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. 2024 Aug 23;14:19627. doi: 10.1038/s41598-024-70747-2

Effects of health education applying role play on decision making in acute myocardial infarction situation among older adults in community

Samoraphop Banharak 1,✉, Ampornpan Threeranut 2, Alin Metprommarat 3
PMCID: PMC11344021  PMID: 39179621

Abstract

Acute myocardial infarction is a silent killer for people worldwide, especially older adults who often experience atypical symptoms, causing late decision-making and a high mortality rate. The unrecognition of atypical symptoms, unconcerned about their risk, and not knowing how to deal with this critical situation are the barriers to a quick decision to visit the emergency department and delaying treatment, resulting in serious adverse outcomes. Therefore, specific and effective health education among older adults is needed. This double-blinded randomized controlled trial explored the effectiveness of health education by applying a role-play promoting decision-making ability program when expecting acute myocardial infarction occurrence among community-dwelling older adults. The participants were 96 community-dwelling older adults in central northeastern Thailand. We collected data between November 2021 and April 2022. The multi-stage sampling was applied to include participants. The intervention was the role-play promoting decision-making ability program and home visit. Outcomes were measured a week before attending and after finishing the intervention. T-tests, Mann–Whitney U test, Chi-square, and Wilcoxon Signed Rank test compared the outcomes between and within groups. Moreover, adjusted analysis was also demonstrated. Results revealed that participants who attended the program improved their knowledge, belief, and decision-making; only perceived susceptibility did not show improvement. Moreover, after demonstrating an adjusted analysis, the program participants had better knowledge about symptoms, perceived benefits, barriers, self-regulation, possible calling 1669, and first action. In conclusion, a role-play promoting decision-making ability program can promote knowledge, belief, and decision-making when expecting acute myocardial infarction occurrence among community-dwelling older adults. This study proved that role-play is one strategy to promote the program's effectiveness by inducing attention before giving older adults health information. Nurses and other healthcare professionals can implement this program as part of standard practice.

Clinical Trial Registration Number: TCTR20210928004 on 28/09/2021.

Keywords: Acute myocardial infarction, Aged, Community-dwelling, Decision making, Health belief model, Heart attack, Randomized controlled trial, Role playing, Symptom

Subject terms: Cardiology, Medical research, Signs and symptoms

Introduction

Acute myocardial infarction (AMI) occurs when the coronary arteries become acutely obstructed by fatty clots or coronary spasms1,2. This serious health problem is a silent killer worldwide, especially among older adults who often experience atypical symptoms1,3,4. It is found that over three million people worldwide suffer from acute myocardial infarction5. There were 805,000 AMI patients reported by the American Heart Association (AHA) in 20196. Of these, 170,000 had an unusual presentation and asymptomatic/silent MI3. These atypical and silent symptoms may result in patients' lack of awareness and late decision-making to seek treatment. As for statistical studies in Thailand, it was found that in 2016, 2017, and 2018, 327,453, 326,946, and 337,441 people experienced AMI. Of these, 21,008, 20,746, and 20,786 resulted in death, respectively7,8. It also found that people experienced AMI every 40 s3, and in every 90 s, they died from AMI9. More than 63% of people with AMI die; of this, 45% die before arriving at hospitals and have no chance to receive treatment10. A study of the incidence of death in each age group found that 9 out of 10 deaths were older adults aged over 70 years4, indicating that AMI was the leading cause of death among older adults11,12.

Patients with delayed treatment, particularly older ones, tend to have more severe symptoms and a higher risk of death1,10,13. Researchers divided phases of delaying treatment into the patient recognition action, transportation, and hospital phases. Older adults spent the longest time in the patient recognition action phase due to the lack of knowledge and understanding about whether the existing symptom is a symptom of AMI1,10,13,14. In addition, non-specific symptoms (atypical symptoms) cause older adults to miss interpretation or interpret symptoms they are experiencing as symptoms of other illnesses or diseases. For example, they interpreted that they were suffering from acid reflux or Gastroesophageal Reflux Disease (GERD) when experiencing heartburn or from peptic ulcer when experiencing abdominal distension or indigestion13. As a result, they respond to symptoms unrelated to or specific to myocardial infarction, such as taking antacids or applying massage therapy to relieve abdominal distension, wait-to-see, even praying for recovery from the symptoms. In addition, some older women also believe that acute myocardial infarction and heart disease are specific diseases or conditions for men. Thus, they interpreted their symptoms in a way related to a woman's disease or other ailments13.

Older people's knowledge and beliefs are essential influences on delayed treatment1,13. Inappropriate recognition and management of non-specific symptoms can delay decision-making for treatment, lead to severe complications, and result in sudden death. This situation highlights that a lack of knowledge and inappropriate beliefs about AMI in older adults significantly contribute to misinterpretation of symptoms, improper symptom management, delayed admission, and the negative consequences of postponed treatment, including death before reaching the hospital1,13. Based on a systematic review, factors contributing to delayed treatment among older adults with AMI can be divided into four groups: socio-demographic factors, environmental factors, psychological and behavioral factors, and clinical characteristics13,15–17. The primary factors causing delayed treatment were psychological and behavioral. Older adults are often more reluctant and confused about their symptoms and hesitate to bother family members when experiencing atypical or unclear symptoms, especially at inappropriate times such as night or early morning. This hesitation leads to prolonged decision-making before seeking treatment1,16–18. This phenomenon underscores that if older adults continue to lack knowledge, harbor misunderstandings, and maintain inappropriate beliefs about AMI and its symptoms, delays in receiving treatment will likely persist.

