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Research Article

Quality of life among patients with chronic heart failure in Nam Dinh Province, Vietnam

[version 1; peer review: 1 not approved]
PUBLISHED 26 Jun 2023
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This article is included in the QUVAE Research and Publications gateway.

Abstract

Background: This study aimed to assess the quality of life of patients with chronic heart failure (HF) to improve their treatment and care.
Methods: This study was conducted to evaluate the quality of life of 89 patients suffering from chronic heart failure and was assessed using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). In addition, the presence of depressive symptoms and perception of social support were also assessed by the Beck Depression Inventory-II (BDI-II) and the Multidimensional Scale of Perceived Social Support (MSPSS).
Results: Of the 89 HF patients, 53.9% were female and 46.1% were male. The mean age of 89 patients was 62.28±13.26 years old, of which 64% were 60 years old and older. The mean time that patients lived with HF was 8.49±4.59 years. The overall Minnesota Living with Heart Failure Questionnaire mean score was high at 67.19±13.31 points. Regarding personal characteristics, the Minnesota Living with Heart Failure Questionnaire scores were significantly higher in women vs men, widowed/divorced vs being married patients, and patients living alone vs living with family detailed (67.52±11.80 vs 66.80±15.02; p=0.032), (67.58±11.62 vs 65.27±20.11; p=0.000), and (73.3±14.95 vs 66.50±13.04; p=0.014), respectively. Regarding heart failure associated features, the Minnesota Living with Heart Failure Questionnaire scores were significantly higher in patients living with longer heart failure, in more severity of Beck Depression Inventory-II, and lower levels of social support (all p-values of 0.000).
Conclusions: The results of the study showed a poor quality of life in patients with chronic heart failure and raised concerns about improving the patients’ quality of life.

Keywords

Heart failure, patients, quality of life, Vietnam

Introduction

In addition to population aging and improvements in cardiovascular diagnosis and treatment, heart failure (HF) is a global clinical and public health problem that is increasing at an alarming rate worldwide.1 HF is associated with increased morbidity and mortality, places a significant burden on the health care system, and is one of the leading causes of hospitalization for adults and the elderly.2 Along with advances in disease diagnosis and treatment, assessing the quality of life (QoL), especially in chronic patients who have to live for many years with the same disease, is considered as one of the important activities in promotion of patient-centred care in which the patient’s views, experiences, and wishes are set forth, help with care decision-making, and ensures that the patient’s wishes are taken into account to guide better management of their condition.3,4

Studies on QoL in patients with chronic HF reflect a common fact that the patients’ QoL was low.5,6 In recent years in Vietnam, as the role of nursing care has been increasingly confirmed, assessment of QoL in patients with chronic conditions, including heart failure, has begun to gain more attention. Beside progress in diagnosis and treatment of HF patients in Nam Dinh province, the patient’s QoL need to be concerned. This study was conducted to assess the QoL of patients with chronic HF in the Province, as baseline data for planning to improve the quality of care and healthcare provision.

Methods

Study patients

The descriptive study design was used and the sample size was conducted by using the sample size formular for descriptive study

n=Z1α/22p1pd2

n: The appropriate sample size with probability α = 0.05 with Z1-α/2 = 1.96; p: Estimating the rate of good quality of live in patients with heart failure (p = 0.785); d: margin of error, d = 0.08. Substituting into the formula, the study sample size was 72. Finally, the sample size consisted of 89 HF patients who were conveniently selected from March 2022 to May 2022 at Nam Dinh Provincial Genereal Hospital, Vietnam.

Criteria for selecting patients into the study included i) age from 18 years old and above, ii) diagnosed with HF, iii) be able to read and write with no matter affecting the ability to communicate, iv) agree to participate in the study. The exclusion criteria were i) patients in a severe condition requiring intensive care; ii) patients with other chronic diseases such as chronic kidney disease (CKD); cirrhosis; chronic obstructive pulmonary disease (COPD); diabetes mellitus; rheumatoid arthritis, etc., which affecting her/his quality of life; iii) patients was first diagnosed with heart failure. The data collection was conducted while the patients received treatment at the Cardiology Department.

General strategies we employed to address sources of bias in the proposed study

Study design: Choosing an appropriate study design and using appropriate control or comparison groups can help minimize biases. Randomizing the allocation of participants to different groups and implementing blinding (single-blind or double-blind) can help reduce selection and information bias. Sample size calculation: Conducting a sample size calculation before the study helps to ensure an adequate number of participants to achieve statistically meaningful results, which can reduce the impact of bias. Participant recruitment: Employing a systematic and unbiased approach to participant recruitment can help to minimize selection bias. This may involve using predefined inclusion and exclusion criteria and avoiding preferential selection of certain individuals. Data collection and measurement: Implementing standardized protocols and validated tools for data collection and measurement can help ensure consistency and accuracy, and reduce measurement bias.

Research measurement

For personal characteristics of the participated patients, age, gender, job, education, marital status, and living status and for features related to heart failure, stage of HF, feeling depressed, and social support were collected.

