Patients’ Knowledge, Attitude, and Practice of Heart Failure: A web-based cross-sectional study

doi:10.21203/rs.3.rs-4694592/v1

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Patients’ Knowledge, Attitude, and Practice of Heart Failure: A web-based cross-sectional study

https://doi.org/10.21203/rs.3.rs-4694592/v1

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There is a lack of comprehensive research on the topic of knowledge, attitude, and practice (KAP) among heart failure patients. This study aimed to investigate the patients’ KAP toward heart failure (HF). This web-based cross-sectional study was conducted among HF patients, using a self-administered questionnaire. A total of 483 valid questionnaires were enrolled, including 254 (52.59%) males. The mean KAP scores were 10.75 ± 3.44 (possible range: 0–20), 22.93 ± 2.43 (possible range: 8–40), 32.21 ± 4.34 (possible range: 8–40), respectively. Multivariate logistic regression showed that knowledge and heart failure mid-range ejection fraction were independently associated with proactive practice. The SEM analysis showed that education exhibited a positive effect on knowledge, while medical insurance showed a notable negative effect on knowledge. Furthermore, left ventricular ejection fraction #10 score demonstrated a positive effect on knowledge, and marital status had a significant positive effect on knowledge. Additionally, kidney disease emerged as a positive effect on practice, while attitude was found to have a negative effect on practice. HF patients had inadequate knowledge, negative attitude and proactive practice towards HF. Targeted educational initiatives, mental health support, and interventions addressing comorbidities and lifestyle changes are recommended to be integrated into HF management protocols.

Knowledge

Attitude

Practice

Heart Failure

Patients

Cross-sectional study

Heart failure (HF), the end stage of various heart diseases such as ischemic heart disease, valvular disease, and heart myopathy, can be categorized into heart failure with preserved ejection fraction (HFpEF), heart failure mid-range ejection fraction (HFmrEF), and heart failure with reduced ejection fraction (HFrEF) [1–3]. Despite considerable therapeutic progress, approximately 10% of HF patients ultimately advance to end-stage HF[4]. With the escalating prevalence of HF, there is an immediate and critical need for exhaustive research and holistic, patient-centered approaches to effectively address this multifaceted condition and provide optimal care and management to a large global population[5].

The knowledge, attitude, and practice (KAP) questionnaire is a vital tool in healthcare for comprehensively assessing the knowledge, attitude, and behavior of a target population while also gauging their demand for and acceptance of relevant content[6–8]. The KAP model elucidates that individual behaviors are shaped by their knowledge and attitude, with the process of behavior change comprising three sequential stages: knowledge acquisition, attitude and belief formation, and the translation of these into practical behaviors[9]. Furthermore, in the context of diseases, self-management emerges as a vital concept for maintaining health and effectively managing illnesses, with self-management interventions ultimately bolstering individuals' capacity to enhance their health status [10]. However, it is important to note that there is a lack of comprehensive research on the topic of KAP among heart failure patients. This systematic approach offers a methodical lens for a thorough examination of the experiences and perceptions of individuals grappling with the intricacies of HF. Therefore, this study aimed to investigate the KAP of HF patients towards HF.

Study design and participants

This cross-sectional study was conducted at Chongqing People's Hospital between April May 2023 among HF patients. Inclusion criteria: 1) heart failure with preserved ejection fraction, Heart failure with preserved ejection fraction, left ventricular ejection fraction, left ventricular ejection fraction, heart failure with mildly reduced ejection fraction, Heart failure with mildly reduced ejection fraction, heart failure with reduced ejection fraction (HFrEF); 2) Age ≥ 18 years. Exclusion criteria: 1) Age ≥ 85 years old; 2) Diagnose patients with acute heart failure. This study was approved by the Ethic Committee of Chongqing People's Hospital(KY S2023-079-01), and all participants provided written informed consent.

Procedures

A self-administered questionnaire was developed with the based on the 2018 Chinese guidelines for heart failure diagnosis and treatment [11], encompassed four dimensions. Following input from four cardiovascular experts, it underwent refinement to eliminate redundancy and enhance clarity. The final questionnaire includes: 1) demographic information of participants, such as age, gender, residence, education, work status, and income; 2) knowledge dimension, comprising 10 questions with scoring as well-understood (2 points), heard of (1 point), or unclear (0 points); 3) attitude dimension, consisting of 8 questions using a five-point Likert scale ranging from very positive (5 points) to very negative (1 point); 4) practice dimension, including 9 questions also using a five-point Likert scale ranging from always (5 points) to never (1 point). Higher scores indicate better knowledge, more positive attitudes, and more proactive practices.

