Abstract
Background:
Heart failure (HF) contributes significantly to the morbidity and mortality of the ageing population and is one of the leading causes of re-hospitalization in Singapore. Studies have shown that patient education covering HF and self-care management can lead to greater compliance with treatment regimens, resulting in lower re-hospitalization rates. This study aimed to measure HF patients’ knowledge on the disease and self-care management, and to explore factors influencing their knowledge level.
Methods:
A questionnaire adapted from the Dutch Heart Failure Knowledge Scale (DHFKS) was completed by 187 patients who were recruited from a tertiary center’s outpatient HF clinic. Data from the survey were analyzed using SPSS (version 22).
Results:
Knowledge of HF in general had the highest score and that of HF symptoms/recognition of HF symptoms the lowest. The knowledge deficit identified was mainly on therapeutic regimens and HF symptoms/recognition of HF symptoms. The respondents’ knowledge was significantly related to their educational level and whether they had received HF education.
Conclusion:
For HF patient education to be effective, the program has to be customized to cater to different target groups and individuals. There is a need to develop patient teaching materials and a program with consideration to the patients’ educational levels, demographic, and comorbidity backgrounds.
Introduction
Heart failure (HF) is a major and growing public health problem worldwide with a significant burden of disease on society and the individual.1,2 This burden of disease can be measured in terms of mortality, readmission rate, and healthcare costs. Repeated HF hospitalization is a burden on the healthcare system and adversely impacts long-term patient outcomes.3,4
Studies have shown that approximately half of hospital readmissions could be prevented if HF patients were compliant to their treatment regimen, and performed symptom monitoring and self-care at home.4–11 Patients’, as well as their caregivers’, level of HF knowledge is significantly related to their level of adherence to recommended care regimens.4–13 Knowledge, therefore, is an essential component for the implementation of self-care strategies.6,12
In addition to advanced therapies, comprehensive and competent care for patients hospitalized with HF requires a strong focus on the education of patients and their families to improve their knowledge on self-care and compliance. 12 Studies measuring HF patients’ knowledge and the outcomes of patient education reported that health literacy was associated with higher HF knowledge and patients’ demographics such as younger age and higher educational level.6,7,12,13 There is a lack of information in the Singapore context on HF patients’ knowledge and self-care skills, as well as preventive interventions in reducing HF admission.
In Singapore, congestive HF accounted for 4.5% of all hospital admissions and 2.5% of overall mortality in patients who were 56 years old and above. 15 Based on unpublished data from a local tertiary hospital, 489 out of 872 (56%) HF admission episodes in 2012 were due to non-compliance to diet (mainly fluid and salt) and medications. The current HF education program was started in 2002 by a multidisciplinary team, which comprised physicians, HF specialty nurses, ward nurses, dieticians, physiotherapists, and pharmacists. Education was delivered through individual bedside teaching and weekly teaching sessions, followed by discussions with the patients and supplemented with written material. Topics of discussions included the self-administering of medications, sodium and fluid restrictions, recognition of disease progression signs and symptoms, daily self-monitoring of weight, and daily activities.
The objective of this study was to assess the effects of demographic conditions and co-morbidities that may influence HF patients’ knowledge level on the disease and self-care. The specific objectives were:
to measure HF patients’ knowledge level on the disease and self-care under the current patient education program; and
to examine the correlation between HF patients’ knowledge level on the disease and self-care, and their demographic conditions and co-morbidities.
The Dutch Heart Failure Knowledge Scale (DHFKS) developed by Van der Wal et al. 14 was adapted in this study. We chose the DHFKS as both English and Mandarin versions were available, have been used extensively, and have been shown to be both reliable and valid for different populations in the Netherlands, US, Taiwan, and Vietnam.6,12–14,16,18
Methods
Design, setting, and participants
This was a quantitative study and was descriptive in nature. It comprised a pilot and main study and was conducted over a period of five months between March and August 2013. The pilot study involving five patients was conducted in March 2013 to test the clarity of the English and Chinese version of DHFKS and the validity of the instrument in the Singapore context. The main study was conducted from 10 April to 28 August 2013. A total of 225 patients in an outpatient HF clinic of a local tertiary center were recruited in the study. Ethical approval was obtained from the Centralized Institutional Review Board prior to study.
