ASSESSMENT OF HEALTH EDUCATION IN THE PREVENTION OF NON-COMMUNICABLE CHRONIC DISEASE COMPLICATIONS: SYSTEMATIC REVIEW

Objective: To evaluate the effectiveness of health education in the prevention of non-communicable chronic diseases. Method: This is a systematic literature review, guided by the question "In patients with non-communicable chronic diseases (NCDs), does health education compared to conventional clinical practice contribute to the prevention of complications?". The selected articles were extracted from the following databases: Biblioteca Virtual em Saúde (BVS), National Library of Medicine (PUBMED), Scientific Electronic Library Online (Scielo), Regional Online Information System for Scientific Journals from Latin America, the Caribbean, Spain, and Portugal (Latindex), and Cochrane Library. Randomized clinical trials in English, Portuguese, and Spanish from the last 10 years with full-text availability were chosen as eligibility criteria, resulting in a final sample of 10 articles. Results: Positive findings were observed regarding the complications of non-communicable diseases, such as: improvement in quality of life and cardiac anxiety scores; reduction in anxiety and depression; increased therapeutic adherence, diabetic foot care, physical activity stimulation, adoption of healthy eating habits, blood glucose self-monitoring and health literacy improvement; reduction in systolic and diastolic blood pressure; improvement in self-management of Type 2 Diabetes Mellitus; overall prevention of NCDs; promotion of motivation for behavioral change in smoking patients, and improvement in renal function with a considerable decrease in serum creatinine and a stable glomerular filtration rate. Implementing educational programs can be helpful in enhancing the quality of life in chronic diseases.


INTRODUCTION
Chronic non-communicable diseases (NCDs) are considered one of the main challenges in the area of health, since they are responsible for a high number of cases of premature deaths, complications, reduction of quality of life and limitation of daily activities (Silva et al., 2018).In the year 2012, CNCDs were responsible for 38 million deaths worldwide and they show a projection of 52 million for the year 2030, there is a significant increase of patients diagnosed with CNCD (Diaz;Cruz, 2017).
Faced with this scenario, the attention to the health of individuals needs to be applied in a continuous, coordinated and integral manner.In this sense, the importance of the realization of health promotion through educational strategies, which aims at planning and care action (Silva et al., 2018).Health education is a fundamental social intervention for conventional clinical practice, which contributes to the formation of the critical sense of the patients regarding the health conditions they present.With the implementation of the strategy, there is the stimulation of the process of awareness and literacy in health both individually and collectively (Ramos et al., 2018).
Health education covers, in most cases, the participation of the multidisciplinary team with the community, whether by means of lectures, focal discussion groups, the production of primers, and educational videos.Therefore, there is a stimulus to the adoption of new habits and health behaviors, such as lifestyle change, regular physical activity, healthy eating, smoking cessation and ethilism, thus preventing several aggravations of patients with CNCD (Ramos et al., 2018).
Despite the potential benefits of the educational strategy in preventing complications related to chronic non-communicable diseases (NCDs), its implementation faces significant challenges.Irregular adherence of patients to educational programs, cultural barriers that can influence the receptivity to health information, and resource limitations in many communities are recurrent obstacles (Guldan, 1996).
In addition, the diversity of social determinants, such as disparities in access to health care, varying educational levels and disparate socioeconomic conditions, contribute to the complexity of the scenario (Coughlin et al., 2020).These challenges highlight the critical need to assess the effectiveness of existing educational strategies, to overcome identified barriers and optimize positive impacts on NCD prevention and management.
Therefore, this systematic review proposes to assess the effectiveness of health education in preventing chronic non-communicable diseases.

