https://doi.org/10.15218/ejnm.2019.15 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article Quality of Life of Patients With Heart Failure at Teaching Hospitals in Erbil City ABSTRACT INTRODUCTION Heart failure (HF) is an imprecise term used to describe the state that develops when the heart cannot maintain an adequate cardiac output or can do so only at the ex- pense of an elevated filling pressure. . Car- diac output is adequate at rest and be- comes inadequate only when the metabol- ic demand increases during exercise or some other form of stress [1,2]. Some cas- es of HF are reversible, depending on the cause. Most often, HF is a progressive, life- long condition that is managed with lifestyle changes and medications to pre- vent episodes of acute decompensate heart failure. These episodes are charac- terized by an increase in symptoms but decreased in cardiac output, and low per- fusion [3]. World Health Organization Quality of Life (WHOQOL) Group defined Quality of Life as an “individual's percep- tion” of their position in life in the context of the culture and value systems in which they live and in relation to their goals, ex- pectations, standards and concerns. It is a broad ranging concept affected in a com- plex way by the person's physical health, Background and objectives: Heart Failure is a common and significant health problem, with an increasing incidence and a gloomy prognosis that is often accompanied by a nega- tive impact on the length and quality of life of patients. This study aimed to assess quality of life among patients with heart failure in Erbil city and to find the association of quality of life domains (physical, level of independence and social relationship) with some socio- demographic data (age, gender, level of education, and marital status) Methods: A quantitative design / a descriptive cross-sectional study was conducted at Hawler and Rizgary Teaching Hospitals in Erbil city Kurdistan region. This study was carried out from November 17th 2014 to November 17th 2015 on non-probability (purposive) samples was selected among 140 heart failure patients who were admitted to coronary care unit and medical ward of both teaching hospitals. Their quality of life was measured by standardized questionnaire of world health organization with some modification. Results: The findings of the study indicated that most patients were Female and Illit- erate, their mean age was 68.75. Moreover, significant associations exist between levels of education with physical ability, level of independence, social domains, and marital state with physical domain. Conclusion: The study concluded that the majority of the study sample had moderate level of quality of life while less than one-fourth of them had poor level. Keywords: Heart failure, Quality of life, Coronary care unit, World health organization Berivan Star Hammad Ameen; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: berivan.hamadameen@hmu.edu.krd) Yousif Mohammed Younis; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 116 Erbil Journal of Nursing & Midwifery Received: 5/1/2019 Accepted: 22/9/2019 Published: 30/11/2019 mailto:berivan.hamadameen@hmu.edu.krd https://doi.org/10.15218/ejnm.2019.15 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article psychological state, personal belief, social relationships, and their relationship to sali- ent features of their environment [4]. Heart failure is a major public health prob- lem in industrialized nations. It seems to be the only common cardiovascular condition, which is increasing in prevalence and inci- dence in North America and Europe. In the United States, HF is responsible for 1 mil- lion hospital admissions and 50,000 deaths annually [5]. The incidence of HF increases with age. American Heart Association esti- mate more than 5 million people in the United States have HF, and 550,000 new cases are diagnosed each year [3,6]. Heart failure is a serious and chronic condition whose prevalence (0.2-0.4% in the general population and up to 17% in people over 70 years of age) continues to increase its incidence is calculated to be around 0.2- 0.3% per year. The estimated prevalence of HF in India is 1.3–4.6 million with an annual incidence of 0.5–1.8 million, in China, the HF prevalence rate among the general pop- ulation was 0.9% [7,8]. There were (509) cases of heart failure in Erbil city in (2013) according to the statistics of Directorate of Health in Erbil. Coronary artery diseases and advancing age are the primary risk fac- tors for CHF, other factors including hyper- tension, diabetes, cigarette smoking, obesi- ty, and high cholesterol level can contrib- ute the factors to the development of Heart failure [9].Causes of heart failure in- clude coronary artery disease, myocardial infarction, cardiomyopathy, heart valve problems, and hypertension [10,11]. Heart failure is a most frequent cause of hospital- ization for people aged 65 and older. Currently, HF continues to have a poor prognosis and is likely to remain a major clinical and health care problem [9]. a measure of QOL requires a definition of the concept. QOL theoretically encom- passes the individual’s physical health, psychosocial wellbeing and functioning, independence, control over life material circumstances, and external environment. Health related to quality of life health re- lated quality of life (HRQL) "the functional effect of an illness and its consequent ther- apy upon a patient, as perceived by the patient [12]. Heart failure is one of the chronic diseases that mainly affect quality of life. The physical condition of patients is compromised be dyspnea, fatigue and loss of muscular mass, and commonly by symp- toms of the underlying cause of their con- dition (e.g. angina). In