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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 5  |  Issue : 4  |  Page : 158-164

Awareness of patients regarding self-management of heart failure attending a tertiary care hospital of North India


1 National Institute of Nursing Education, PGIMER, Chandigarh, India
2 Department of CTVS and Cardiology, PGIMER, Chandigarh, India

Date of Submission29-Mar-2020
Date of Acceptance28-Oct-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Sukhpal Kaur
National Institute of Nursing Education, PGIMER, Chandigarh - 160 055
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jncd.jncd_41_19

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  Abstract 


Background: Heart failure is a rampant health problem affecting millions of people worldwide. Patients' knowledge about this complex disease contributes toward its self-management at home thereby, reduction in frequent hospitalizations and increased health-care cost.
Aim: This study aims to assess the awareness of patients regarding self-management of heart failure.
Methods and Results: A cross-sectional study was conducted on diagnosed patients having heart failure for at least 6 months with left ventricular ejection fraction <40% from functional class New York Heart Association II–IV ambulatory. One hundred and one participants were interviewed individually during routine visit. A prevalidated questionnaire was used to collect demographic characteristics, status of illness and knowledge of patients. Data were analyzed using descriptive and inferential statistics. 66.3% of the patients had insufficient knowledge about heart failure. Acceptable level of knowledge was found in 11.9% of the participants. Weak linear correlation (r = -0.232, P = 0.019) was found between education and mean knowledge score. Significant association of education and habitat with higher knowledge was seen in binomial logistic regression model.
Conclusion: Lack of awareness regarding self-management of disease was found in majority of the patients. Structured teaching programs with special emphasis on nature of illness, lifestyle modifications, identifying worsening symptoms and their management at home were needed.
Heart failure, knowledge, self-management

Keywords: Heart failure, knowledge, self-management


How to cite this article:
Kumari B, Kaur S, Dutta M, Bahl A, Barwad P. Awareness of patients regarding self-management of heart failure attending a tertiary care hospital of North India. Int J Non-Commun Dis 2020;5:158-64

How to cite this URL:
Kumari B, Kaur S, Dutta M, Bahl A, Barwad P. Awareness of patients regarding self-management of heart failure attending a tertiary care hospital of North India. Int J Non-Commun Dis [serial online] 2020 [cited 2021 Jan 19];5:158-64. Available from: https://www.ijncd.org/text.asp?2020/5/4/158/305996




  Introduction Top


India is facing a great burden of cardiovascular diseases. The prevalence of heart failure in North India is reported to be approximately 1.2/1000, i.e., 8–10 million patients with the annual mortality of 0.1–0.16 million patients.[1] Heart failure is a complex disease and is associated with exacerbated symptoms such as dyspnea, orthopnea, cough, edema resulting in frequent hospitalization and a poor quality of life.[2] These symptoms may vary over the period of time and mostly depend on the presence of elevated left- and right-sided ventricular pressures. Sometimes, the patients can present without symptomatic structural and functional abnormalities namely left ventricular systolic or diastolic dysfunction, which are thought to be the precursors of the disease. Early identification of these precursors is important because of poor outcomes.[3]

Low health literacy among heart failure patients correlates well with the poor self-management and hence poor outcomes.[4] It requires patients as well as family members to develop necessary skills to identify, manage, and control the heart failure symptoms at home so that the disease progression can be halted.[5],[6] Effective management of heart failure symptoms necessitates knowledge related to concept of disease, pathophysiology, signs and symptoms, medications, and lifestyle modifications.[7] Health-care providers can decrease the burden related to poor outcomes of heart failure patients by providing them necessary knowledge and skills regarding self-management of heart failure symptoms.[8] Even the patients trained in community settings by the untrained health educators can become competent enough to manage themselves at home with the better understanding of disease condition.[9]

Lack of knowledge has been considered as one of the barriers to self-care in heart failure in addition to others, which can be overcome by empowering patients through structured teaching programs on individual basis.[10] A better knowledge is a key concept of patient's activation for improved self-management behavior of heart failure patients.[11] It has been seen that patients with low activation had difficulty in managing their symptoms as they had lack of confidence and knowledge.[12]

Good level of knowledge has been positively correlated to improvement in adherence to self-care activities.[13] As compared to the previous scenario where the patients used to have passive role in management of their disease, now the patient is considered as an important key person in health care team.[14] It has been reported that the patients who exhibit good knowledge, seek delayed medical attention for pressing symptoms as they continue to manage themselves at home.[15] However, in the developing countries, patients do not seek medical attention for days or months after the appearance of symptoms due to lack of awareness.[16] Keeping this in mind, the study was planned to assess the awareness of heart failure patients regarding their disease and its management.


