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Original Article

Influence of Social Support and Negative Emotional Status on Self-care Adherence in Symptomatic Patients with Heart Failure

In-Suk Yang
Korean Journal of Adult Nursing 2016;28(3):302-313.
Published online: June 30, 2016

Department of Nursing, Kyungil University, Gyeongsan, Korea

Corresponding author: Yang, In-Suk Department of Nursing, Kyungil University, 50 Gamasil-gil, Hayang-eup, Gyeongsan 38428, Korea. Tel: +82-53-600-5664, Fax: +82-53-600-5679, E-mail: insookyang@gmail.com
• Received: April 5, 2016   • Accepted: June 20, 2016

Copyright © 2016 Korean Society of Adult Nursing

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    The objective of this study was to identify factors related to self-care adherence in symptomatic patients with heart failure (HF).
  • Methods
    Using a cross-sectional design, a convenience sample 209 outpatient clinic patients were recruited at two medical centers. Between October 2011 and August 2012, data were collected using the structured questionnaire. Factors related to self-care adherence were examined using hierarchical multiple regression.
  • Results
    Mean age of participants was 67.71 years and a half of them (53.6%) were female. They showed relatively low self-care adherence with mean scores of 61.88±12.92. Lower self-care adherence was reported in asking for low sodium items, weighing oneself, checking for ankle edema, and exercising for 30 minutes. The overall model significantly explained 23.9% of variance in self-care adherence. Among the predictors, education, New York Heart Association functional classification, and social support were statistically significant in influencing self-care adherence. The variable of negative emotional status such as anxiety and depression were not found to be significant.
  • Conclusion
    These findings demonstrate that social support could help self-care adherence among symptomatic patients with HF. Thus, programs targeting self-care adherence in this population should consider the strategies improving social support.
  • Key Words: Social support; Anxiety; Depression; Self care; Heart failure
Table 1.
Differences in Self-Care Maintenance based on Sociodemographic and Clinical Characteristics (N=209)
Characteristics Categories   n (%) or M±SD Self-care maintenance
M±SD t or F or r p (Scheffé)
Age (year) ＜65   69 (33.0) 65.00±13.87 3.19 .043
65~74   70 (33.5) 60.86±11.73    
≥75   70 (33.5) 59.82±12.68    
Gender Male   97 (46.4) 64.97±12.20 3.30 .001
Female   112 (53.6) 59.20±12.98    
Education completed No formal educationa   24 (11.5) 53.13±10.84 4.70 .001
≤Elementary schoolb   75 (35.9) 60.60±12.29   (a＜b, c, d, e)
≤Middle schoolc   29 (13.9) 64.48±12.72    
≤High schoold   43 (20.6) 63.60±12.61    
≥Collegee   38 (18.2) 65.99±13.45    
Spouse No   100 (47.8) 60.40±12.38 -1.59 .113
Yes   109 (52.2) 63.23±13.30    
Occupation Unemployed   146 (69.9) 60.72±12.86 1.99 .048
Employed   63 (30.1) 64.56±12.75    
Monthly income ($) ＜2,000   125 (59.8) 61.36±12.47 -0.71 .481
≥2,000   84 (40.2) 62.65±13.59    
NYHA classification IIa   126 (60.3) 64.86±11.55 15.11 ＜.001
IIIb   61 (29.2) 60.00±13.17   (a＞b, c)
IVc   22 (10.5) 50.00±12.30   (b＞c)
Left ventricular ejection fraction (%) ≤50   116 (55.5) 62.26±13.27 0.48 .632
＞50   93 (44.5) 61.40±12.51    
NT pro-BNP (pg/mL)     4,092.10±7,125.53 61.88±12.92 -.04 .526
Etiology Coronary artery disease   48 (23.0) 61.72±13.03 1.39 .248
Hypertension   51 (24.4) 60.34±12.01    
Valvular heart disease   28 (13.4) 63.75±11.81    
Cardiomyopathy   60 (28.7) 64.04±13.36    
Other   22 (10.5) 57.50±14.31    
Time since diagnosed (month) ≤60   112 (53.6) 61.21±12.78 0.91 .437
61~120   45 (21.5) 64.17±13.79    
121~180   24 (11.5) 59.48±12.81    
≥181   28 (13.4) 62.95±12.15    
Number of hospitalization     1.91±3.59 61.88±12.92 -.04 .109
Number of medication 1~2   34 (16.3) 64.12±16.35 2.45 .089
3~4   112 (53.6) 62.83±12.41    
≥5   63 (30.1) 58.97±11.35    
Comorbidity* MI Yes 26 (12.4) 61.15±14.08 -0.31 .761
No 183 (87.6) 61.98±12.78    
Cerebrovascular disease Yes 36 (17.2) 59.93±13.41 -0.99 .321
No 173 (82.8) 62.28±12.82 -0.99 .321
Diabetes mellitus Yes 64 (30.6) 62.23±11.67 0.26 .796
No 145 (69.4) 61.72±13.47    
Moderate-severe renal disease Yes 12 (5.7) 65.42±15.03 0.98 .330
No 197 (94.3) 61.66±12.79    
Ulcerative disease Yes 20 (9.6) 56.13±14.59 -1.88 .074
No 189 (90.4) 62.49±12.62    

NYHA=New York Heart Association; MI=Myocardial Infarction; NT pro-BNP=N-terminal prohormone of Brain Natriuretic Peptide; *Multiple responses.