The aging process, multi-pathology, and level of education significantly impact older adults' decision-making abilities. As people age, they often experience sensory and cognitive dysfunctions due to decreased blood supply to the hippocampus and frontal lobe, leading to memory deficits, slower interpretation and analysis of situations, and delayed recall19. They also have their own beliefs based on their experience that might be inappropriate16. Additionally, older adults frequently suffer from multiple pathologies, such as diabetes mellitus and hypertension, which can distort vascular and nervous systems. Consequently, their chronic diseases cause atypical symptoms of AMI, like shortness of breath, fainting, abdominal or chest discomfort, and sudden confusion when having AMI13,17. These factors cause older adults to take longer to learn, remember, differentiate, and interpret existing symptoms, resulting in delayed decision-making and seeking treatment compared to younger adults17. Furthermore, if they have a combination of aging, multi-pathology, and low education levels, it creates significant barriers to recognizing atypical symptoms and deciding to go to the hospital late13,17,18. This delay prevents them from receiving timely and essential cardiac treatments, leading to severe complications and death1,13,20. The most effective treatment for AMI patients must be administered within the "golden period" of two hours, but older adults often take more than six hours to decide on admission or seek treatment1,6. Therefore, appropriate and specific ways of educating older adults that concerning their aging process and promoting appropriate beliefs and decision-making are crucial to addressing this problem and improving their outcomes.

Role-play is an innovative method to draw attention and promote appropriate and quick responses/decisions that can be used as an intervention or a part of an intervention21–24. It is changing one’s behavior to assume a role by unconsciously filling a social role and consciously acting out an adopted role; both can be with a group or individuality23,24. According to Bruce et al., role-playing is crucial for a child's psychological development24. According to certain studies, role-playing can lead to behavioral changes. For example, smokers who were instructed to pretend to have lung cancer reported feeling negative about smoking and quit it25. Role-playing was also used to promote decision-making for prostate cancer screening among Black male patients and their providers21, and empathy promoted interventions for health professionals22. The systematic review and meta-analysis found no researcher applied role-play to promote quick and immediate decision-making, such as AMI situation26. However, Jasemi et al. reported that role-playing helps nursing students operate ethically and with greater sensitivity27, Makarov et al. reported that role-playing has been utilized in interventions to enhance shared decision-making skills among patients and healthcare providers21, and Kiosses et al. confirmed that programs applying role-playing have been shown to improve not only the knowledge and skills of participants but also their empathic behavior, which is crucial for effective patient care22. Furthermore, role-play and scenarios efficiently foster older persons' emergency response, awareness, and readiness in emergencies like disasters28.

It is not only role-playing, but the Health Belief Model (HBM) is also an essential part of the program structure to promote decision-making. This conceptual model links belief components in health decision-making, emphasizing measuring beliefs and decision-making at the individual level. The HBM is widely used to explain why people practice health behaviors or do not follow the advice on protecting their health29,30. This model was developed to describe a person's decisions regarding health behaviors. The structure of the health belief model has four main components and two subcomponents: perceived susceptibility, perceived severity, perceived benefits of treatment and prevention, perceived barriers, self-efficacy, and cues to action30,31. In cases of AMI, if older adults know about the AMI symptoms and risk factors and have an appropriate belief through attending the attractive role-playing and health education concerning older adult limitations, this will encourage them to realize the importance and make decisions to seek treatment quickly. Decision-making behavior is individuals' actions and processes when making choices. However, decision-making ability is the cognitive capacity and skills that enable individuals to make decisions32,33. It involves understanding information, weighing options, considering potential outcomes, and making a choice. In the context of AMI, decision-making ability is critical for patients and healthcare providers to make timely and effective decisions32,33. This ability is improved by health education interventions by improving knowledge, behavioral interventions by improving self-efficacy, and technological interventions by using applications or decision-support systems. Good decision-making ability can promote appropriate decision-making behavior in AMI situations32–34. This study aimed to explore the effectiveness of a health education program applying role-play in promoting decision-making ability to encourage older adults to make appropriate and timely decisions in situations of AMI.

AIMS

The aim of this study was to study the effectiveness of a role-play promoting decision-making ability program when expecting acute myocardial infarction occurrence on knowledge, belief, and decision making among community dwelling older adults.

Designs/methodologies

Research design, sample and setting

The study used a double-blinded, randomized controlled trial with a two-group pretest–posttest design; the older adults and outcome evaluators (research assistants) were blinded. The population of interest was community-dwelling older adults living in a semi-urban community in central, northeastern Thailand. We applied multi-stage sampling for this study, starting with cluster sampling, followed by simple random sampling. The cluster sampling was used to select two similar semi-urban communities from 18 communities. The two communities are about 12 km from downtown and super tertiary hospitals, providing call centers, ambulances, emergency services, and advanced cardiac procedures. These two semi-urban communities also had primary care units, and people living there had similar lifestyles and occupations. After study settings randomization was done, a simple random sampling was used to include older adults in each group; this was done by drawing lots (house numbers) from all meeting inclusion criteria from the two communities. The sample size was determined using the equation for experimental research that compares means between two independent groups35 and based exclusively on a previous study by Sanprakhon, Choosri, and Wongviseskul30. With an alpha level of 0.05, a power of 0.95, a variance of 3.12, and a mean difference of 2.23, a power analysis determined that 43 participants would be necessary for each group. However, the 10% possible dropout rate was added for sample size calculation, and 48 older adults for each group would be enough, meaning 96 community-dwelling older adults participated in this study.