  Materials and Methods Top


A cross-sectional study was conducted among patients suffering from heart failure meeting the inclusion criteria from July 1, to October 31, 2018 at Advanced Cardiac Centre of Post Graduate Institute of Medical Education and Research Chandigarh India. Hundred and one diagnosed patients of heart failure for at least 6 months with left ventricular ejection fraction (LVEF) <40% and New York Heart Association (NYHA) Class II to ambulatory Class IV were included in the study.

Ethical considerations

Written informed consent was obtained from all the participants or their legal representatives before enrolment into the study. The study was approved by Institute Ethics Committee PGIMER Chandigarh. Confidentiality of the information obtained and identity of participants was assured.

Data collection

Data were collected using a questionnaire having three parts. Part-A comprised of demographic and personal characteristics, Part-B incorporated information regarding clinical profile and Part C was a prevalidated questionnaire for the assessment of knowledge of patients regarding heart failure and its management.[17] This standardized questionnaire has established good internal consistency with Cronbach's alpha 0.749.[17] Permission to use the questionnaire was obtained electronically. It was then pretested on 10 patients suffering from heart failure for more than 6 months to assess the feasibility for main study. No major modifications were made in three sections of the instrument.

Information was obtained regarding demographic characteristics such as age, sex, educational qualification, occupation, monthly income; personal characteristics such as lifestyle pattern, dietary habits, and substance use; clinical status like diagnosis, NYHA class at the time of diagnosis and at the time of enrolment into the study, comorbidities, symptoms of heart failure, vital parameters like heart rate, blood pressure, LVEF, urine output, etc., laboratory parameters, medications and device therapy; regarding knowledge of heart failure and its management. Functional status of the patients was evaluated by the investigator using New York Heart Association classification system.

Questionnaire about heart failure patient's knowledge of their disease consisted of five factors. First factor was general factor having five items which enquired information regarding concept of heart failure, risk factors and sign and symptoms. Second factor was treatment factor having three items related to knowledge of treatment in heart failure, lifestyle modifications and ways to perform self-care. Third factor was related to physical exercise and hence called as physical exercise factor. It consisted of five items related to the type of exercise and role of exercise in self-care. Fourth factor was known as drug factor having 2 items related to the knowledge of medicines in heart failure. The last or fifth factor was called as diverse factor which comprised of items regarding knowledge of treatment, self-care, lifestyle and risk factors of heart failure. Every item comprised of four multiple choice options having one correct option, one incomplete answer to the query, one wrong answer and one option as “I don't know.” The total knowledge score of a patient was categorized into five categories as mentioned in original study.[14]

The mean knowledge score for the sum of each response was calculated for nineteen items. Further the questionnaire was divided into three subsections, i.e., section 1 comprising of item 1–6, section 2 comprising of item 7–12 and section 3 comprising of item 13–19. Sum of individual responses for each sub-sections were calculated and mean scores were written as score 1 for section-1, score 2 for section 2, and score 3 for section 3. Based on the total mean score for nineteen items and mean score for three sub-sections of the questionnaire, participants were classified into “less than mean” (LM) and “equal to or more than mean” (EMM) for knowledge. The methodology of determining the odds among the study population after stratifying into LM and EMM, or into subgroups had been previously described in KAP studies conducted in other fields.[18],[19],[20] Similar methodology for our study.

Statistical analysis

Data were entered into Excel sheet and later imported to Statistical Package for Social Sciences (IBM SPSS statistics version 22, IBM, Armonk, New York, Westchester) for analysis. The data were described as mean ± standard deviation for continuous variables and frequency (%) for categorical variables. Spearman rank order correlation was used to find out correlation between ordinal and continuous variables. Correlation of continuous variables was calculated using Pearson Product Moment correlation. The level of statistical significance was kept at P = 0.05. Normality of the continuous variables was evaluated with Shapiro–Wilk. Results of binomial logistic regression were shown as odds ratio (OR) with 95% confidence intervals (CIs).

The determination of demographic factors such as age, habitat, educational status, marital status, per capita income, socio economic status, dietary habits, and lifestyle responsible for LM and EMM based on total score as well as score-1, score-2, and score-3 was planned. For this, univariate analysis for the identification of independent variables by keeping a cut off of P < 0.25 was conducted initially. The selected variables having two options were then taken for constructing binomial logistic regression model. Variables were retained in the model based on a P < 0.05 along with taking the importance of the variable clinically. The OR and 95% CI of the final model are presented.


