Hrev_master Healthcare in Low-resource Settings 2023; volume 11(s1):11179 Patient’s knowledge, gender, and physical activity level as the predictors of self-care in heart failure patients Mifetika Lukitasari,1,2 Ulfia Fitriani Nafista3 1Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Malang, Indonesia; 2Brawijaya Cardiovascular Research Center, Universitas Brawijaya, Malang, Indonesia; 3Nursing Faculty, University of Indonesia, Depok, Indonesia Abstract Introduction: Self-care management is the fundamental approach for Heart Failure (HF) management and is influenced by patient ability in preventing rehospitalization, mortality, and mor- bidity. Therefore, this study aims to investigate the predictors of a patient’s ability in HF self-care management. Design and Methods: A cross-sectional study was carried out on 96 patients with HF. The data were collected through inter- views using questionnaires on demographic characteristics, phys- ical activity (IPAQ), knowledge (Dutch Heart Failure Knowledge Score), and self-care management (Self Care Heart Failure Index). Subsequently, the data were analyzed using logistic regression analysis, and the best fit model for predicting self-care manage- ment in HF patients was generated. Results: The proportion of samples was 56.3% female, with mostly primary school (50%) as their education level. Furthermore, the proportion of patients with adequate HF self-care management was only 21% of the total participant. Based on the results, the patient’s physical activity level, HF knowledge, and gender were verified as a predictor of self-care management. Conclusions: The HF knowledge level, physical activity level, and gender were the predictors of HF self-care management. Introduction Heart Failure (HF) is the major cause of death and disability that has affected approximately 26 million people worldwide due to non-communicable diseases.1 It was responsible for more than 10% of the total health expenditure for cardiovascular disease in the USA.2 In 2017, approximately 5.7 million people in the US suffered from HF with a projection of more than 8 million HF patients in 2030.3 Previous data showed that despite considerable improvement after 60-90 days of hospitalization, patients suffered from high mortality and frequent rehospitalization due to an episode of acute decompensation.4 Meanwhile, frequently rehos- pitalized HF patients are more susceptible to a reduced quality of life. HF patients need to deal with the complexity of care leading to a lack of self-care behaviors. Self-care in HF is focused on treatment adherence, lifestyle modifications, disease symptoms monitoring, and response to HF exacerbations. This makes ade- quate self-care behavior to be important for successful HF man- agement and ideal quality of life, reduced rehospitalization, as well as mortality rate.5–7 Several factors that contribute to self-care behavior include patients’ sociodemographic factors, knowledge of HF, and physical activity levels.8–10 A previous study suggested that depression, cognitive function, and patients’ cognitive func- tion are the predictors of self-care behavior.11 The identification of these predictors is essential to support the formulation of effective educational strategies to meet individuals’ needs. Therefore, this study aims to investigate the predictors of a patient’s ability in HF self-care management. Design and Methods A cross-sectional study was carried out on 96 HF patients in RSD Dr. Soebandi Jember from October 2019 to March 2020. Adult HF patients with the stable condition, without cognitive lim- itation, and no paralysis were also included. However, HF patients with NYHA level IV and congenital heart disease were excluded. The data were collected using a structured questionnaire with a face-to-face interview, while purposive sampling was used to select respondents. The instrument used included European Heart Failure Self-care Behaviour Scale (SCHFI) for self-care level assessment,12 IPAQ questionnaire for physical activity measure- ment,13 Dutch Heart Failure Knowledge Scale for HF knowledge assessment,14 and sociodemographic questionnaire. The data were analyzed using logistic regression to identify the predictors of self-care behavior. Results and Discussions Socio-demographic and clinical characteristics showed that out of 96 participants, the proportion of women was 56,3% (Table 1). The proportion of NYHA class was similar between adequate and inadequate self-care management group, their marital status, and physical activity level. Meanwhile, a significant difference between