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The effect of education using the interactive avatar application on self-care and the ability to identify and respond to the symptoms of heart attack in patients with acute coronary syndrome: a randomized clinical trial

BMC Health Services Research volume 25, Article number: 572 (2025) Cite this article

Abstract

Background

This study aimed to assess the effectiveness of an interactive avatar application in enhancing self-care behaviors and improving recognition and response to heart attack symptoms among patients with Acute Coronary Syndrome (ACS).

Methods

A non-blinded, two-arm, randomized controlled trial was conducted with 78 ACS patients randomly allocated to either an intervention group or a control group. The control group received conventional education, while the intervention group received conventional education supplemented with training via an interactive avatar application. The application provided guidance on self-care practices, recognition of heart attack symptoms, and appropriate responses. Data were collected at baseline, 1 month, and 3 months post-discharge using demographic questionnaires, the Self-Care of Coronary Heart Disease Inventory, and the ACS Response Index. Statistical analyses included chi-square tests, independent samples t-tests, and Mann-Whitney U tests.

Results

At the 3-month follow-up, participants in the intervention group exhibited significantly higher scores on both the Self-Care of Coronary Heart Disease Inventory and ACS Response Index compared to the control group (P < 0.05). Furthermore, during the 3-month follow-up period, all patients in the intervention group (100%) ceased activity and took sublingual nitroglycerin upon experiencing heart attack symptoms, compared to 80% in the control group.

Conclusions

The interactive avatar application proved effective in improving knowledge, attitudes, beliefs, and self-care behaviors among ACS patients. This innovative educational tool holds promise for enhancing patient outcomes in ACS management.

Trial registration

This study was registered at the Iranian Registration Clinical Trial Center (Code: IRCT20220920056001N1, Date: 2023-01-03).

Peer Review reports

Background

Acute Coronary Syndrome (ACS) is a critical cardiovascular condition that requires timely intervention to ensure patient survival. The majority of ACS-related deaths occur within the first few hours of symptom onset, highlighting the importance of minimizing delays in seeking medical attention. A key factor contributing to these delays is patients’ lack of awareness about ACS symptoms and their inability to recognize and respond appropriately [1]. The primary delay in these such occurs before patients reach an emergency medical facility, commonly referred to as the patient’s decision time or delay [2, 3]. Early symptom recognition and prompt help-seeking behavior are essential in reducing mortality rates by shortening the time to hospital arrival [1, 4]. These behaviors constitute key components of self-care, which play a vital role in improving clinical outcomes for ACS patients [5, 6]. Self-care consists of three components: Self-care maintenance, Self-care monitoring, and Self-care management. A lack of awareness regarding Self-care behaviors can lead to poor clinical outcomes, highlighting the importance of self-care education for patients [1].

Despite the well-established importance of self-care and symptom recognition, conventional patient education methods, such as face-to-face interactions and printed materials, pose challenges, particularly for individuals with low health literacy [1, 7]. The advancement of technology has introduced mobile applications as innovative tools for health education. Among these, avatar-based applications—employing digital human-like characters to communicate through facial expressions, body language, and speech, offer a novel, patient-centered learning approach that enhances comprehension and engagement. These applications enable users to actively participate in the learning process [5, 8, 9].

The theoretical foundation of this approach is based on Social Cognitive Theory (SCT), which emphasizes observational learning, self-efficacy, and behavior modification through modeled experiences. According to SCT, individuals acquire new behaviors and knowledge by observing others and reinforcing learned behaviors through positive or negative feedback [1, 10]. In the context of patient education, avatars serve as modeled agents that reinforce interactive feedback and enhance patient engagement through personalized learning experiences [9]. By applying these principles, avatar-based applications have demonstrated the potential to enhance self-care adherence and improve the recognition and timely response to Acute Coronary Syndrome (ACS) symptoms [1]. These applications are particularly beneficial for individuals with low health literacy by simplifying complex medical information while replicating human interactions [1, 11, 12].

Literature review

Previous studies have explored the effectiveness of avatar-based applications in various health conditions. For example, a study by Wonggom et al. in Australia, involving 36 patients with heart failure, aimed to assess the effect of an interactive Avatar application on patients’ knowledge and self-care. The results showed that three months after discharge, the application significantly improved the level of knowledge in the intervention group (P = 0.002) [5]. Similarly, Bedra et al. evaluated the feasibility and patient acceptance of avatar-based education for ileostomy in 15 patients with new stomas and assessed its impact on knowledge and self-efficacy. Their findings indicated significant improvements in ileostomy knowledge and stoma care self-efficacy following the intervention [13]. Avatar technologies have also been applied in other areas such as mental health issues [14], diabetes mellitus [15], acute coronary syndrome [16], and obesity [17] demonstrating their versatility across diverse conditions.

