Journal of Cardiovascular Nursing

Vol. 31, No. 1, pp 22Y30 x Copyright B 2016 Wolters Kluwer Health | Lippincott Williams & Wilkins

Self-care and Its Predictors in Patients With Chronic Heart Failure in Western Iran Soraya Siabani, MD, PhD(c); Tim Driscoll, BSc (Med), MB, BS, MOHS, PhD; Patricia M. Davidson, PhD, RN, FAAN; Farid Najafi, MD, PhD; Marisa C. Jenkins, RN, BHSc(Nsg), MNsg(Manag), MScMed (ClinEpi); Stephen R. Leeder, MD, PhD, FRACP Background: Chronic heart failure (CHF) is an increasing and costly health problem worldwide. Effective self-care behaviors reduce the cost and improve CHF outcomes. Interventions targeting improvement of self-care need to identify the baseline status of patients and factors associated with self-care to tailor the programs to patients’ needs. Aim: The aim of this study was to describe self-care and its predictors in patients with CHF in western Iran. Methods: In a cross-sectional study, 255 patients with CHF in Kermanshah were recruited and 231 (mean [SD] age, 66 [13] years; 51.5% women) completed the interviews. Self-care maintenance, self-care management, and self-care confidence were evaluated using a Persian heart failure self-care index. Each of these 3 measures had a total possible score of 100, with 22 indicators. Results: The mean (SD) self-care scores were low: maintenance, 33.8 (10.7); management, 32.2 (12.0); and confidence, 43.6 (15.6). Self-care maintenance was significantly and positively associated with education, disease duration, and living conditions. Self-care management was significantly and positively associated with education and number of hospital admissions. However, the parameter estimates in all those relationships were small. Conclusion: Self-care in patients with CHF in Iran needs major improvement, and many determinants of self-care identified by other studies were not consistently associated with poor self-care scores in Iran. Further research considering a wide range of factors associated with self-care (eg, socioeconomic and health systemYrelated factors) and application of culturally relevant interventional strategies is recommended.

congestive heart failure, medical adherence, self-care determinants, self-care predictors self-management

KEY WORDS:

C

hronic heart failure (CHF) is a progressive cardiac condition that is a major cause of mortality in many countries.1 Various studies in different countries have reported prevalence rates of CHF ranging from 0.4% to 4.3% in the general population and 2% to 20% in people older than 75 years.1,2 The number of people with CHF is predicted to double in the next 20 years,3,4 especially in less economically developed countries. In Iran, Soraya Siabani, MD, PhD(c)

cardiovascular diseases, with a prevalence of 22% in the population of 30 years or older,5 rank first as a cause of mortality in the general population.6 Self-care in patients with CHF is defined as a naturalistic decision-making process and includes behaviors and activities designed to maximize quality of life and medical stability in patients with heart failure.7 It includes self-care maintenance (eg, healthy lifestyle, adherence

PhD student in Public Health-Epidemiology, Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, New South Wales, Australia, and Faculty member, School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran.

Marisa C. Jenkins, RN, BHSc(Nsg), MNsg(Manag), MScMed (ClinEpi)

Tim Driscoll, BSc (Med), MB, BS, MOHS, PhD

Stephen R. Leeder, MD, PhD, FRACP

Professor, Epidemiology and Occupational Medicine, School of Public Health, Sydney Medical School, The University of Sydney, New South Wales, Australia.

Patricia M. Davidson, PhD, RN, FAAN Professor of Cardiovascular and Chronic Care, Dean and Professor of School of Nursing, Department of Acute and Chronic Care, The Johns Hopkins University, Baltimore, Maryland.

Farid Najafi, MD, PhD Professor of Epidemiology, Research Center for Environmental Determinants of Health, School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran.

Tutor in Clinical Epidemiology and Biostatistics, School of Public Health, Sydney Medical School, The University of Sydney, New South Wales, Australia. Emeritus Professor of Public Health and Community Medicine, Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, New South Wales, Australia. Facilities and financial support were provided by Kermanshah University of Medical Sciences and the University of Sydney. The authors have no conflicts of interest to disclose.

