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NURSING DEPARTMENT, MEDICINE AND HEALTH COLLEGE

Lishui University, China FACULTY OF HEALTH AND OCCUPATIONAL STUDIES

Department of Caring Sciences

Student thesis, Bachelor degree, 15 credits Nursing

Degree Thesis in Nursing

Supervisor: Jian Hua Chen (Grace), RN, MSc, Lecturer Examiner:Britt-Marie Sjolund,RN,PhD,Senior lecturer

Factors related to self-care in older patients with heart failure

A descriptive literature review

Shi Yiran (Lino) Yu Jinying (Yuki)

2020

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Abstract

Background: Heart failure is becoming an important public health problem with its increasing economic burden which is closely related to its high complication rate, mortality and cost more and more evidence indicated that improving self-care of patients with heart failure is important to prevent heart failure related outcomes and to improve health-related quality of life.

Aim: To describe the factors related to self-care in older patients with heart failure.

Methods: A descriptive literature review was used. A total of 9 quantitative studies and 1 mixed study were searched through PubMed to summarize the factors affecting self- care of the elderly with heart failure.

Results: By analyzing 9 quantitative and 1 mixed research, this review divided the influencing factors into three categories: patient characteristics, psychological status and cognitive impairment. All of these factors affected the self-care of patients in several aspects, including self-care management, self-care confidence, self-care maintenance.

Most of the factors were related to patients themselves, such as age, health literacy, and health-related quality of life. These factors affected many aspects of self-care in elderly patients with heart failure, advanced age worsen self-care management and reduced self-care confidence.

Conclusions: There were good and bad factors affecting the self-care of the elderly with heart failure, and there were some promoting factors and some regressing factors.

Understanding the relevant factors, nurses could take different nursing compensation modes to help patients cope with self-care deficits according to the specific situation of patients.

Key words: Factors, Heart failure, Older patients, Self-care

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摘要

背景:心力衰竭已成为一个重要的社会公共卫生问题。

目的:描述影响老年心力衰竭患者自我护理的因素。

方法:采用描述性综述,借助 PubMed 进行文献检索,应用 9 篇量性研究和 1 篇 混合型研究归纳老年心力衰竭患者自我护理的影响因素。

结果:老年心力衰竭患者自我护理的影响因素有三大类:患者自身有关、心理因 素和认知。大部分因素与患者自身有关,如年龄、健康素养、与健康相关的生活质 量等。

结论:影响心衰老年人自我护理的因素有好有坏,护士根据患者的具体情况,采 取不同的护理补偿模式有助于帮助患者应对自我护理缺陷。

关键词:影响因素,心力衰竭,老年患者,自我护理

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1 Introduction ... 1

1.1 Self-care- definition ... 1

1.2 Heart failure- definition ... 2

1.3 Older patients- definition ... 2

1.4 The nurse’s role ... 2

1.5 Nursing theory ... 3

1.6 Earlier review ... 3

1.7 Problem statement ... 4

1.8 Aim and research questions ... 4

2 Methods ... 4

2.1 Design ... 4

2.2 Database and Search strategy ... 4

2.3 Selection criteria ... 6

2.4 Selection process ... 6

2.5 Data analysis ... 8

2.6 Ethical considerations ... 8

3 Result ... 8

3.1 Factors related to the patients’ characteristics ... 10

3.1.1 Age ... 10

3.1.2 Gender ... 10

3.1.3 Comorbidity ... 11

3.1.4 Social support ... 11

3.1.5 Education ... 11

3.1.6 Duration of disease ... 12

3.1.7 New York Heart Association class ... 12

3.1.8 Health related quality of life ... 13

3.1.9 Rehospitalization rate ... 13

3.1.10 Number of medication, Job, Cardiologist referrals, Prosthetic heart value .. 13

3.2 Factors related to the psychological status ... 14

3.2.1 Depression ... 14

3.2.2 Self-confidence ... 14

3.2.3 self-efficacy ... 14

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3.3 Factors related to the cognitive impairment ... 14

3.3.1 Cognitive ... 14

3.4 The characteristics of studies ... 15

4 Discussion ... 16

4.1 Main results ... 16

4.2 Result discussion ... 16

4.2.1 Factors related to the patients’ characteristics ... 16

4.2.2 Factors related to the psychological status ... 21

4.2.3 Factors related to the cognitive impairment ... 22

4.3 Methods discussion ... 22

4.4 Clinical implication ... 24

4.5 Suggestion for future research ... 24

5 Conclusion ... 25

References ... 26 Appendix 1: Table 2. Overview of the selected articles

Appendix 2: Table 3. The aims and results of the selected articles Appendix 3: Table 4. The themes and categories of the results

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1 Introduction

Heart failure (HF), a common disease in elderly population, is an age-related disease due to a series of changes in the body (Dharmarajan & Rich, 2017). With the growth of the global population and the aging of the population, the incidence and prevalence of heart failure have increased significantly (Dharmarajan & Rich, 2017). Therefore, heart failure has become the most common reason for hospitalization of the elderly, and the social burden of heart failure become increasingly heavy (Dharmarajan & Rich, 2017;

Moser, 2017). As the burden of heart failure increased, it is closely associated with high rates of complications, mortality and cost, making heart failure as an important public health problem (Sedlar et al., 2017). It was found that the causes of admission and complications in most patients with heart failure can be avoided, but this depends on various factors (Moser, 2017). There is also increasing evidence that improving self- care in patients with heart failure is important to prevent heart failure related outcomes and improve health-related quality of life (Sedlar et al., 2017). Therefore, nurses need to constantly update and develop nursing plans and procedures to reduce mortality in patients with heart failure (Dharmarajan & Rich, 2017). However, self-care is very important in the long-term care and disease control of chronic diseases such as heart failure (Jaarsma et al., 2017). Self-care is needed by everyone, when the patient's self- care ability is lower than self-care needs, nurses should give timely support (Alligood, 2004). Nurses need to consider various factors affecting the elderly with heart failure when providing support, and formulate effective self-care measures to improve self-care effect (Zavertnik, 2014).