  Results Top


Totally 101 participants were included in the study. The mean age of patients was 52.6 ± 12.4 years (range 21–78 years). There were 19 young patients (<40 years), 63 middle-aged (41–64 years) and 19 old (>65 years). Other sociodemographic and personal characteristics of the participants are shown in [Table 1].
Table 1: Baseline characteristics of the participants (n=101)

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Median duration of heart failure was 1.1 years. 70% of the participants were having NYHA Class II symptoms followed by NYHA Class III in 24% and NYHA Class IV in approximately 6% of the participants. Rest of the clinical parameters are depicted in [Table 2].
Table 2: Clinical profile of participants (n=101)

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[Table 3] depicts the assessment of knowledge of patients regarding self-management of heart failure as per Questionnaire about Heart Failure Patients' Knowledge of their disease. Correct responses of the participants are described as frequency (%).
Table 3: Correct responses of the patients of heart failure as per heart failure knowledge questionnaire (n=101)

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Frequency distribution of participants based on knowledge scores is described in [Supplementary Table 1]. The minimum and maximum attainable score was 0 and 57, respectively. The mean knowledge score was 15.73 ± 8.40 (range = 2–40.5). The median knowledge score was 14. Nearly 66% of the patients had insufficient knowledge about heart failure and its management. Approximately 20.8% of the participants possessed little knowledge about the disease. Acceptable level of knowledge regarding heart failure was found in 11.9% of the participants which was quite less. However, none of the participants possessed excellent knowledge about heart failure. Out of total 101 patients, 62.5% were having LM knowledge and 37.6% were having EMM knowledge.



Considering the subsections, score 1 comprised of 68.3% LM and 31.7% EMM knowledge, score 2 incorporated 56.4% LM and 43.6% EMM knowledge, score 3 composed of 46.5% LM and 53.5% EMM knowledge.

A weak negative linear correlation was found between mean knowledge score and educational status (r = -0.23, P = 0.019).

Univariate analysis of total knowledge score, score 1, score 2, and score 3 was performed against the demographic and personal characteristics. Results of univariate analysis with individual demographic and personal variables are depicted in [Supplementary Table 2]. Based on it, variables such as educational status, gender, habitat, occupation, dietary habits, and history of substance use were selected for final binomial logistic regression. Binomial logistic regression was performed to ascertain the effects of these variables on the likelihood that patients are more knowledgeable about heart failure [Supplementary Table 3].



Evaluation of association of knowledge score of subsection 1 with demographic variables

The odds of having knowledge score EMM did not turn significant for participants who were highly qualified like graduates (OR = 0.733, 95% CI = 0.086-6.276) and postgraduates (OR = 0.606, 95% CI = 0.040–9.252). Similarly, the negative association was not found in the participants having EMM knowledge score who inhabited the rural areas. No significant association was found between professional occupants and EMM knowledge score (OR = 0.401, 95% CI = 0.013–12.59).

Evaluation of association of knowledge score of sub-section 2 with demographic variables

The participants who were high school passed had 5.756 times association of having knowledge score EMM (95% CI = 1.087–30.46). Similarly, the diploma holders had 13.705 times association of having knowledge score EMM (95% CI = 2.212–84.92). However, the odds of having knowledge score EMM were not significant for graduate and post graduate participants. Similarly, the negative association was not seen between lower educational qualification, participants living in rural areas, working as professionals and knowledge score EMM.

Evaluation of association of knowledge score of sub-section 3 with demographic variables

Participants who were educated till 8th standard had 4.112 times association of having knowledge score EMM (95% CI = 1.017–16.62). Whereas the odds of having knowledge score EMM did not turn significant for participants who were more educated than middle schoolers as well as less educated than the same. Inhabitants of rural areas had 4.112 times association of having EMM knowledge scores (95% CI = 1.017–16.62). The odds of having knowledge score EMM in participants residing in sub-urban areas (OR = 0.618, 95% CI = 0.185–2.058), professional workers (OR = 0.618, 95% CI = 0.185–2.058), were not significant.

Evaluation of association of knowledge score of sub-section 'total score' with demographic variables

Positive association was seen among the participants who were post graduate and above and knowledge score EMM (OR= 18.21, 95% CI = 0.873-379.73) but was not significant. Similarly, the odds of participants being more knowledgeable were not significant for primary passed (OR = 2.899, 95% CI = 0.667–12.603), eighth passed (OR = 2.322, 95% CI = 0.540–9.985), matriculation (OR = 1.927, 95% CI = 0.378–9.829), 10 + 2 or diploma holders (OR = 3.505, 95% CI = 0.646–19.00), and graduates (OR = 2.868, 0.313–26.25). Participants living in the rural areas were not negatively associated with odds of having knowledge score EMM (OR = 1.192, 95% CI = 0.322–4.414). The odds of participants having knowledge score EMM were not significant for professional occupants (OR = 0.201, 95% CI = 0.005–7.680).