Inclusion and exclusion criteria

Eligibility to participate in the study was based on seven criteria: (1) male or female between the ages of 60 and 80 years old; (2) capable of reading and writing Thai; (3) oriented to time and place; (4) no hearing and visual problem; (5) no depression symptom as screening with a 2-question (2Q) depression screening form (Respond “No” for both questions), or dementia as screening with the Thai Mental State Examination (score ≥ 23 points); (6) no disturbing signs/symptoms, such as knee osteoarthritis, severe pain (10-point numerical scale ≥ 5 points) or high fever (axillary temperature ≥ 38.5 °C) to join program activities such as role-play and Emergency Call (1669) situation; and (7) willing to participate in this study by completing consent form. In cases of family members or caregivers of older adults who are required to participate in primary cardiopulmonary resuscitation (CPR), they must not have any health problems or symptoms that limit the practice of CPR, such as heart disease, chest pain, asthma, or chronic obstructive pulmonary disease (COPD), arthritis, severe pain (PS ≥ 5 points), high fever (BT ≥ 38.5 degrees), or abnormal vital signs.

Exclusion criteria were (1) older adults with an acute illness after starting the activity, such as low blood pressure, difficulty breathing, chest pain, and dizziness, and (2) Older adults participating in less than 6 out of 8 activities.

Data collection

The total number of older adults in the two communities was 674; however, 142 did not meet the inclusion criteria, and 31 declined to participate. Only 501 were randomly included in this study using simple random sampling (drawing lots of house numbers). Finally, the 96 participants were randomly included in the control or experimental groups. These two groups lived in different sites and were about 12 km away from downtown, and they did not know they were in control or experimental groups. Moreover, the two research assistants were allowed to participate in this study only for outcomes evaluation, and they did not know they were measuring outcomes for participants in control or experiential groups. The two research assistants not working in these two communities assessed their knowledge, beliefs, and decision-making a week before starting this study. They re-evaluated these outcomes a week after finishing the intervention. The experimental group received a health education applying role-play promoting decision-making ability program and home visits for eight weeks to improve their knowledge, belief, and decision-making, and the control group received routine care, home visits, and brochures during the same period. The study lasted from November 2021 to April 2022.

Research instruments

  1. Screening: The depression symptom was screened using a 2-question (2Q) depression screening form with a sensitivity of 97.3 and a specificity of 45.636. Cognitive function was screened using the Thai Mental State Examination (TMMSE) with a sensitivity of 82 and a specificity of 7037. The TMMSE also achieved Cronbach’s alphas as 0.8138.

  2. Demographic and clinical information: This included sex, age, marital status, education level, income, occupation, health insurance, health status, chronic diseases, self-experience of AMI, and seeing or knowing other persons experiencing AMI.

  3. Primary outcomes: Knowledge was measured by the 12-item knowledge of coronary artery disease (CAD) risk factors and the 15-item knowledge of AMI symptoms. These two questionnaires had three response items, including “yes”, “no,” and “not sure.” If older adults checked “yes” for the correct answer, they got one score, but if they checked “no” for the correct answer, they got zero. Older adults who checked “not sure” got zero for every question. The total scores were 12 and 15, respectively, and the test–retest reliability for these two questionnaires was 0.78 and 0.90, respectively13.

The belief was measured by six questionnaires, including the four items of perceived susceptibility, 15 items of perceived severity, four items of perceived benefit, 15 items of perceived barrier, four items of perceived self-regulation, and four items of perceived cue to action. There were six response items for perceived susceptibility and cue to action from 1 (not at all) to 6 (very likely), and six response items for the other four questionnaires for 1 (strongly disagree)–6 (strongly agree). Total scores for each questionnaire were 24, 90, 24, 90, 24, and 24, and Cronbach’s Alpha Coefficients were 0.90, 0.95, 0.92, 0.90, 0.90, and 0.84, respectively13,39.

The two questions measured decision-making; one asked how likely the older adults were to take seven of any actions (such as calling emergency service/1669, taking medicine, drinking water, and smelling cologne/herb) if they were in the presence of someone having an AMI. This question had seven response items from 1 (not at all) to 7 (certain). We picked only one action, calling 1669, for our analysis, and the other six actions just be provided to not guide the best action for older adults for the next question. The second question asked older adults to choose the best first plan-of-act when they were in the presence of someone having an AMI. This question had seven choices, including seven of the above actions. If older adults checked on calling 1669, one was entered; if they checked on other actions, zero was entered for data analysis. Cronbach's Alpha Coefficient for this questionnaire was 0.9539. When analyzing data, we prepared the first question as a continuing variable and the second as a dichotomous one.

Intervention

Based on a systematic review, the researchers developed a health education applying role-play promoting decision-making ability program for community-dwelling older adults28. The structure of this program was a health belief model, the details were based on systematic review results, and the content was updated with the content suggested by the American Heart Association. The program content included heart disease and AMI, etiology, signs and symptoms, treatment and management, emergency service and call, appropriate action in AMI situations, cardiopulmonary resuscitation (CPR) training, appropriate decision-making activities, asking for help, and program review. Moreover, role-playing related to each activity was used to draw attention from the older adults before starting the program.