1.1 Self-care- definition

Self-care is a complex process involving three components, self-care maintenance (taking medication on time), self-care monitoring (measuring body weight) and self- care management (adjusting medication dosage according to changes in symptoms), which constitute an overall concept (Jaarsma et al., 2017; Zavertnik, 2014). Orem defines self-care as a series of activities initiated and implemented by mature people to maintain their life, healthy functions, sustainable personal development and happiness within a specified time range and to meet their own functions and development needs (Alligood, 2014). Self-care is an important part of long-term management of patients with heart failure (Sedlar et al., 2017). For patients with heart failure, it is necessary to

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constantly adjust and adapt to self-care in the course of disease progression (Jaarsma et al., 2017).

1.2 Heart failure- definition

Heart failure (HF) is the last stage of heart disease, which occurs when the heart muscle cannot pump enough blood and oxygen to meet the needs of the body (Huang et al., 2017). HF is a “complex clinical syndrome that can be caused by any structural or functional heart disease that impairs ventricular congestion or bleeding capacity”, and HF is a clinical syndrome rather than a disease (Dharmarajan & Rich, 2017). The high prevalence of heart failure in the elderly is also associated with common age-related changes of cardiovascular structure and function (Dharmarajan & Rich, 2017). These changes reduce chronotropism and inotropic responses, increase intracardiac pressure at ventricular filling, and increase afterload (Dharmarajan & Rich, 2017). Thus, the ability of the heart to respond to stress is impaired either physiologically (e.g., exercise) or pathologically (e.g., myocardial ischemia or sepsis) (Dharmarajan & Rich, 2017).

Patients with heart failure would have dyspnea, fatigue, leg edema, insomnia, anorexia and poor memory and other corresponding symptoms (Huang et al., 2017).

1.3 Older patients- definition

Older patients are defined as people aged 65 years or older (ZaverTnik, 2014).

1.4 The nurse’s role

Self-care is crucial for patients with heart failure (Jaarsma et al., 2017). Nurses need to learn how to promote patients' self-care skills (Sedlar et al., 2017). Understanding of factors related to self-care for patients with heart failure is of great practical of guiding both patients and nurses, which the first step to identify patient characteristics and take these characteristics as the goal of health education to improve self-care (Sedlar et al., 2017). Elderly patients had many challenges in self-care, and these elderly people needed nurses to provide them with a personalized self-care guidance and determined the special needs of patients (Zavertnik, 2014). It’s necessary for nurses to provide evidence-based care and nurse-patient cooperation to help patients better implement self-care, and most importantly to enable patients to conduct complex self-care in daily life (Moser, 2017).

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1.5 Nursing theory

This article was based on Orem's theory of self-care (Alligood, 2014). Orem's self-care theory consisted of three parts: self-care theory, self-care deficit theory and nursing system theory (Alligood, 2014) (Figure 1). The theory of self-care described what is self-care and what needs of self-care; the theory of self-care deficit described when people needed care, which is the core of the theory of self-care; the theory of nursing system describe how to meet individual therapeutic self-care needs through the nursing system (Alligood, 2014). This review is mainly based on the self-care theory in the three parts of self-care theory. The self-care theory focused on what is self-care, what self-care needs people had, and what factors would affect individual self-care ability (Alligood, 2014). The clinical significance of this review was based on the core of Orem's self-care theory, self-care deficit theory, after understanding the general conditioning factors (affected self-care agency) (Alligood, 2014). When the self-care agency is less than the therapeutic self-care demands, the individual had the deficit of self-care. At this time, they needed the intervention and care of nursing, so that the individual is in a balance status that the self-care agency could meet the therapeutic self- care demands (Alligood, 2014).

Figure1. Self-care nursing theory; Deficit, when self-care agency < self-care demands, deficit relationship current or project (Alligood M.R., (2014), Self-care Deficit Theory of Nursing, Nursing Theorists and their work (Eighth edition). Chapter 14, P. 249.).

1.6 Earlier review

Through reading a large number of literatures, many previous studies were very vague for the age limit of participants. Nursing defects was dynamic, and all factors were not

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suitable for all groups. For example, in the systematic review of Sedlar, they

summarized and classified the factors related to self-care of patients with heart failure by summarizing the results from 30 studies (Sedlar et al., 2017). In this review, the factors were divided into personal and environmental factors. Factors related to self-care were gender, education, depression, cardiac function, etc. The age groups of participants in these studies were not uniform (Sedlar et al., 2017). In another review, Moser and Watkins thought that the elderly face more nursing problems, but they did not define the elderly. In this paper, the two authors came up with a factor model that affected self- care decision-making, including psychosocial status, health and nutrition (Moser &

Watkins, 2008). In Moser's review, self-care was summarized, including the definition of self-care, the importance of self-care, and suggestions for improving self-care (Moser et al., 2012). All articles focused on providing better guidance for clinical workers (Moser et al., 2012).

1.7 Problem statement

Most of the researchers described that the prevalence of heart failure is increasing with the aging of the population. Many studies had noticed the importance of self-care for chronic diseases, especially for the elderly with HF, while the elderly self-care is not good. About the factors affected the elderly self-care, which were not very specific.

Therefore, it’s necessary for nurses and nursing students to know the influencing factors in order to improve the self-care ability of the elderly with HF.

1.8 Aim and research questions

To describe the factors related to self-care in older patients with heart failure and research question was:

What factors are related to the self-care of the older patients with heart failure?

2 Methods

2.1 Design

A descriptive literature review was used in the study (Polit & Beck, 2017).

2.2 Database and Search strategy

The articles were searched from databases of both PubMed and Cinahl through the library of the University-of-Gavle (HIG), with some limitations, such as 10 years,

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Humans, English, Full text (Table 1). The search term “Heart failure”, “self- care” ,“factors” ,“older patients” were combined by Boolean terms (AND). At the beginning, 304 articles were found that matched all the search terms, and at last 10 potential articles could be used.

Table1. Search strategy for the project Database

Date of search

Limits Search terms Number of

hits

Potential articles (exclude duplicated ones) Pubmed

2019-5-13

10years, Humans English, Full text,65+ years

“Heart failure”

(Mesh)

40380

Pubmed 2019-5-13

10years, Humans English, Full text,65+ years

“self-care” AND

“factors” AND

“heart failure”

(Mesh)

267 10

Cinahl 2019-5-13

10years, Human English, Full Text

Heart failure 34591

Cinahl 2019-5-13

10years, Human English, Full Text

“self-care” AND

“factors” AND

“heart failure”

507

Cinahl 2019-5-13

10years, Human English, Full Text

“self-care” AND

“factors” AND

“older patients”

AND“heart failure”

58 0

Total: 10

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2.3 Selection criteria

The inclusion criteria were: 1) Scientific articles could be answer the aim which was related to self-care of older patients with heart failure, 2) Articles were quantitative and qualitative researches, 3) Sampling was 65 years older or above, 4) Patient with heart failure.