Inclusion criteria were patients who had been admitted to the tertiary center for HF between 1 January 2008 and 31 December 2012, been discharged from the hospital for more than three months, been following-up at the outpatient HF clinic, were able to read or speak English or Mandarin, and were between 21 and 75 years old. Exclusion criteria were patients who had cognitive impairment, visual impairment, physical disability, end-stage renal disease, end-stage HF, or who were pregnant or bedridden. An information sheet was given to the participants prior to answering the questionnaire. Consent to participate in the survey was assumed by the return of a completed questionnaire.
Survey questionnaires and data collection
The survey instrument consists of two parts. The first part contains participant’s demographic characteristics (age, gender, marital status, educational level, mobility status, employment status, whether living with caregivers, etc.), comorbidities (diabetes, smoking, alcohol drinking, depression, etc.), and whether they had received HF education during the past hospitalization. The second part is the DHFKS (see Appendices 1 and 2).
The 15 self-administered, multiple-choice questions covered HF knowledge in general (four items: Q6, Q7, Q9, Q11), knowledge of HF treatment (six items: Q3, Q4, Q10, Q12, Q13, Q15), and knowledge of HF symptoms and symptom recognition (five items: Q1, Q2, Q5, Q8, Q10). Respondents were given three options for each question and they had to circle the most appropriate answer. Each correct answer is awarded one point; no points are awarded for wrong or unanswered questions. The total possible score for HF knowledge ranges from 0 to 15. The higher the score, the more the respondent is presumed to know about HF.
We obtained permission from the author of the DHFKS to slightly modify the scale in our study to make the questions more appropriate in a local context. On the advice of a HF specialist, the fluid restriction range in Q3 was modified from 1.5–2.5 liters to 1.0–1.5 liters, in line with the fluid intake of the Singapore-based study population. As the available Chinese version of DHFKS was modelled for the Taiwanese population, a slight adjustment was made in light of the local linguistic differences. A pilot study was conducted after the adjustments to test the content validity and face validity of both the Chinese and English versions of the questionnaire.
Statistical analysis
Analyses were performed using SPSS version 22.0. Descriptive statistics were presented as mean (SD) for numerical variables, and n (%) for categorical variables. Univariate and multivariate analyses were performed using the General Linear Model to determine the relationship of demographical and clinical categorical variables with HF knowledge, both across and within all HF knowledge categories. Post-hoc pairwise comparisons were made and adjusted with the Bonferroni correction. Statistical significance was set at p < 0.05.
Results
A total of 225 HF patients participated in the study (a response rate of 100%). There were 38 questionnaires excluded from statistical analysis due to incomplete answers. There were no significant differences in age, gender, educational level, diabetes, smoking, depression, and whether the subjects received HF education during previous hospitalization between the 187 participants who completed the questionnaire and the 38 participants who did not. There were 143 (76.5%) participants that used the English version of questionnaire and 44 (23.5%) who used the Chinese version.
Demographic and clinical characteristics
Chinese participants made up 73.8% of the population. Most of the respondents in this population were aged 50 years old and above (n = 127, 67.9%), male (78.6%), and married (70.1%). More than two thirds of this study population had less than high school education and 46.0% of participants were living with their caregivers. In clinical variables, 40.6% of the respondents were suffering from diabetes and 28.3% were current smokers. The demographic and clinical characteristics of participants are shown in Table 1.
Demographic and clinical characteristics of the study population.
Level of knowledge on HF
The total mean score of HF knowledge in this population was 10.1 (±2.4). Among the three categories of knowledge, knowledge of HF in general had the highest score and those of HF symptoms/symptom recognition the lowest (Figure 1).
Knowledge score (%) of respondents with HF education as compared to those without HF education.