This program was proved by five experts, including two cardiologists, two cardiac nurses, and one researcher who was an expert in gerontological nursing. The program's activities and materials relied on the principle of providing health education concerning aging processes and impairment40–42. We spend a short period and divide health education programs into a few short sections. Teaching strategies included both class teaching (lecture) and practicing. The tasks for practicing were uncomplicated, including a few steps, and they were done step by step. Health educators provided a good environment and appropriate places for teaching and training. The teaching style considered the context and culture of older adults. Suitable media were applied to communicate health information to this target group, as well as large letters and visible pictures to read and see.

Moreover, uncomplicated sentences, informal language, and friendly colors were provided. Finally, a handbook was provided for older adults to take back home to review. This program included eight-week activities, which each week started with a greeting and introduction (5 min), role-playing about the situation related to weekly activities (10 min), giving health education/training health activities (15–30 min), and conclusion (5 min). There were between 45 and 60 min in total for each session. Finally, the handbook was prepared using large letters, black letters on a yellow background, simple and informal sentences, clear pictures, and brief content/short text. Before conducting this research, this program was piloted with ten older adults to ensure its feasibility and acceptability. This program was able to draw attention from and suitable for older adults; however, two unclear pictures were suggested to be changed, and the size of the letters was suggested to make it bigger from 18 to 20. Then, it was revised based on the limitations and suggestions of older adults. The final eight-week activities with all details are shown in the figure (Fig. 1).

Fig. 1.

Fig. 1

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Health education applying role-play promoting decision-making ability program.

In the control group, the participants received brochures and home visits by the registered nurses in their community setting. The participants had chances to ask questions and discuss when measuring vital signs during home visits. This home visit was once a week with or without the participant's family members.

Validity and reliability

The study protocol was developed and prospectively registered to avoid bias, and this study was conducted strictly following the registered protocol. A checklist for all activities was provided and completed to confirm that the primary investigator did all activities and procedures following the protocol. To avoid bias, a randomized was performed two times, including cluster sampling and simple random sampling, and a double-blinded design was applied (research assistants and participants did not know which groups were control or intervention groups). The four actors who performed role-play earned a bachelor's degree in nursing. They were trained and performed acting rehearsals many times until they achieved this program's main points of health information and aims before performing role-play to older adults. Moreover, the two research assistants participated in the recruitment and data collection processes (baseline and post-intervention). However, the principal researcher only implemented intervention using a flipchart and PowerPoint. The two research assistants earned master's degrees in nursing, had research experience, and were trained for screening and data collecting before starting this study. All questionnaires were checked twice and completed before the older adults left the school. The screening process and findings were reported using the diagram and standard statement.

Ethical considerations

The research received approval from the Khon Kaen University Center for Ethics in Human Research (Approval Number: HE642163) on July 15, 2021, following the ethical principles of the Declaration of Helsinki. Volunteers who participated in the study received information about the purpose of the research, confidentiality of data, reporting data in the aggregate, and the ability to withdraw from the study without losing care or medical treatment—those who agreed to participate signed informed consent. Finally, the study protocol was prospectively registered on 28/09/2021, and the clinical trial registration number was TCTR20210928004.

Data analysis

Data were analyzed initially by calculating descriptive statistics using the IBM® SPSS® version 28 statistical software under a university license. Demographic characteristics between control and experimental groups were compared by applying the Chi-square Test, Fisher Exact Test, and Independent t-test. Normal distribution was explored using Kolmogorov–Smirnov and Shapiro–Wilk, Skewness and Kurtosis, Histogram, and normal Q–Q and Box plots before exploring between-groups and within-group comparisons. In normal distributions, independent-sample t-tests were examined for knowledge, belief, and decision-making differences between the experimental and control groups. However, the Mann–Whitney U test was applied for non-normal distribution variables.

In the same way, in cases of normal distribution, paired-sample t-tests compared within-group differences; however, the Wilcoxon (Matched Paired) Signed Rank test was applied for non-normal distribution variables. A Chi-square was generated when comparing a categorical variable, first of action. Finally, the adjusted analysis was performed to explore actual results after we found that sex, income, and knowledge of risk factors differed between control and experimental groups at the baseline.

Results

Participants enrolment and withdrawal

Of the 674 community-dwelling older adults who were screened for eligibility, 173 older adults were excluded. The reasons for exclusion were not meeting the criteria for 142 older adults and declined to participate in this study for 30 older adults (Fig. 2). The 501 older adults from each community were randomized into control and experimental groups by drawing their house numbers. All 96 participants (48 participants per group) remained in this study. More females were in the experimental and control groups (Table 1), and the proportion of sex was significantly different between the two groups. The average age was 70.56 years (SD = 5.99). About half of the participants were widows, and over 80% attended formal education for only four years. Most had yearly incomes between 5001 and 10,000 Thai baht (about $150–$300 in US dollars; most received support from the Thai government about 600–800 Thai baht ($15–$20) a month), and this level of income was significantly different between the intervention and control groups. Most had no occupation or were farmers and used the universal coverage scheme as their health insurance. More than half defined their health status as neutral or good. Almost 70% reported that they had chronic diseases, including hypertension, diabetes mellitus, dyslipidemia, and chronic kidney disease. Only two older adults had direct experience with AMI, and only four older adults took part in the situations of someone having AMI.