Despite the growing interest in avatar-based education, previous studies have rarely involved patients directly in the design process. The European Society of Cardiology emphasizes the importance of collaboration between consumer, and patient organizations, healthcare professionals, and app developers for the development of all digital health solutions [18]. This collaborative approach ensures that applications are both acceptable to users and technically feasible [19]. Additionally, one notable area for improvement in existing research is the limited cultural adaptation in avatar design for patients. Researchers highlight that cultural adaptation is a crucial factor for success; if users perceive that an avatar’s persona does not reflect their cultural identity, they are likely to disregard the information provided by the avatar [20]. Indeed, one defining characteristic of avatars is their ability to be personalized according to users’ cultural backgrounds. This personalization fosters a deeper connection with users and enhances interaction with the avatar [21].

Research objective

Based on these areas for improvement, our study aimed to answer whether interactive avatar-based education, when culturally tailored to the patient and developed through a collaborative process, can improve self-care behaviors and enhance recognition and response to heart attack symptoms in ACS patients. This study has the potential not only to expand existing knowledge but also to provide insights into designing accessible health interventions using avatars to improve self-care among ACS patients.

Methods

This randomized clinical trial (Iranian Registration Clinical Trial Center Code: IRCT20220920056001 N1, Date: 2023 - 01- 03), was conducted on patients with acute coronary syndrome who were hospitalized in the cardiac wards and Coronary Care Units (CCU) of two major teaching hospitals in Mashhad, Iran, from May 2022 to February 2024. The trial adhered to CONSORT (Consolidated Standards of Reporting Trials) guidelines.

Participants and sampling

The study included participants with a confirmed diagnosis of acute coronary syndrome (ACS) by a cardiac specialist, as documented in their medical records. The diagnosis typically considered ischemic symptoms, specific electrocardiogram (ECG) changes, and elevated cardiac biomarkers but ultimately relied on the specialist’s clinical judgment. Inclusion criteria were willingness to provide informed consent, stable clinical condition (defined as hemodynamic stability and absence of life-threatening arrhythmias), age over 18 years, and ability to communicate in Persian. Exclusion criteria encompassed voluntary withdrawal from the study, unstable clinical conditions, or death.

Participants were recruited using convenience sampling from cardiac wards and Coronary Care Units (CCU). Randomization was conducted using computer-generated random numbers to ensure unbiased group allocation. To prevent contamination, a time-block randomization method was employed using an online tool. Block A was assigned to the control group, while Block B was assigned to the intervention group, with sampling alternated weekly between groups based on predetermined blocks.

The sample size was calculated to include 39 participants per group (total n = 78) based on power analysis. This calculation assumed a medium effect size of 0.7, 80% statistical power, a 95% significance level, and an anticipated attrition rate of 10%. As a result, 39 participants were assigned to each group.

Data collection

In this study, participants were randomly assigned to either the intervention group, which received education through an avatar-based application, or the control group, which received conventional education. Data were collected at baseline, and one - and three-month follow-up using validated questionnaires. The primary outcome measures included self-care behaviors, patients’ knowledge, attitudes, and beliefs regarding heart attack symptoms, and ability to respond to heart attack symptoms. Both groups were followed up for a period of one- and three months post-discharge to assess outcomes.

This study was conducted as an open-label trial (unblinded) in which both participants and researchers were aware of the group assignments due to the nature of the intervention. Patients were recruited consecutively from these wards based on the predefined inclusion and exclusion criteria.

Instruments

The data collection tools employed in this study included a demographic information questionnaire, the Self-Care of Coronary Heart Disease Inventory, the Acute Coronary Syndrome (ACS) Response Index, and a questionnaire assessing the ability to respond to heart attack symptoms.

1. Demographic information questionnaire

A researcher-developed demographic questionnaire was used to collect comprehensive data from the participants. This instrument gathered information on sociocultural characteristics (age, sex, education level, occupation), clinical history (duration of coronary artery disease), and hospitalization details (History of hospitalization due to cardiovascular disease, Duration of hospital stay). The researcher completed the questionnaire through interviews with the patient or a review of the patient’s clinical file, ensuring the acquisition of pertinent background information for each study participant.