Correspondence Soraya Siabani, MD, PhD(c), Victor Coppleson Bldg (D02), The University of Sydney, New South Wales, Australia ([email protected]). DOI: 10.1097/JCN.0000000000000211

22 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Self-care in Patients With Heart Failure in Iran 23

to medicine and dietary advice) and self-care management (eg, seeking assistance when symptoms occur). According to the model of self-care created by Riegel and colleagues,7 self-care confidence is defined as sufficient self-confidence to carry out maintenance and management activities in relation to the patient’s illness. Heart failure symptoms and signs that are expected to be recognized and managed by patients as a part of effective self-care include peripheral edema (resulting in weight gain) and pulmonary congestion (presenting as breathlessness).8 Self-care is an important component of plans for disease management in patients with CHF9 because effective self-care (eg, adherence to prescribed medicines) can delay both death and morbidity caused by CHF.10,11 In addition, self-care activities improve quality of life12,13 and there is a significant positive association between self-care and psychosocial factors (eg, self-esteem).14 In fact, self-care and psychosocial factors have a reciprocal relationship with each other.15,16 Evidence shows that a healthy regimen and exercise, which are 2 essential parts of self-care behaviors, reduce comorbidities commonly associated with CHF (eg, obesity, hypertension, and cognitive dysfunction).15 Furthermore, lack of adherence to medication, medical regimen, and diet is the main reason for up to 70% of admissions (the most expensive aspect of CHF17) and effective self-care reduces readmission significantly.17Y20 The assessment of self-care and changes attributed to self-care that improve CHF outcomes requires a precise understanding of the self-care process. The current study was conducted to explore self-care and its attributes in patients with CHF in Iran.

Methods A cross-sectional study was conducted in 2012 in Kermanshah, a state in west Iran with a population of approximately 2 million people, as a prelude to a randomized controlled trial of different ways of educating

patients in self-care. The study protocol was approved by both the University of Sydney and Kermanshah University of Medical Sciences human research ethics committees. All patients diagnosed with heart failure and admitted at least once to the Imam Ali Hospital in the period of August 2010 to June 2012 were eligible for inclusion in the study. Potential participants were excluded if they were unable to be contacted, declined to participate in the study, were younger than 18 years, or had a serious mental or cognitive disorder and/or a disabling physical problem (including if the physical problem was class IV CHF as defined by the New York Heart Association8). The Imam Ali Hospital is the major referral center for cardiovascular disease in the western part of Iran. A cardiovascular nurse working in the medical record office at the hospital was employed to collect the contact number and addresses of eligible patients. Approximately 450 admissions for CHF were identified prior to exclusions (some of these were repeat admissions), and 255 participants were eventually recruited into the study (Figure). The participants were asked to sign the consent form after reading the participant information statement. Those who were illiterate were asked to have one of their relatives read the information and consent forms to them prior to signing for them, if requested to do so, as proxy. Data were collected through personal interview. The interviews were conducted by 3 experienced trained nurses at the patients’ homes (60%) or at the hospital, according to the participants’ preferences. The data collection instrument was a questionnaire in 2 parts. The first part contained 13 questions that covered demographic information such as age, gender, level of education, living situation, occupation, smoking, and treated hypertension and diabetes mellitus as well as details concerning CHF such as duration of heart failure and the number of hospitalizations due to CHF in the past year. The second part of the questionnaire was the Persian version of the Self-Care Heart Failure Index that had

FIGURE. Flow chart summarizing the selection of patients with CHF for the study.

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24 Journal of Cardiovascular Nursing x January/February 2016 previously been validated.21 It comprised 22 questions to assess self-care in patients with CHF in Iran. The Persian Self-Care Heart Failure Index is a quantitative, ordinal, self-report scale used to evaluate and measure the self-care in patients with CHF. It covers a range of self-care components including adherence to medicines and dietary regimens, recognition of symptoms and signs of heart failure, symptom evaluation, treatment implementation, and treatment evaluation.7 There are 10 questions (1Y10), called indicators, about self-care maintenance, 6 (11Y16) about self-care management, and 6 (17Y22) about self-care confidence (Table 2). All but 2 indicators can receive an integer score from 1 to 4, with a higher score indicating more appropriate behavior. Another 2 indicators include a choice of ‘‘zero’’ (number 16), and one of these also includes a choice of ‘‘not applicable’’ (number 11). The maximum score for all 22 indicators is 4. Using the approach of Riegel et al,7 each of the selfcare maintenance, self-care management, and self-care confidence scores was scaled separately from 0 to 100.22 Self-care maintenance and self-care confidence were assessed for all patients who answered at least 60% of questions in each domain. Self-care management was calculated only for those patients who had been symptomatic during the 2 preceding months (Figure). After univariate analysis, multiple linear regression analysis was used to identify variables associated with 1 or more of the outcomes, taking into account the potential effect of other variables. A separate analysis was undertaken for each of the 3 outcomes of interest. All variables were included in the initial model, and a backTABLE 1