Before the official launch, a preliminary pilot test was carried out, involving a sample size of 50 participants, which resulted in a Cronbach's α coefficient of 0.875, indicating a good internal consistency. Further examination of the internal consistency within the questionnaire's knowledge, attitude, and practice sections yielded Cronbach's α coefficients of 0.819, 0.582, and 0.846, respectively, indicating a commendable level of internal consistency among the items within each section. Six research assistants, all certified nurses with extensive clinical nursing experience exceeding five years in the cardiology department, were responsible for distributing the questionnaires. They were thoroughly acquainted with the research protocol. Convenience sampling was employed to recruit participants, using phone calls, WeChat, and QQ to reach potential respondents. During the survey process, the research assistants facilitated by posing clarifying questions while participants provided genuine feedback. In the event of any uncertainties, the research assistants offered guidance without influencing or biasing the responses. The questionnaire was administered through the WeChat-based Wenjuanxing app, which generated a QR code for data collection via WeChat. Participants accessed and completed the survey by scanning this QR code through WeChat. To ensure the quality and completeness of the data, all questionnaire items were mandatory, and the research team diligently assessed submitted questionnaires for completeness, internal consistency, and logical coherence. A blank questionnaire translated into English is attached as an Appendix.

Statistical analysis

The statistical software used was Stata 17.0 (Stata Corporation, College Station, TX, USA). Quantitative variables were described using mean ± standard deviation (SD), and group comparisons utilized t-tests or analysis of variance. Categorical variables were described as n (%). Pearson correlation analysis was employed to assess correlations among knowledge, attitude, and practice scores. Logistic regression was used for univariate and multivariate analyses of practice, with scores using 70% of the total score as the cut-off value[12]. Inclusion of multiple regression variables used single-factor variables with P-values < 0.05. Hypotheses (H1: Knowledge was effected by age, education, medical insurance, and left ventricular ejection fraction #10 score; H2: Attitude was effected by monthly per capita income, marital status, and knowledge; H3: Practice was effected by kidney disease, left ventricular ejection fraction #10 score, attitude, and knowledge) were validated using structural equation modeling (SEM). All statistical tests were two-tailed, and a p-value less than 0.05 was considered statistically significant.

Initially, a total of 499 responses were collected from participants. However, a number of questionnaires were excluded from the analyses based on specific criteria: including, 2 questionnaires with abnormal age values, 1 questionnaire with unreasonable response times, 5 questionnaires with unreasonable responses to the questions (smoking, medical insurance type, and left ventricular ejection fraction), and 9 questionnaires with incomplete or incorrectly entered data. Consequently, the final dataset consisted of 483 valid questionnaires. Among them, there were 254 (52.59%) males, while 246 (50.93%) participants fell within the 60–80 age range, 372 (77.02%) from urban areas, with 325 participants (67.29%) being retired. Moreover, the majority of participants had junior high school or lower education, accounting for 216 (44.72%) individuals, 97 (40.58%) with a monthly per capita income > 10,000 yuan, and marital status predominantly consisted of 446 married participants (92.34%). Smoking habits showed 370 (76.6%) never smoked. Finally, left ventricular ejection fraction status revealed 197 (40.79%) with HF with preserved ejection fraction (HFpEF) (Table 1).