adequate and inadequate self-care management groups was also observed in the mean for respondents’ age, level of edu- Significance for public health Self-care is the most essential part of Heart Failure (HF) management in the community. It improvement needs to consider related factors to ameliorate patient outcomes, prevent mortality, and morbidity in HF. This study suggested that women with higher physical activity levels and a good knowledge of HF had better self-care management in the community. Article [page 66] [Healthcare in Low-resource Settings 2023; 11(s1):11179] No n- co mm er cia l u se on ly cation, and knowledge on HF. The result showed that most HF patients had inadequate self- care management, where people with adequate self-care were 22%, while the rest were inadequate (Table 2). Based on the activ- ity level measured using IPAQ score and analyzed with regression logistic to determine a correlation with self-care, it shows an ade- quate correlation of p = 0.042. Based on the predictors of self-care management as shown in Table 3, gender played a significant role in patient self-care level. The results showed that women have better self-care compared to men with an odds ratio of 6.527, 95%CI (1.680-25.352). Furthermore, HF patients’ knowledge also contributed to manage- ment adequacy with an odds ratio of 39.694, 95%CI (6.923- 227.583). A high physical activity level was discovered as the pre- dictor of adequate self-care management compared to a low phys- ical activity level with an odds ratio of 6.572, 95%CI (1.410- 30.640). This model was considered fit based on the result of the Hosmer Lemeshow test, which showed a significance of 0.571. Meanwhile, the pseudo-R-square score showed that the adequacy of self-care management is explained by women’s gender, high physical activity, and good knowledge on HF by 45.2%. Participants who had adequate self care management were women patients, high physical activity level, and adequate knowl- edge on HF. This study also showed that most patients with HF in the community had inadequate self-care management. Therefore, self-care promotion needs to be enhanced from the primary level as prevention to follow-up programs for patients after hospitaliza- tion. This makes it necessary to promote their self-care on HF management, improve cardiovascular health level, and personal management.15 There is also a need for continuous training to educate patients on their chronic condition and maintain life qual- ity.16 Knowledge on HF was a strong predictor of HF patients’ self- care management in the community.17 A previous study showed that the higher the knowledge the better their self-care level, even 9 months after being discharged from the hospital.18,19 This is because knowledge is closely related to education received by patients from a health care professional. This plays a critical role in patient self-care regiment, form an understanding of weight management, daily intake, lowering alcohol level, smoking reduction, daily physical exercise, medication, and adhering to health care professional.20 An introduction to patient self-care should continue to be carried out as periodic education in the community for patients to improve their quality of life. Therefore, multidisciplinary education strategies are considered an effective method in improving self-care management. Sociodemographic factors such as gender, level of education, income, and age were considered as the predictors of self-care management in HF patients.21 This study suggested that among all these factors, only gender significantly contributed to self-care behavior while the others did not show any significance. A previ- ous study showed that a higher level of education, living alone, and a New York Heart Association (NYHA) functional classification Article Table 1. Table of Socio Demography and Clinical Characteristic. Characteristics Adequate Self-Care (n=21) Inadequate Self-Care (n=75) p value Age 64.10±11.55 57.76±12.64 0.041 Educational Level 0.000 Not Attended School 1 (4.8) 5 (6.7) Primary School 5 (23.8) 43 (57.3) Junior High School 3 (14.3) 14 (18.7) Senior High School 4 (19) 11 (14.7) Higher Education 8 (38.1) 2 (2.7) Gender 0.017 Male 14 (66.7) 28 (37.3) Female 7 (33.3) 47 (62.7) Marital Status 0.440 Married 19 (90.5) 73 (97.3) Unmarried 2 (9.5) 2 (2.7) NYHA CLASS 0.987 Class I 3 (14.3) 10 (13.3) Class II 13 (61.9) 46 (61.3) Class III 5 (23.8) 19 (25.3) Physical Activity Level 0.591 Low 2 (9.5) 8 (10.7) Moderate 11 (52.4) 30 (40) High 8 (38.1) 37 (49.3) Knowledge on HF 0.000 Good 10 (47.6) 3 (4.0) Poor 11 (52.4) 