Table 2.
Social Support, Negative Emotional Status, and Self-Care Maintenance (N=209)
Variables Categories n (%) Actual range M±SD
Social support     1~5 2.67±1.15
 Directive guidance     1~5 2.60±1.25
 Emotional support     1~5 2.84±1.27
 Tangible support     1~5 2.63±1.08
 Social interaction     1~5 2.76±1.24
Negative emotional status
 Anxiety 0~7 138 (66.0) 0~21 6.09±4.68
8~10 31 (14.8)    
11~21 40 (19.1)    
 Depression 0~7 105 (50.2) 0~21 8.00±4.76
8~10 48 (23.0)    
11~21 56 (26.8)    
 Self-care maintenance ＜70 150 (71.8) 27.50~100 61.88±12.92
≥70 59 (28.2)    
Table 3.
Descriptive Statistics for Individual Items of the Self-care Maintenance Scale (N=209)
Items Never or rarely Sometimes Frequently Always or daily M±SD
n (%) n (%) n (%) n (%)
Weigh oneself 68 (32.5) 80 (38.3) 47 (22.5) 14 (6.7) 2.03±0.91
Check ankles for swelling 73 (34.9) 71 (34.0) 43 (20.6) 22 (10.5) 2.07±0.99
Prevent disease (e.g., flu shot, avoid ill people) 28 (13.4) 53 (25.4) 76 (36.4) 52 (24.9) 2.73±0.98
Do some physical activity 40 (19.1) 48 (23.0) 51 (24.4) 70 (33.5) 2.72±1.12
Keep doctor or nurse appointments 3 (1.4) 12 (5.7) 61 (29.2) 133 (63.6) 3.55±0.67
Eat a low sodium diet 67 (32.1) 55 (26.3) 48 (23.0) 39 (18.7) 2.28±1.10
Exercise for 30 minutes 90 (43.1) 53 (25.4) 26 (12.4) 40 (19.1) 2.08±1.15
Forget to take one of medications 9 (4.3) 8 (3.8) 34 (16.3) 158 (75.6) 3.63±0.76
Ask for low sodium items when eating out or visiting others 135 (64.6) 47 (22.5) 15 (7.2) 12 (5.7) 1.54±0.86
Use a pill box or reminders to remember taking medications 98 (46.9) 33 (15.8) 33 (15.8) 45 (21.5) 2.12±1.22
Table 4.
Bivariate Associations among Key Variables (N=209)
Variables Categories Negative emotional status Self-care maintenance
Anxiety Depression
r (p) r (p) r (p)
Social support   -.41 (＜.001) -.42 (＜.001) .31 (＜.001)
Negative emotional status Anxiety - .73 (＜.001) -.31 (＜.001)
Depression - - -.33 (＜.001)
Table 5.
Hierarchical Regression Model of Predicting Self-care Maintenance in Patients with Symptomatic Heart Failure (N=209)
Step Variables Categories β t p
Step 1 Age 65~74 -.10 -1.26 .208
≥75 -.08 -0.96 .338
Gender Male .05 0.63 .532
Education completed Elementary school .25 2.40 .017
Middle school .24 2.46 .015
High school .22 2.09 .038
≥College .25 2.25 .026
Occupation Employed .01 0.17 .866
NYHA Class III -.13 -1.92 .056
Class IV -.32 -4.74 ＜.001
Adjusted R2=.16, F=4.73, p＜.001
Step 2 Age 65~74 -.11 -1.40 .163
≥75 -.13 -1.51 .133
Gender Male .05 0.57 .571
Education completed Elementary school .26 2.54 .012
Middle school .23 2.47 .014
High school .19 1.83 .069
≥College .22 2.03 .043
Occupation Employed .05 0.77 .441
NYHA Class III -.12 -1.78 .077
Class IV -.29 -4.31 ＜.001
Social support   .25 3.64 ＜.001
Anxiety   -.08 -0.85 .398
Depression   -.04 -0.37 .709
Adjusted R2=.24, F=6.03, p＜.001

R2 Change=.09 (p＜.001); NYHA=New York Heart Association; Reference (Age:＜65, Gender: Female, Education: No formal education, Occupation: Unemployed, NYHA: Class II).