ward elimination strategy was used to obtain the best model for each outcome factor. This involved sequentially removing from the model the variable with the highest P value and then rerunning it. This process was repeated until all variables in the model had a P value less than 0.05. After removing nonsignificant variables as described, interaction terms involving the remaining explanatory variables were tested, again using a backward elimination approach. Residuals were checked to ensure that the basic regression model assumptions were met. The analysis was undertaken using SAS version 9.3 and Statistical Package for the Social Sciences version 21.

Results Two hundred thirty-one participants (half were women) completed the interviews. The participants’ mean age was 66 years, and men were significantly younger (by 6 years) than women (t = 3.6; P G .001). Only 6% of the patients lived alone; 59% lived with their partners, and this was significantly more common for men than for women (# 2 = 37.1; P G .001). Approximately half of the participants had a paid job, and approximately half were illiterate (Table 1 ). Smoking was more common in men than in women (# 2 = 15.6; P G .0001), but it was not associated with age (P = .1). Approximately two-thirds of the participants had 1 or more CHF risk factors including diabetes, hypertension, or smoking. Six participants had all 3 risk factors, 28% had 2 risk factors, and 45% had only 1 risk factor. The median duration between diagnosis of CHF and the interview date (disease duration) was 36 months,

Distribution of Demographic Characteristics in 231 Patients With CHF in Western Iran

Men Age HF duration (mo) No. admissions

% (n) Mean (SD) Median = 36 Median = 1

51.5 (119) 66.0 (13.0) IQR25a = 12 IQR25 = 1

IQR75b = 69 IQR75 = 2

Range = 360 Range = 10

Total

Women

Men

c

Work status Worker or farmer (blue collar) Staff or business (white collar) Unemployed or retired Housewife Living situation Spouse Alone Children or others Hypertension Diabetes Smoker Education Illiterate Lower than high school High school or higher

% 10.0 36.4 23.4 46.2

(n) (23) (67) (43) (85)

% (n) 0.8 (1) 0 (0) 5.9 (7) 93.3 (111)

%c 10.0 48.5 32.5 0

(n) (23) (112) (75) (0)

59.4 6.1 34.5 56.7 29.0 24.2

(136) (14) (79) (131) (67) (56)

41.5 6.8 51.7 63.9 34.5 13.4

74.4 5.4 16.2 49.1 23.2 35.7

(87) (6) (18) (55) (26) (40)

58 (134) 21.2 (49) 20.8 (48)

c

(49) (8) (61) (76) (41) (16)

77.3 (92) 14.3 (17) 8.4 (10)

Abbreviations: HF, heart failure; IQR, interquartile range. a Lower (first) quartile. b Upper (third) quartile.

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37.5 (42) 28.6 (32) 33.9 (38)

Self-care in Patients With Heart Failure in Iran 25

ranging from 0 to 30 years. Disease duration was up to 12 months in 31% of the participants, up to 24 months in 42%, up to 36 months in 54%, and up to 60 months in 72%. The participants had been admitted to the hospital because of heart failure symptoms on 426 occasions, with a median of 1 and a range from 0 to 10 (percentiles; 25th = 1 and 75th = 2). Eighty-seven percent (n = 200) of the participants had been symptomatic during the 2 months preceding the interviews. Table 2 presents the means of the 3 scales and 22 indicators of self-care in the participants in the current study. The highest mean (SD) among all indicators was 3.6 (0.7) for the indicator ‘‘not forgetting to take one of prescribed medicines.’’ The next highest scores were for ‘‘try to avoid getting sick (eg, flu shot, avoid ill people),’’ with a mean (SD) of 2.9 (0.7), as well as ‘‘how likely are you to call your doctor or nurse for guidance?’’ and ‘‘how confident are you that you can follow the treatment advice you have been given?’’, both with a mean (SD) of 2.6 (0.8 and 0.9, respectively). All other indicators of selfcare maintenance, self-care management, and self-care confidence had means much less than these. The mean and SD of self-care scales (valid scores were from 0 to 100) were 33.8 (10.7), 32.2 (12), and 43.6 (15.6) for self-care

