Factors related to Self-care Behaviors among Older Adults with Heart Failure in Thai Nguyen General Hospital, Vietnam

Factors related to Self-care Behaviors among Older Adults with Heart Failure in Thai Nguyen General Hospital, Vietnam Nguyen Ngoc Huyen Master student in Gerontological Nursing, Faculty of Nursing, Burapha University, Thailand Email: huyen_ddlsyk@yahoo.com.vn Pornchai Jullamate, Waree Kangchai Faculty of Nursing, Burapha University, Thailand Email: pornchai@buu.ac.th, wareek@buu.ac.th Abstract Self-care behavior is well known to prevent frequent hospitalization and to reduce the mortality rates among older adults with heart failure. This descriptive correlational study aimed to explore the level of self-care behavior and to examine the relationships between related factors (gender, income, educational level, comorbidity, heart failure knowledge and social support) and self-care behaviors among older adults with heart failure. One hundred and twenty-six participants were conveniently sampled and participated into this study during January to March 2011. The data collection was performed at the Cardiology-Rheumatology Unit of Thai Nguyen General Hospital, Vietnam using four questionnaires: The Demographic and Clinical Data Form, The Dutch Heart Failure Knowledge Scale (with its reliability of.72), The European Heart Failure Selfcare Behaviors Scale-9 (with its reliability of.73), and The Multidimensional Scale Perceived Social Support (with its reliability of.74). Percentage, mean, standard deviation, Spearman Correlation Coefficient and the Pearson Product Moment Correlation Coefficient was used to analyze the data. The results revealed that the samples had low level of self-care behaviors of heart failure ( X =33.58, SD = 5.32). Knowledge of heart failure and social support statistically significant correlated with self-care behaviors (r =.66, and r =.53, p <.01, respectively). Nursing intervention programs in regarding of social support and knowledge of heart failure are recommended for enhancing self-care behaviors of older adults with heart failure. Keywords Heart failure, Older adults, Self-care behaviors. I. INTRODUCTION Heart failure (HF) is the only cardiovascular condition whose prevalence and incidence increase with age worldwide [1]. It mainly affects about 6-10% of the people aged over 65 years [2]. HF is the most common reason for hospitalization and readmission among older adults with heart failure [3]. It is reported that hospitalization rose from 877,000 to 1,106,000 in 2006, an increase of 171% in American [4]. Self-care behaviors are important to optimize heart failure patients to prevent serious complications and consequences. However, many patients with HF have inadequate selfcare behaviors [5]. Self-care behaviors among older adults with HF have been reported to be complex and difficult for them since patients must adhere to symptom monitoring, and treatment regimens [6]. One reason may be that the elderly have multiple age-associated changes in the most organ systems such as cardiovascular, respiration, digestion, vision, hearing, etc [7,8]. In The First International Conference on Interdisciplinary Research and Development, 31 May - 1 June 2011, Thailand 7.1

Nguyen Ngoc Huyen, Pornchai Jullamate, and Waree Kangchai addition to complexity of HF treatment regimens, most of older adult patients also have many co-morbid diseases [3]. Nonadherence to medication and lifestyle change are other major problems in older adults with HF [9]. Poor self-care behaviors with lack of adherence to a HF regimen lead to 20-60% of HF rehospitalization [10]. Despite improved selfcare behavior for adherence to treatment of HF, the mortality rate of HF remains high contributing to 300,000 deaths each year in the United States [11]. HF self-care behaviors are influenced by various factors including gender, educational level, income, co-morbidity, knowledge of HF and social support [12,13,14]. Nevertheless, findings from the literature review show inconclusive relationships among those factors and HF self-care behaviors. Additionally, those studies were performed in Western countries, which are culturally quite different from Vietnam. Although factors related to self-care behaviors had been widely discussed in the literature. However, formal study on this issue in Vietnam is limited. It is necessary to ascertain the relationships among those factors and such behaviors. Therefore, the aim of this study is to explore self-care behaviors and associated factors affecting such behaviors among older adults with HF in Thai Nguyen, Vietnam. II. METHODOLOGY This descriptive correlational study was conducted at Cardiology- Rheumatology Unit of Thai Nguyen General Hospital located in central of Thai Nguyen province, northeastern of Vietnam. It consists of 700 beds and is recognized as the greatest hospital in this province. The samples of 126 older adults with heart failure at the Cardiology-Rheumatology Unit of the Thai Nguyen General Hospital were recruited by convenient sampling method with the following criteria: age of 60 and over; had a medical diagnosis of heart failure, and had stable health condition with neither any serious complications nor cognitive impairment. Data were collected during January to March, 2011. Approval of the Institutional Review Board of the Faculty of Nursing, Burapha University, and the permission from the Director of Thai Nguyen General Hospital were obtained. Permission for using the instruments was also obtained. HF older adults who admitted to the Cardiology- Rheumatology Unit were invited to participate in this study, and they agreed to sign a consent form. The right of participants to withdraw from the study, as well as confidentiality was presented. They were interviewed to complete the questionnaires for 15 to 20 minutes. The completion of the questionnaires was checked at the end of each interview. Data were entered into a file in a statistical software program for analyzing. 1. Instruments 1.1. The Demographic and Clinical Data Form. It consists of two parts. The first part included items on age, gender, marital status, educational level, income, paying for the treatment, living condition. The second part was completed by the researcher and included information from the patient s medical record on aetiology of HF, and comorbid condition. 1.2. The Revised European Heart Failure Self-care Behavior Scale (EHFScBS-9) It was developed by Jaarsma (2009) [15] consisting of 9 items which covers information on the self-care behavior of patients with HF including daily weighing, fluid restriction, and medication, and contacting health care providers when they experience increased weight gain. The EHFScBS-9 is a 5-point Likert scale from 1 I completely agree to 5 I completely disagree. After discussing with the author of this instrument, the researcher converted the scoring by 5 I completely agree to 1 I completely disagree. Thus, higher score indicates better self-care behaviors. Special Issue of the International Journal of the Computer, the Internet and Management, Vol. 19 No. SP1, June, 2011 7.2