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    DOI: https://doi.org/10.7475/kjan.2016.28.3.302
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    DOI: https://doi.org/10.7475/kjan.2016.28.3.302
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    Influence of Social Support and Negative Emotional Status on Self-care Adherence in Symptomatic Patients with Heart Failure
    Influence of Social Support and Negative Emotional Status on Self-care Adherence in Symptomatic Patients with Heart Failure

    Differences in Self-Care Maintenance based on Sociodemographic and Clinical Characteristics (N=209)

    Characteristics Categories   n (%) or M±SD Self-care maintenance
    M±SD t or F or r p (Scheffé)
    Age (year) ＜65   69 (33.0) 65.00±13.87 3.19 .043
    65~74   70 (33.5) 60.86±11.73    
    ≥75   70 (33.5) 59.82±12.68    
    Gender Male   97 (46.4) 64.97±12.20 3.30 .001
    Female   112 (53.6) 59.20±12.98    
    Education completed No formal educationa   24 (11.5) 53.13±10.84 4.70 .001
    ≤Elementary schoolb   75 (35.9) 60.60±12.29   (a＜b, c, d, e)
    ≤Middle schoolc   29 (13.9) 64.48±12.72    
    ≤High schoold   43 (20.6) 63.60±12.61    
    ≥Collegee   38 (18.2) 65.99±13.45    
    Spouse No   100 (47.8) 60.40±12.38 -1.59 .113
    Yes   109 (52.2) 63.23±13.30    
    Occupation Unemployed   146 (69.9) 60.72±12.86 1.99 .048
    Employed   63 (30.1) 64.56±12.75    
    Monthly income ($) ＜2,000   125 (59.8) 61.36±12.47 -0.71 .481
    ≥2,000   84 (40.2) 62.65±13.59    
    NYHA classification IIa   126 (60.3) 64.86±11.55 15.11 ＜.001
    IIIb   61 (29.2) 60.00±13.17   (a＞b, c)
    IVc   22 (10.5) 50.00±12.30   (b＞c)
    Left ventricular ejection fraction (%) ≤50   116 (55.5) 62.26±13.27 0.48 .632
    ＞50   93 (44.5) 61.40±12.51    
    NT pro-BNP (pg/mL)     4,092.10±7,125.53 61.88±12.92 -.04 .526
    Etiology Coronary artery disease   48 (23.0) 61.72±13.03 1.39 .248
    Hypertension   51 (24.4) 60.34±12.01    
    Valvular heart disease   28 (13.4) 63.75±11.81    
    Cardiomyopathy   60 (28.7) 64.04±13.36    
    Other   22 (10.5) 57.50±14.31    
    Time since diagnosed (month) ≤60   112 (53.6) 61.21±12.78 0.91 .437
    61~120   45 (21.5) 64.17±13.79    
    121~180   24 (11.5) 59.48±12.81    
    ≥181   28 (13.4) 62.95±12.15    
    Number of hospitalization     1.91±3.59 61.88±12.92 -.04 .109
    Number of medication 1~2   34 (16.3) 64.12±16.35 2.45 .089
    3~4   112 (53.6) 62.83±12.41    
    ≥5   63 (30.1) 58.97±11.35    
    Comorbidity* MI Yes 26 (12.4) 61.15±14.08 -0.31 .761
    No 183 (87.6) 61.98±12.78    
    Cerebrovascular disease Yes 36 (17.2) 59.93±13.41 -0.99 .321
    No 173 (82.8) 62.28±12.82 -0.99 .321
    Diabetes mellitus Yes 64 (30.6) 62.23±11.67 0.26 .796
    No 145 (69.4) 61.72±13.47    
    Moderate-severe renal disease Yes 12 (5.7) 65.42±15.03 0.98 .330
    No 197 (94.3) 61.66±12.79    
    Ulcerative disease Yes 20 (9.6) 56.13±14.59 -1.88 .074
    No 189 (90.4) 62.49±12.62    

    NYHA=New York Heart Association; MI=Myocardial Infarction; NT pro-BNP=N-terminal prohormone of Brain Natriuretic Peptide; *Multiple responses.