MATERIALS AND METHOD
The present study is a systematic review of intervention/treatment of Randomized Clinical Trials (RCTs), which uses the hypothetical-deductive pattern itself (Saturni et al., 2014), being considered the gold standard for an illustration that covers independent and dependent variables, allowing to analyze the cause and effect relationship between them.This test provides a synthesis of the results regarding the intervention strategy developed, through systematic research mechanisms, based on a critical evaluation and the use of selected information (Sharma;Srivastav;Samuel, 2020).
Thus, in the initial drafting process, the formulation was made of the issue of PEAK acronym (patient, intervention, comparison and outcomes/outcomes), which is a strategy proposed by the Evidence Based Practice (PBE).Thus: "In patients with chronic noncommunicable diseases (NCDs), does health education in comparison with traditional clinical practice contribute to the prevention of complications?".Thus, the P= Patients with chronic non-communicable diseases, I= Health Education Programs, C= Conventional Clinical Practice, O= Collaborates to prevent complications.
In addition, a bibliographic research was carried out in the electronic databases: Virtual Library on Health (VHL), National Library of Medicine (PUBMED), Scientific Electronic Library Online (Scielo), Regional System of Información en Línea for Scientific Journals of Latin America, el Caribe, España y Portugal (LatinMed) (Scielo), Regional System of Información en Línea for Scientific Journals of Latin America, el Caribe, España and Portugal (Latindex).The study included the combinations of the following English Health Science Descriptors (DeCS) associated with the boolean operator "AND": "Health Education"e "Noncommunicable Chronic Diseases".
Continuing with the other stages for carrying out the research, the selection of the articles was performed, evaluating titles and abstracts, carried out by two independent researchers, through the Rayyan review application, which performs the screening of abstracts and titles, providing a high level of utilization, allowing a quick overview of the research, obtaining a high average saving of time (Ouzzani et al., 2016).
From the research carried out in the databases, 5994 documents were identified in total and the study was finalized with 10 selected articles (Figure 1).In the screening process the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes or the PRISMA Recommendation were adopted.To this end, the inclusion criteria used were: publication in the last 10 years, to be Randomized Clinical Trial (ECR), considering also studies with languages in English, Portuguese and Spanish.The exclusion criteria for the sample are duplicate documents that are unrelated to the search question.From such research, The classification of the articles was performed by two participants of the study independently and the quality of the studies found was evaluated by means of the schematization referred to by Jadad et al. (1996).Such a tool is of extreme relevance in research, since it has a direct relationship with the reduction of biases that aim at internal validation and reliability.The scale is based on five questions with yes/no options, seeking to analyze whether the study has a description of losses, is described as randomized, as double-blind, verifying whether such characteristics are adequate.Each affirmative answer scores 1, with a maximum score of 5. Articles that score three or more are rated as good quality.5

RESULTS
Table 1 is emphasizing data related to study characteristics.In it, all the selected studies are classified as randomized and double-blind clinical trials.Most of the studies were published in Iran, China and Australia, with publications in 2021 and 2022 (20%; n=2, each) being the most representative.Table 2 shows data directed to authors, groups analyzed, intervention used, number of participants and evaluation method.The study with the highest number of participants had an n=8217 and the lowest one, an n=30.In addition, the groups most analyzed are patients with Type 2 Diabetes Mellitus, presenting as their main intervention group education based on theory in health literacy and self-care behaviors, being analyzed by software and questionnaires, such as as chi-square test, independent and paired t test, unidirectional variance analysis (ANOVA).Semi-structured interviews based on the HITAM model and the Mobile Application Rating Scale were also conducted.In addition, they were evaluated by the Quality-Adjusted Life Year Index (QALY), which is a measure of the complications of the disease, measuring the impact of the interventions on the quality and quantity of life of the patients.The index incorporates cardiovascular risk factors and rates of unfavorable cardiac events to measure the cost-benefit of the intervention.

2,306
The 10-item Prudence Score was used to compare the improvement in health habits between the intervention and control groups.Table 3 shows the number of intervention sessions that have taken place, ranging from 4 to 96 sessions.When analyzed in relation to the time of therapy per session of 5 minutes to a period of 2 hours.
In addition, the most widely used types of health education intervention were the elearning ADDIE model (analysis, design, development, implementation and evaluation), educational programs to present educational material, health applications to help in the selfmanagement of diabetes, instant messaging with brief motivational interview to assist in smoking cessation, evaluation, creation of individual plans and lectures addressing aspects of chronic non-communicable diseases, Teach Back/ShowBack Method, support groups with stories told by patients themselves about coping with hypertension and personalized feedback prepared by computer, which highlighted behaviors in accordance with recommendations guidelines and provided guidance to improve non-compliant behaviors.
Also, the main results were highlighted in which all show significant improvement of complications of non-communicable diseases, for example, we can cite the use of instant messages with brief motivational interview, in which intervention group and health promotion had a significantly higher percentage of intention to stop smoking at 6 months.
In addition, health management strategies have also proven particularly effective.Health management reduced anxiety symptoms by 4.8%, depression symptoms by 6.6%, current smoking by 14.3%, all-cause mortality by 9.0%, all-cause hospitalizations by 16.1%, and visits to the all-cause emergency department by 18.1% (P < 0.05 for all).
Multimedia education using the Teach Back/Show Back Method is also an example of good results in improving complications of non-communicable diseases.After 1 month and 3 months of educational intervention, a significant difference was observed between mean quality of life scores and cardiac anxiety in the intervention groups, thus delaying complications.exercise) to predict the risk of death from the disease, increased by 0.7 per subject in the control group and decreased by 0.4 per subject in the health management group (difference 1.1, 95% CI 0.2-2.0,P < 0,001).Health management reduced anxiety symptoms by 4.8%, depression symptoms by 6.6%, current smoking by 14.3%, all-cause mortality by 9.0%, all-cause hospitalizations by 16.1%, and visits to the all-cause emergency department by 18.1% (P < 0.05 for all).However, it increased the use of immunomodulators by 58.9%, the use of respiratory drugs by 14.1-21.9%,and awareness scores for COPD by 57.2% (P < 0.05 for all).The only significant effect of the randomized clinical trial (RCT) in one year was a reduction in blood pressure (systolic blood pressure -4.65 mmHg, 95% CI: -9.18 to -0.12, and diastolic blood pressure -3.30 mmHg, 95% CI: -5.35 to -1.26).The Incremental Cost-Effectiveness Ratio (ICER) for the intervention, based on the assumption that costs would repeat each year and the effect could be maintained, was $1862 per QALY earned.Barahimi et al. (2017)

