).  Explanation of management (medical or intervention) e.g. thrombolytic therapy, heart surgery, angioplasty, pacemaker implantation.  Address and discuss anxieties associated with the above. CPR: - See heart disease topics, emergency procedures, community resources   - Employ adult learning principles - Encourage group disclosure and sharing of experiences - Understand group work principles (group dynamics and participant behaviour to foster a positive learning environment for all) - Encourage the group to generate their own solutions to encourage ownership of knowledge - Use theories and strategies for behaviour change - Tailor the education mode to suit individual needs - Assess knowledge and learning style/preferences - Address misconceptions - Establish/provide a supportive learning environment - Address knowledge, attitude, beliefs and skills of the individual - Develop client-set, client- focussed learning objectives in collaboration with the health professional - Provide written confirmation of information provided “Education involves more than the transfer of information.  It is not confined to formal education sessions, but is an integral component of physical activity and exercise prescriptions, counselling sessions and informal gatherings such as morning teas.  Individuals can benefit from the experiences of others in similar situations so time should be allowed for group members to share their experiences either in a formal or informal way.” Regularly conduct process, impact and outcome evaluations
Table 2: Summary of the literature review of best practice on CR patient education. CR indicates cardiac rehabilitation; CACR: Canadian Association of Cardiac Rehabilitation; AACVPR: American Association of Cardiovascular and Pulmonary Rehabilitation; BACPR: British Association of Cardiovascular Prevention & Rehabilitation; NHFA: National Heart Foundation of Australia; ACRA: Australian Cardiac Rehabilitation Association; ACE: angiotensin-converting-enzyme; CVA: cerebrovascular accident; ECG: electrocardiogram; CPR: cardiopulmonary resuscitation.