Factors related to Self-care Behaviors among Older Adults with Heart Failure in Thai Nguyen General Hospital, Vietnam 1.3. The Multidimensional Scale of Perceived Social Support (MSPSS) It was developed by Zimet (1988) [16] aiming to measure the perceived social support. The MSPSS is a 12-item instrument to measure on three subscales of social support: (1) Significant Other Subscale (4 items), (2) Family Subscale (4 items), and (3) Friends Subscale (4 items). Each item was made on a 7-point Likert-type scale ranging from 1 very strongly disagree to 7 very strongly agree. Total mean score of social support ranges from 1 to 7. The more mean score the older adults with HF have, the higher received social support they perceive. 1.4. The Dutch Heart Failure Knowledge Scale (DHFKS) It was developed by Van der Wal (2005) [17] consisting of 15 multiple-choice items which is divided into three parts: (1) four items concerns HF in general, (2) six items evaluates on diet, fluid restriction and activity which measure HF treatment; and (3) five items measure symptoms and symptom recognition. For each item, a patient can choose one correct answer from three choices so 1 point is given, whereas a person receives 0 point when the answer is wrong or missing. The possible total score for knowledge of HF ranges from 0 to 15. The higher score the older adults with HF patient have, the better knowledge they have. 2. Psychometric properties of the instruments Translation and back translation of the original EHFScBS-9, DHFKS, and MSPSS were performed by three bilingual in English and Vietnamese by using back-translation technique as recommended [18]. Then the author confirmed all three back translation versions with the original authors. Internal consistency reliability of the EHFScBS-9 and MSPSS was.73, and.74, respectively; and the KR-20 of the DHFKS was.72. 3. Data analysis Descriptive statistics were used for the demographic data and for level of self-care behaviors. Pearson Product Moment Correlation Coefficient and Spearman Correlation Coefficient were used to examine the relationship between the independent and dependent variables. The significance level was set at.05 and statistical software program was used for all data analysis. III. RESULTS There are 61 male (48.4%), and 65 female (51.6%) with age ranging from 60 to 90 years old (mean age = 70.38). About 46% of participants were married and 34.1 % were widowed. The majority of patients (68.3%) had only complete general education. Most of them were lived with family (77.8%), and were paid their treat by health insurance (77.8%). The highest percentage (36.5%) of individual and family had a monthly income more than 6,500,000 VND (9,000 Bath). TABLE 1 DEMOGRAPHIC DATA OF HF PATIENTS (N=126) The First International Conference on Interdisciplinary Research and Development, 31 May - 1 June 2011, Thailand 7.3