Does not mention
The e-learning model used was the ADDIE model (analysis, design, development, implementation and evaluation), After the intervention of elearning, there was a significant improvement in the glomerular filtration rate including the analysis of students, teaching method and infrastructure, through a verbal educational class and group discussions to describe how to use the developed educational system. of the patients, besides an improvement in the factors for analysis, such as average blood pressure and high density lipoprotein serum level.For the evaluation of the quality of the selected studies (Table 4), scores were awarded according to the application of the criteria of the Jadad et al scale.(1996).Thus, in Table 5, it was observed that 90% of the chosen articles presented low risk of bias (score >3), 70% of them with maximum score (5).

DISCUSSION
The analysis provided a comprehensive overview of the educational strategies employed to prevent and manage complications related to chronic non-communicable diseases (NCDs).The studies examined adopted diverse approaches, but in general culminating in notably positive outcomes, such as: improvement in quality of life scores and cardiac anxiety (Mohammadi et al., 2021); reduction of anxiety and depression (Bijani et al., 2022;Lou et al., 2015); increase in therapeutic adherence, diabetic foot care, stimulation of physical activity, healthy eating, self-monitoring of glycemia and increase in health literacy (Zeidi;Morshedi;Otaghvar, 2021); reduction in systolic and diastolic blood pressure (in the case of patients with diabetes mellitus, 2015); improvement in self-management of Diabetes mellitus 2 (Jeffrey et al., 2019); general prevention of CNCDs (Parekh, et al., 2012); promotion of the motivation of the behavioral change capacity of smoking patients (Li et al., 2022) and improvement of renal function with considerable decrease in serum creatinine and a stable level of glomerular filtration rate (Barahimi et al., 2017).Mohammadi et al (2021) examined the effectiveness of the Teach-Back method, in a randomized study of 120 patients with heart failure.Initially, the patient is asked to retell their understanding of the material using their own words.In this process, the instructor uses simple and understandable language, avoiding specific medical terms.If there is any difficulty assimilating, the instructor repeats the information until the patient fully understands.After 1 and 3 months, a significant difference was found between the intervention and control group in quality of life scores and cardiac anxiety.
Another very robust study sought to examine the effectiveness of the health management program that included health status assessment, regular lectures, smoking cessation counseling, stimulation of regular exercise practice, rehabilitation training, psychological counseling and regular follow-up.In this survey, 8,217 participants diagnosed with Chronic Obstructive Pulmonary Disease (COPD) took part throughout the implementation period from May 2008 to May 2012, of which 4,197 were in the intervention group and 4,020 in the control group, receiving conventional care.After 4 years, the health management group showed a significant reduction in the BODE index (Body Mass, Obstruction, Dyspnea and Exercise), indicating clinical improvements.There was a decrease in symptoms of anxiety, depression, current smoking, all-cause mortality, hospitalizations and visits to the emergency department (Lou et al., 2015).All of these aspects are extremely important for the sufferers of the disease, since there is an inverse correlation between the presence of psychic symptoms and the quality of life (Lima et al., 2020).
Educational intervention based on the theory of health literacy and self-care behaviors has been demonstrated as an excellent alternative for preventing complications in patients with type 2 diabetes mellitus (DM2), since its application resulted in improved regular adherence to prescribed medication, increased foot care, stimulation of regular physical exercise, healthy eating and self-monitoring of blood glucose.Health literacy aims to empower patients to acquire and understand health therapies, thus helping in making appropriate health decisions.Most subjects did not have sufficient health literacy.This model of behavioral change was analyzed from five 45-minute training sessions, which demonstrated positive changes in participants' cognitive-psychological health along with desirable health outcomes and improved self-care (Zeidi; Morshedi; Otaghvar, 2021).In fact, studies have shown that low LS has a major impact on general health, especially in chronic patients (Oscalices et al., 2019;Sousa et al., 2022).
In addition, according to Zeidi, Morshedi and Otaghvar (2021), after the educational intervention, there was a significant reduction in patients with low levels of health literacy, since several educational strategies were made, such as: lectures, discussion in focus groups, methods of questions and answers, practical implementation of competencies, presentation of educational film of 10 minutes, production of directed pamphlet and educational primer.In this way, simple and understandable communication between the participants was stimulated, and there was the repeated propagation of important information related to health by means of the dynamization of the educational process.As demonstrated by other authors, in addition to the harms, lack of understanding in health matters can influence compliance with treatment, hinder persistence in care and even prevent access, highlighting the importance of appropriate interventions (Oscalices et al., 2019;Paes, 2021;Silva et al., 2023).
Differently, in another similar study, in which a DM2 educational control program was implemented, the only significant finding was a reduction in systolic and diastolic blood pressure, but even so the final cost-effectiveness was analyzed and proved positive, supporting the implementation of more interventions of this type (Mash et al., 2015).In a parallel investigation, also aimed at this same population, we sought to evaluate the effectiveness of the use of mobile applications, achieving globally satisfactory results in the self-management of Diabetes Mellitus 2 (Jeffrey et al., 2019).Improving the capacity to make daily decisions and a deeper understanding of the condition itself become particularly important in this population, since self-management appears as a determining element for the significant improvement in the quality of life of affected individuals (Paes et al., 2022).
There were also interventions that focused on the prevention of CNCDs.A survey, conducted in Brisbane, Australia, assessed the effectiveness of a computer-tailored feedback system delivered through general medical practice.The feedback sought to guide and direct lifestyle factors such as diet, physical activity, smoking, and alcohol consumption.The intervention demonstrated notable improvements in the Prudence Score, which evaluates behavior in relation to the above-mentioned health practices (Parekh et al., 2012).