2. Self-care of coronary heart disease inventory

The Self-care of Coronary Heart Disease Inventory, developed by Dickson et al. [22], assesses self-care behaviors. Scores range from 16 to 88, with higher scores indicating better self-care [23, 24]. Tavakoli et al. translated and validated the Self-care of Coronary Heart Disease Inventory for Persian-speaking populations, demonstrating robust psychometric properties with a correlation coefficient of 0.85 and Cronbach’s alpha of 0.91 [24].

3. The ACS response index

The ACS Response Index, developed by Lupker et al. [25], comprises three subscales assessing patients’ knowledge, attitudes, and beliefs regarding heart attack symptoms [26]. In the Iranian context, Rezaei et al. evaluated the instrument’s psychometric properties, confirming its validity and reliability in measuring heart patients’ knowledge, attitudes, and beliefs about heart attacks [27].

4. Ability to respond to heart attack symptoms questionnaire

The Ability to Respond to Heart-Attack Symptoms Questionnaire is a two-part researcher-developed instrument. The first part of the questionnaire consisted of 10 items related to heart attack symptoms (such as chest pain and arm pain). In the second part, 20 behaviors to deal with heart attack symptoms were listed (such as stopping the activity and calling the emergency medical service). Participants chose yes/no answers when they experienced heart attack symptoms. This questionnaire captures the participants’ real experiences of heart attacks and their responses to symptoms during the three-month follow-up period. The content validity of this tool was established through an expert panel review. The reliability of the questionnaire was determined using the Kuder-Richardson coefficient, which yielded a value of 0.647.

Procedure

Development of an avatar-based application

Before the intervention, the educational content for the application was developed through an extensive review of relevant texts and articles. The content included information on the signs and symptoms of a heart attack, appropriate actions to take during a heart attack, and self-care behaviors for patients with acute coronary syndrome. The prepared content was subsequently reviewed by nursing and medical experts, and necessary revisions were made based on their comments and suggestions.

In the next phase of development, the textual content, visual elements, and character dialogues for the avatar were provided to app design experts for implementation. During this stage, the avatar character underwent multiple reviews by experts and hospitalized patients with acute coronary syndrome to ensure that its cultural attributes—such as facial features, skin tone, body posture, and attire—aligned with Iranian cultural norms.

Once the initial version of the application was completed, it was submitted to app design experts for performance evaluation on Android mobile devices. Following approval by software engineers, the application was assessed by cardiologists, cardiac nurses, cardiovascular researchers, software experts, and patients with acute coronary syndrome. Feedback from these evaluations was systematically incorporated to improve the application’s functionality and cultural appropriateness.

A pilot study was then conducted with 10 patients diagnosed with acute coronary syndrome. Their feedback was carefully analyzed, and further refinements were made to prepare the final version of the application for clinical trials (Fig. 1).

Fig. 1
figure 1

Examples of screenshots from the avatar-based education application

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The avatar designed for this application featured an animated character that allowed users to personalize its attributes. Patients could select the avatar’s gender (male or female), clothing color, glasses (optional), hair color (for male avatars), and scarf color (for female avatars). Through this personalized avatar, patients could access all educational content in text, image, and audio formats. Additionally, a reminder menu enabled patients to record their medication times so that the application could send reminders at the specified times. The application also included a test menu with a basket of questions, allowing patients to review educational content, evaluate their understanding, and receive feedback based on their scores.

This study utilized a two-arm randomized controlled design. The control group received conventional education, whereas the intervention group was provided with an avatar-based interactive application to enhance their education.

Control group

Participants in the control group, after providing informed consent, completed the demographic information questionnaire, Self-Care of Coronary Heart Disease Inventory, and the ACS Response Index in person at baseline. These instruments were selected for their validated reliability in assessing self-care behaviors and symptom recognition in coronary heart disease patients with coronary heart disease. The participants received conventional education, which included face-to-face education and pamphlets about heart attack signs and symptoms, appropriate responses to heart attack symptoms, and related self-care behaviors, delivered by a nurse educator. This education session typically lasted approximately 15 min and was conducted before discharge. Follow-up assessments using the Self-Care of Coronary Heart Disease Inventory, ACS Response Index, and Ability to Respond to Heart Attack Symptoms questionnaire were conducted via phone one- and three months post-discharge. These time points were chosen to evaluate both the short- and medium-term retention of information and changes in self-care behaviors.

