Barriers And Enablers To Self-care Behaviors Of Patients With Chronic Heart Failure Based On COM-B Model

Objectives:Utilizing the Capacity,Opportunity,Motivation-Behavior(COM-B)model,this study aimed to explore self-care behaviors(including self-care maintenance and self-care management)and to determine their barriers and enablers among patients with chronic heart failure,thus providing reference for designing intervention strategies and improving self-care behaviors.Methods:This study employed a cross-sectional design.A total of 321 patients with chronic heart failure were selected to participate in the study from November 2015 to April 2016.Data were collected with the Self-Care of Heart Failure Index(SCHFI),Duke Activity Status Index(DASI),Heart Failure Knowledge Test(HFKT),Health Literacy Scale for Patients with Chronic Disease,Multidimensional Scale of Perceived Social Support(MSPSS),MacArthur Scale of Subjective Socioeconomic Status,and a self-designed general information questionnaire.Data were analyzed using SPSS 20.0 and Mplus 7.0.Results:1.The scores for self-care maintenance ranged from 10.00 to 93.32 and the mean score was(48.42±15.86).Two hundred and nighty-eight patients(92.8%)scored less than 70.The scores for self-care management ranged from 10.00 to 95.00,and the mean score was(54.35±19.32).Two hundred and forty-three patients(75.7%)scored less than 70.2.The sociodemographic and clinical characteristics of patients with chronic heart failure were related to self-care behaviors.Age and LVEF were positively correlated with score for self-care maintenance,and patients who had lower education and lower average monthly income,were doing physical work and living in rural area,with disease duration less than 6 months,hospitalized due to heart failure less than 3 times,and had less than 3 comorbidities scored lower on self-care maintenance than those had higher education and higher average monthly income,were doing brainwork,freelance work or retired,and living in urban area,with disease duration equal to or more than 6 months,hospitalized due to heart failure equal to or more than 3 times,and had equal to or more than 3 comorbidities(P<0.05 or P<0.01).LVEF was negatively correlated with score for self-care management,and patients who were doing physical work and living in rural area,with disease duration less than 6 months,hospitalized due to heart failure less than 3 times,and had NYHA class II scored lower on self-care management than those were doing brainwork,freelance work or retired,and living in urban area,with disease duration equal to or more than 6 months,hospitalized due to heart failure equal to or more than 3 times,and had NYHA class III and IV(P<0.05 or P<0.01).3.The mean score for functional status was(18.27±1.90),and it was positively correlated with score for self-care management(r=0.163,P<0.01).The mean score for heart failure knowledge was(4.02±2.05),and it was positively correlated with scores for self-care maintenance and self-care management(r=0.218,0.453,P<0.01).The mean score for health literacy was(99.53± 12.51),and it was positively correlated with scores for self-care maintenance and self-care management(r=0.407,0.161,P<0.01).The mean score for social support was(64.71 ±7.41),and it was positively correlated with score for self-care maintenance(r=0.223,P<0.01).The mean score for socioeconomic status was(9.84±2.95),and it was positively correlated with score for self-care maintenance(r=0.189,P<0.01).The mean score for self-care confidence was(57.09±13.42),and it was positively correlated with scores for self-care maintenance and self-care management(r=0.260,0.400,P<0.01).4.The results of path analysis showed that health literacy,social support,self-care confidence,and age had direct effects on self-care maintenance,and direct effects were 0.265,0.159,0.128,and 0.139,respectively.Functional status,heart failure knowledge,self-care confidence,and LVEF had direct effects on self-care management,and direct effects were 0.115,0.303,0.324,and-0.133,respectively.In addition,heart failure knowledge,health literacy and social support indirectly affected self-care maintenance and self-care management through self-care confidence.This model can explain 27.2%of the variance in self-care maintenance and 34.9%of the variance in self-care management(R2=0.272,0.349).5.The results of mediation examination using bootstrapping showed that the mediation effects of self-care confidence in the relationships between heart failure knowledge,health literacy,social support and self-care maintenance were 0.032,0.023,and 0.025,respectively.The mediation effects of self-care confidence in the relationships between heart failure knowledge,health literacy,social support and self-care management were 0.075,0.054,and 0.058,respectively.All of the above mediation effects were significant.Conclusions:1.The levels of self-care maintenance and self-care management are relatively low in patients with chronic heart failure,and the majority of patients perform inadequate self-care behaviors.2.Patients with chronic heart failure report poor functional status,inadequate heart failure knowledge,moderate health literacy and social support,low self-confidence,and the majority of patients lack self-care confidence.3.Health literacy,social support,self-care confidence,and age directly affect the level of self-care maintenance among patients with chronic heart failure.Functional status,heart failure knowledge,self-care confidence,and LVEF directly affect the level of self-care management.In addition,heart failure knowledge,health literacy and social support indirectly affect the levels of self-care maintenance and management through the mediation of self-care confidence.4.Inadequate heart failure knowledge and lack of self-care confidence are barriers to self-care maintenance.Impaired functional status,inadequate heart failure knowledge,and lack of self-care confidence are barriers to self-care management.Higher levels of health literacy and social support are enablers to self-care maintenance and self-care management.5.In order to improve self-care maintenance and self-care management of patients with chronic heart failure,healthcare providers may use COM-B model as a theoretical framework,and implement targeted interventions according to above factors.