maintenance, self-care management, and self-care confidence, respectively (Table 2). Analyses of univariate relations between each outcome variable (self-care maintenance, self-care management, and self-care confidence) and the 10 explanatory variables of interest (age, gender, employment, education, living circumstances, the number of admissions, disease duration, diabetes, hypertension, and current smoker) revealed no significant relationship with diabetes, hypertension, and smoking. However, self-care maintenance was negatively associated with age (t = j3.4; P G .001), positively associated with education level (F = 9.50; P G .001), and higher for people living alone (mean, 36.4) compared with those living with a spouse (mean, 34.9) or living with their children or other family members (mean, 31.9) (F = 3.25; P = .035). Self-care management was associated with education (F = 3.42; P G .035), but the association did not strengthen smoothly with increasing education. Self-care confidence was not significantly associated with age (F = 2.59; P = .08) (Table 3). In the multivariate analysis, self-care maintenance was negatively related to age, positively related to disease duration, and positively related to the level of education

TABLE 2 Distribution of the Mean of the 3 Factors and 22 Indicators (Observed Variable) of Self-care in 231 Patients With CHF in Kermanshah

Self-care maintenance 1. Weigh yourself?a 2. Check your ankles for swelling?a 3. Try to avoid getting sick (eg, flu shot, avoid ill people)?a 4. Do some physical activity?a 5. Keep your doctor or nurse appointments?a 6. Eat a low-salt diet?a 7. Exercise for 30 minutes?a 8. Forget to take one of your medicines?a 9. Ask for low salt items when eating out or visiting others?a 10. Use a system (pill box, reminders) to help you remember your medicines?a Self-care management If you have had trouble in the last 2 months, 11. How quickly did you recognize it as symptom of heart failure?b 12. How likely are you to reduce the salt in your diet?c 13. How likely are you to reduce your fluid intake?c 14. How likely are you to take an extra water pill?c 15. How likely are you to call your doctor or nurse for guidance?c 16. How sure were you that the remedy helped or did not help?c Self-care confidence 17. How confident are you that you can keep yourself free of heart failure symptoms?d 18. How confident are you that you can follow the treatment advice you have been given?e 19. How confident are you that you can evaluate the importance of your symptoms?e 20. How confident are you that you can recognize changes in your health if symptoms occur?e 21. How confident are you that you can do something that will relieve your symptoms?e 22. How confident are you that you can evaluate how well a remedy works?e a

n

Mean

SD

231 231 230 230 231 230 231 231 231 231 231 200

33.8 1.6 1.6 2.6 2.1 2.3 2.0 1.4 3.6 1.5 1.6 32.2

10.65 0.59 0.63 0.79 0.89 0.79 0.90 0.65 0.67 0.67 0.81 12.04

200 200 200 200 200 200 231 231 231 231 231 231 231

1.9 2.1 1.7 1.3 2.6 0.9 43.6 2.1 2.9 2.4 2.3 1.8 2.3f

0.95 0.74 0.69 0.58 0.87 0.85 15.60 0.74 0.69 0.76 0.78 0.80 0.62

Categories used were 1 (never or rarely), 2 (sometimes), 3 (frequently), or 4 (always or daily). Categories used were not applicable (have not these), 0 (not recognized), 1 (not quickly), 2 (somewhat quickly), 3 (quickly), or 4 (very likely). c Categories used were 1 (not likely), 2 (somewhat likely), 3 (likely), or 4 (very likely). d Categories used were 0 (not try anything), 1 (not sure), 2 (somewhat sure), 3 (sure), or 4 (very sure). e Categories used were 1 (not confident), 2 (somewhat confident), 3 (very confident), or 4 (extremely confident). f Self-care defined on the Self-Care of Heart Failure Index of 2 or lower (never/rarely or only sometimes performing these behaviors) is low self-care. b

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26 Journal of Cardiovascular Nursing x January/February 2016 TABLE 3