Intervention group

In the intervention group, following the completion of the baseline questionnaire, the researcher installed an avatar-based interactive app on each patient’s mobile device and provided usage instructions to patients. The application was initially used under the supervision of the researcher to address any immediate questions and ensure proper usage. These tasks were performed during hospitalization so that the patient had the opportunity to use the app and ask his/her questions. In this way, content is delivered through a user-selected avatar, incorporating multimodal learning elements, such as text, images, and audio, to enhance engagement and accommodate diverse learning preferences. This multimodal learning approach aimed to optimize information retention and the application of self-care strategies.

After discharge, patient follow-up on application usage was conducted through biweekly phone calls to maintain engagement and promptly address any issues. During these calls, the researcher responded to participants'questions and inquired about their application usage over the preceding three days. If a participant reported non-use, the researcher investigated the reasons, resolved any usability concerns, and ensured continued access to the application. Once the issue was resolved, the researcher emphasized the importance of consistent application usage until the next scheduled follow-up, three days later.

Application usage was monitored through patient self-reporting, and follow-up assessments were conducted at one and three months post-discharge, following the same protocol as that used for the control group.

It should be noted that both groups received standard hospital care throughout the study period. This approach ensured that all participants, regardless of the group assignment, received appropriate medical attention, thereby maintaining ethical treatment standards and allowing for a clear evaluation of the impact of the application.

Data analysis

In the present study, before the initiation of sampling, the researchers anticipated an attrition rate of 10%. However, despite efforts to follow up with participants throughout the study, an attrition rate of 12.8% was observed. According to the researchers, this attrition rate aligns with expectations for randomized controlled trials involving follow-up periods [28, 29]. Nevertheless, data were analyzed according to the intention-to-treat (ITT) principle to ensure an unbiased assessment of the intervention’s effectiveness.

The reasons for attrition in both the intervention and control groups are detailed as follows:

As illustrated in the CONSORT flowchart (Fig. 2), 79 patients were initially enrolled in the study. One patient was excluded due to failure to install the application, resulting in a final randomization of 78 patients into intervention and control groups.

Fig. 2
figure 2

Consort flowchart of the study process

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At the one-month follow-up, the intervention group experienced attrition of three participants (one due to medical instability and two failures to answer the phone call), leaving 36 participants who completed the questionnaire. In the control group, five participants did not complete the study (one due to medical instability, one voluntary withdrawal, and three failures to answer phone calls), resulting in 34 active participants.

At the three-month follow-up, two additional participants from the intervention group dropped out (one due to medical instability and one failure to answer phone calls), reducing the group size to 34 participants. The control group remained unchanged with 34 active participants. The overall attrition rate was therefore 12.8% (10/78), with identical rates observed in both groups (12.8% in both intervention and control groups). Ultimately, data from 39 patients in each group were analyzed according to the ITT principle (Fig. 2).

In the study, data were analyzed according to the intention-to-treat principles, using the Statistic Package for the Social Sciences (SPSS) software (Version 26). Descriptive statistics for approximately normally distributed numerical variables were presented as mean (SD), while categorical variables were reported as N (%). To compare quantitative variables between groups, either an independent t-test or the Mann-Whitney U test was employed based on data distribution normality.

The t-test was used to assess the differences in mean self-care scores before the intervention and one month afterward regarding beliefs about recognizing ability to recognize heart attack symptoms between the intervention and control groups. The Mann-Whitney U test was applied to compare mean self-care scores at one- and three months post-intervention, as well as knowledge regarding the ability to recognize heart attack symptoms at baseline, one-month, and three months post-intervention. Additionally, this test was used to evaluate changes in belief about the ability to recognize heart attack symptoms before the intervention and three months afterward in both the intervention and control groups.

Qualitative variables between groups were compared using chi-square tests. The selection between t-tests and Mann-Whitney U tests was determined by assessing data normality using the Kolmogorov-Smirnov test. For data measured at multiple time points, repeated measures analysis of variance (ANOVA) was applied for normally distributed data, while non-normally distributed data or ordinal variables were analyzed using Friedman tests.