Fig. 2.

Fig. 2

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CONSORT 2010 flow diagram.

Table 1.

Descriptive statistics of older adults’ demographic characteristics.

Demographic characteristics Control group (n = 48) Experimental group (n = 48) Total (n = 96) P-value
n % n % n %
SexF 0.04
 Male 11 22.90 3 6.30 14 14.60
 Female 37 77.10 45 93.70 82 85.40

Age (years)I

(Mean = 70.56, S.D. = 5.99, Min. = 60, Max. = 87)

 (Mean = 70.25, S.D. = 6.84, Min. = 60, Max. = 87) (Mean = 70.85, S.D. = 5.07, Min. = 61, Max. = 82) – – 0.62
 60–69 24 50.00 21 43.80 45 46.90 0.51
 70–79 20 41.60 25 52.00 45 46.90
 ≥ 80 4 8.40 2 4.20 6 6.20
Marital statusF 0.52
 Single 3 6.30 3 6.30 6 6.30
 Married 22 45.80 17 35.40 39 40.60
 Widow 20 41.70 24 50.00 44 45.80
 Divorce 3 6.30 2 4.20 5 5.20
 Separate 0 0 2 4.20 2 2.10
Education levelF 0.32
 4 years 40 83.30 40 83.30 80 83.40
 6 years 0 0 2 4.20 2 2.10
 9 years 5 10.40 3 6.30 8 8.30
 12 years 2 4.20 1 2.10 3 3.10
 16 years (bachelor degree) 0 0 2 4.20 2 2.10
 Over 20 years (doctoral degree) 1 2.10 0 0 1 1.00
Income (bath/month)F 0.003
 None 1 2.10 5 10.40 6 6.30
 3000–5000 4 8.30 14 29.20 18 18.80
 5001–10,000 14 29.20 11 22.90 25 26.00
 10,000–20,000 7 14.60 7 14.60 14 14.60
 20,001–50,000 18 37.50 4 8.30 22 22.90
 > 50,000 4 8.30 7 14.60 11 11.50
OccupationF 0.26
 None 15 31.30 12 25.00 27 28.10
 Farmer 17 35.40 19 39.60 36 37.50
 Own business 5 10.40 1 2.10 6 6.30
 House wife 8 16.70 10 20.80 18 18.80
 Retired 0 0 4 8.30 4 4.20
 General employee 2 4.20 1 2.10 3 3.10
 Other 1 2.10 1 2.10 2 2.10
Health insuranceF 0.08
 Universal Coverage Scheme 42 87.50 32 66.70 74 77.10
 Civil Servants Medical Benefit Scheme 5 10.40 13 27.10 18 18.80
 Privacy Health Insurance 1 2.10 1 2.10 2 2.10
 Out of Pocket 0 0 2 4.20 2 2.10
Health statusF 0.46
 Not good 1 2.10 1 2.10 2 2.10
 Quite BAD 2 4.20 5 10.40 7 7.30
 Neutral 27 56.30 25 52.10 52 54.20
 Good 18 37.50 15 31.30 33 34.40
 Excellent 0 0 2 4.20 2 2.10
Chronic diseaseC 0.51
 Yes 31 64.60 34 70.80 65 67.30
 No 17 35.40 14 29.20 31 32.30
Heart diseaseC 0.08
 Yes 0 0 3 6.30 3 3.10
 No 48 100.0 45 93.80 93 97.90
HypertensionC 0.15
 Yes 20 41.70 27 56.30 47 49.00
 No 28 58.30 21 43.80 49 51.00
Diabetes mellitusC 0.63
 Yes 12 25.00 10 20.80 22 22.90
 No 36 75.00 38 79.20 74 77.10
DyslipidemiaF 0.62
 Yes 1 2.10 3 6.30 4 4.20
 No 47 97.90 45 93.20 92 95.80
Chronic kidney diseaseF 0.50
 Yes 0 0 2 4.20 2 2.10
 No 48 100.0 46 95.80 94 97.60
Self-experience of AMIF 0.50
 Yes 2 4.20 0 0 2 2.10
 No 46 95.80 48 100.0 94 97.60
Seeing other experience of AMIF 1.00
 Yes 2 4.20 2 4.20 4 4.20
 No 46 95.80 46 95.80 92 95.80
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AMI acute myocardial infarction, C Chi-square test, F Fisher exact test, I independent t-test.

Primary outcomes

At baseline (pretest), there were no statistical differences between groups in knowledge, belief, and decision-making, except in knowledge of risk factors, for which the scores in the control group were slightly higher than in the experimental group. After completing the decision-making ability promoting program, the participants in the experimental group had statistically better knowledge, belief, and decision-making, including knowledge of AMI symptoms, perceived benefit, barrier, self-regulation, possible calling 1669, and appropriate first of action than those in the control group (Table 2).

Table 2.

Pretest (baseline) and posttest comparisons of knowledge, belief, and decision making between experimental and control groups (independent-samples t-test).

