Evaluation of the effectiveness of an interactive avatar-based education application for improving heart failure patients’ knowledge and self-care behaviours: A pragmatic randomised controlled trial

INTERVENTION: 1. Brief name Fluid Watchers 2. Why Avatar‐based technologies for supporting education are an innovative approach for patients with low literacy, low health literacy and English as a second language. The use of avatar technology for patient education have shown benefit in chronic diseases such as cancer, diabetes and depression for improving knowledge, self‐care behaviours and quality of life. Research has demonstrated positive outcomes in clinical practice. However this technology has not been evaluated among patients with HF. 3. What (Material) A tablet computer will be provided to all intervention group participants to view the app and to take home for the study period. 4. What (Procedure) Once participants are assigned to the avatar‐based education group, a research nurse will provide them a tablet computer with the app installed. The research nurse will provide explanations and instructions to participants on how to use the avatar‐based education application. Participants in this group will be asked to use the app before they are discharged from heart failure clinic. The app will be provided information about heart failure and self‐care. After that, the research nurse will ask them some questions regarding the information provided and their thoughts about the app. 5. Who provided This study intervention is a self‐administered avatar‐based education application. The avatar‐based education application is installed on a tablet computer. The research nurse will provide a tablet computer to the participant to use the app during the six‐month study period. 6. How The avatar‐based education application will be presented to the participants in the intervention group. The participant will be asked to review the app and the research nurse will assist the participant to become familiar with using the app before participant take the app home to use during six‐month study period. 7. Where The avatar‐based education application will be provided to participants to use at their own time. The application is installed on a tablet computer, and does not require internet for operation. Participants can review the app at any time and any location that is convenient to them. 8. When and How much Participants will be encouraged to use the app as often as they like during the six‐month study period. Two telephone follow‐up calls (at one‐month and six‐month) will be scheduled with the participants. Information on the number of times the participant has reviewed the app will be collected during the follow‐up telephone calls. 9. Tailoring The avatar‐based education application contains information on heart failure and heart failure self‐care, based on the Heart Foundation, “Living well with heart failure” booklet. When using the app, the participant can make and customise their own avatar and the participant can skip sections of the app, or repeat sections, and can exist at any point, based on their individual needs. Page logic is also built in the app, and are specific for individual patient based on their answer to a specific question. For example, is the participant answers “no” to the question, “if you have a pace maker?”, then the app will skip the pacemaker information section. However, the participant can choose to view that section later, if they still would like to learn about pacemaker, despite they do not have one. 10. Modification 11. How well (Planned) The frequency of using the avatar‐based education application will be assessed by asking participants and recording in tablet for confirmation of the data. 12. How well (Action) The intervention is a self‐administered education application. The number of times that participants reviewed the app will be collected during the telephone follow‐up. The education app was developed through an action research. It has been reviewed by clinical research, research and academic experts in the area of HF. Any errors and glitches in the app reported by research nurse or the participant will be forward to the IT experts for immediate modification. We do not foresee a modification that would be required on the contents of the education app. CONDITION: Heart failure PRIMARY OUTCOME: Knowledge ; Knowledge will be assessed with the Dutch Heart Failure Knowledge (DHFKS). ; SECONDARY OUTCOME: Readmission ; Readmission will be assessed for HF‐cause readmission including both emergency and elective admissions to hospital and unplanned visit general physician units as measured by self‐reporting and review of the medical records for verification of the information. ; Satisfaction ; Satisfaction will be assessed by the investigator developed Avatar‐based application satisfaction questionnaire, which is adapted from validated education material acceptability surveys. ; Self‐care behaviours ; Self‐care behaviours will be assessed with The Self‐care Heart Failure Index (SCHFI) Version 6.2. ; ; INCLUSION CRITERIA: 1. A confirmed diagnosis of HF 2. Individuals with a newly diagnosed HF within 1 year; with a previous hospitalisation for HF 2. New York Heart Association Functional Class (NYHA‐FC) I‐IV 3. Normal cognitive function. Normal cognitive function is defined as a score of 26 or higher on the Montreal Cognitive Assessment (MOCA‐Test). 4. Sufficient English language ability to communicate and to follow the study procedure 5. Willing to give informed consent.