To compare mean self-care scores across time points (baseline, one month, and three months post-intervention), Friedman tests were applied within the intervention group, while repeated measures ANOVA was utilized for the control group. Similarly, Friedman tests were performed for comparisons of mean scores related to knowledge, attitudes, and beliefs in both intervention and control groups. Responses to heart attack symptoms were analyzed using descriptive statistics. A p-value of less than 0.05 was considered statistically significant.

Results

The results of the present study indicated that participants had a mean age of 56.12 ± 9.67 years, with a predominance of male participants (66.7%). Regarding demographic characteristics, there were no statistically significant differences between the intervention and control groups, indicating that the two groups were homogeneous (Table 1).

Table 1 Demographic characteristics of the study participants
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The intergroup comparison revealed no statistically significant difference in mean self-care scores between the intervention and control groups at baseline (P = 0.06) or one-month post-intervention (P = 0.55). However, at the three-month follow-up, the intervention group demonstrated significantly higher mean self-care scores than the control group (P = 0.008). Intragroup comparisons indicated a significant decrease in the mean self-care scores across all three time points in the control group (P = 0.001) (Table 2).

Table 2 The mean scores of self-care in the intervention and control groups
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Analysis of the knowledge dimension of the ability to identify heart attack symptoms revealed no significant difference in the mean scores of the knowledge dimension between the intervention and control groups at baseline (P = 0.651). However, the intervention group demonstrated significantly higher mean scores at one month (p < 0.001) and three months (p < 0.001) post-intervention. Intragroup comparisons indicated a significant increase in the mean knowledge scores regarding the identified heart attack symptoms across all three time points in both the control and intervention groups (p < 0.001) (Table 3).

Table 3 The mean scores of knowledge dimension of the ability to identify heart attack symptoms in the intervention and control groups
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Concerning the attitude dimension, no significant differences were observed between the intervention and control groups at baseline (P = 0.710) or one-month post-intervention (P = 0.605). However, at the three-month follow-up, the intervention group exhibited significantly higher mean scores than the control group (P = 0.004). The mean attitude scores for the intervention group were (10.31 ± 3.41) at baseline, (12.72 ± 3.98) at one month, and (14.12 ± 3.34) at three months, compared to (10.33 ± 3.90), (12.24 ± 3.85), and (11.59 ± 3.47) for the control group at the same time points, respectively. The intragroup comparison revealed a significant increase in the mean scores of the attitude dimension regarding the identified heart attack symptoms across the three measurements in both the control and intervention groups (P < 0.001) (Table 4).

Table 4 The mean scores of attitude dimension of the ability to identify heart attack symptoms in the intervention and control groups
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The mean scores of the belief dimension showed no statistically significant difference between the intervention and control groups at baseline (P = 0.540) or one month post-intervention (P = 0.938). However, at the three-month follow-up, the intervention group demonstrated significantly higher scores than the control group (P = 0.003). Further intragroup analysis indicated divergent trends in the belief dimension scores. The control group exhibited a significant decrease across the three measurements, whereas the intervention group showed a significant increase (P < 0.001). Intragroup comparisons indicated a significant decrease in the mean scores for the belief dimension across all three time points in the control group (P < 0.001) (Table 5).

Table 5 The mean scores of belief dimension of the ability to identify heart attack symptoms in the intervention and control groups
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During the first month of follow-up post-intervention, 10 participants experienced heart attack symptoms: 6 in the intervention group and 4 in the control group. In the intervention group, 100% of participants ceased activity and rested upon experiencing symptoms, 66.7% informed nearby individuals, and 100% administered sublingual nitroglycerin. In the control group, 75% rested and informed others, 50% administered sublingual nitroglycerin, and 50% called for emergency services.

In the subsequent two-month period (1–3 months post-intervention), eight patients reported heart attack symptoms: three in the intervention group and five in the control group. In the intervention group, all patients (100%) ceased activity and administered sublingual nitroglycerin. In the control group, 80% of symptomatic patients rested and took sublingual nitroglycerin. Notably, no patients in either group contacted emergency services during this period.

Discussion

The discussion section is organized based on the study findings and is presented as follows:

Self-care

The results of this study demonstrated that three months post-discharge, the mean self-care scores were significantly higher in the intervention group than in the control group, while no statistically significant difference between the two groups was observed at baseline and one month later.