addition, dietary re- strictions, difficulties in executing occupa- tional and family responsibilities, progres- sive loss of self-reliance and self-control, the side effects of medication, and recur- rent hospitalizations are also taken into consideration, and it is easy to understand how the quality of life of these patients can deteriorate [13].Decreased functional capacity and psychological deterioration in end-stage HF patients may have a negative impact on the quality of life. Functional inability to perform activities is one of the most common problems in patients with HF. Functional impairment has a stronger association with quality of life in HF pa- tients than cardiac function does [14]. Heart failure is one of the chronic diseases that mainly affects quality of life, which is leading to compromised physical activities of daily living of patient, thus to preventing and to controlling of heart failure take much attention in Kurdistan to reduce mortality and morbidity of heart failure. This study aimed to assess the quality of life in patients with heart failure in Erbil city and to find out the association of qual- ity of life domains (physical, level of inde- pendence and social relationship) with some socio-demographic data (age, gen- der, level of education, and marital status). 117 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2019.15 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article The data were analyzed using of (SPSS Windows Software Version 20). Data anal- ysis approach for this study included two approaches: Descriptive data analysis ap- proach includes (Frequency and Percent- age) and inferential statistical data analysis approach includes (Chi-square and Fisher’s Exact Test). Table 1 shows the distribution of the socio- demographic characteristics of 140 adult heart failure patients. The age of the pa- tients ranged from 25- ≥65 years. The high- est percentage 68.7% of the samples were in the age group≥65 years. 60.7% of them were female. It was shown that the highest percentage 72.8% were illiterate. The ma- jority 58.6% of the samples were married for 61.5%, in regard to residential area, the highest percentage of the samples were from urban. Moreover, the highest per- centage 54.4 % were reported housewife. In addition, 60% were out of work, the rest 40% returned to work after diagnosis of their disease. Table 2 shows overall level of quality of life of HF patients among 140 HF patients. The highest percentage (75.7%) of patients had fair level of QOL and (13.6%) of patients had poor level of QOL while (10.7%) had good level of QOL. Table 3 shows the association between age group and quality of life domains, the high- est percentage (68.7%) of the patient's age was age group ≥ 65 years and the lowest percentage (0.7%) was inage group 25-34 years. The finding of the study showed that there was no significant relationship between patients’ age group and the rest of other quality of life domains including physical P=0.56, level of independence P=0.31, and social P=0.76 domains. Descriptive cross-sectional study design was conducted to assess the quality of life of patients with heart failure in Erbil City. Among non-probability (purposive) sam- ples of 140 adult patients with heart failure who were admitted to the Coronary Care Unit and medical wards in both Hawler and Rizgary Teaching Hospitals. The study start- ed from November 17th 2014 to November 17th 2015. Approval was obtained from ethical committee in Nursing College / Hawler Medical University. The study was carried out after providing approval by General Director of Health in Erbil (DOH), Hawler and Rizgary Teaching Hospitals, oral consent was taken from research partici- pants. Inclusion criteria for selecting the samples of the study included patients who agrees to participate in the study. Patients aged more than 18 years, diagnosed with heart failure, conscious patient, both gen- der and patients who had psychiatric disor- ders and patient’s diagnosis before 3 month of heart failure were excluded. The data was collected through the interview method questionnaire. It was developed by researcher and adopted with revised from WHO regarding quality of life, Data were gathered through the using of question- naire which consisted of following parts: Part one,Demographic data: It was concerned with demographic char- acteristics of the patients such as age, gen- der, marital status, level of education, resi- dential area occupation before and after diagnosis disease. Part two: Overall of QOL and associations between patients age group and QOL domains, pa- tients’ gender and QOL domains, patients’ level of education QOL domains, patient’s marital status QOL domains. The calcula- tion of overall quality of life was catego- rized to three groups of good quality of life, fair quality of life, and poor quality of life. 118 METHODS Erbil Journal of Nursing & Midwifery RESULTS https://doi.org/10.15218/ejnm.2019.15 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article 119 Erbil Journal of Nursing & Midwifery Socio-demographic characteristics F Age group / years 25-34 1 35-44 3 45-54 16 55-64 24 ≥ 65 96 Total 140 Gender Male 55 Female 85 Total 140 Educational level Illiterate 102 Able to read and write 21 Primary school graduate 11 Secondary school graduate 4 College graduate 2 Total 140 Marital status Single 2 Married 86 Divorced 3 Widowed 48 Separated 1 Total 140 Residential area Rural 58 Urban 82 Total 140 Occupation before Employed 17 disease Unemployed 31 Housewife 76 Retired 16 Total 140 Occupation after Returned to work 56 Lower case Out of work 84 Total 140 Table 1. Socio-demographic characteristics of heart failure patients https://doi.org/10.15218/ejnm.2019.15 