Self-Care Scales in Terms of Living Situation, Education Level, and Employment in 231 Patientsa With CHF in Kermanshah n Mean Age Self-care maintenance Self-care management Self-care confidence Duration of disease Self-care maintenance Self-care management Self-care confidence No. admission Self-care maintenance Self-care management Self-care confidence Gender Self-care maintenance Female Male Self-care management Female Male Self-care confidence Female Male Education Self-care maintenance High school or higher Lower than high school Illiterate Self-care management High school or higher Lower than high school Illiterate Self-care confidence High school or higher Lower than high school Illiterate

t = j3.43; df = 1; P G .001 t = j0.13; df = 1; P = .89 t = j1.81; df = 1; P = .07 t = 2.28; df = 1; P = .23 t = 2.35; df = 1; P = .02 t = 1.35; df = 1; P = .18

N

t = 1.19; df = 1; P = .23 t = 2.48; df = 1; P = .01 t = 0.51; df = 1; P = .61 Mean SD

119 32.8 112 34.9 t = 1.5; df = 1; P = .13

11.18 10.0

102 33.2 12.70 98 31.1 11.27 t = j1.24; df = 1; P = .22 119 43.2 112 44.0 t = 0.42; df = 1; P = .68

48 49 134 F = 9.50; df

16.13 15.08

37.6 10.32 36.8 10.99 31.3 9.99 = 2,228; P G .001

37 28.4 10.14 43 35.4 14.86 120 32.2 11.18 F = 3.42; df = 2,197; P = .035

Living with Self-care maintenance Alone Children/other Spouse F = 3.25; df = 2,226; P = .041 Self-care management Alone Children/other Spouse F =3.44; df = 2,196; P = .034 Self-care confidence Alone Children/other Spouse F =1.49; df = 2,226; P = .23 Employment Self-care maintenance Housewife Staff or business man (white collar) Unemployed or retired Worker or farmer (blue collar) F = 1.57; df = 3,227; P = .197 Self-care management Housewife Staff or business man (white collar ) Unemployed or retired Worker or farmer (blue collar) F = 1.33; df = 3,196; P = .265 Self-care confidence Housewife Staff or business man (white collar) Unemployed or retired Worker or farmer (blue collar) F = 0.23; df = 3,227; P = .87

SD

14 36.4 12.01 79 31.4 10.57 36 34.9 10.45

14 39.6 12.78 70 30.5 12.49 115 32.3 11.46

14 49.2 16.15 79 41.8 16.87 136 44.0 14.82

112 23 75 21

32.3 11.11 34.3 9.45 35.7 10.35 34.1 9.88

96 18 67 19

33.1 12.44 28.1 9.87 32.7 12.01 29.2 11.46

112 23 75 21

42.9 45.7 44.0 43.4

16.36 18.89 13.89 14.13

48 44.0 15.89 49 47.8 15.56 134 41.9 15.33 F = 2.59; df = 2,228; P = .07

Tests are based on univariate analyses. a For self-care management, only symptomatic patients were included in the analyses (n = 200).

(higher in persons with primary or higher education). Self-care management was positively related to the number of admissions but was negatively related to primary education (" = j2.2) and postYprimary education (" = j4.3) in comparison with persons with no formal education. (P = .02). In addition, self-care management was positively related to living circumstances, with higher levels for persons living alone (" = 8.7) and persons living with a spouse (" = 3.0) compared with persons living with children and others (P = .04) (Table 4). None of the explanatory variables accounted for a practically important difference in these measures. On the basis of the multivariate analysis, self-care confidence was not associated with any explanatory variable.

Both self-care maintenance and self-care management were positively but not highly correlated with each other and with self-care confidence. The correlation coefficient between self-care maintenance and self-care management was 0.42 (P G .001), that between self-care maintenance and self-care confidence was 0.36 (P G .001), and that between self-care management and self-care confidence was 0.33 (P G .001).