Consistent with our findings, previous studies have shown that avatar-based interventions improve self-care activities, such as daily weight monitoring, dietary control, physical activity, and foot care [30, 31]. For instance, Clark et al. conducted a two-phase study (qualitative and quantitative) to develop a culturally appropriate electronic resource for Aboriginal heart failure patients and assess its feasibility and acceptability. The qualitative phase emphasized the importance of cultural relevance in design—such as incorporating local community elements like clothing, skin tone, and voice in the avatar—while the quantitative phase revealed a 95% increase in self-care confidence, a 26.1% increase in self-care maintenance, and a 1.9% increase in self-care management among participants who received avatar-based educational resources [32].

Self-care is a naturalistic decision-making process that influences actions to maintain physiological stability, enhance symptom perception, and manage symptoms effectively [33]. Avatar-based technology has demonstrated a positive impact on self-care behaviors, particularly among individuals with chronic conditions [34]. Avatars enhance health interventions by increasing user engagement and enjoyment. Through identification or embodiment, avatars create immersive experiences that foster greater adherence to self-care practices. Evidence suggests that individuals receiving personalized guidance from virtual agents experience improved physical and psychosocial outcomes. This effectiveness is attributed to the adaptability of digital characters, which can be customized to align with users’ cultural, social, and personal preferences [5, 35,36,37].

In present study, the effectiveness of the interactive avatar application in promoting self-care can be attributed to several factors. The application’s use of visual, written, and audio content likely enhanced patients’ learning experiences. Additionally, reminders from researchers may have reinforced the importance of health education and motivated participants to engage with the materials regularly. The avatar nurse feature provided patients with a relatable figure reminiscent of bedside caregivers, potentially fostering stronger connections with the application and increasing their commitment to learning.

Conversely, some studies have reported findings inconsistent with ours regarding avatar-based education’s impact on self-care. For example, Gallagher et al. evaluated a game-based application (MyHeartMate) designed for lifestyle modification in patients with coronary artery disease. Although highly acceptable to patients, the app did not lead to significant improvements in risk factors or lifestyle behaviors except for triglyceride levels [38]. Similarly, Wonggom et al. [5] conducted a randomized controlled trial evaluating an avatar-based education application for heart failure patients but found no significant between-group differences in self-care behavior or healthcare utilization at 30- or 90-day follow-ups [11].

One possible explanation for these discrepancies may be differences in adherence and engagement levels with the applications. User willingness to engage with an application is influenced by perceptions, needs, and preferences [38]. Additionally, these findings underscore the complexity of digital health interventions and highlight factors such as intervention design, patient demographics, and implementation strategies as potential contributors to variability in outcomes [39].

Overall, self-care is a multifaceted concept extending beyond awareness of specific behaviors. Its enhancement depends on various factors, including challenges associated with habit changes, resilience during stressful life events, complexities in managing chronic diseases, and considerations for individuals with mental health disorders. Social networks—including family members and healthcare professionals—play an essential role in shaping self-care behaviors. Furthermore, cultural factors significantly influence the selection and implementation of self-care practices, emphasizing the need for culturally sensitive interventions [40].

Knowledge, attitude, and belief dimensions of the ability to identify heart attack symptoms

The results of this study demonstrate that at one- and three months post-intervention, the mean scores of knowledge regarding the recognized heart attack symptoms were significantly higher in the intervention group than in the control group. Intragroup comparisons revealed a significant increase in mean knowledge scores within the control group. Furthermore, three months post-intervention, the mean scores for both the attitude and belief dimensions were significantly higher in the intervention group than in the control group.

The findings of the present study align with those of Tongpeth et al. [1], who investigated the efficacy of an avatar application for teaching heart attack symptom recognition and response in patients with acute coronary syndrome. Their study demonstrated that the mean score of knowledge, attitude, and belief were significantly higher in the intervention group than in the control group at both one- and six months post-intervention [1]. Similarly, Wonggom et al. reported that heart failure patients using an avatar-based application demonstrated significantly greater improvements in knowledge at 90 days compared to those receiving usual care [5]. In another study by Bedra et al. interactive multimedia education for patients with new stomas significantly improved participants’ knowledge and self-efficacy, with high levels of acceptance reported through attitudinal surveys [13]. Additionally, Zhang et al. demonstrated that a co-designed, self-administered virtual nurse avatar-guided education app improved heart disease knowledge, attitudes, and beliefs among ACS patients, with high acceptability among both nurses and patients [16].