The key areas of knowledge deficit identified in this study were: 1) treatment, especially in therapeutic regimen; and 2) causes, symptoms, and consequences of HF (Table 2). In the treatment category, respondents lacked adequate understanding of weighing monitoring. Only 55.6% of the respondents were able to make the connection between an increase in weight and HF condition, and only 40.1% of respondents knew that those with severe HF condition should weigh themselves daily. A total of 74.9% of the respondents were aware that they needed to be on a fluid restriction, while 71.3% knew that they should suck an ice cube when thirsty. However, 20% of them held the misperception that they should consume as little water as possible. In addition, more than 50% of the respondents in our study group were unable to recognize signs and symptoms of worsening HF. Only 13.9% of respondents were aware that the flu can cause rapid worsening of HF condition, while 59.4% thought that a high-fat diet would cause rapid worsening of HF condition.
Itemized breakdown of heart failure (HF) knowledge questionnaire comparing patients with and without HF education.
P-value for comparison of “Patients with HF education” and “Patients without HF education” groups.
Factors affecting HF knowledge
The significant differences shown in the overall HF knowledge section were: educational level (p < 0.001, Table 3), diabetes mellitus (p = 0.049), living with a caregiver (p = 0.034), and having received HF education (p = 0.020). However, only two factors remained significant in the multivariate analysis (education level: p < 0.001; the receipt of HF education: p = 0.011).
Relationship of demographical and clinical variables across the different categories of heart failure (HF) knowledge.
Reported in percentage (%).
P-value (unadjusted).
P-value (adjusted).
Marital status “single” includes unmarried/widowed/separated/divorced.
Post-hoc pairwise comparisons showed individuals with a lower educational level (below the high school level) had a lower overall HF knowledge score than those with a higher educational level (high school level and above; 64.7% vs. 74.2%, p < 0.001). There is a significant difference in all three categories of knowledge scores between the groups with lower educational level and those with at least high school education, with HF knowledge in general 56.1% vs. 65.2% (p = 0.014), treatment 71.3% vs. 79.4% (p = 0.018), and HF symptoms/symptom recognition 63.5% vs. 75.3% (p = 0.001).
A total of 151 (80.7%) participants in this study indicated that they had received HF education during hospitalization (Table 1). Participants who had received HF education scored higher in all the categories of knowledge than those who did not (Table 3). However, HF education was only found to be significantly related with the high score in HF general knowledge (60.4% vs. 50.7%, p = 0.020). There was no significant relation found in the knowledge score in HF treatment and in HF symptoms/symptom recognition. HF education was also found to be significantly related to patients’ high scoring in questions asked about the function of the heart (Q9, p = 0.031), the main causes of HF (Q11, p = 0.009), fluid restriction (Q3, p = 0.034), the important reason for regular weighing (Q1, p = 0.006), and the purpose of water pills (Q13, p = 0.002).
Notably, respondents living with a caregiver had significantly lower scores than those not living with one in overall HF knowledge (64.7% vs. 69.5%, p = 0.034, Table 3) and knowledge of HF symptoms/symptom recognition (63.3% vs. 69.7%, p = 0.049).
There were no significant differences in overall HF knowledge scores when respondents were compared by age group, gender, ethnic group, marital status, employment status, or mobility status (Table 3).
Discussion
This study is the first to employ a well-validated questionnaire to assess a wide variety of aspects related to knowledge of HF disease and self-care management in Singapore.
Current HF patients’ knowledge of disease and self-care management
The mean HF patients’ knowledge score of this study population was 10.1 (±2.4), which was above the level considered to be adequate (>10), but lower than the ideal for individuals who had recently received standardized in-hospital HF education. These findings are similar to those in the study by Dennison et al. in which mean knowledge score was 11.4 ±2.3. 13 The knowledge deficits identified in this study such as weight monitoring, fluid restriction, and recognition of worsening signs and symptoms were consistent with studies conducted in patient populations outside Singapore.6,18 A local study carried out by Malhotra et al. also reported that patients expressed the desire for more functional knowledge about symptom management, side effects, and disease progression. 19 These findings would inform future educational interventions to focus on the areas of therapeutic regimen, general HF knowledge, symptoms, and symptom recognitions.