Control group (n = 48) Experimental group (n = 48) t/Z df p-value/Z-value 95% CI
Median Mean SD Median Mean SD Lower Upper
Baseline (pretest)
 Knowledge about risk factorsM 10.00 8.35 2.80 6.00 5.56 3.41 4.20 90.61 < 0.001 1.53 4.06
 Knowledge about AMI symptomsM 7.00 7.33 1.87 6.50 5.94 3.27 2.00 74.80 0.052 0.31 2.48
 Perceived susceptibilityM 8.50 11.33 5.73 8.00 9.94 5.68 1.75 94.00 0.083 − 0.42 4.21
 Perceived severityM 70.00 68.78 11.79 66.00 58.83 25.11 1.07 66.76 0.292 1.86 17.85
 Perceived benefitM 20.00 20.81 3.17 22.00 19.29 6.42 0.14 68.89 0.854 − 0.54 3.58
 Perceived barrierM 38.00 38.98 15.55 45.00 43.15 18.53 0.94 94.00 0.385 − 11.10 2.76
 Perceived self-regulationM 15.00 13.96 4.14 14.00 14.06 6.37 0.38 80.71 0.719 − 2.29 2.08
 Perceived cue to actionM 15.00 15.15 3.18 15.00 14.04 6.90 0.21 66.07 0.802 − 1.08 3.29
 Possible calling 1669M 7.00 6.48 0.82 7.00 5.71 1.83 1.50 65.29 0.125 0.19 1.35
 First of actionC – n % – n % – 1 0.152 – –
  Calling 1669 – 29 60.42 – 21 43.75
  Other – 19 39.58 – 27 56.25
Posttest
 Knowledge about risk factorsM 10.00 9.17 1.65 10.00 9.21 1.37 0.18 94.00 0.406 − 0.66 0.57
 Knowledge about AMI symptomsM 8.00 6.83 3.05 9.00 8.88 1.57 3.28 70.19 < 0.001 − 3.03 − 1.06
 Perceived susceptibilityM 16.00 13.79 6.11 15.00 13.96 5.47 0.16 94.00 0.427 − 2.52 2.18
 Perceived severityI 75.00 73.00 10.54 78.00 75.13 11.58 − 0.94 94.00 0.175 − 6.61 2.36
 Perceived benefitM 20.00 20.46 3.78 24.00 22.96 1.74 3.60 66.01 < 0.001 − 3.70 − 1.30
 Perceived barrierM 31.00 31.94 15.81 42.00 43.06 14.93 3.34 94.00 < 0.001 − 17.36 − 4.89
 Perceived self-regulationM 14.50 14.60 4.24 17.00 16.58 4.70 2.39 94.00  < 0.001 − 3.79 − 0.17
 Perceived cue to actionM 19.00 17.54 4.13 18.00 17.43 4.51 0.03 94.00 0.354 − 1.65 1.86
 Possible calling 1669M 7.00 6.23 0.97 7.00 6.73 0.94 3.56 93.89 < 0.001 − 0.89 − 0.11
 First of actionC – n % – n % – 1 0.049 – –
 Calling 1669 – 32 66.67 – 40 83.33
 Other – 16 33.33 – 8 16.67
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AMI acute myocardial infarction, Calling 1669 calling an ambulance in Thailand, I independent t-test, M Mann–Whitney U test, C Chi-square test.

Although participants in the experimental group scored better in knowledge, belief, and decision-making than the control group, these outcomes improved within each group over the eight weeks. Within the control group, perceived susceptibility, barrier, and cue to action scores improved from baseline (pretest) to post-test. In the same way, knowledge of risk factors and AMI symptoms, perceived susceptibility, severity, benefit, self-regulation, cue to action, possible calling 1669, and first of act of older adults in the experimental group improved from baseline (pretest) to post-test (Table 3).

Table 3.

Pretest (baseline) and posttest comparisons of knowledge, belief, and decision making within each group (paired samples t-tests).

Baseline (pretest) Posttest t/Z df p-value/Z-value 95% CI
Median Mean SD Median Mean SD Lower Upper
Control group (n = 48)
 Knowledge about risk factorsW 10.00 8.35 2.80 10.00 9.17 1.65 1.38 47 0.169 − 0.14 1.77
 Knowledge about AMI symptomsW 7.00 7.33 1.87 8.00 6.83 3.05 0.69 47 0.488 − 1.47 0.47
 Perceived susceptibilityW 8.50 11.33 5.73 16.00 13.79 6.11 2.14 47 0.033 0.03 3.88
 Perceived severityD 70.00 68.78 11.79 75.00 73.00 10.54 2.45 47 0.510 − 0.64 − 0.06
 Perceived benefitW 20.00 20.81 3.17 20.00 20.46 3.78 0.72 47 0.470 − 1.69 0.98
 Perceived barrierW 38.00 38.98 15.55 31.00 31.94 15.81 2.32 47 0.020 − 13.10 − 0.98
 Perceived self-regulationW 15.00 13.96 4.14 14.50 14.60 4.24 0.89 47 0.375 − 0.76 2.05
 Perceived cue to actionW 15.00 15.15 3.18 19.00 17.54 4.13 3.79 47 < 0.001 1.17 3.62
 Possible calling 1669W 7.00 6.48 0.82 7.00 6.23 0.97 1.73 47 0.084 − 0.56 0.06
 First of actionC – n % – n % – 1 0.520 – –
  Calling 1669 – 29 60.40 – 32 66.70
  Other – 19 39.60 – 16 33.30
Experimental group (n = 48)
 Knowledge about risk factorsW 6.00 5.56 3.41 10.00 9.21 1.37 5.01 47 < 0.001 2.62 4.68
 Knowledge about AMI symptomsW 6.50 5.94 3.27 9.00 8.88 1.57 5.10 47 < 0.001 2.09 3.78
 Perceived susceptibilityW 8.00 9.94 5.68 15.00 13.96 5.47 3.64 47 < 0.001 2.07 5.97
 Perceived severityW 66.00 58.83 25.11 78.00 75.13 11.58 3.88 47 < 0.001 8.88 23.71
 Perceived benefitW 22.00 19.29 6.42 24.00 22.96 1.74 3.05 47 0.001 1.60 5.73
 Perceived barrierD 45.00 43.15 18.53 42.00 43.06 14.93 .02 47 0.490 − 0.28 0.29
 Perceived self-regulationW 14.00 14.06 6.37 17.00 16.58 4.70 1.87 47 0.031 0.03 5.02
 Perceived cue to actionW 15.00 14.04 6.90 18.00 17.43 4.51 2.36 47 0.009 1.03 5.76
 Possible calling 1669W 7.00 5.71 1.83 7.00 6.73 0.94 3.62 47 < 0.001 0.51 1.53
 First of actionC – n % – n % – 1 < 0.001 – –
  Calling 1669 – 21 43.80 – 40 83.30
  Other – 27 56.20 – 8 16.70
Open in a new tab

