Introduction

Heart failure (HF), often referred to as congestive heart failure (CHF), decompensatio cordis (DC), and congestive heart failure (CCF), is when the heart does not pump enough to maintain blood supply to satisfy the metabolism needs of the body tissue. Heart failure signs and symptoms usually include shortness of breath, extreme tiredness, and swelling of the legs. With exercise or when lying down, the shortness of breath is typically worse, and can wake the person at night. There is also a general characteristic of a restricted capacity to exercise. Typically, chest pain, like angina, does not occur because of heart failure. Heart failure is caused by any disease that, by injury or overloading, decreases the efficiency of the heart muscle. These variations in workload over time, induced by long-term activation of neurohormonal processes such as the renin-angiotensin pathway, result in fibrosis, dilation, and anatomical changes from elliptical to spherical in the form of the left ventricle. 38 million people in the world are estimated to experience heart failure (HF) [1–4]. In previous studies, the prevalence of HF incidence ranges from 1-2% in the adult population [5,6]. The data obtained in Indonesia is that 5% of the total patients who are hospitalized are patients with heart failure (HF). More than 50% of patients who experience heart failure are due to cardiovascular disease [7]. The condition is predicted to increase the aging population and the increasing success of the treatment of patients with acute coronary syndrome so that many patients with these conditions would survive. The rising prevalence of heart failure patients is be closely related to morbidity, mortality, and higher health costs. Therefore, heart failure is one of the leading health problems in developing countries [8].

Heart failure is a chronic disease that is often associated with high morbidity and mortality, low quality of life and frequent rehospitalization [9]. Chronic conditions experienced by patients with heart failure require patients to be able to perform self-care in their care. Self-care is defined as a process of health care through health promotion practices and disease management. There are three components in self-care, namely self-care maintenance (for example, taking the medication regularly), self-care monitoring (for example, measuring body weight regularly) and self-care management (for example, adjusting the dosage of diuretics according to symptoms that appear) [10,11].

Self-care is an essential factor that affects the improvement of the health conditions of heart failure patients. Some studies have reported that patients with effective self-care will have a better quality of life, reduce mortality and rehospitalization [11]. Although self-care in patients with heart failure plays a vital role in improving health conditions, many patients have inadequate self-care behaviour [12]. Self-care behaviour can be influenced by several factors, including gender, level of education, income, comorbidity, knowledge of heart failure, and social support [10,13].

The influence of individual factors on patient self-care is still little investigated in Indonesia, and some of the available literature has not yet been taken as complete variables. Therefore, a study about the relationship between self-care in heart failure patients with individual and environmental factors such as social demographics, i.e. age, gender, marital status, income, level of education, psychological conditions, physical and social characteristics need to investigate. The previous studies were examining the relationship between self-care to literacy and knowledge [14], social support [15,16], depression [16,17], cognitive impairment [18,19]. Among previous studies, there were a few studies that have examined the integration of several variables that are known to affect self-care in heart failure patients.

Therefore, before nursing interventions are implemented to improve self-care in heart failure patients, it is also important to identify factors that affect the self-care. By knowing the factors that affect self-care, especially for Indonesian, clinical nurses will be able to consider the use of more appropriate strategies to improve self-care in heart failure patients. This study aimed to determine the factors that affect self-care of heart failure patients in Surakarta, Indonesia.

Material and methods

Research Design

This type of research was a quantitative study using an analytic observational study design with a cross-sectional approach. In this study, responses were heart failure patients who were registered at the Cardiac Outpatients Clinic of the UNS Surakarta Hospital, Central Java. Responses were selected based on established inclusion criteria, including: (1) age> 20 years old, (2) diagnosed with heart failure more than six months, (3) being able to communicate well, and (4) willing to become respondents. The exclusion criteria were patients who had a mental illness and were taking antidepressants.

Ethical Consideration

The recent study received ethical approval from the Research Ethics Committee, Universitas Muhammadiyah Surakarta. Data collection was carried out in July-September 2020. All participants were told about the objectives and procedures as well as the protection of the privacy and rights related to this study. The informed consent form was signed by all study participants.

Instruments

We collected data regarding demographic characteristics, such as age, gender, education level, and marital status during the initial interview. We also obtained HF severity using interviews and categorized by NYHA classification, comorbid disease and duration of heart failure. Other variables of the study were self-care, self-efficacy, family support, and anxiety. All interviews were conducted in Indonesian.

Demography characteristic

The questionnaires on the demographic characteristics were filled in by the participants, including age, gender, education level, marital status, and duration of heart failure.

NYHA Classification

Participants filled out the questionnaire about the severity of the patient's disease using the New York Heart Association (NYHA) classification, which was reviewed by researchers based on complaints expressed by the patient.

Self-Care

The questionnaire used in this study was the European heart Failure Self-care Behaviour Scale (EHFScBS-9) [11]. There are nine questions in the questionnaire which use a 5-point Likert scale, from 1 (I strongly agree) to 5 (I strongly disagree). Scores between 9-45, with a lower score, indicate better self-care. The English version of the EHFScBS-9 questionnaire has been translated into Indonesian. Furthermore, the Indonesian version of the EHFScBS-9 questionnaire was tested for validity and reliability on 30 heart failure patients at Dr. Moewardi Hospital, Surakarta. Results demonstrated that the questionnaire was valid and reliable.