Diabetes, smoking, and HF knowledge
Participants with diabetes scored lower than participants without diabetes in the questionnaire. In the univariate analysis, there was a positive correlation between the diabetic group and their low scores in overall knowledge, general HF knowledge, as well as in symptom recognition (Table 3). Knopman et al. reported that older adults with diabetes are at an increased risk of cognitive dysfunction with regard to verbal learning, memory problems, working memory, and psychomotor function. 20 In a local study by Malhotra et al., HF patients reported that dealing with comorbidities further complicated their physical and psychological symptoms such as poor memory, attention, fatigue, and depression. 19 Although the differences in our study were not statistically significant after adjustment for other variables, this could possibly explain the low scores in the current study. This highlights the need for patient education and intervention to be tailored to the needs of this group of patients.
Smokers also scored poorly compared with non-smokers in this study. This can be explained by the established link between cognitive function and smoking. 21 The psychological construct of the risk-taking attitude of smokers, including feeling less control over their lives and chronic condition, might also contribute to the low score.22,23 HF patient education needs to be integrated with a smoking cessation counseling program in this group of patients.
Respondents’ educational level
The respondents’ educational levels showed significant correlation to HF knowledge levels in both bivariate and multivariate analyses. This indicates that educational level is an independent predictor of HF respondents’ knowledge in our study population.
This reinforces findings from other studies that there is a direct correlation between the educational level of HF patients and the level of disease-specific knowledge.6,7,14,16 This finding demonstrates that different educational strategies may be required to tailor the information to suit the individual’s educational level and learning needs, in order to aid their understanding and retention of information about HF.
In-patient HF education
HF education was positively correlated with the respondents’ HF knowledge score in both bivariate and multivariate analyses, which indicated that the current HF education program is a major determinant of knowledge for this study population.
Our findings show that HF education may need to be more specific to allow or provide opportunity for patients to clarify their own belief, doubt, and misconceptions; for instance, the misunderstandings in fluid restriction and weighing monitoring, as well as causes of worsening HF. Also, HF education was only found significantly associated with the high score in HF general knowledge but not in the treatment knowledge and HF symptom/symptom recognition knowledge. Studies have shown that HF patients require more information than previously thought by healthcare workers.24–26 Despite receiving HF education, there remains a significant knowledge deficit in HF treatment and cause, symptoms, and consequences of HF. HF education should employ different types of intervention strategies to enhance patients’ understanding and improve information retention rates. There also needs to be more seamless communication and coordination within the multidisciplinary team administering the HF education program.
HF patients are often in a poor condition when hospitalized, and lack the physical and mental capacity to assimilate the information provided. 25 Many patients and their families may not be ready to learn at the time of diagnosis, regardless of how thorough the instructional session. The physical and psychological symptoms of HF such as breathlessness, mild cognitive impairment, fatigue, anxiety, sleep disturbance, and depression make it generally challenging for patients to receive and retain information, especially in the acute environment, when symptoms are present. 12 Dealing with comorbidities may further complicate the situation, especially among older patients.18,21 Most of our respondents in this study population were aged 50 years or older, with almost half having diabetes. In current practice, patient education is documented in medical records, even if the education provided is cursory. The documentation may not reflect the extent of the counseling and patients’ understanding, or any assessment of their understanding. 26 Although this study was not designed to test the in-hospital education intervention, findings showed that effective HF education strategies are needed in additional to oral and/or printed educational information. More interactive discussions, various communication platforms, the evaluation of learning outcome, and follow-up with healthcare providers may help patients better understand their condition, prevent misunderstandings, and promote the retention of knowledge taught.