AMI acute myocardial infarction, Calling 1669 calling an ambulance in Thailand, D dependent t-test, W Wilcoxon (matched paired) signed rank test, C Chi-square test.

Finally, after an adjusted analysis was generated (adjusted by sex, income, and baseline knowledge of risk factors), the participants in the experimental group still had statistically better knowledge, belief, and decision-making, including knowledge of AMI symptoms, perceived benefits, barrier, self-regulation, possible calling 1669, and appropriate first of action, than those in the control group (Table 4).

Table 4.

Pretest (baseline) and posttest comparisons of knowledge, belief, and decision making between experimental and control groups (adjusted analysis).

Control group (n = 48) Experimental group (n = 48) t/wald df p-value MD/OR (Exp(B)) 95% CI
Median Mean SD Median Mean SD Lower Upper
Posttest
 Knowledge about AMI symptomsa 8.00 6.83 3.05 9.00 8.88 1.57 4.23 95 < 0.001 2.39 1.27 3.51
 Perceived benefita 20.00 20.46 3.78 24.00 22.96 1.74 4.26 95 < 0.001 2.94 1.57 4.32
 Perceived barriera 31.00 31.93 15.81 42.00 43.06 14.93 3.68 95 < 0.001 13.22 6.08 20.35
 Perceived self-regulationa 14.50 14.60 4.24 17.00 16.58 4.70 2.43 95 0.017 2.54 0.47 4.62
 Possible calling 1669a 7.00 6.23 0.97 7.00 6.73 0.94 2.64 95 0.010 0.60 0.15 1.04
 First of actionb – n % – n % 8.11 1 0.004 6.22 1.77 21.90
  Calling 1669 – 32 66.67 – 40 83.33
  Other – 16 33.33 – 8 16.67
Open in a new tab

Calling 1669 calling an ambulance in Thailand;

aLinear regression adjusted by sex, income, and baseline knowledge of risk factors.

bLogistic regression adjusted by sex, income, and baseline knowledge of risk factors.

Harms or adverse events

This study found no harm, adverse event or unintended effect happening to the participants in ether groups.

Discussion

Community-dwelling older adults improved almost all selected outcomes after attending the decision-making ability promoting the program, except for the perceived barrier. These results demonstrated that this program could be used to improve knowledge, belief, and decision-making among community-dwelling older adults. A comprehensive development of the program based on the principle of giving health education concerning aging processes and impairment40,41 is an essential part of this program to promote achievement on improving knowledge, belief, and decision making among community-dwelling older adults for this study. This program was applied not only in a short period, sub-sections, class teaching (lecture) and uncomplicated practicing (few steps, and go step by step), a good environment and appropriate place, integrated context, culture, and lifestyle of learners, but also applied the proper media, large letters, and visible picture to read and see. Moreover, a handbook with uncomplicated sentences, formal language, and friendly colors was also provided so that they could be taken back home to review40–42. Tianmongkol pointed out that the Thai Chara front (TH-Chara) size 16–18 is straightforward and easy to read by older adults; this was applied to our handbook42. Finally, Sungvorawongphana et al. also proved that pictures and colors of health information materials were significant parts of giving health education to older adults43. Letter color and clear, visible pictures to read and see can catch older adults’ attractiveness and promote their understanding. The program materials for this study were a flipchart, PowerPoint, and handbook, which applied huge and clear pictures and used black letters on yellow backgrounds. These three concepts effectively promoted readability and understanding for our target population43.

The provided health information is important, but the way to induce older adults' attention and make them ready for the provided health information and activities is also essential. This program always started with role-play, followed by class teaching (Flipchart lecture) or practice (CPR training and calling 1669) and a handbook review. The reason for applying and starting the program with role-play is to make the program attractive, induce older adults' attention, and improve knowledge, belief, and decision-making by giving specific health information related to AMI. Jasemi et al. found that role-play and lectures were more effective in promoting ethical sensitivity and ethical performance among nursing students than those who did not27. Moreover, role-play is more effective than the lecture method27. This innovative method was used to promote knowledge, belief, decision-making, and skills among healthcare professionals, nurse students, Black, White, and Asian people in the context of quitting smoking, ethic consideration, Empathy, cancer prevention, psychological development, BPH, and disaster21–28. Role-play was proved not only by children and adult groups (nursing students, healthcare professionals, healthy and ill patients) in ethical sensitivity and healthcare prevention issues but also among older adults in emergencies28. Seo et al. reported that role-play and scenarios effectively promote emergency response, awareness, and readiness among older adults in emergencies like disasters28. With innovative methods, such as role-play, this program reflects a good combination of health information, material, and methods to achieve the best outcomes for this study.