The exclusion criteria were: 1) The interventions without self-care, 2) Articles

mentioned other chronic diseases not heart failure, 3) The article was only a hypothesis without specific results, 4) The articles were about the interplay of factors, 5) Reviews.

2.4 Selection process

First, we found a large amount of literature in the database by search terms excluded another part of the articles by reading the title of the article, and then discussed whether it matched the topic and could get the results of this study by reading the abstract. One person selected the best article according to the exclusion criteria; the other downloaded the best article and opened the article for final confirmation and exclusion, and finally confirms 10 articles, showed in Figure 2.

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Figure2. Exclusion process of articles (PRISMA 2009)

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2.5 Data analysis

According to Polit & Beck (2017), the researchers need to use the data analysis methods when they write the review. First, both the author of this review read the articles one by one have been published respectively, understood the research methods of the articles, summarized the participants, and summarized the methods of data collection and so on, and then talked with each other and discussed which article could be answer the aims and research questions. Finally, marked for each article as a code to facilitate the classification, which was presented in Table 2, then the researchers summarized the results and conclusions of all the articles (Polit & Beck, 2017), which allowed the two authors of this review to better reconfirm the results of each article, and finally

summarized all the articles, the results could be answer the aim and research questions of this study were marked for repeated reading. Two authors of this review summarized each article main result which had been shown in Table 3. In the end, two authors of this review write their conclusion, divided those conclusions that have been coded into several categories, and then emerged some small points together to complete the conclusion part as well as described it clearly. All the conclusions were expressed without their own feelings (Polit & Beck, 2017).

2.6 Ethical considerations

Establish an ethical research issue and respect the authors of all documents (Polit &

Beck, 2017). The articles selected have been read and commented on objectively, without any emotion or color of authors, and without any influence of the author's personal opinions and attitudes. The results of the study have been presented objectively and completely without modification according to the author's willing. Describe the results correctly and do not plagiarism.

3 Result

This article described the factors affecting self-care of elderly people with heart failure.

All the conclusions were drawn from 10 articles, including 9 quantitative and 1 mixed studies. According to the three scales of self-care, self-maintenance, self-management and self-confidence, the synthesized results were summarized and classified into three categories: patients’ characteristics, psychological status, and cognitive impairment (Figure 3). The part of the literature was summarized in Table 2. The purpose and

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conclusions of the literature were shown in Table 3. Classifications of all conclusions were shown in Table 4.

Figure 3. The factors related to the self-care in older patients with heart failure

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3.1 Factors related to the patients’ characteristics

After reading these research articles, there were 10 articles related to patients’

characteristics. Themes were divided in 13 sub-categories including age, gender, comorbidity, social support, education, duration of disease, rate of rehospitalization, New York Heart Association class, number of medication, health related quality of life, job, cardiologist referrals, prosthetic heart value (Buck et al., 2012; Cameron et al., 2009; Cocchieri et al., 2015; Liu et al., 2014; Matsuoka et al., 2016; Peters-kilmm et al., 2013; Sethares & Asselin, 2017; Siabani et al., 2016; Uchmanowicz et al., 2017; Veroff et al., 2012).

3.1.1 Age

A total of 7 articles (Cameron et al., 2009; Cocchieri et al., 2015; Liu et al., 2014;

Matsuoka et al., 2016; Peters-kilmm et al., 2013; Uchmanowicz et al., 2017; Siabani et al., 2016) described factors related to “age”. According Uchmanowicz’s study, it found poorer self-care was associated with older age (Uchmanowicz et al., 2017). One study used the Self-care Heart Failure Index version 6.2 (SCHFI v.6.2) to measure three components of heart failure self-care: maintenance, management, and confidence (Cocchieri et al., 2015). It showed that older age was correlated with lower self-care confidence and maintenance scores (Cocchieri et al., 2015). It meant that older age was related to poorer self-care (Cocchieri et al., 2015). There were two research showed that advanced age was negatively related to self-care behaviors (Liu et al., 2014; Matsuoka et al., 2016). From other two studies, it found that greater age was correlated with fewer self-care behaviors (Cocchieri et al., 2015; Siabani et al., 2016). However, two studies (Cameron et al., 2009; Peters-kilmm et al., 2013) were different from the above ones.

One study found that increased age was related to better overall self-care adherence.

And another research pointed out that age had a significant effect in self-care

maintenance (Cameron et al., 2009). To be specific, age was greatly related to self-care maintenance (Cameron et al., 2009).

3.1.2 Gender

Two articles were related to the theme of “gender” (Cameron et al., 2009; Cocchieri et al., 2015). Gender was significantly associated with self-care management (Cameron et al., 2009). In Cocchieri et al. (2009) study, for example, it pointed out that male gender was correlated with lower self-care management (Cameron et al., 2009). In another

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study, it pointed out the similar result that male gender was related to fewer self-care confidences, maintenance, management (Cocchieri et al., 2015).

3.1.3 Comorbidity

Two articles were based on “comorbidity” (Cameron et al., 2009; Peters-kilmm et al., 2013). One of them pointed out that presence of peripheral arterial disease was independently correlated with self-care adherence. Specifically, peripheral arterial disease was associated with lower self-care adherence, and have been reported that moderate-to-severe comorbidity had a significant effect in self-care maintenance and management, and showed that significant comorbidity was associated with poorer self- care maintenance and management (Cameron et al., 2009).

3.1.4 Social support

There were 3 articles related to the theme “social support” (Cocchieri et al., 2015;

Uchmanowicz et al., 2017; Siabani et al., 2016). In Uchmanowicz et al. (2017) study, they used the EHFScBS-9 (European Heart Failure self-care Behavior Scale, revised into a nine-item scale) to evaluate self-care behaviors, and found that higher EHFScBS- 9 scores, better self-care. But in the other two studies, they pointed out the different results. One study also showed living circumstances were correlated with self-care management (Siabani et al., 2016). Then they found persons who living alone or living with a spouse had higher levels of self-care management than those living with children and others (Siabani et al., 2016), which was litter similar to Cocchieri’s study, the Cocchieri et al. (2015) pointed out that one of factors of poor self-care maintenance was having a caregiver.