Table 1

Demographic characteristics
Variables	N(%)	Knowledge, mean ± SD	P	Attitude, mean ± SD	P	Practice, mean ± SD	P
Total Score		10.75 ± 3.44		22.93 ± 2.43		32.21 ± 4.34
Gender			0.915		0.313		0.404
Male	254(52.59)	10.76 ± 3.74		22.82 ± 2.46		32.33 ± 4.5
Female	229(47.41)	10.73 ± 3.09		23.05 ± 2.41		32.08 ± 4.17
Age, year			0.028		0.648		0.449
< 60	78(16.15)	11.1 ± 3.68		22.97 ± 2.1		31.9 ± 4.77
60–80	246(50.93)	10.29 ± 3.44		22.97 ± 2.39		32.39 ± 4.42
> 80	159(32.92)	11.29 ± 3.24		22.84 ± 2.66		32.09 ± 4.01
Residence			0.139		0.654		0.940
Rural	41(8.49)	9.68 ± 4.07		23.05 ± 2.05		32.17 ± 4.09
Urban	372(77.02)	10.86 ± 3.3		22.9 ± 2.48		32.18 ± 4.44
Suburban	70(14.49)	10.77 ± 3.7		23.03 ± 2.4		32.41 ± 4.01
Education			0.003		0.178		0.785
Junior High School or Below	216(44.72)	10.35 ± 3.643		23.13 ± 2.367		32.2 ± 4.545
High School/Technical School/College	102(21.12)	10.2 ± 3.574		22.87 ± 2.174		31.72 ± 4.288
Bachelor's Degree or Above	165(34.16)	11.62 ± 2.895		22.7 ± 2.654		32.53 ± 4.1
Occupation			0.132		0.063		0.397
Retired	325(67.29)	10.56 ± 3.42		22.78 ± 2.41		32.31 ± 4.13
Not Retired	158(32.71)	11.15 ± 3.47		23.23 ± 2.46		32.01 ± 4.77
Monthly Per Capita Income, Yuan			0.127		0.029		0.932
< 5,000	190(1.04)	10.53 ± 3.73		23.1 ± 2.433		32.16 ± 4.305
5,000–10,000	196(38.3)	10.83 ± 3.234		22.56 ± 2.327		32.31 ± 4.331
> 10,000	97(40.58)	11.02 ± 3.263		23.33 ± 2.565		32.12 ± 4.487
Marital Status			0.434		0.013		0.698
Married	446(92.34)	10.79 ± 3.44		22.86 ± 2.44		32.22 ± 4.39
Other	37(7.66)	10.30 ± 3.53		23.76 ± 2.25		32.14 ± 3.83
Underlying disease
Diabetes	104(21.53)	10.63 ± 3.45	0.635	23.1 ± 2.36	0.426	32.72 ± 4	0.190
Hypertension	286(59.21)	10.98 ± 3.36	0.120	22.81 ± 2.5	0.292	32.57 ± 4.22	0.067
Kidney disease	47(9.73)	10.81 ± 3.79	0.980	22.94 ± 2.75	0.931	33.53 ± 4.4	0.021
Other diseases	143(29.61)	10.42 ± 3.49	0.217	23.04 ± 2.46	0.760	31.28 ± 4.58	0.009
Medical insurance			0.022		0.727		0.080
Only social medical insurance	439(90.89)	10.91 ± 3.41		22.91 ± 2.52		32.35 ± 4.38
Only commercial medical insurance	1(0.21)	9		23		34
Both	39(8.07)	9 ± 3.49		23.1 ± 1.43		30.87 ± 3.79
None	4(0.83)	10.25 ± 2.5		23.25 ± 0.5		29.5 ± 3.79
Smoking Habit			0.465		0.393		0.246
Never Smoked	370(76.6)	10.78 ± 3.36		22.88 ± 2.48		32.28 ± 4.36
Former Smoker	52(10.77)	10.92 ± 4.44		22.94 ± 2.17		32.6 ± 4.27
Current Smoker	61(12.63)	10.43 ± 3.00		23.23 ± 2.38		31.44 ± 4.30
Left Ventricular Ejection Fraction Status			< 0.0001		0.106		0.019
Heart Failure with Reduced Ejection Fraction (HFrEF)	144(29.81)	9.58 ± 3.69		22.99 ± 2.26		31.62 ± 4.51
Heart Failure with Preserved Ejection Fraction (HFpEF)	197(40.79)	11.4 ± 3.17		22.74 ± 2.61		32.17 ± 4.26
Heart Failure with Mid-range Ejection Fraction (HFmrEF)	142(29.4)	11.04 ± 3.26		23.12 ± 2.34		32.87 ± 4.23

The mean scores of knowledge, attitude and practice were 10.75 ± 3.44 (possible range: 0–20), 22.93 ± 2.43 (possible range: 8–40), 32.21 ± 4.34 (possible range: 8–40), respectively. Notably, the knowledge score varied from heart failure patients with different age (p = 0.028), education (p = 0.003), and left ventricular ejection fraction status (p < 0.001). Additionally, as for the attitude score, there were difference among them with different monthly per capita income (p = 0.029). Finally, the difference of practice score were found among them with different left ventricular ejection fraction status (p = 0.019) (Table 1).