Self-efficacy

The questionnaire used to describe the self-efficacy in this study was the Cardiac Self-Efficacy Scale or the CSE Scale. CSES consists of 13 question items grouped into two subscales: Controlling symptoms and maintaining body functions. This questionnaire uses a Likert scale consisting of 5 points, ranging from 0 (not confident) to 4 (very confident). Higher scores indicate a better level of cardiac self-efficacy [20]. In the current investigation, we conducted a two-phase study. In the first stage, the English version of the CSES questionnaire was translated into Indonesian. The similarity of translations and the validity of their contents were checked. In the second stage, the Indonesian version of CSES, was tested for validity and reliability with 30 heart failure patients at Dr. Moewardi Hospital, Surakarta, with a Cronbach α by 0.805 that indicated the questionnaire was valid.

Family support

The family support questionnaire used in this study was the Multidimensional Scale of Perceived Social Support (MSPSS). This questionnaire consists of 3 evaluated aspects, including significant factors, friends, and family, including 12 question items with a Likert scale consisting of 7 points for each question (1 = strongly disagree once to 7 = strongly agree). Assessment or scoring on the MSPPS is done by adding up all the scores on the 12 questions then dividing them into 12 (final score range 1-7).

In the current study, the domain focuses on family support, so the scoring method is to add up the scores on 4 question items related to the family, then the total score is divided by 4. The results of the assessment are divided into three categories, namely low support (1-2.9), moderate support (3-5), and high support (5.1-7). This family support questionnaire has been tested for validity and reliability with a Cronbach value of 0.91 [21].

Anxiety

The questionnaire used in this study was Generalized Anxiety Disorder-7 (GAD-7), which was used to measure anxiety levels. General Anxiety Disorder-7 (GAD-7) consists of 7 questions related to the patient's psychological condition during the last two weeks. This questionnaire uses a Likert scale which has four answer choices in the range 0-3 (0: never feels symptoms; 3: almost every day), so the score is between 0-21. Low scores indicate minimal anxiety, while higher scores indicate more severe anxiety [22]. Based on the instrument reliability test conducted by researchers at the cardiac outpatient's clinic of Dr Moewardi Hospital in Surakarta, Cronbach's alpha was 0.746 so the instrument was reliable and valid.

Data Analysis

The data analysis was done by a computer program. The instrument reliability coefficient was tested using Cronbach's alpha value. Variant analysis and independent t-test were used to differentiate self-care, self-efficacy, family support, level of anxiety, and severity of heart failure. Pearson's correlation coefficient was used to identify multicollinearity and the correlation between self-care and the factors that influence it. In addition, linear regression was used to analyse the variables that influence self-care in a recent study.

Result and Dissection

The study results consisted of respondent characteristics, including age, gender, education, length of illness, marital status, NYHA degree, comorbidity status (Table 1).

Respondents in this study consisted of 73 respondents. The mean age of the respondents was 58 ± 12.08 years. The majority of the gender was male (86.5%), most of the respondents had a secondary education level (senior high school) (41.1%). The disease severity based on the NYHA classification (NYHA I-III) had almost the same number of respondents in each category, 39.7%; 35.6%; 24.7%; with the duration of the disease less than five years (78.1%). The most common comorbid among respondents was Hypertension, 41.1%. The majority of respondents had a partner of 86.3% (Table 1).

In this study, it was found that there was a significant difference in the mean between self-care based on age category (t = 0.043, p = 0.006) and duration of the disease (t = 0.046, p = 0.002). The mean score of self-care in the 60 years, 18.03 ± 4.21, and 20.24 ± 4.19, respectively. Likewise, the mean score of self-care in the category of the duration of the disease 5 years (20.19 ± 4.05). Meanwhile, the mean self-care score on other demographic characteristics such as gender, education level, comorbidity, marital status, and NYHA classification did not have a significant difference (Table 2).

Table 1: Description of demographic characteristic among patients with Congestive Heart Failure (CHF)

Table 2: Comparison of self-care score with respect to demographic characteristic among patients with Congestive Heart Failure (CHF)

*p<0.01

Self-care score has a significant relationship with self-efficacy (r = 0.784, p = 0.001), family support (r = 0.83, p = 0.001), age (r = - 287, p = 0.02) and anxiety (r = -0.522, p = 0.001). Based on the correlation direction, there are differences, self-efficacy and family support had a positive correlation with self-care. In contrast, age and anxiety had a negative correlation to self-care. The correlation of self-care with self-efficacy and family support was significant, self-care and anxiety had a strong correlation, and self-care with age had a good correlation (Table 3).

Table 3: Correlation of self-care with self-efficacy, family support, duration of disease, anxiety and age among patients with Congestive Heart Failure (CHF)

*p<0.05

In carrying out the stages of regression analysis to identify factors that affected self-care, independent variables showed significant differences in self-care according to general characteristics (Table 2) and showed a significant correlation between self-care and related variables (Table 3). There are four variables to be analysed, including family support, self-efficacy, disease duration, age, and anxiety. The analysis results obtained only two variables that affect self-care, i.e. self-efficacy and family support. Seen in Table 4, family support has the strongest factor (β= 1,949, p= 0.000), followed by self-efficacy (β= 0.226, p= 0.001).

Table 4: Factor affecting self-care among patients with congestive heart failure (CHF)