3.1.5 Education

Six articles were based on “education” (Liu et al., 2014; Matsuoka et al., 2016; Sethares

& Asselin, 2017; Siabani et al., 2016; Uchmanowicz et al., 2017; Veroff et al., 2012). In a randomized controlled study (RCT), the intervention group had statistical significance compared with the control group (Veroff et al., 2012). In other words, when patients got some knowledge, they could improve self-care (Liu et al., 2014; Matsuoka et al., 2016;

Sethares & Asselin, 2017; Uchmanowicz et al., 2017; Veroff et al., 2012). For example, in Liu’s study, it showed illness knowledge was significantly and negatively correlated with self-care behaviors, which meant when participants understood more knowledge about heart failure, their self-care behaviors improved (Liu et al., 2014), which were

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same as Sethares and Asselin’ study, gaining knowledge about symptoms of heart failure can better self-care (Sethares & Asselin, 2017). One study found higher

education level was associated with greater self-care (Uchmanowicz et al., 2017). And one study mentioned that self-care maintenance was positively correlated with the higher level of education (Siabani et al., 2016). But self-care management was

negatively related to primary education and post-primary education in comparison with person with no formal education (Siabani et al., 2016). In Matsuoka et al. (2016) study, Japanese heart failure knowledge scale was used to assess knowledge of heart failure, the higher scores indicated greater knowledge of heart failure (Matsuoka et al., 2016).

This study pointed out higher critical health literacy had fewer self-care behavior and lower heart failure knowledge scores was significantly associated with lack of self-care behavior (Matsuoka et al., 2016).

3.1.6 Duration of disease

There were 3 articles that was correlated with the theme “duration of disease”

(Cocchieri et al., 2015; Siabani et al., 2016; Uchmanowicz et al., 2017) One study found duration of disease was positively related to self-care maintenance (Siabani et al., 2016). One study showed that longer duration of disease was associated with lower self- care (Uchmanowicz et al., 2017). In the Cocchieri et al. (2015) study, they pointed out the factor of low self-care maintenance was having a shorter disease duration.

3.1.7 New York Heart Association class

There were 3 articles that were based on “New York Heart Association class”

(Cocchieri et al., 2015; Matsuoka et al., 2016; Uchmanowicz et al., 2017). Those studies all mentioned that New York Heart Association (NYHA) class was correlated with self- care (Cocchieri et al., 2015; Matsuoka et al., 2016; Uchmanowicz et al., 2017).

One study showed that lower NYHA class was related to better self-care (Uchmanowicz et al., 2017). And one study said that more functionally compromised was correlated with poorer self-care management scores, in the Self-care Heart Failure Index version 6.2 (SCHFI v.6.2) lower scores indicated poorer self-care (Cocchieri et al., 2015). In this study (Matsuoka et al., 2016) NYHA functional class was associated with fewer self-care behavior.

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13 3.1.8 Health related quality of life

There were 2 articles that were associated with the theme of “health related quality of life” (Buck et al., 2012; Peters-kilmm et al., 2013). In the Buck et al.( 2012) study, they said that no significant correlations were found with self-care maintenance or

management and health-related quality of life (HRQOL). Moreover, this study pointed out self-care confidence was an independent determinant of HRQOL, and found patients reporting better HRQOL had higher self-care confidence scores. They used the Self-care of Heart Failure Index to measured self-care, higher scores indicated better self-care (Buck et al., 2012). One study found higher perceived health-related quality of life was independently associated with poorer self-care adherence (Peters-kilmm et al., 2013).

3.1.9 Rehospitalization rate

There were 2 articles which were correlated with the theme of “rehospitalization rate”

(Matsuoka et al., 2016; Uchmanowicz et al., 2017). These two studies had same results;

one study found that higher numbers of hospitalization was correlated with worse self- care (Uchmanowicz et al., 2017). Matsuoka et al. (2016) found prior hospitalization for heart failure was association with fewer self-care behaviors.

3.1.10 Number of medication, Job, Cardiologist referrals, Prosthetic heart value There was one article which were correlated with the themes of “number of medication, job” (Cocchieri et al., 2015). One article was based on “cardiologist referrals, prosthetic heart value” (Peters-kilmm et al., 2013). In the Cocchieri et al. (2015) study, they found that taking fewer medications was associated with lower self-care maintenance, and confidence scores, in the Self-care Heart Failure Index version 6.2 (SCHFI v.6.2) lower scores indicated poorer self-care. This article said that being unemployed was correlated with lower self-care management scores, lower scores indicated poorer self-care

(Cocchieri et al., 2015). One article pointed out that number of cardiologist referrals was associated with greater overall self-care adherence (Peters-kilmm et al., 2013). And Peter-kilmm et al., (2013) found that presence of a prosthetic heart value was correlated with greater overall self-care adherence.

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3.2 Factors related to the psychological status

There were 2 articles related to this theme, this theme was divided 3 categories including depression, self-confidence, self-efficacy (Cameron et al., 2009; Peters- Kilmm et al., 2013).

3.2.1 Depression

There was 1 article correlated with this theme “depression” (Cameron et al., 2009).

Cameron et al. (2009) found that depression contributed significantly to the variance in self-care management. Further, depression was associated with poor self-care (Cameron et al., 2009).

3.2.2 Self-confidence

There was one article related to this theme “self-confidence” (Cameron et al., 2009).

This study said that self-care confidence contributed significantly to the variance in self- care management (Cameron et al., 2009). Specifically, self-confidence was associated with better self-care (Cameron et al., 2009).

3.2.3 self-efficacy

Peter-kilmm et al., (2013) found that higher levels of self-efficacy were associated with greater overall self-care adherence.

3.3 Factors related to the cognitive impairment

There were 3 articles related to this theme, and the category was only including

cognitive impairment (Cameron et al., 2009; Cocchieri et al., 2015; Uchmanowicz et al., 2017).

3.3.1 Cognitive

There were 3 articles based on “cognitive” (Cameron et al., 2009; Cocchieri et al., 2015;

Uchmanowicz et al., 2017). Cameron et al.( 2009) pointed out cognitive function contributed significantly to the variance in self-care maintenance and self-management.