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article 120 Erbil Journal of Nursing & Midwifery Table 2: Overall levels of quality of life domains of heart failure patients 35-44 45-54 ≥65 Age group/ years Total QOL domains F F F F F F Physical Never domain Some times Always Total Independence Never domain Some times Always Total Social domain Never Some times Always Table 3. Association between patients’ age group and quality of life domains of heart failure patients NS: Non significant DC: Decimal Overall Quality of Life F Good 15 Fair 106 Poor 19 Total 140 Table 4 illustrates the associations be- tween gender and quality of life domains of HF patients. Concerning gender, the highest percentage (60.7%) of patients was female. This table shows there was no significant relationship between gender and quality of life domains, physical P=0.92, level of independence P= 0.26, and social P=0.99. Table 5 shows the asso- ciation between levels of education and quality of life domains of HF patients. Re- garding levels of education, the majority of patients (72.8%) were illiterate. The results found that there was a highly sig- nificant relationship between patients’ levels of education and levels of inde- pendence p=0.009, significant relation- ship with physical p=0.012 and social do- main p=0.05. Table 6. Association be- tween patients ’marital status and quality of life domains. Table 6 shows the associ- ation between marital statues and QOL domains. It has indicated that the high- est numbers of the sample (61.5%) were https://doi.org/10.15218/ejnm.2019.15 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article married. The results have also shown that there was significant relationship between the marital status and physical 0.01. While there was no significant relationship be- tween patients’ marital status and QOL in level of independence, and social domain 0.24, 0.7 respectively. 121 Erbil Journal of Nursing & Midwifery Table.4 Association between patients’ gender and quality of life domains of heart failure patients Gender Female Total Chi-square QOL domains F Physical domain Never Some times Always Total Independence Never domain Some times Always Total Social domain Never Some times Always Total NS: Non-significant Dec.: Decision Educational level Illiterate Able to Primary Secondary College Total Chi-square read and school school graduate write graduate graduate & Dec. QOL domains F F F F F F Physical Never domain Some times Always 15 Total Independence Never domain Some times Always Total Social Never domain Some times Always Total Table .5 Associations between patients’ level of education and QOL domains of heart failure patients S: Significant VHS: Very Highly Significant Dec.: Decision https://doi.org/10.15218/ejnm.2019.15 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article domains of HF patients, there was no sig- nificant association between gender and quality of life domains as shown in table 4, the result of study consistent with the study done by Erceg et al (2013) who found that there were no significant differ- ences between male and female patients regarding health-related quality of life. Ta- ble 5, shows that there was significant re- lationship between levels of education and physical domain, level of independence domain and social domain.The highest per- centage of patients was illiterate. The study results were supported by Erceg et al (2013) who reported that the education level of the patients correlated positively with the physical dimension of health- related quality of life but not with emo- tional dimension[20]. The findings of the present study in table 6 shows there was a significant association between marital status and physical domain. While there was no significant association with level of independence and social domain. This is similar with the study carried out by Luttik et al (2006) who revealed that patients liv- ing with a partner had (12%) less events The result shows that most of the patients were in age group of ≥ 65 years. This is sim- ilar to the cross-sectional study which car- ried out on 103 patients with Heart Failure in Brazil [15] and the majority of the pa- tients in this study were females. This re- sult is similar to the results of study which carried out in Tehran by Hatmi et al (2015) who found that most of the heart failure patients were female [16].Regarding levels of education, the present study revealed that majority of the patients (72.8%) were illiterate. About the marital status, the ma- jority of the patients were married, which was consistent with the result of study done by Dunlay et al (2015) on 1128 . The result of the study indicates that the high- est percentage (68.7%) of the patients’ age was 65 years and more. It is in line with study done by Yaghoubi et al (2012) by in- creasing age significant decrease occur in patient’s quality of life [19].Regarding asso- ciation between gender and quality of life 122 Erbil Journal of Nursing & Midwifery Marital status Single Married Divorced Separated Total Chi-square QOL domains F F F F Physical domain Never Sometimes 0 63 2 35 1 101 0.01 Always S Total 140 Independence Never domain Sometimes Always Total Social Never domain Sometimes Always Total Table 6. Association between patients’marital status and quality of life domains of heart failure patients NS: Non-significant S: Significant DC: Decision DISCUSSION https://doi.org/10.15218/ejnm.2019.15 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article [7] Evangelista, L.S., Moser, D.K., Westlake, Ch., Pike,N., Ter-Galstanyan, A. and Dracup, K. Correlates of Fatigue in Patients With Heart Failure. Progress in Cardiovascular Nursing banner.2008;23(1):12-17. [8] Lee, SH. 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