Discussion Self-care in CHF is defined as a process in which patients perform daily activities that prevent or detect early symptoms of CHF deterioration, maintain or restore their own

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Self-care in Patients With Heart Failure in Iran 27 TABLE 4

Variables Associated With Self-care Maintenance and Self-care Management Based on Multivariate Analyses Self-care Scales Self-care maintenance

Parameter

Parameter Coefficient

Significance

a

Education Primary High school or higher Disease duration (mo)

P = .03 4.5 4.5 0.032

P = .09

Self-care managementb No. admissions Education Primary High school or higher Living with Alone Spouse a

1.4

P = .03 P = .02

j2.2 j4.3 P = .04 8.7 3.0

Adjusted for education and disease duration (other potential explanatory variables were not statistically significant in the multivariate analyses). Adjusted for the number of admissions, education, and living arrangement (other potential explanatory variables were not statistically significant in the multivariate analyses).

b

health, and manage stable background symptoms. The current study indicates that patients with CHF admitted to Imam Ali Hospital in Iran did not engage in optimal or even satisfactory self-care. The satisfactory score for each self-care subscale selfcare maintenance, self-care management, and self-care confidence is a minimum of 70 of a possible score of 100. However, the mean scores for all 3 subscales in this population was less than 40% of the maximum score. Only 1 individual indicator had a mean score of close to 80% of the maximum, and 4 indicators had mean scores of approximately 50%. The rest had means scores of 40% or less. This means that the majority of the participants never or rarely performed self-care behavior in areas such as limiting salt consumption and engaging in minimal physical activity.23 Studies in different countries, with a few exceptions,24 have also found poor self-care maintenance among their study participants.25Y31 Nevertheless, the scores in this study indicated worse self-care maintenance behaviors in the study population than those in previously reported groups. The differences may be partly caused by variations in the interpretation of the questionnaire,30 but they may also reflect real differences in approach to self-care in persons with CHF in Iran. The main factors reported as hindering effective selfcare in patients with CHF include insufficient self-care knowledge and/or skill in patients, patients’ attitude, cognitive deterioration, memory loss, comorbidities, physical restriction, poor family and/or environmental support, lack of teaching or communication skills in educators, and limitations (eg, time, human resources, and/or money) in terms of healthcare providers.32Y34 Some of these factors might explain poor self-care in patients living in Kermanshah, but there are contradictory findings in the current study. For instance, family support is reported frequently as an important promoter for better self-care in patients with CHF.35,36 Only 6 participants in the

current study were living alone, and surprisingly, those living alone had better self-care in all 3 measured domains. A partial explanation for this might be that, in Iran, especially in Kermanshah, younger people usually live with both grandparents and elderly parents unless the older persons prefer to live alone. In such populations, it might be that people can only manage to live alone if their CHF is mild and their self-confidence is good. Regardless, lack of family support alone cannot explain insufficient selfcare in the study population. Daily weighing and regular exercise for 30 minutes per day were other weak indicators of self-care in the current study, as has been found elsewhere.16,29,30,37 Nonetheless, our results showed even lower means for these 2 indicators than those that had been reported in other studies. Physical limitation might be a reason for avoiding exercise, but it is not known whether this applied here. Physical functioning has been mentioned as a barrier for self-care mainly because of aging.32,38,39 Not only is heart failure a disabling health problem by itself, but it also mostly affects the elderly population2 who often experience other disabling problems that can limit their mobility, such as severe arthritis. In contrast to other studies that have indicated an association between age and self-care,16,24 in this study, age was not associated with self-care management or self-care confidence. The participants in the current study were somewhat younger than the participants in other comparable studies,24,27,30 which is a possible explanation for the finding. Noncompliance has been identified as a critical cause of symptom exacerbation and declining outcome in CHF.40 Scores of approximately 70 to 80 or more are commonly used as the optimal cutoff for medical adherence.7,41 In this study, ‘‘adherence to prescribed medicines’’ was good (980%), which compares favorably with other studies.16,40,41 A review analyzing the results of studies