Cocchieri et al. (2015) used the Mini Mental State Examination (MMSE) which was a 19-item instrument that was widely used to assess global cognitive function, with higher scores indicating better cognition. They used the Self-care Heart Failure Index version 6.2 (SCHFI v.6.2) to assess three components of heart failure self-care (Cocchieri et al., 2015). Then they found lower MMSE score was correlated with lower self-care

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management, maintenance, and confidence scores (Cocchieri et al., 2013), that meant lower cognition had poorer self-care. One study found that patients with cognitive impairment without dementia and patients with normal MMSE showed significantly better self-care than those with moderate dementia (Uchmanowicz et al., 2017).

3.4 The characteristics of studies

All articles were published between 2009 and 2017. These 10 articles were conducted in nine different countries, two of these studies were conducted in the United States (Buck et al., 2012; Sethares & Asselin, 2017), one was in Boston (Veroff et al., 2012), one was in Western Iran (Siabani et al., 2016), one was in Poland (Uchmanowicz et al., 2017), one was in Taiwan (Liu et al., 2014), one was in Italy (Cocchieri et al., 2015), one was in Germany (Peters-kilmm et al., 2013), one was in Japan (Matsuoka et al., 2016), one was in Australia (Cameron et al., 2009). The design of these studies had three kinds, there were 7 studies were a cross-sectional design (Cameron et al., 2009; Cocchieri et al., 2015; Liu et al., 2014; Matsuoka et al., 2016; Peters-kilmm et al., 2013; Siabani et al., 2016; Uchmanowicz et al., 2017), one study was randomized controlled design (Veroff et al., 2012), one study was second analysis (Buck et al., 2012), and one study was a mixed method design (Sethares & Asselin, 2017).

There were 4858 participants in the 10 studies, the average age of participants in all the studiea were 65 years or older (Buck et al., 2012; Cameron et al., 2009; Cocchieri et al., 2015; Liu et al., 2014; Matsuoka et al., 2016; Peters-kilmm et al., 2013; Sethares &

Asselin, 2017; Siabani et al., 2016; Uchmanowicz et al., 2017; Veroff et al., 2012). In Liu et al and Uchmanowicz et al’ studies participants must be over 65 years old (Liu et al., 2014; Uchmanowicz et al., 2017). The average age of participants in one study was 72.9 years old (Buck et al., 2012). The majority of two group in the study were both 75 years or older (Veroff et al., 2012). The mean age of participants in one study was 66 years old (Siabani et al., 2016). One was 70.7 years old (Sethares & Asselin, 2017). One was 72 years old (Cocchieri et al., 2015). One was 69.0 years old (Peters-kilmm et al., 2013). One was 67.7 years old (Matsuoka et al., 2016). One was 73 years old (Cameron et al., 2009).

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4 Discussion

4.1 Main results

The results were divided into the three categories, first was the patient characteristics (age, gender, comorbidity, social support, education, duration of disease,

rehospitalization rate, New York Heart Association class, number of medication, health related quality of life, job, prosthetic heart value), second was the psychological status (depression, self-confidence, self-efficacy), the last was cognitive impairment.

These factors had a good or bad effect on self-care in older patients with heart failure.

Some factors could improve self-care, like higher education level was related to better self-care; good cognition showed greater self-care, etc. while some factors could be decreased the self-care in some way. For example, patients who had lower Mini mental status examination (MMSE) scores (worse cognition) had lower self-care management, maintenance, and confidence scores (better self-care). Patients who had a job could have better self-care management. Patients had more numbers of hospitalization was related to poorer self-care. Longer duration of illness was associated with worse self-care, and in other study, a shorter time was having poorer self-care maintenance.

4.2 Result discussion

4.2.1 Factors related to the patients’ characteristics Age

In this study, “age” was one of the factors that affected the self-care of the elderly with heart failure, most studies showed that the age of patients with heart failure had a

negative correlation with self-care ability, and with the increased of age, self-care ability decreases (Cameron et al., 2009; Cocchieri et al., 2015; Liu et al., 2014; Matsuoka et al., 2016; Peters-kilmm et al., 2013; Uchmanowicz et al., 2017; Siabani et al., 2016). which was similar to related study (Holzapfel et al., 2009). While some study have been showed that a higher self-care behavior score was related to older age, which indicated that the older the patients with heart failure, the worse the self-care ability (Kato et al., 2009; Loai et al., 2009). Loai et al. (2009) found out the negative correlation with age and self-care They further pointed out that older age was associated with lower self- care management scores (lower self-care), and poorer self-care confidence. With the increased of heart failure patients' age, their nursing confidence was also declining. As

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they would face the suffering of effectively maintaining self-care, at this time, patients would have self-care deficit, required the intervention of nurses, actively communicated with patients, increasing patients' confidence, to better completed self-care. However, the review also comes to the opposite conclusion. They believed that with the increasing age, patients with heart failure would not face self-care deficit, but could better maintain self-care. However, most of the studies still thought that the influence of age on self- care was negative. With the increasing age, the function of individuals would naturally decline, and they would face more problems of life self-care. When the individual's nursing ability was lower than the therapeutic self-care demands, the self-care deficit would appear, and the balance would be broken, during this time, nurses needed to take measures to provide help to maintain a balance between self-care agency and

therapeutic self-care demands, which was similar to the Orem's theory of self-care (Alligood, 2014).

Gender

In the review, there were differences in self-care agency between men and women, and men' self-care was generally biased (Cameron et al., 2009; Cocchieri et al., 2015), which was similar to related studies (Heo et al., 2008; Kessing et al., 2009; Loai et al., 2017). Self-efficacy was only correlated with greater self-care in women and not in men (Kessing et al., 2009). Loai et al. (2017) reported that female was related to lower self- care behavior. Another study reported that more heart failure management knowledge was associated to better self-care behaviors in men, and men’s age was entered into the second step, early age was only correlated with greater self-care behaviors in men, and also showed that better self-care confidence was associated with greater self-care behaviors in women (Heo et al., 2008). All the conclusions drawn from the researches indicated that there were differences in gender in self-care. Age brought worse self-care to men' self-care, but in any case, could women bring better self-care? This was a direction worthy of in-depth research and exploration. Gender differences might lead to different therapeutic self-care demands and provide for clinical workers better guidance, develop individualized self-care program (Alligood, 2014).

