Self-care behavior and associated factors among adult heart failure patients in outpatient cardiac follow-up unit at Wachemo University Nigist Eleni Comprehensive Specialized Hospital, Southern Ethiopia

Heart failure (HF) is a serious medical condition that occurs when the heart is unable to pump sufficient blood to meet the oxygen and nutrient needs of the tissues. This is due to a problem with contraction of the heart (systolic HF) or a problem with filling of the heart (diastolic HF) [1].The severity of symptoms and signs was classified into four classes (I-IV) by the New York Heart Association (NYHA) [1]. The Prevalence and burden associated with HF are progressively increasing in both developed and developing countries. Heart failure affects at least 26 million people globally [2], and in the US, approximately 6.2 million adults are living with heart failure, with an expected increase in the prevalence of 46% by 2030 [3]. In Africa, the cardiovascular diseases are the leading cause of morbidity and mortality, with an admission rate of up to 25% [4]. In the USA, the total cost of care (direct and indirect costs) for heart failure in 2020 is expected to reach $43.6 billion, with over 70% of costs attributed to medical costs [5]. During the 2015–2019 periods, total HF-associated costs in Spain reached 15,373 euros ($18405.32) per person [6].

Worldwide, health care is focused on reducing re-hospitalization due to heart failure and improving survival and well-being [7]. Multidisciplinary management programs focused on enhancing HF self-care significantly reduce HF and all-cause of hospitalizations in patients with heart failure [8].Self-care behavior is a modifiable factor that emphasizes the action to be taken by HF patients to maintain life and healthy functioning and to improve overall health-related quality of life [9]. In this process, heart failure patients engage in their own care and make decisions about managing symptoms or illness by performing it at any time, even in healthy and ill states [10]. The key elements of self-care include three behaviors. First, self-care maintenance; second, self-care monitoring and third, self-care management [7, 10, 11]. Good self-care is an essential behavior in long-term management and maintenance of physiological stability and better medical and person-centered outcomes [12, 13]. Poor self-care behavior deteriorates the outcomes of heart failure patients. Self-care behavior among heart failure patients in both developed and developing countries such as Ethiopia is poor [14]. This leads patients to often experience poor quality of life, poor treatment outcomes and recurrent hospitalization with developing serous symptoms, including breathing problems, fluid retention with weight gain and leg edema, and chronic fatigue [15‐17]. The majority of HF patients in Ethiopia develop mental disorders and depression (51.1%), due to poor self-care behavior [18]. Different studies in both developed and developing countries have shown a wide range of levels of poor self-care behavior. According to a secondary analysis conducted in Sweden, the percentage of poor self-care was 59% [19]; in Kenya, the percentage of poor self-care behavior was 50.8% [20]; and in Ethiopia, the percentage of poor self-care behavior was 62.3% in west Amhara Region Referral Hospitals (14), 62.7% in the Jimma University Specialized Hospital [21], and 54.2% in the Tigray region [22]. Factors associated with poor self-care behavior were New York Heart Association (NYHA) class, co morbidity, duration of disease, knowledge deficit, depressive symptoms, anxiety, age, gender, income, social support, educational levels, marital status, living status, smoking cigarette, alcohol consumption, insomnia and functional capacity. [22‐27].

There were limited studies have been conducted on self-care behavior and associated factors among heart failure patients in our country [14, 22, 28]. Additionally, there was no sufficient evidence that illustrate the topic in the study area.

Therefore, this study was aimed to assess the level of self-care behavior and associated factors among adult heart failure patients at the outpatient cardiac follow-up unit of Wachemo University Nigist Eleni Comprehensive Specialized Hospital (WCUNECSH), Hosanna, and southern Ethiopia.

On the basis of previous scholarly articles, the conceptual framework for factors that are assumed to be associated with self-care behavior is categorized into four categories as shown in Fig. 1 socio-demographic, cognitive and psychological, clinical and behavioral factors.

To ensure the quality of the data, the questionnaire was examined by senior experts for content validity, and a pretest was performed on 5% of the total population. To maintain consistency of the tool, the questionnaire was first translated from English to Amharic and Hadiyyisa. Then, the Amharic and Hadiyyisa versions of the questionnaire were translated back to English by a language expert who was blinded to the first English version of the questionnaire. The principal investigator provided training to the data collectors and supervisor for two days before the actual data collection task. The data were collected by two BSc nurses and Supervisor who closely followed and supervised the data collectors. All completed questionnaires were examined for completeness and consistency during data management, storage, cleaning and analysis by the principal investigator. To minimize the recycling of the participants, the card was checked, and color code was given for each patient card.