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28 Journal of Cardiovascular Nursing x January/February 2016 from 15 countries aiming to describe self-care behaviors and activities in patients with CHF30 and a descriptive study conducted in the United States with similar objectives29 found that ‘‘adherence to medicines’’ had obtained the highest score among various aspects of self-care scores in their study participants. However, the scores were not as high as our finding. The reason for good adherence in the current study might simply be that it is easier to take medicine on time than to undertake other indicators of self-care scales such as daily weighing or regular exercise. The paternal role of physicians in Iran and a deep traditional belief in medical treatment ordered by physicians could also have an influence, as found elsewhere.30 Of note, a study by Jang and colleagues29 comparing self-care in patients with Korean and American cultural backgrounds found that differences in culture-specific attitudes related to self-care were not associated with significant self-care differences. If adherence is related to the important place of physicians in Iranian society, this raises the question as to why patients do not follow all orders from physicians rather than just those related to medical treatment. In addition, in this study, ‘‘calling the doctor or nurse when exacerbation symptoms occur’’ had the best score among the indicators of self-care management, whereas it obtained the lowest mark in a similar study conducted by Jang and colleagues.29 They compared differences and similarities of self-care activities in 2 groups with different cultural background and found that ‘‘seeking medical assistance’’ scored lowest among the different aspects of self-care activities in both American and Korean groups. Self-care confidence is sometimes portrayed as an outcome in its own right but might be better seen as a modifier or moderator of self-care behaviors.7,42 Supporting this interpretation is the fact that none of the separate indicators were significantly related to self-care confidence. Self-care confidence indicators in our study participants scored relatively higher than self-care maintenance and selfcare management indicators, but the scores were still low. The results showed that 2 aspects (indicators) of selfcare concerning ‘‘taking extra water pill when exacerbation symptoms occur’’ and ‘‘being sure that the remedy helped or did not’’ obtained the lowest scores among the 22 indicators. The poor score for the first indicator can likely be explained by the easy access to medicines in drugstores in Iran. Therefore, excessive use of self-prescribed medicine is a major health problem in this country. Hence, patients are usually advised by physicians and health professionals to avoid taking any medicine unless explicitly ordered by a physician. An effective intervention to improve self-care in patients with CHF will likely be built on the identification and understanding of the causes and predisposing factors for this suboptimal behavior. However, many of the factors identified in the literature as obstacles or facilitators for self-care in patients with CHF did not appear to influence

self-care in the current study. The main predictors of self-care maintenance were age, disease duration, and education level, and the main predictors of self-care management were the number of admissions, education level, and living situation, but the influence of each of these factors in self-care was small and not clinically significant. Problems such as complications of CHF symptoms, comorbidity burden, cognitive decline, memory loss, and complexity of the self-care process23,32 might be impossible or very difficult to address. However, increasing patients’ knowledge and self-care skills, which are likely to be very important predictors of self-care, should be able to be improved.

Limitations More than 50% of the included patients were illiterate. Illiteracy might have led to errors in some of the self-care indicator responses by the participants, but it is unlikely that this would have significantly affected the major findings of the study. Another limitation of our study was the fact that information on many potentially important explanatory variables or confounders such as economic situation, the quality of the participant’s relationship with family, emotional problems, access to healthcare systems, and factors related to health providers was not able to be collected in the study. Similarly, there was no information on some important comorbidities (eg, arthritis, memory loss, depression, and chronic obstructive pulmonary disease) that are common in elderly people and that probably influence self-care in patients with CHF.32,43

Conclusion Patients with CHF in Iran do not display satisfactory self-care behaviors. Effective interventions are needed to develop self-care to improve CHF outcomes. Factors such as education, living situation, disease duration, and the number of admissions are statistically associated with the self-care components in this population but unlikely to be practically important. Therefore, these factors are not useful predictors of the level of self-care. Furthermore, some determinants of self-care, such as age and gender, identified by other studies in different countries, were not consistently associated with poor self-care scales in the setting of the current study. Interventions targeting self-care improvement in different populations need culturally adjusted, evidence-based strategies and consideration of a wide range of determinants, including local factors. There are many areas that appear to be sensible targets for interventions aimed at improving self-care in these people. These include factors such as socioeconomic status, psychological conditions, and the factors related to health delivery system. In addition, further descriptive self-care research that considers a wide range of comorbidities influencing self-care in this population is recommended. Researchers interested in working in such

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Self-care in Patients With Heart Failure in Iran 29

What’s New and Important? h People with CHF in Iran need a major improvement in their self-care competence. h Education, living situation, disease duration, and the number of admissions are statistically associated with the self-care components in this population but unlikely to be practically important. h Some determinants of self-care identified by studies in other countries are not consistently associated with poor self-care scales in Iran.

12. 13.

14.

15.

areas are recommended to analyze information related to comorbidities using an instrument such as the Charlson Comorbidity Index44 to estimate comorbidity burden in patients with CHF in this population and to assess the relationship between self-care and the comorbidity score.

16.

17.

Acknowledgments 18.

The authors thank Professor Barbara Riegel for all her help and guidance in conducting the study and Dr Karen Byth Wilson for her biostatistical advice.

19.

20.

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