Comorbidity

This study found that individuals with multiple chronic disease was tended to poorer self-care and the lack of personal understanding of how to deal with complications led

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to many difficulties in self-care of patients with heart failure (Cameron et al., 2009;

Peters-kilmm et al., 2013), which was similar to related studies (Dickson et al., 2011;

Hwang et al., 2014; Moser & Watkins, 2008). Dickson’ et al. (2011) found same results that individuals with multiple chronic diseases were tended to have poorer self-care.

Hwang et al. (2014) also found that patient with low self-care had more comorbidities than those with better self-care. When patients faced a variety of diseases and got multiple pieces of information from multiple information providers, especially when individual information conflicted, patients were forced to choose a self-care, but they did not have a good ability to integrate information (Dickson et al., 2011). The result of this process was the lack of self-care skills, which ultimately led to the increased risk of poor nursing results (Dickson et al., 2011). In the study of Moser and Watkins (2008), the same conclusion was drawn that the lack of personal understanding of how to deal with complications led to many difficulties in self-care of patients with heart failure.

Due to the confusion of various situations and the measures for various complications, the limited self-care decision-making process for patients has caused considerable obstacles (Moser & Watkins, 2008). When one patient had multiple diseases, the individual therapeutic self-care demands far greater than self-care agency, which was matched with the Orem's theory of self-care (Alligood, 2014). In health education and nursing guidance, nurses should ensure the effectiveness of information transmission, not just to indoctrinate patients blindly, but to ensure that patients could make self-care decision, and provide patients with a feasible nursing program.

Social support

Social support played an important role in self-care of patients with heart failure (Cocchieri et al., 2015; Uchmanowicz et al., 2017; Siabani et al., 2016), which was similar to related studies (Buck et al., 2014; Dickson et al., 2013; Gallagher et al., 2011;

Graven et al., 2015; Loai et al., 2017; Moser & Watkins, 2008). The presence of caregivers would reduce the self-care of patients with heart failure, for example, one systematic study of the relationship between caregivers and self-care found that caregivers promoted self-care of patients through different ways, and information care had an importance role in heart failure self-care (Buck et al., 2014). Loai et al. (2017) found that the number of people living with patients was also related to self-care. For example, the fewer people living together, the weaker self-care behavior and self-care maintenance of patients with heart failure. There was a common result in many studies,

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social support played an important role in self-care, the higher the level of social support, the more self-care behaviors of patients (Dickson et al., 2013; Gallagher et al., 2011; Graven et al., 2015; Moser & Watkins, 2008). Dickson and his team used a mixed method to conduct research. Through qualitative research, they found that social support and social norms play an important role in self-care. Through quantitative research, they found that there was a significant relationship between social support and self-care of heart failure. For example, cultural beliefs support some self-care behaviors (stick to medication) (Dickson et al., 2013). In Moser and Watkins' research (2008), similar conclusions were also drawn, lack of social support was related to readmission and increased risk of death of patients with heart failure, independent of other factors, further explaining the role of social support in self-care. As one of the general

conditioning factors, social support shows the importance of social support through the above research, so nurses should give more care to patients, and inform patients' families of the role of family support to patients, so as to increase patients' self-care ability, the same as Orem's theory of self-care report (Alligood, 2014).

Education

In this review, we have found high knowledge level and better knowledge of the heart failure, could better promote self-care, when the patient could identify the symptoms when the disease changed, then timely medical treatment to improve the cure rate, better knowledge of disease motivates patients self-care (Liu et al., 2014; Matsuoka et al., 2016; Sethares & Asselin, 2017; Siabani et al., 2016; Uchmanowicz et al., 2017; Veroff et al., 2012), these results were similar to related study (Hwang et al., 2014; Kato et al., 2009; Loai et al., 2017; Moser & Watkins, 2008). For example, study of Moser and Watkins (2008), as a generation of elderly people over 65 years old, the level of education is generally lower than that of later generations, and the level of education was one of the factors related to self-care. The higher the level of education, the higher the quality of education, betters the self-care behavior of patients with heart failure.

Most studies showed that the patients had more heart failure related knowledge patients had the better self-care. In Hwang et al.(2014) study, the higher level of knowledge was related to better self-care. As the same results, the patients had less failure related knowledge in Loai's research led to the worse self-care maintenance and self-care confidence of patients. However, it was also pointed out that the knowledge related to heart failure had no significantly with self-care maintenance behavior (Kato et al.,

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2009). As a clinical worker, we should pay attention to the publicity and popularization of disease-related knowledge, so that patients could better understand their own

conditions, timely find their own changes and identify symptoms, timely seek medical treatment, so as to avoid the deterioration of their conditions. It could also improve the patients' self-health literacy, understand the importance of effective self-care, so as to maintain and implement self-care.

New York Heart Association class

This study found that lower New York Heart Association class (NYHA class) was led to poorer self-care (Cocchieri et al., 2015; Matsuoka et al., 2016; Uchmanowicz et al., 2017), which was similar to many studies (Hwang et al., 2014; Kessing et al., 2014;

Moser & Watkins, 2008). They pointed out that the worse the cardiac function; the less the patients were able to establish self-care through limited activity, which led to self- care failure (Moser & Watkins, 2008). NYHA class as a general condition factors, patients and nurses needed to work together. Patients should perform self-care well to delay the declining of heart function. Nurses should give correct guidance. When patients' self-care agency was lower than the therapeutic self-care demands, they should make compensation in time (Alligood, 2014). From supportive-education system to partly compensatory system to wholly compensatory system, which was a dynamic nursing system determined according to the specific situation of patients unification, be similar to the Orem's theory of self-care (Alligood, 2014).

Job

This review concluded that unemployment leads to worse self-care (Cocchieri et al., 2015), which was contrary with some studies (Kato et al, 2009; Kessing et al., 2014;

Loai et al., 2017). These two opposite conclusions had no further conclusion that employment affected economic income then led to poor self-care. This was only a guess, and the specific relationship needed further research. The above research shows that both unemployment and on-the-job are related to poor self-care, and the specific reason is a direction worth exploring.

Duration of disease, rehospitalization, and health related quality of life, cardiologist referrals, prosthetic heart value

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Few literatures had studied these factors. The review found that the shorter duration of disease was related to the poor self-care maintenance, but the longer duration of disease was associated with the worse self-care. The more inpatients, the worse self-care.