Another strategy used to promote health in patients with CNCDs and with difficulty of smoking cessation was the realization of instant messages, such as WhatsApp/WeChat delivered by mobile devices, an intervention of counseling centered on the individual, which encouraged the exploration and resolution of ambivalences, and promoted the motivation of the capacity of patients to change behavior.This method was considered satisfactory and easy to use by the study participants, who reported that the frequency of brief messages was appropriate.Therefore, continuous professional counseling and support related to smoking cessation, overcoming withdrawal symptoms and promoting physical well-being was promoted (Li et al., 2022).
In addition, the rate of adherence was 73.2%, since instant messaging was flexible, efficient and brief, and this strategy involved the participation of the multiprofessional team.Thus, nurses, for example, provided the initial messages to the smoking patients who were waiting for the medical consultation to already go promoting the motivation for smoking cessation, behavioral change and their referral to the health services (Li et al., 2022).
For patients with Multiple Sclerosis between 20 and 55 years old, an intervention based on the educational peer-to-peer model of Pender's health promotion was performed, which presented positive results similar to the theory of health literacy in the field of quality of life, stress management, care confidence, self-efficacy of participants, lowering rates of anxiety, stress, increasing the participation of individuals in the therapeutic plans and autonomy (Bijani et al., 2022).
In this sense, Pender's model stems from cognitive theory, and emphasizes motivational factors and the adoption of health behaviors.The educational material is presented through video, pamphlets and images, and the content of each session was uploaded as voice messages by the peer, the participant who had sufficient knowledge about the disease and good health literacy.The results showed that the average scores for quality of life, stress management and patient self-efficacy measured immediately and 3 months after the intervention, changed significantly, indicating that peer education based on Pender's health promotion model was effective (Bijani et al., 2022).
The social support resulting from the discussion focus groups conducted with diabetics has had positive effects on the control of DM, either by directly impacting health-related behaviors, such as encouraging healthy lifestyles, or by the protective effect of social support, which contributes to the reduction of stress and health-related psychological problems, in addition to promoting motivation to self-care (Zeidi; Morshedi; Otaghvar, 2021).Active and participatory practices, such as focus discussion groups, thus promote integral care with diabetic patients, taking into consideration cultural and psychosocial aspects, highlighting the empowerment and autonomy of the patient for their treatment (Almeida et al., 2019).
At the same time, it was identified that the social support brought about by this strategy promotes a better coping of patients in the resolution of problems, besides increasing their resilience in the face of difficulties, improving physical, psychological health and quality of life (Bijani et al., 2022).Thus, the member of a peer group enjoys social support: improvement in mental health, decrease in physical and psychological problems, the rate of relapse and hospitalization (Zeidi;Morshedi;Otaghvar, 2021).
Education also plays a key role in providing the necessary care to patients with Chronic Kidney Disease (CKD) from the application of e-learning, a self-management program that resulted in a significant improvement in participants' self-efficacy over a period of 1 year, as well as an improvement in renal function with considerable decrease in serum creatinine and a stable level of glomerular filtration rate, thus promoting self-regulatory strategies to prevent CKD progress (Barahimi et al., 2017).
In the previous study cited, the educational methods included individual and group consultations involving the multidisciplinary team of professionals to be carried out training on initial prevention, adaptation of nutritional behaviors with reduction of salt consumption and stimulation of physical activity, smoking prevention and lifestyle modification.In addition to improving renal function, this program has resulted in improved analysis factors such as mean blood pressure and high-density lipoprotein serum level (Barahimi et al., 2017).Thus, the active participation of patients in the training results in the prevention of CKD complications, since it promotes knowledge about the hemodialysis process and the care involved in the success of self-care (Coelho et al., 2019).
For patients with Systemic Arterial Hypertension (SAH), important literacy-sensitive interventions were identified, such as one intervention including stories told in the patients' own words and the other intervention based on the didactic content contained in a Digital Versatile Disk (DVD).The results, from a 12-month follow-up of elderly patients with SAH, showed long-term beneficial effects of both interventions, mainly from storytelling intervention, promoting blood pressure reduction and improvement of important lifestyle risk factors for SAH and cardiovascular diseases (Nguyen et al., 2018).
For the authors, the experience of telling stories is a human activity that offers numerous opportunities for the effective promotion of health, being able to generate positive changes in the consumption of alcohol and salt, in the regular practice of exercises and in smoking cessation.Most patients stated that DVDs with stories were understandable, informative, of satisfactory duration, and encouraged lifestyle modification and reduction of blood pressure levels in this population.In view of this, it is identified that health education is a fundamental tool for promoting self-care and a better quality of life for the patient, and the educational dynamics of told stories modify life habits and prevent complications of HAS (Pereira et al., 2021).
The majority of the studies analyzed (70%) according to the Jaddad scale presented a maximum score, indicating a good overall quality in the evaluation of the randomized clinical trials.No study scored less than 3.
In short, it is worth highlighting an important limitation identified in this study, which corresponds to the few trials found applying the same type of educational intervention in health, most of which dealt with different patterns of educational programs and making it difficult to compare the data presented.However, the positive effect of applying health education to prevent complications from chronic non-communicable diseases has undoubtedly had a direct impact on patients' quality of life.