Older adults in the experimental group and older adults in the control group improved their outcomes. We found that perceived susceptibility, perceived benefit, and perceived cue of action among older adults in the control group after finishing this study were higher than baseline. This result is possible because a home visit can reach their awareness and perception. However, knowledge cannot be improved without giving health education. Other studies also found that providing a home visit with giving advice can reach patients’ knowledge, awareness, attention, self-care, self-efficacy, and adopted health behaviors among older adults and other age groups for several health issues such as medication adherence, asthma, blood pressure control, blood sugar level, and heart failure44–48. However, only a home visit cannot be used to promote all components and provide the most effective outcomes compared to multiple interventions or activities49. Moreover, the systematic review and meta-analysis found that the innovative methods, including multiple interventions such as a heart attack survival kit, red cardboard containing essential information, a list of warning signs of AMI, a group discussion, a home visit by the firefighter, strong recommendation to call 911 (calling an ambulance in USA), and primary step for cardiopulmonary resuscitation (CPR) were the most effective method promoting of calling 911 and taking aspirin26. Results from the systematic review and meta-analysis can be used to reflect why interventions in our experimental group promoted knowledge, belief, and decision-making more effectively.

The adjustment analysis confirmed that the decision-making ability-promoting program was more effective than the control group. We have found that older adults in the experimental group have higher scores in the knowledge of AMI symptoms, perceived benefit, perceived barrier, perceived self-regulation, possible calling 1669, and appropriate first-of-act planning when experiencing AMI. It was confirmed that multi-method or multifactorial intervention programs are superior to single interventions49. However, this program could improve decision-making ability, which might slightly affect or cannot be used to confirm the time to seek treatment and delay the time to receive treatment. This issue is still an area of interest and should be further explored in real situations and long-term studies. Finally, this study found that older adults in the experimental group reported higher scores of perceived barriers than in the control group. This unexpected finding might be because some questions under this component ask about quitting the job, income, and treatment and service costs, and older adults in the experimental group have slightly less income when compared with the control group.

Another point is that the cue to act, which is defined as something to induce awareness or induce people to decide to do something or practice health behaviors30,31, in the experimental group was improved after attending the program. However, this outcome was similar when compared with the control group. Family members and caregivers greatly support older adults in making decisions and performing health behaviors50–52. Although this intervention encouraged family members and caregivers to participate in the program, only 1–2 times joining activities might not be enough for older adults to feel support from their surrounding people and commit action in an AMI situation. This unexpected finding suggests that the family members or caregivers should engage in the program often (almost every time) for future study.

Limitations and recommendations

Although we have tried to develop program activities and materials relying on the principle of giving health education concerning aging processes and sensory impairment, this study was conducted under the COVID-19 pandemic situation and social distancing policy, social distancing seat arrangement, and mask on all the time. Conducting research under this policy may be a barrier when role-playing and providing health education. It may be a reason why older adults only achieve some of the outcomes we have expected and measured. For future studies, this program should be conducted again if the pandemic situation improves (normal situation); if not, the mobile application would be appropriate. Most participants for this study were female; this variable should be a concern when applying this result to future studies and practice. Long-term evaluations should be carried out to determine the persistence of knowledge, belief, and decision-making ability since this study evaluated these outcomes a week after finishing interventions. This study was conducted among older adults for the situation when expecting AMI occurrence; future studies should explore the effectiveness of this program in the actual situation of AMI or study among hospitalized older adults who already experienced AMI after they were discharged.

Conclusion

This study showed that a health education applying role play promoting decision-making ability program could improve knowledge, belief, and decision-making among community-dwelling older adults. Registered nurses or other health care professionals should explore alternative methods to improve these essential outcomes for this target population since they are prone to experience atypical symptoms of AMI and delay treatment. Nurses and healthcare professionals can implement this program as part of standard practice or adjust it to fit the lifestyles and needs of community-dwelling older adults. Role-play might be one strategy to promote the program's effectiveness by inducing attention before giving older adults health information, and this could improve knowledge and belief and promote quick decision-making for this target group of people when experiencing acute myocardial infarction.

Acknowledgements

We would like to thank those who contributed to developing the health education applying role-play promoting decision-making ability program. A special thanks is extended to the community-dwelling older adults who participated in the study. Lastly, we would like to acknowledge the registered nurses at primary care units and staff at older adult schools for their cooperation and participation during the research process.

Author contributions

All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE: http://www.icmje.org/recommendation/): 1. Substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; Drafting the article or revising it critically for important intellectual content.

Funding

This research project was financially supported by the young researcher development project of Khon Kaen University (Grant number YRDP-KKU-0212182020). Appreciation is extended to this research project for making this research possible.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to prohibited laws (and/or rules, regulations, and contracts). However, they are available from the corresponding author upon reasonable request.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets generated and/or analyzed during the current study are not publicly available due to prohibited laws (and/or rules, regulations, and contracts). However, they are available from the corresponding author upon reasonable request.

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