Therefore, clinical workers should do a good job in health education and discharge education to reduce the number of patients hospitalized again. Patients took more drugs led to poor self-care maintenance and self-care confidence. Due to the increase in the number of drugs, patients might not be able to adhere to the drug taking. Nurses and family members should increase the supervision of drug taking to maintain better self- care. The better health related quality of life, the worse the patient's self-care

compliance, but the better self-care, so the nurses needed to increase the self-care compliance of supervision patients while improving the quality of life related to health.

The more patients consult specialists, the better self-care. Patients with heart valves can better engage in self-care.

4.2.2 Factors related to the psychological status

This study found that psychological factors also affected self-care, depression would lead to worse self-care, but self-efficacy and self-confidence could better promote self- care, so psychological factors of patients had good or bad effects on self-care (Cameron et al., 2009), which was similar to related article (Holzapfel et al., 2009). Furthermore, self-care ability of patients with mild depression was lower than that of patients with non-depression and patients with severe depression, but there was no significant difference between patients with severe depression and patients with non-depression, they also pointed out that the probability of poor self-care ability of patients with mild depression was higher, and the consequences include deterioration of the condition and readmission (Holzapfel et al., 2009). However, the results from this study were different from some studies (Hwang et al., 2014; Kessing et al., 2016), which concluded that lower depression was associated with better self-care. In the further study of Moser and Watkins (2008), depression would lead to the decline of drug compliance and

eventually led to worse self-care.

In this study, the self-efficacy and self-confidence related to the psychological factors of patients have positive effects on the self-care of patients with heart failure (Cameron et al., 2009; Peter-kilmm et al., 2013), which was similar to related study (Kessing et al., 2016). In Kessing et al. (2016) study, they believed that self-efficacy and self-

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confidence tend to respond to the same structure, so the two terms could be used

interchangeably, and they reached the same conclusion as this review, that self-efficacy has a positive impact on self-care. When clinical workers faced the general condition factors, nurses needed to expand the positive side and increase patients' confidence in themselves and diseases to better complete self-care, which was similar to the theory of self-care (Alligood, 2014).

4.2.3 Factors related to the cognitive impairment

In this review, cognitive impairment would lead to worse self-care. When patients had cognitive impairment, they would also have impairment of self-care in life, so they could not do self-care well (Cameron et al., 2009; Cocchieri et al., 2015; Uchmanowicz et al., 2017), which was similar to related studies (Hajduk et al, 2013; Hjelm et al, 2009;

Moser & Watkins, 2008). Many studies (Hajduk et al, 2013; Hjelm et al, 2009; Moser &

Watkins, 2008) had also concluded that cognitive impairment is related to self-care, for example, Hjelm et al. (2009) concluded that cognitive impairment was associated with self-care. The author believed that cognitive impairment was related to poor self-care, but in the study of Hajduk et al. (2013), there was no significant difference between self-care compliance of patients without cognitive impairment and that of patients with overall cognitive impairment. In the study of Moser and Watkins (2008), they further pointed out how cognitive impairment led to the failure of self-care. They believed that due to the poor memory and learning ability, memory and attention deficit, self-care compliance was poor (Moser & Watkins, 2008). When patients had cognitive problems, nurses need to pay more time and energy to care for patients, which was a large part of the full compensation nursing system (Alligood, 2014).

4.3 Methods discussion

The review requires a large number of articles with high credibility to support the results, making the results more credible. The articles were searched in PubMed and Cinahl databases through the library of the University-of-Gavle (HIG), with some limitations, such as year and language. All the literatures were published in 2009-2019..

In order to improve the reliability of the conclusions, all the adopted literatures were in this 10-year period, and all of them were in English. When searching for literature, the author used Blooean search operators AND and OR (Polit & Beck, 2017) to connect each search term, making the searched literature more relate to the topic of the article

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and getting more reliable conclusions. The search terms used in this review are “self- care” AND “factors” AND “older patients” AND “heart failure”. Review literatures were excluded. Two types of literature were adopted, qualitative and mixed study, which were highly related to the theme (Polit & Beck, 2017). Because the subject of the study had age-specific, participants were required to be 65 years old or older, and the literature that did not meet the requirements was excluded. All the documents were approved by the ethics committee and confirm to the ethics. The two authors read the literature repeatedly together to summarize the classification conclusion, so as to prevent the omission and loss of the conclusion (Polit & Beck, 2017). In order to better summarize all the results in the literatures, authors made tables to summarize the types, themes, main results, etc. of the documents, and coded them to prepare for the

subsequent collation. In the process of reading, and English were not the first languages of the author. When translating the abstract parts into Chinese, authors of this article encountered some problems. In order to avoid adding the author's personal views, authors sought help from supervisor timely to better understand, grasped the key points of the literature, and classified and summarized the conclusions more accurately. The selected articles read and commented objectively by the authors, without any emotion and color of the author, and be affected by the author's personal views and attitudes. The results will be presented objectively and completely.

This study also had some strengths and weaknesses. The strengths was the definition of patients' age that enabled readers to better understand the factors that affect self-care of elderly patients with heart failure, and these factors were specific to this group, so when nurses faced the elderly group, they could better take some individualized nursing interventions to improve patients' self-care. In this review, 7 articles were cross- sectional study, 1 second analysis study, 1 mixed method study, and 1 randomized controlled study. The disunity of research design was the deficiency of this review.

Because of the limitation of participants' age, some good research might be lost.

Research design also has its own shortcomings. In the cross-sectional study, the data were obtained at a location and over a period of time that objectively reflected the location and the time period in which certain factors were associated with self-care in older patients with heart failure (Polit & Beck, 2017). However, there was no continuity of development of the same individual (Polit & Beck, 2017). What’s more, this review focused on the older patients with heart failure in nine countries only, which was not generalizable.

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4.4 Clinical implication

As the burden of heart failure increased, it is closely related to high rate of

complication, mortality and cost, making heart failure as an important public health problem (Sedlar et al., 2017). There is increasing evidence that improving self-care in patients with heart failure is important for preventing heart failure related outcomes and improving health-related quality of life (Sedlar et al., 2017). Promoting self-care of patients with heart failure was very important for their prognosis, but it was also one of the most difficult problems facing clinical workers (Moser et al., 2012). It was of great practical significance for patients with heart failure to improve the understanding of the factors related to self-care of heart failure, because this was the first step to determine the characteristics of specific patients, which needed to be guided in the educational intervention aimed at promoting self-care of heart failure (Sedlar et al., 2017).