  Discussion Top


Knowledge regarding therapeutic regimen, dietary precautions, physical activity, and treatment options is very important for heart failure patients as they are on complex medical regimen and require frequent hospitalizations for worsening outcomes. Before initiating any educational program, it is mandatory to know the level of knowledge patients possess. It negotiates the healthcare providers regarding the extent of information to be supplemented to make the patient empowered regarding self-management of heart failure at home. The assessment of level of knowledge about heart failure is also necessary to roughly determine the duration of cardiac rehabilitation program. To ensure accurate self-management of heart failure, patients and health care providers must exchange their knowledge regarding the management of worsening symptoms.[21],[22] Keeping this in mind, exploration of demographic variables as predictors of good knowledge about heart failure disease was done in participants attending out patients department of a tertiary care center in North India.

Majority of the participants were males (70%) and the mean age of participants was 53.4 ± 12.4 years. Similar age group and percentage of male participants were included in a study done by Razazi et al.[23] who identified the relationship between health literacy and knowledge regarding heart failure with frequent hospitalizations. Many studies have proven that the younger patients tend to exhibit good knowledge regarding heart failure disease, dietary restrictions, and therapeutic regimen as compared to older ones as they have good access to educational facilities and modern day technologies.[23],[24],[25],[26] However, in the present study, the relationship of age and knowledge did not turn significant in univariate analysis possibly due to large variation in age ranging from 24 to 78 years.

The average knowledge score in the present study was 15.73 ± 8.40 which is almost similar to the study done by Hwang et al.[27] where the mean knowledge score was 20 ± 7.0 and by Liu et al.[28] with mean knowledge score of 13.9 ± 2.6.

Nearly half of the participants were suffering from comorbid conditions out of which 26.73% were suffering from type 2 diabetes mellitus. It has been reported in the study done by Knopman et al.[29] that patients having diabetes are prone to have significant cognitive impairment. However, no correlation between diabetes mellitus and insufficient knowledge about heart failure disease was found in this study.

In this study, nearly 66% of the participants possessed insufficient knowledge about the management of heart failure. Acceptable level of knowledge regarding heart failure was found in only 11.9% of the participants which was quite less. These findings are consistent with the studies done in Asian countries which reported knowledge deficit in lifestyle modifications and identification of heart failure symptoms.[30],[31] Insufficient knowledge about the illness and self-care in heart failure has also been reported by Liu et al.[28] 20% the patients in this study were illiterate which could be responsible for low average score of knowledge regarding heart failure and its self-management as evident from a study done by Nesbitt et al.[32]

Variables like gender, habitat, occupation, educational status, dietary habits, and history of substance use were associated with knowledge score. However, among this educational status and habitat remained significant in binomial logistic regression analysis. It suggests that both of these are independent predictors of patients' knowledge in this study. The association of heart failure specific knowledge with educational status has already been established in few studies.[30],[33],[34]

Participants who were educated till 10th standard (OR = 5.756) and twelfth passed or diploma holders (OR = 13.705) had positive association with EMM knowledge score whereas the participants who were graduated or above were having less likelihood of being more knowledgeable. It means the participants who possessed optimum knowledge, could be able to spend enough time for self-care activities. It could be the contributory reason for them being more knowledgeable about heart failure disease and its management.

Positive association of having knowledge score EMM was seen in participants who were educated till 8th standard (OR = 4.112). Although the participants who were highly qualified had higher knowledge scores but odds did not turn significant for having knowledge score EMM. The possible hypothesis is that there can be large variation in the responses of participants who were highly educated or they may be over occupied by other works which can hamper their tendency to acquire more knowledge about their disease. Participants who were living in rural areas showed positive association of having knowledge score EMM possibly because they are less busy in occupational activities and able to spend enough time in taking care of themselves. Moreover, people living in urban areas have time constraints for making healthier choices. No association of patients being more knowledgeable was seen in those who were professional workers.


  Conclusion Top


Despite high prevalence of heart failure in developing countries including India, majority of patients suffering from heart failure are unaware about the concept of heart failure, its causes, symptoms, medications and lifestyle modifications. Very few possess the acceptable level of knowledge regarding heart failure and its management which lend them up in frequent hospitalizations contributing to poor quality of life of patients and healthcare burden on nation. To make the patients aware of the disease, structured education programs have been proven to be beneficial. Multidisciplinary approach should be considered while treating a heart failure patient with more focus on education regarding the disease and ways to monitor, control and manage the symptoms at home. Patients should be enrolled in cardiac rehabilitation clinics and empowered to maintain the utmost level of health. Future qualitative studies are warranted to understand the psychosocial issues behind lack of awareness regarding such an overwhelming and debilitating disease.

Limitations

Admitted heart failure patients requiring frequent admissions were excluded from the study which can alter the results. Another limitation of the study was the assessment of knowledge of participants using self-reported measures which can lead to social desirability bias.

Ethical approval

Written informed consent was obtained from all the participants or their legal representatives before enrolment into the study. The study was approved by Institute Ethics Committee PGIMER Chandigarh. Confidentiality of the information obtained and identity of participants was assured.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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