The distribution of knowledge dimensions revealed that the three questions with the highest number of participants choosing the "Well Understood" option were "Heart failure (HF) is a severe manifestation or advanced stage of various heart diseases," (K1) with 53.42%, "HF is mainly characterized by difficulties in breathing, fatigue, and fluid retention (pulmonary congestion, systemic congestion, and peripheral edema)" (K2) with 34.16%, and "Diuretics can eliminate sodium and water retention, improve congestion, and relieve breathing difficulties and edema" (K3) with 25.67%. Conversely, the three questions with the highest number of participants choosing the "Uncertain" option were "Avoiding triggers like respiratory infections, overexertion, and emotional fluctuations in daily life is important." (K7) with 26.5%, "If drug therapy is ineffective and HF worsens repeatedly, comprehensive treatment measures and surgical interventions need to be considered." (K4) with 24.43%, and "During HF exacerbations, patients should rest in bed; performing passive leg exercises in bed can prevent deep vein thrombosis. After clinical improvement, moderate activity is recommended, avoiding muscle disuse atrophy." (K8) with 23.81% (Table S1).

Regarding attitudes, what seems to give cause for optimism is a significant majority of the patients (76.19% totally) agreed or strongly agreed that they are willing to actively follow the treatment plan (A3). Similarly, a high percentage (69.36% totally) claimed that they hope to receiving more health education from doctors to assist them in managing the disease (A4). Additionally, an overwhelming (61.9% totally) of the patients realised that the disease is caused by poor lifestyle or unhealthy habits, and they plan to be more attentive and proactively intervene (A5). However, it is worth noting that a considerable portion (50.32% totally) of the patients admitted to being very afraid of exercise and reluctant to engage, even if it may be beneficial (A8). Meanwhile, what's worrying is that a substantial number of patients acknowledged feelings of depression, anxiety, and unease, with 19.25% strongly agreeing and 56.94% agreeing that they often experience such emotions (A1). Furthermore, 16.77% strongly agreed, and 42.65% agreed that they feel a loss of control and autonomy, helpless and powerless against the disease (A2). These findings illuminate the complex attitudes and emotional states of patients in response to their disease and treatment (Table S1).

In practice dimension, 21.12% of participants consistently adhere to prescribed medications (P3.1), regular follow-up (P2) is a common practice among 43.06% of participants. On the other hand, lifestyle changes, including quitting bad habits (P1), show varying levels of commitment, 44.31% often engage in such changes, 25.67% do so only sometimes, and 14.08% occasionally adopt these practices. Furthermore, medication-related practices (P3.2) show that 39.54% often use methods to ensure timely medication, 29.61% do so sometimes, whereas 15.53% occasionally or never follow these methods for the time control of medication administration (Table S1).

The Pearson correlation analysis revealed that knowledge was negatively correlated with attitude (r = -0.200, P < 0.001), attitude and practice were negatively correlated (r = -0.156, P = 0.001), conversely, there was a positive correlation between knowledge and practice (r = 0.198, P < 0.001) (Table 2).

Table 2

Pearson correlation analysis
	Knowledge	Attitude	Practice
Knowledge	1
Attitude	-0.200(P < 0.001)	1
Practice	0.198(P < 0.001)	-0.156(P = 0.001)	1

Multivariate logistic regression showed that knowledge (OR = 1.078, 95% CI: 1.02–1.14, P = 0.008) and HFmrEF (OR = 1.781, 95% CI: 1.097–2.891, P = 0.02) were independently associated with proactive practice (Table 3).