Therefore, Sedlar et al. (2017) believed that the skills needed to promote the

development of patients' self-care skills and the adoption of self-care behaviors should be part of the curriculum for medical professionals. Effective self-care is associated with many positive outcomes, which could be equated with or greater than medication (Moser et al., 2012). Promoting effective self-care should be the primary task of all clinical workers who care for patients with heart failure (Moser et al., 2012). The prognosis of heart failure could be greatly improved by putting self-care into practice and making it receive the same attention and status as drug prescription (Moser et al., 2012). Therefore, this review summarizes the conclusions of relevant research, provided the basis for clinical workers to understand the influencing factors of self-care of

patients with heart failure, and promoted nurses to provide better self-care for patients.

4.5 Suggestion for future research

In the selected articles, there were 9 of them were quantitative studies, and only one of them was mixed research. More literature were needed to explore what factors affected self-care of elderly patients with heart failure, and how many factors were related to self-care in older patients with heart failure. In the future research, it’s necessary to do more qualitative research, such as interviews, to understand the impact of these factors on their self-care and their experience from the perspective of patients. The study also found that the promotion of self-care in elderly patients with heart failure is far less than

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the bad factors. More researches are needed to focus on the factors that can promote the self-care of elderly patients and guide the clinical practice. This review showed that same factor led to different results, which was a direction for further study. It was not only the order’s self-care had defects; it existed in every age group. As long as the patients had self-care defects, the nurses should give timely help and supplies.

5 Conclusion

There were good and bad factors that affecting the self-care of the older with heart failure. When confronted with different kinds of influencing factors, the self-care of the elderly with heart failure has improved or decreased. Even confronted with the same influencing factors, the self-care of the older with heart failure could also show different effects. With the increased of age, the self-care of the elderly with heart failure was getting worse and worse. However, in some studies, it turned out that with the

increased of age, the older with heart failure adhere to self-care well. Among them, age, education and cognition had great influence on the self-care of the older with heart failure. Nurses could alleviate and prevent some self-care defects, though, some factors related to physiological and natural changes were inevitable. There is a long way to go to do some researches to provide more advisable suggestions to improve the quality of care and self-care of elderly patients with heart failure. In the future, more studies of factors affecting self-care in elderly patients with heart failure are needed to try to find out how to better promote self-care to reduce social burden.

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Appendix 1: Table 2. Overview of the selected articles

Author(s) Title Design

(possibly approach)

Participants Data collection methods Data analysis method(s)

Code

Buck, H.G., Lee, C.S., Moser, D.K., Albert, N.M., Lennnie, T., Bentley, B., Cater, L.W.&

Riegel, B. (2012)

Country:America

Year of

publication:2012

Relationship Between Self- care and Health-Related Quality of Life in Older Adults With Moderate to Advanced Heart Failure

A

quantitative approach.

A second analysis study design

N=207

Age≥65y (mean,72.9 y)

Men,58%(n=121);

women,42%(n=86)

White,83%(n=171);

African American , 13%(n=27);Hispanic,1.

4%(n=3)

The majority of the sample was enrolled from 2 sites in the Midwestern United States.

Included were populations accrued from large and small outpatient and inpatient facilities providing an intentional

heterogeneity.

A secondary analysis of nine existing national longitudinal data sets of elderly heart failure patients from the United States and Australia.

A

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Veroff, D.R., Sullivan, L.A., Shoptaw, E.J., Venator, B., Arvelo, T.O., Baxter, J.R., Manocchia, M.&

Wennberg, D.

Country:Boston

Year of

publication:2012

Improving Self-Care for Heart Failure for Seniors:

The Impact of Video and Written Education and Decision Aids

A

quantitative approach.

Randomized controlled study design (RCT)

N=2439 (intervention group, n=1170; control group, n=1269)

The majority of individuals in both group were 75 years or older (76%, n=1850)

Female (55%, n=1338)

The 2439 participants, randomly divided into two groups,

intervention group had 1170 participants, control group included 1269 participants, in the two groups of education publicity materials in the mail after 4 weeks, get the results of the survey, by telephone survey of intervention group also includes an extra satisfaction project in the evening, from Monday to Friday, on Saturday morning and

afternoon, there are as many as 6 times trying to collect research data. All participants who complete the phone interview will receive a cash reward of $5.

T-test of continuous variables and chi- square test of

percentages were used to determine the similar statistical test between intervention group and control group. Cochran- mantel-haenszel test was used as

classification variable in two different waves.

Chi-square test and Cochran-Mantel- Haenszel test were used to calculate P value, which was statistically processed (p < 0.05).

B

(38)

Sibani, S., Driscoll, T., Davidson, P.M., Najafi, F., Jenkins, M.C.&

Leeder, S.R.

Country:Western Iran

Year of

publication:2016

Self-care and Its Predictors in Patients With

Chronic Heart Failure in Western Iran

A

quantitative approach

A cross- sectional study design

N=231

Mean age:66y

Men ,51.5%(n=119);wo men,48.5%(n=112)

Data were collected by three trained nurses through personal interviews. The location of interviews was determined by the participants. The data were collected by questionnaires, which included 13 questions about demography, and the second was self-care heart failure index.

After univariate analysis, considering the influence of other variables, multiple linear regression was used to analyze the variables related to the results. Delete the variable with the highest p value sequentially from the model, then run it again and repeat the process until the p value of all variables in the model is less than 0.05. As mentioned above, after removing the important

variables, the

C

(39)

interaction items involving the

remaining explanatory variables are tested again by using the reverse elimination method. Check

residuals to ensure that basic regression model assumptions are met.

Sethares, K.A.&

Asselin, M.E.

Country:America

Year of

publication:2017

The effect of guided reflection on heart failure self-care maintenance and

management:

A mixed methods study

A mixed approach

One-group mixed method pre- test/post-test study design

N=10

Mean age:70.6

Men ,60%(n=6);women ,40%(n=4)

A one-to-one structured family interview (1 hour) was conducted for each participant. The

interview was conducted by an experienced nurse around the Gibbs reflective cycle. A diary was kept for each participant. The author followed the participants by telephone every week to

Quantitative:Data is input to SPSS 22, cleaned up and analyzed. Descriptive statistics were

performed on all the variables studied.

Qualitative:quantitativ e

D

References

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