Nguyen Ngoc Huyen, Pornchai Jullamate, and Waree Kangchai Most of subjects (50.8%) had no comorbidity. The finding of this study showed the low level of HF self-care behaviors ( X = 33.58, SD= 5.32). There were significant, moderate and positive correlations between knowledge of HF, social support and self-care behaviors (r =.66, and r =.53, p <.01, respectively). Gender, educational level, income, and comorbidity were no significant correlations with self-care behaviors (Table 2) IV. DISCUSSION Overall, the finding demonstrated that half of older adults with HF (50.9%) had low level of self-care behaviors. This finding is consistent with other studies which found that self-care behaviors of elderly with HF remain low [19]. Self-care behaviors might be difficult for older adults with HF because of age-related changes such as cardiovascular, respiration, digestion, vision, and hearing [8]. In this study, most of the participants (76.2%) had completed low education level. Therefore, when these factors are combined with lack of education, the complexities of self-care required for successful self-care of heart failure is compromised. Despite focusing on patient education on selfcare behaviors every month by the nurses at the Cardiology- Rheumatology Unit of Thai Nguyen General Hospital, the process of selfcare is not readily learned or understood by most patients with heart failure [20]. Clearly, selfcare must be learned, and it must be deliberately performed continuously in time [21]. The reason for this is that older adults cannot perform those behaviors, which may lead to low level of self-care behaviors among them. Knowledge of HF moderate correlates with self-care behaviors (r=.66, p <.01). This study revealed that most of patients (76.2%) had low educated, may be they have a low level of knowledge of HF. Orem, (2001) mentioned that knowledge is power that enables self-care; it must be specific and organized around meeting of known self-care requisites. Base on Orem s theory, older adults self-care behaviors are influenced by their knowledge about the specifics of HF self-care to perform the behaviors. To help patients meet their requirements for selfcare, greater attention needs to be given to understanding the inhibiting and promoting effects of Basic Conditioning Factors on self-care performance. In addition, knowledge about HF is also significantly related to adherence self-care behaviors in an elderly HF population [9]. These studies demonstrate that knowledge is a factor affecting the performance of self-care behaviors in patients with HF. In this study, the impact of knowledge on self-care behaviors among patients with HF is clear. Even though it is recognized that knowledge is essential for self-care, knowledge is not sufficient for older adults to perform selfcare behaviors. The results are consistent with previous reports in the literature review [14,22,23]. Social support had moderate and positive statistically significant relationship with selfcare behaviors (r =.53, p <01). The results are similar to previous studies by Gallager et al. (2011) [24] and Sayer et al. (2008) [25] which found that perceived of social support was significantly related to patients overall heart failure self-care. One possible explanation is that Vietnamese culture and tradition encourages young family members to care for older people especially parents till death [26]. It is noticed that approximately 77.8% of participants in this study lived with their family. In addition, social support from family and friends is associated with better HF treatment adherence [24]. This may be support older adults with HF to adhere to selfcare behaviors. Special Issue of the International Journal of the Computer, the Internet and Management, Vol. 19 No. SP1, June, 2011 7.4

Factors related to Self-care Behaviors among Older Adults with Heart Failure in Thai Nguyen General Hospital, Vietnam Gender did not have a large influence on HF self-care behaviors, contrary to the results of Riegel et al. (1995) [27] which found that females reported taking better care of themselves than males. However, Lee et al. (2009) found that older HF patients were associated with worse self-care, especially response to symptoms which occur for both men and women. Thus, it may be explained why gender had no relation to self-care behaviors. Surprisingly, the relationship between educational level and self-care behavior should not be interpreted as suggesting that a patient who is lower educated cannot learn self-care. Because self-care is a process that patients can be taught. Older adults who had lower educational level may spend more time to learn self-care than do those who had high educational level [13]. In addition, educational level is always positively associated with income, which may influence self-care, although income was not a significant of self-care in this study. TABLE 2 RELATIONSHIPS BETWEEN GENDER, EDUCATIONAL, INCOME, CO-MORBIDITY, KNOWLEDGE OF HF, AND SOCIAL SUPPORT (N=126). Co-morbidity was not significant with HF self-care behaviors. 49.2% of subjects in this study had only one co-morbid condition. This can be explained that multiple comorbid conditions might be a barrier to prevent HF patients to perform self-care [28]. The presence of co-morbidities contributes to difficultly in self-care in four major areas: medication taking, dietary adherence, symptom monitoring, and decision making about how to manage multiple conditions [29]. However, the present study concerns about only HF older adults had comorbidity or not. The numbers of patients who had and had no co-morbidity are almost the same (49.2 % and 50.9%) therefore; it is not surprising that why this study did not find the relationship between co-morbidity and such behaviors. V. CONCLUSION AND RECOMMENDATION HF is a common condition in the older population. HF self-care behaviors are essential for patients with HF to master for achieving the best possible health outcomes. The important conclusions from the data reported in this study are that self-care behaviors among older adults in the Vietnamese population with HF were low level. Modifiable factors related to self-care behaviors include knowledge of HF and social support. Based on research findings, nurses can develop assessment plans to identify older adult patients with HF who have low selfcare behaviors. Nursing intervention programs regarding social support and knowledge of HF are recommended for enhancing self-care behaviors of older adults with HF. ACKNOWLEDGEMENT I would like to express my appreciation to the Faculty of Nursing, Burapha University for partial funding support I also would like to thank the staffs at the Cardiology Rheumatology Unit in Thai Nguyen General Hospital, and all participants who make a great contribution to this work. REFERENCES [1] S.A. Hunt, W.T. Abraham, M.H. Chin, A.M. Feldman, and G.S. Francis, et al, ACC/AHA 2005 Guideline update for the diagnosis and management of chronic heart failure in the adult Summary article: A report of the American College of Cardiology/American Heart Association task force on practice guidelines: Developed in collaboration with the international society for heart and lung transplantation, Circulation., Vol. 112, pp. e154-e235, Sep. 2005. [2] J.J. Mc Murray, and M.A. Pfeffer, Heart failure, Lancet., Vol. 365, pp. 1877-1889, May- Jun. 2005. The First International Conference on Interdisciplinary Research and Development, 31 May - 1 June 2011, Thailand 7.5

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