The effectiveness of the avatar-based application in improving knowledge among ACS patients can be attributed to several key features. The application provided flexible learning environments, enabling patients to engage with and better understand their medical conditions through personalized and interactive methods [41]. Also, the avatar nurse facilitated learning by employing body language and direct communication, while multimodal presentations—including pictures, videos, written text, and audio-enhanced comprehension. The use of simple, patient-friendly terminology further supported understanding. Additionally, participants had opportunities to communicate with researchers during the training process. The application also included self-assessment capabilities with immediate feedback, all within a user-friendly design that promotes ease of use.

In present study, the observed increase in mean knowledge scores within both groups may be partially explained by participants’ access to alternative information sources such as the Internet or television. This exposure likely influenced all participants regardless of group assignment. However, the significantly greater improvement in the intervention group suggests that the avatar-based application provides additional benefits beyond these common information sources. Future studies could benefit from tracking participants’ use of external information sources to better quantify their impact and to isolate the specific effects of the intervention. This approach provides a more nuanced understanding of how various information channels contribute to patients’ knowledge and self-care behaviors.

The ability to respond to heart-attack symptoms

The findings of the present study revealed that during the subsequent two-month follow-up period (1–3 months post-intervention), only eight patients reported heart attack symptoms—three in the intervention group and five in the control group. In the intervention group, all symptomatic patients (100%) rested and administered sublingual nitroglycerin. In the control group, 80% of symptomatic patients ceased activity and took sublingual nitroglycerin. These results are consistent with those reported by Tongpeth et al. [1], who found that among 16 patients experiencing acute coronary syndrome (ACS) episodes over a three-month follow-up period, 90% experienced pain relief after nitroglycerin administration. Only two patients (one from each group) required emergency hospital referral due to persistent pain. Tongpeth et al. also reported that 11 patients in their intervention group administered nitroglycerin after the onset of pain [1].

On the other hand, in the present study, during the follow-up periods, none of the patients experiencing acute coronary syndrome (ACS) episodes, contacted emergency medical services. Given the small number of patients who experienced heart attack symptoms during follow-up (three patients in the intervention group), it is not feasible to draw statistically significant conclusions. Therefore, larger-scale studies with extended follow-up periods are necessary to rigorously evaluate the long-term efficacy of avatar-based education in improving patients’ responses to heart attack symptoms.

Moreover, understanding why patients choose not to contact emergency medical services warrants a dedicated investigation. Previous studies have identified several factors contributing to this reluctance. For instance, Heidari et al. examined 300 cardiac patients admitted to hospitals and found that only 13% contacted emergency services after experiencing heart attack symptoms [42]. Similarly, Alavi et al. reported that only 25% of 248 patients with acute myocardial infarction called an ambulance when experiencing cardiac symptoms [43]. Dracup et al. assessed the impact of an individualized educational intervention on reducing prehospital delay in ACS patients but found no statistically significant difference in emergency service utilization or ambulance contact between intervention and control groups over a two-year follow-up period. However, they observed a greater tendency among the intervention group to take aspirin upon symptom onset. The authors attributed this lack of difference in prehospital delay to factors such as annual income and ambulance insurance coverage, which influenced the likelihood of seeking medical assistance. Additionally, self-treatment practices and psychological barriers were identified as potential contributors to delays in calling an ambulance [44]. Similarly, Cannoodt et al. highlighted financial constraints as well as social and geographical factors as significant barriers to utilizing emergency medical services [45].

Given the complex interplay of economic, cultural, and social determinants influencing patients’ decisions to seek emergency medical services, it is unlikely that a mobile application alone could address these barriers in the short term. Instead, comprehensive research is needed to assess public beliefs about emergency services and correct misconceptions that may contribute to delays in seeking care. The present study highlights this as a critical area for future research.

Strength and limitations

This study presents notable strengths, including its randomized controlled design, and the assessment of both short- and medium-term outcomes. Also, in the present study, the avatar-based application was developed through a collaborative process involving cardiologists, cardiac nurses, cardiovascular researchers, app developers (information technology experts and experts in app design), as well as consumers (ACS patients). Furthermore, efforts were made to incorporate the cultural and social context of ACS patients within the target population into both the design of the avatar’s persona and the educational content provided within the app. These cultural adaptations involve considerations of language, religious beliefs, and family dynamics, which hold particular significance within the healthcare system of Iran.