Table 3

Univariate and multivariate logistic regression analysis
Practice	Univariate logistic regression		Multivariate logistic regression
	OR (95%CI)	P	OR (95%CI)	P
Knowledge	1.091(1.034–1.151)	0.001	1.078(1.02–1.14)	0.008
Attitude	0.919(0.853–0.991)	0.028	0.928(0.86–1.002)	0.057
Gender
Male	REF
Female	0.868(0.607–1.243)	0.44
Age, year
< 60	REF
60–80	1.488(0.892–2.481)	0.128
>80	1.241(0.721–2.135)	0.435
Residence
Rural	REF
Urban	1.361(0.713–2.599)	0.35
Suburban	1.737(0.798–3.782)	0.164
Education
Junior High School or Below	REF
High School/Technical School/College	0.752(0.469–1.206)	0.237
Bachelor's Degree or Above	1.207(0.801–1.818)	0.368
Occupation
Retired	REF
Not Retired	1.151(0.786–1.684)	0.471
Monthly Per Capita Income
< 5,000	REF
5,000–10,000	1.278(0.856–1.909)	0.23
> 10,000	1.155(0.707–1.886)	0.565
Marital Status
Married	REF
Other	0.784(0.401–1.534)	0.478
Underlying disease
Diabetes	0.806(0.171–3.789)	0.785
Hypertension	0.907(0.498–1.654)	0.75
Kidney disease	0.975(0.488–1.949)	0.942
Other diseases	2.017(0.605–6.718)	0.253
Smoking
Never Smoked	REF
Former Smoker	1.606(0.875–2.945)	0.126
Current Smoker	0.721(0.419–1.242)	0.239
Left Ventricular Ejection Fraction Status
Heart Failure with Reduced Ejection Fraction (HFrEF)	REF		REF
Heart Failure with Preserved Ejection Fraction (HFpEF)	1.25(0.813–1.922)	0.31	1.076(0.688–1.682)	0.748
Heart Failure with Mid-range Ejection Fraction (HFmrEF)	1.934(1.206–3.104)	0.006	1.781(1.097–2.891)	0.02

The SEM analysis showed that education exhibited a positive effect on knowledge (β = 0.366, P = 0.001), while medical insurance showed a notable negative effect on knowledge (β = -0.649, P = 0.010). Furthermore, left ventricular ejection fraction #10 score demonstrated a positive effect on knowledge (β = 0.591, P = 0.003), and marital status had a significant positive effect on knowledge (β = 0.876, P = 0.032). Additionally, kidney disease emerged as a positive effect on practice (β = 0.486, P = 0.023), while attitude was found to have a negative effect on practice (β = -0.192, P = 0.015) (Fig. 1 and Table 4). The SEM model yielded favorable model fit indices, as indicated in Table S2, suggesting a well-fitting model.

Table 4

Total effects
			Estimate	S.E.	C.R.	P
Knowledge	<---	Age	0.091	0.223	0.409	0.683
Knowledge	<---	Education	0.366	0.114	3.202	0.001
Knowledge	<---	Medical Insurance	-0.649	0.251	-2.584	0.010
Knowledge	<---	Left Ventricular Ejection Fraction #10 Score	0.591	0.197	3.000	0.003
Attitude	<---	Monthly Per Capita Income	0.090	0.146	0.616	0.538
Attitude	<---	Marital Status	0.876	0.409	2.140	0.032
Attitude	<---	Knowledge	-0.109	0.032	-3.433	< 0.001
Practice	<---	Kidney Disease	0.486	0.214	2.275	0.023
Practice	<---	Left Ventricular Ejection Fraction #10 Score	0.462	0.249	1.855	0.064
Practice	<---	Attitude	-0.192	0.079	-2.428	0.015
Practice	<---	Knowledge	0.244	0.057	4.303	< 0.001

This study suggested that HF patients showed inadequate knowledge, negative attitude and proactive practice towards HF. Incorporating targeted educational initiatives, bolstered by robust mental health support, alongside comprehensive interventions to address comorbidities and facilitate lifestyle modifications, are strongly recommended for seamless integration into the management protocols for HF.

The study's results provide valuable insights into the knowledge, attitudes, and self-care practices of HF patients. Participants demonstrated insufficient knowledge regarding HF, underscoring the need for comprehensive education initiatives to improve their understanding of the condition. Moreover, the presence of negative attitudes toward HF management raises concerns about potential barriers to effective care. Encouragingly, the study identified pockets of proactive self-care practices, indicating areas of strength that can be built upon. Addressing these knowledge deficits, mitigating negative attitudes, and further promoting proactive self-care practices should be prioritized in future interventions to enhance the clinical management of HF [13, 14].