This study was aimed to assess the level of self-care behavior and associated factors among adult heart failure patients at the outpatient cardiac follow-up unit of Wachemo University Nigist Eleni Comprehensive Specialized Hospital (WCUNECSH), Hosanna, and southern Ethiopia. The findings of this study showed that, poor self-care behavior among heart failure patients was 58.3% (95% CI: 52.6, 64.9). This finding is consistent with studies conducted in Zimbabwe (53.8%) [40], Tigray (54.2%) [22], the western Amhara region (62.3%) [14] and Jimma University (59.2%) [28]. This similarity might be due to socioeconomic status of the countries where the studies were conducted. This finding is higher than those of studies conducted at Gondar Referral Hospital (48.0%) [16] and Kenya (50.8%) [20]. The possible variation might be due to differences in care-providing techniques, sample sizes and levels of health education for heart failure patients.

Regarding poor self-care behavior among heart failure patients, the poorest self-care behaviors observed in this study were on regular physical exercise (44.2%), daily weight monitoring (40.8%) and taking shortness of breath as easy (40.0%). This finding is in line with the findings of other studies conducted in the western Amhara region, which reported mean scores for regular physical exercise (4.62), daily weight monitoring (4.44) and taking shortness of breath as easy (4.30) [14] as well as Gondar Referral Hospital regular physical exercise (80.0%) and daily weight monitoring (91.6%) [39].

Concerning the factors associated with poor self-care behavior in this study, participants aged >54 years were 9.891 times more likely to have poor self-care behavior than participants aged ≤54 years. This was consistent with studies conducted in Jordan [41], Korea [17] and Tigray [22]. However, this finding is inconsistent with a study conducted at Jimma University Referral Hospital [28]. One possible explanation might be physiological changes in vision and fatigue related to age and disease conditions.

Heart failure patients who had poor knowledge about self-care behavior were 6.980 times more likely to have poor self-care behavior than those who had good knowledge. This result is supported by studies conducted in Tigray [22], the western Amhara region [14], Gondar Referral Hospital [39] and Jimma University referral hospital [28]. The possible reason might be that poor knowledge about disease may predispose heart failure patients to poor self-care behavior and give less attention to self-care activities.

Respondents who had depressive symptoms were 4.973 times more likely to have poor self-care behavior than respondents who had no depressive symptoms. This finding is supported by studies conducted at Jimma Referral Hospital [28] and in the western Amhara region [14]. This might be due to the decreased intention of patients with depression to follow recommended practices and perform self-care activities.

Patients who had low social support were 6.060 times more likely to have poor self-care behavior than patients with high social support. This finding is consistent with studies conducted in Korea [17] and Tigray [42]. This might be because social support can contribute to motivating patients to adopt and maintain up in all aspects of self-care activities [22].

Participants who had insomnia were 4.801 times more likely to have poor self-care behavior than were those who had no insomnia. This result is in line with a study conducted in the United States [24]. The possible reason might be that inadequate rest, stress related to poor sleep and altered quality of life reduces inspiration and attention to self-care behavior.

Respondents who presented with a duration of heart failure <1 year were 5.782 times more likely to have poor self-care behavior than respondents whose duration of disease was ≥1 year. This finding is supported by studies conducted in Tigray [22], the western Amhara region [14] and Jimma Referral Hospital [28]. The possible reason might be that experience and continued health education on self-care behavior for a long period of time can improve the level of awareness of the importance of self-care activities [22].

Limitations of this study is that the cause and effect relationships between outcome and different associated variables were not identified because of the nature of the study design (cross-sectional, which lacks follow-up evaluation). In addition, there may be information (recall/social desirability) biases because of the nature of the tool used (self-reporting). Therefore, researchers should conduct further studies with different designs such as prospective, follow-up, and qualitative research, in the same study area as well as in different parts of the country to further explore problems related to self-care behavior and to elucidate the relationships between factors and self-care behavior.

Self-care behavior is crucial for heart failure patients to achieve positive and feasible health outcomes. In this study, more than half of the participants attending Wachemo University Nigist Eleni Comprehensive Specialized Hospital in the outpatient cardiac follow-up unit exhibited poor self-care behavior. Among the study variables, older age, poor knowledge, depressive symptoms, low social support, insomnia and short duration of heart failure were identified as factors associated with poor self-care behavior among heart failure patients. Thus, the findings highlight the importance of assessing the level of self-care behavior and implicate directions for taking action to enhance the level of self-care behavior. It is better if Wachemo University Nigist Eleni Comprehensive Specialized Hospital and governmental and private health institutions need to target patients with poor self-care behavior among adult heart failure patients to encourage patients to follow self-care strategies and link patients with depression and insomnia to psychiatric units for treatment and health profesionals to provide comperehensive counseling and health education to patients/families attending cardiac units.