Living with a caregiver
The presence of a caregiver was found in our study to be significantly related to HF respondents’ knowledge in the bivariate and multivariate analysis. In this study, a caregiver was defined as someone who assists in either or all of the patient’s daily living activities, including seeing to dietary needs, the taking of medications, etc. The overall knowledge score of HF patients living with caregivers was lower than those who had no caregiver. This is different from overseas studies, where the patients who are married tend to have a greater knowledge about their disease.4,12,27,28
This result could have arisen from the targeting of HF education at the caregivers rather than the patients. According to a study by Malhotra et al., local patients felt that physicians discussed their illness with their family rather than with them. They felt that being better informed would allow them to manage their disease and get a general understanding of their condition, as well as empower them to make decisions and plan for their remaining days. 19 Social support from family and friends has been shown to indirectly affect patients’ motivation and cognitive ability to receive and process information provided on HF and self-care management.9,10,17,22,29 However, both patients and caregivers should be equally involved in HF education.
The factors identified in our findings include HF education, the respondents’ educational level, and living arrangements (with or without caregiver). These factors may be used to identify high-risk patients and to tailor interventions to improve HF patients’ knowledge. Effective HF education strategies such as more interactive discussions, various communication platforms, and follow-up with healthcare providers may help patients better understand their condition, prevent misunderstandings, and promote retention of knowledge taught. Educational intervention should be tailored to suit the learning needs of different groups of patients (who may have different learning styles) and followed by an evaluation or reassessment of its effectiveness. Due to the unique characteristics, behaviors, and beliefs in the multi-racial and multicultural context of Singapore, we should focus on individualized educational and therapeutic interventions to maximize the effectiveness of patient education.
Study limitations
The number of respondents in this study was small and drawn from a single center. As a convenience sample, the population studied did not represent the total HF patient population of Singapore. Moreover, the questionnaire did not allow for subjects to elaborate on their views and answers, and demographic data such as specific age, type of diabetes, hypertension, and atrial fibrillation were not collected. Detailed information on respondents’ HF stage and their caregivers was also not collected. A pre- and post-design could also be used to best evaluate an educational intervention. The results of this study could be a baseline for the evaluation of a revised educational program in the near future. Future research should establish what type and what level of information has the potential to improve physiological, cognitive, emotional, and behavioral outcomes for patients and their caregivers. Future studies should explore effective educational interventions, evaluate different educational outcomes and quality of life of HF patients, as well as establish the types and levels of information that have the potential to improve physiological, cognitive, emotional, and behavioral outcomes for HF patients and their caregivers.
In our study, Cronbach’s alpha was calculated to assess internal consistency (reliability) of the questionnaire after the modification of the fluid restriction question. Our study had a small statistical power reliability of 0.538 measured via Cronbach’s alpha, which was lower than the values reported by DHFKS authors (0.62), but comparable to the values reported in the US study (0.58).12,13
Conclusion
The results of this study indicate that the knowledge of HF patients in Singapore may be inadequate, despite the education provided. There are considerable knowledge deficits among HF patients, especially in the areas of weight monitoring, cause of HF disease, symptoms, and symptom recognition.
The patients’ educational level, whether in-patient HF education has been administered, and the patients’ living arrangements are factors identified in our study to be significantly related to patients’ knowledge of disease and self-care management. These factors identified in our study implicate the high-risk population and target groups differentiated by demographics. Clinical education should incorporate these factors as they evolves in order to be relevant and effective. Both caregivers and patients should be actively involved in patient education and be equally empowered. The rapid growth of the aging population requires efficient and cost-effective education, practical measures, and interventions in patient self-care that can empower patients at the community level. Hopefully, our study sheds light on how patient education can be tailored to the individual’s needs and encourages attempts to address and enhance patients’ retention of knowledge.
Footnotes
Appendix 1
You may or may not be familiar with the items below, but please try your best to answer each question by
Adopted from Dutch Heart Failure Knowledge Scale by Van der Wal. 14
Appendix 2
Acknowledgements
We thank the nursing department and all the nursing managers at the National Heart Centre Singapore for their support in this survey. We are also grateful to cardiologist Adjunct Assistant Professor David Sim Kheng Leng and the heart failure education team, all the staff at the National Heart Centre Singapore outpatient clinic, and all the participants who contributed to this paper.
Declaration of conflicting interests
None declared.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.