The observed correlation between age and knowledge underscores the importance of tailoring educational strategies to different age groups. Younger patients may require more comprehensive information about HF, given their lower baseline knowledge. In contrast, older patients, who demonstrated higher knowledge levels, might benefit from interventions focusing on the practical aspects of managing their condition, such as adherence to treatment plans[15, 16].

The discrepancies in knowledge highlighted in our study pinpoint specific areas where patient education can be improved. Patients' uncertainty about avoiding HF triggers and the necessity of comprehensive treatment measures during worsening HF indicates the need for clear and concise communication between healthcare providers and patients[17–19]. Educating patients about these aspects may lead to more proactive self-care and fewer HF exacerbations.

The emotional challenges reported by a substantial portion of patients, including feelings of depression, anxiety, and unease, deserve special attention in clinical practice. Healthcare providers should be trained to recognize and address these emotional states effectively[20, 21]. Offering psychological support and integrating mental health professionals into HF care teams could help patients cope with these emotional burdens and enhance their overall quality of life[22, 23].

While the majority of participants reported adherence to prescribed medications and regular follow-up, there is room for improvement in lifestyle changes and medication-related practices. Healthcare providers should actively engage patients in discussions about lifestyle modifications and offer practical guidance on implementing healthier habits[24, 25]. Moreover, patient education on medication management and timely administration should be reinforced to ensure optimal therapeutic outcomes[26–28].

The correlations among knowledge, attitude, and practice emphasize the complexity of patient behavior in managing HF. Enhancing patient knowledge can positively influence self-care practices[6, 29, 30]. However, the negative correlation between attitude and both knowledge and practice suggest that patient attitudes can act as barriers. Clinicians should recognize and address these attitudes through patient-centered care and tailored interventions.

The identification of knowledge and HFmrEF as independent predictors of proactive practice reaffirms the significance of knowledge dissemination and patient education[31, 32]. This finding highlights the need for tailored educational interventions for patients with different HF subtypes, ensuring that they receive the appropriate information and support to actively manage their condition. The SEM analysis provides a holistic view of the factors affecting knowledge, attitude, and practice in HF patients. It underscores the positive impact of education on knowledge and hints at the potential challenges posed by healthcare access disparities associated with certain insurance types[33, 34]. The positive influence of marital status on knowledge highlights the role of social support in HF management [35].

This study had limitations. The cross-sectional design restricts causal inference and temporal changes, while the specific geographic focus limits generalizability. The study does not thoroughly account for confounding variables, lacks contextual information, and relies on various measurement scales without details on their validation. Additionally, the study may suffer from social desirability bias, and its outcome measures are limited to knowledge, attitude, and practice, potentially missing other vital aspects of HF management.

In conclusion, HF patients showed inadequate knowledge, negative attitude and proactive practice towards HF. Implementing tailored patient education programs targeting knowledge gaps, particularly among younger patients and those with HFmrEF are recommended, while also integrating mental health support to address emotional distress. Additionally, healthcare providers should intensify efforts to promote lifestyle changes and medication adherence, all while considering the influence of social factors such as marital status and education, to provide more holistic and patient-centered care is recommended.

Ethics approval and consent to participate

This work has been carried out in accordance with the Declaration of Helsinki (2000) of the World Medical Association. This study was approved by the Ethic Committee of Chongqing People's Hospital(KY S2023-079-01), and all participants provided written informed consent.

Consent for publication

Not applicable.

Availability of data and materials

All data generated or analyzed during this study are included in this article and supplementary information files.

Competing interests

The authors declare that they have no competing interests.

Funding

None

Authors' contributions

Ping Jin, Zhisong Shu, Zhenhong Ou and Hongping Li carried out the studies, participated in collecting data, and drafted the manuscript. Ping Jin and Kun Cui performed the statistical analysis and participated in its design. Ping Jin, Hongping Li and Yuhui Luo participated in acquisition, analysis, or interpretation of data and draft the manuscript. All authors read and approved the final manuscript.

Acknowledgements

None.

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No competing interests reported.

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Patients’ Knowledge, Attitude, and Practice of Heart Failure: A web-based cross-sectional study

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