However, the limitations should be considered when interpreting the results. One significant limitation in present study is the potential disparity in technological proficiency and health literacy among patients. This variability could influence the extent to which individuals benefit from mobile-based educational interventions. To mitigate potential confounding effects, a random assignment strategy was employed in this study to allocate participants to either the intervention or control group. However, for future research, it is recommended to assess participants’ baseline health literacy and technological proficiency before the intervention. Additionally, a hybrid approach integrating digital interventions with traditional educational materials (e.g., booklets and pamphlets) should be considered. Such an approach could accommodate a broader patient demographic and ensure equitable access to educational content for all patients, regardless of their digital literacy. Furthermore, conducting studies with extended follow-up periods is essential to determine definitively the long-term efficacy of avatar-based education on participants’ responses to ACS symptoms.

Another limitation stems from the fact that questionnaires related to the research variables were completed by patients through self-reporting. While self-reporting introduces the potential for bias, it was deemed the most feasible and practical method for data collection, given the home-based follow-up design which spanned one to three months. To minimize these biases, several measures were implemented. Patients received detailed instructions on accurately completing the questionnaires, and assessments and follow-ups were conducted at multiple time points to enhance data reliability. Moreover, the research variables were measured using questionnaires whose validity and reliability had been rigorously assessed and confirmed. While more objective methods, such as direct monitoring or clinical assessments, could have further strengthened the study’s validity, they were not practical within the framework of a home-based follow-up design. Nonetheless, future research could enhance the validity of findings by integrating self-reported data with more objective evaluation methods.

Conclusion

The study results demonstrate that education via a collaborative, culturally tailored avatar application significantly enhanced self-care behaviors and improved the ability to identify heart attack symptoms among patients with ACS compared to the control group receiving conventional education. The application’s features, including ease of installation on mobile devices, comprehensive self-care content, and information presented in an accessible language, render it a valuable tool for patient education. This approach shows promise for educating patients with acute coronary syndrome, especially those residing in remote areas with limited access to medical centers. The effectiveness of the intervention in improving self-care and symptom recognition suggests its potential for broader implementation in cardiac rehabilitation programs.

Data availability

Data is provided within the manuscript or supplementary information files.

Abbreviations

ACS:

Acute Coronary Syndrome

CCU:

Coronary Care Unit

ECG:

Electrocardiogram

SCT:

Social Cognitive Theory

CONSORT:

Consolidated Standards of Reporting Trials

ANOVA:

Analysis of variance

SPSS:

Statistic Package for the Social Sciences

BMI:

Body Mass Index

ITT:

Intention-To-Treat

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Acknowledgements

Not applicable.

Funding

This study was part of a thesis conducted at the School of Nursing and Midwifery, Mashhad University of Medical Sciences. This study was financially supported by the Research Deputy of Mashhad University of Medical Sciences [grant number 4010182].

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Authors and Affiliations

  1. Student Research Committee, School of Nursing and Midwifery, Mashhad University of Medical Science, Mashhad, Iran

    Nahid Keivanlou

  2. Department of Nursing Practice, College of Nursing and Health Sciences, Texas A&M University-Corpus Christi, Corpus Christi, TX, USA

    Faezeh Babaieasl

  3. Department of Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran

    Jamshid Jamali

  4. Department of Cardiology, Faculty of Medicine, Mashhad Medical Sciences, Islamic Azad University, Mashhad, Iran

    Saeedeh Baghyari

  5. Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

    Zahra Dalir

  6. Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

    Nayyereh Davoudi

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  1. Nahid Keivanlou
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Contributions

NK acquired data and drafted the manuscript. FB was involved in the conceptualization and substantive intellectual contributions to the revision. JJ analyzed and interpreted the data. SB was involved in the conceptualization. ZD was involved in the design. ND Made substantial contributions to conception, design, and revision. All authors read and approved the final manuscript.

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Correspondence to Nayyereh Davoudi.

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Ethics approval and consent to participate

This study was approved by the Ethics Committee of the Mashhad University of Medical Sciences (Code: IR.MUMS.NURSE.REC.1401.062). These registrations ensured compliance with national and international ethical standards, enhancing the study’s credibility and transparency. The study was conducted in accordance with the Declaration of Helsinki. In this study, all methods were performed according to the relevant guidelines and regulations. Informed consent was obtained from all the participants.

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The authors declare no competing interests.

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Keivanlou, N., Babaieasl, F., Jamali, J. et al. The effect of education using the interactive avatar application on self-care and the ability to identify and respond to the symptoms of heart attack in patients with acute coronary syndrome: a randomized clinical trial. BMC Health Serv Res 25, 572 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12913-025-12756-z

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