    Social Support, Negative Emotional Status, and Self-Care Maintenance (N=209)

    Variables Categories n (%) Actual range M±SD
    Social support     1~5 2.67±1.15
     Directive guidance     1~5 2.60±1.25
     Emotional support     1~5 2.84±1.27
     Tangible support     1~5 2.63±1.08
     Social interaction     1~5 2.76±1.24
    Negative emotional status
     Anxiety 0~7 138 (66.0) 0~21 6.09±4.68
    8~10 31 (14.8)    
    11~21 40 (19.1)    
     Depression 0~7 105 (50.2) 0~21 8.00±4.76
    8~10 48 (23.0)    
    11~21 56 (26.8)    
     Self-care maintenance ＜70 150 (71.8) 27.50~100 61.88±12.92
    ≥70 59 (28.2)    

    Descriptive Statistics for Individual Items of the Self-care Maintenance Scale (N=209)

    Items Never or rarely Sometimes Frequently Always or daily M±SD
    n (%) n (%) n (%) n (%)
    Weigh oneself 68 (32.5) 80 (38.3) 47 (22.5) 14 (6.7) 2.03±0.91
    Check ankles for swelling 73 (34.9) 71 (34.0) 43 (20.6) 22 (10.5) 2.07±0.99
    Prevent disease (e.g., flu shot, avoid ill people) 28 (13.4) 53 (25.4) 76 (36.4) 52 (24.9) 2.73±0.98
    Do some physical activity 40 (19.1) 48 (23.0) 51 (24.4) 70 (33.5) 2.72±1.12
    Keep doctor or nurse appointments 3 (1.4) 12 (5.7) 61 (29.2) 133 (63.6) 3.55±0.67
    Eat a low sodium diet 67 (32.1) 55 (26.3) 48 (23.0) 39 (18.7) 2.28±1.10
    Exercise for 30 minutes 90 (43.1) 53 (25.4) 26 (12.4) 40 (19.1) 2.08±1.15
    Forget to take one of medications 9 (4.3) 8 (3.8) 34 (16.3) 158 (75.6) 3.63±0.76
    Ask for low sodium items when eating out or visiting others 135 (64.6) 47 (22.5) 15 (7.2) 12 (5.7) 1.54±0.86
    Use a pill box or reminders to remember taking medications 98 (46.9) 33 (15.8) 33 (15.8) 45 (21.5) 2.12±1.22

    Bivariate Associations among Key Variables (N=209)

    Variables Categories Negative emotional status Self-care maintenance
    Anxiety Depression
    r (p) r (p) r (p)
    Social support   -.41 (＜.001) -.42 (＜.001) .31 (＜.001)
    Negative emotional status Anxiety - .73 (＜.001) -.31 (＜.001)
    Depression - - -.33 (＜.001)

    Hierarchical Regression Model of Predicting Self-care Maintenance in Patients with Symptomatic Heart Failure (N=209)

    Step Variables Categories β t p
    Step 1 Age 65~74 -.10 -1.26 .208
    ≥75 -.08 -0.96 .338
    Gender Male .05 0.63 .532
    Education completed Elementary school .25 2.40 .017
    Middle school .24 2.46 .015
    High school .22 2.09 .038
    ≥College .25 2.25 .026
    Occupation Employed .01 0.17 .866
    NYHA Class III -.13 -1.92 .056
    Class IV -.32 -4.74 ＜.001
    Adjusted R2=.16, F=4.73, p＜.001
    Step 2 Age 65~74 -.11 -1.40 .163
    ≥75 -.13 -1.51 .133
    Gender Male .05 0.57 .571
    Education completed Elementary school .26 2.54 .012
    Middle school .23 2.47 .014
    High school .19 1.83 .069
    ≥College .22 2.03 .043
    Occupation Employed .05 0.77 .441
    NYHA Class III -.12 -1.78 .077
    Class IV -.29 -4.31 ＜.001
    Social support   .25 3.64 ＜.001
    Anxiety   -.08 -0.85 .398
    Depression   -.04 -0.37 .709
    Adjusted R2=.24, F=6.03, p＜.001

    R2 Change=.09 (p＜.001); NYHA=New York Heart Association; Reference (Age:＜65, Gender: Female, Education: No formal education, Occupation: Unemployed, NYHA: Class II).
    Table 1. Differences in Self-Care Maintenance based on Sociodemographic and Clinical Characteristics (N=209)

    NYHA=New York Heart Association; MI=Myocardial Infarction; NT pro-BNP=N-terminal prohormone of Brain Natriuretic Peptide; *Multiple responses.

    Table 2. Social Support, Negative Emotional Status, and Self-Care Maintenance (N=209)

    Table 3. Descriptive Statistics for Individual Items of the Self-care Maintenance Scale (N=209)

    Table 4. Bivariate Associations among Key Variables (N=209)

    Table 5. Hierarchical Regression Model of Predicting Self-care Maintenance in Patients with Symptomatic Heart Failure (N=209)

    R2 Change=.09 (p＜.001); NYHA=New York Heart Association; Reference (Age:＜65, Gender: Female, Education: No formal education, Occupation: Unemployed, NYHA: Class II).

    Table 1.

    Table 2.

    Table 3.

    Table 4.

    Table 5.

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