CONCLUSION
In summary, the results obtained in this systematic review highlight the positive effectiveness of health education in preventing and managing complications associated with chronic non-communicable diseases.Although a limitation in the diversity of interventions applied in the analyzed trials has been identified, consistency in positive outcomes strengthens evidence of the beneficial impact of these approaches.
The scarcity of homogeneous studies underlines the need for more robust research to specifically assess the effectiveness of educational interventions alone.Nevertheless, the collective results indicate that the implementation of educational programs can play a crucial role in improving the quality of life of patients affected by chronic non-communicable diseases, instigating a greater attention of health professionals and public policy makers for the incorporation and expansion of educational strategies in the integral management of these conditions.

Table 1 :
General characterization of the articles selected to compose RS.

Table 2 :
Methodological characterization of the articles selected to compose RS.

Authors (Year) Analyzed Group Intervention used and comparator Sample Evaluation method
Assessment of Health Education in The Prevention of Non-Communicable Chronic Disease Complications:Systematic Review ___________________________________________________________________________ Rev. Gest.Soc.Ambient.|Miami | v.18.n.1 | p.1-19 | e04904 | 2024.7 rates of unfavorable cardiac events to measure the costbenefit of the intervention.

Table 3 :
Methodological characterization of the articles selected to compose RS.

Table 4 :
Evaluation of the quality of the studies selected in this research according to the Jadad scale Total Assessment of Health Education in The Prevention of Non-Communicable Chronic Disease Complications: Systematic Review ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.1 | p.1-19 | e04904 | 2024.