72 (96) Table 2. Multivariate logistic regression for self-care level and indpendent variable. Variables Sig B Exp (B) 95% CI for Exp (B) Lower Upper Physical Activity Level (High) 0,017 1.883 6.572 1.410 30.640 Knowledge on HF 0.000 3.681 39.694 6,923 227,583 Gender 0,007 1.876 6.527 1.680 25.352 [Healthcare in Low-resource Settings 2023; 11(s1):11179] [page 67] No n- co mm er cia l u se on ly were associated with better self-care maintenance, management, and confidence.22 A detailed study on gender differences also showed that 37% of married women were less likely to report ade- quate self-care maintenance compared to unmarried women.23 Several studies showed that gender was not the predictor of self- care management in HF patients.20,24 Meanwhile, it affected the outcome as suggested in a previous study which stated that there are different outcomes between men and women based on mortal- ity and rehospitalization after practicing self-care management.8 This indicated that self-care needs to be implemented based on gender differences to improve patients’ prognoses. HF condition will significantly affect a patient’s tolerability to daily activities as shown in the NYHA classification. It was also shown that continuous exercise will improve patients’ physical activity level, which contributed to HF patients’ self-care adequa- cy. Meanwhile, providing an understanding of patient output such as activity related to their part for personal self-care is the key for patients and families to maintain a quality life. This makes it nec- essary for patients with activities limitations to create a certain modification and acceptance related to the change for a better self- care.25 The health care professional motivation and supervision will improve patients’ daily exercise to ameliorate patients’ physi- cal activity level and self-care adequacy. Therefore, in clinical practice, patients’ confidence and self-efficacy in practicing regu- lar physical exercise should be supported to improve their physical activity level and self-care management. Although self-care itself is highly associated with clinical symptoms, there is a need for intervention and targeted self-cate to reduce the number of clinical event.26 The level of patient’s NYHA showed no contributions on patient’s self-care in this study, there- fore, further report on clinical level is recommended. Another rea- son that contributed to patient level of self-care is the duration of HF diagnosis because those who has been diagnosed with HF more than 1 year usually is 1.8 times better for self-care.20 Therefore, comprehensive assessment on self-care and its determinants is essential in HF patient care to achieve better outcome.27 Conclusions The results showed that continuous education on activity restriction and their treatment regimens are important to promote adequate self-care in HF patients. Although a woman can have ade- quate self-care, there is a need to study and promote self-care in both males and females. 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Article Correspondence: Mifetika Lukitasari , Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Jl. Puncak Dieng, Kunci, Kalisongo, Kec. Dau, Malang, East Java Indonesia 65151. Tel.: +62 341 5080686, Fax: +62 341 5080686. E-mail: mifetika.fk@ub.ac.id Key words: Self-care, heart failure, heart failure knowledge, heart fail- ure physical activity. Acknowledgment: The author is grateful to Brawijaya University, Malang, for the funding, support, and motivation during this study. Contributions: All authors contributed equally, namely UFN conducted this study and ML served as supervisors and reviewed the final article. Conflict of interests: The author declares no conflict of interest. Funding: This study was financially supported by Brawijaya University through the Hibah Peneliti Pemula scheme. Clinical Trials: This study has been approved by the Health Research Ethics Committee of Saiful Anwar Hospital. Availability of data and materials: All data generated or analyzed during this study are included in this published article. Informed consent: Written informed consent was obtained from a legal- ly authorized representative(s) for anonymized patient information to be published in this article. Conference presentation: Part of this paper was presented at the 2nd International Nursing and Health Sciences Symposium that took place at the Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia. Received for publication: 11 December 2021. Accepted for publication: 10 May 2022. 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