Based on New York Heart Association (NYHA)7 classifications, heart failure patients are divided into four stages: NYHA I: Patients who have cardiac disease without any resulting limitations on physical activity. In NYHA II, patients had cardiac disease that slightly limited their physical activity. They were comfortable when at rest. In NYHA III patients, there was marked restriction in physical activity due to cardiac disease. They felt comfortable while resting. NYHA IV: Patients were unable to perform physical activity without discomfort owing to cardiac disease. Symptoms of anginal syndrome or cardiac insufficiency can manifest at rest.

In order to measure the QoL of HF patients, this study used the Minnesota Living with Heart Failure Questionnaire (MLHFQ), a commonly used tool to measure the HF patients’ QoL,8 the MLHFQ consists of 21 questions, each valued from 0 to 5, asked the patient how much the heart failure affected her/his life during the past 4 weeks, corresponding to from “No” to “Very much”. The total score ranged from 0 to 105 points, the overall MLHFQ score of each patient was calculated from the scores for all questions, the higher overall MLHFQ scores indicate the poorer QoL. The scores were classified into 3 levels9: < 24 points, 24 – 45 points and > 45 points correspond to high, moderate and poor levels of QoL, respectively.

To assess the presence and severity in depressive symptoms, the Beck Depression Inventory-II (BDI-II),10 the BDI-II consists of 21 self-reported items from 0 to 3 points and a range of scores from 0 to 63 points, classified into 4 levels11: 0–13 points, 14–19 points, 20–29 points and 30–63 points correspond to no depression, mild depression, moderate depression and severe depression, respectively.

The Multidimensional Scale of Perceived Social Support, a 12-item report of perceived adequacy of social support from three sources: family, friends, and significant other12 was also used in this study, each report has 7 choices from 1 corresponding to “Strongly disagree” to 7 corresponding to “Strongly agree” and the scores range from 12–84 points, divided into 3 levels13: 12–48 points, 49–68 points, 69–84 points correspond to low, moderate and high levels of social support, respectively.

Ethical considerations

This study was approved by Nam Dinh University Scientific and Human Research Ethics Committee (IRB-VN01012: No.469/GCN-HDĐD dated 03/3/2022). The purpose of the study was explained to patients who met the inclusion criteria. The study involved voluntary participation, anonymity was preserved, and the participants signed consent forms before participating. All patients were informed that they could refuse to participate or discontinue participation at any time.

Data analysis

The characteristics and features of the participants were described using frequency, percentage, mean, and standard deviation. ANOVA and T-tests were used if more than two means needed to be compared. Statistical significance was determined at a p-value of 0.05, and the data were analyzed using SPSS statistical software, version 25.

Results

The mean age of 89 patients in the study was 62.28 ± 13.26 years (median: 65), the youngest was 33 years old and the oldest was 88 years old.24 The mean duration living with HF since the first HF diagnosis was 8.49 ± 4.59 years (median: 8), the shortest was 1 year and the longest was 21 years. All the 89 participants selected based on the criteria completed the study.

The overall Minnesota Living with Heart Failure Questionnaire (MLHFQ) mean score of 89 patients was 67.19 ± 13.31 points, the lowest score was 33 points and the highest score was 98 points. There were 89.9% of the total patients who had the overall MLHFQ score more than 45 points and no one had MLHFQ score less than 24 points. The scores of physical and emotional domains were 25.78 ± 5.98 points and 16.80 ± 4.19 points, respectively.

The majority of patients (64%) were over 60 years old and the proportions of male and female patients were 46.1% and 53.9%, respectively. More than half of participants (57.3%) were farmers. Regarding educational level, 42.7% of participants graduated from secondary school, no one had a university degree or higher. The percentages of patients living with a spouse and living with family were 83.1% and 89.9%, respectively.

The MLHFQ scores were higher (i.e. poorer QoL) in female patients compared with male patients (67.52 ± 11.80 points vs 66.80 ± 15.02 points; p-value of 0.032), divorced; single; widowed patients compared with married patients (67.58 ± 11.62 points vs 65.27 ± 20.11 points; p-value of 0.000), patients living alone compared with patients living with family (73.33 ± 14.95 points vs 66.50 ± 13.04 points; p-value of 0.014).

The number of patients lived with HF for 6-10 years, had NYHA-III, had severe depressive symptoms, and perceived low social support accounted for high percentages in the study sample which were 48.3%, 50.5%, 89.9%, and 86.5%, respectively.

The MLHFQ scores were higher (i.e. poorer QoL) in patients lived longer with HF, had more severe heart failure, had more severe depression, and had lower levels of social support in comparison with patients who had lower levels of corresponding features (all p-values of 0.000).

Discussion

The mean age of the HF patients in our study was 62.28 ± 13.26 years old. This age may be similar to or different from the age of HF patients in other studies regarding HF for example, it was 62.9 ± 14.6 years old in the study by Pressler et al. (2010)14; 64.4 ± 15.0 years old in the study by T.N.P. Do et al. (2019)15; 77.8 ± 5.9 years old in the study by Erceg et al. (2013)16; or 65.8 ± 12.9 years old in the study by Nesbitt et al. (2014).17 These age differences may be due to differences in the sample size, study time, and country. However, they reflect that population aging and heart failure tend to increase with age, especially at ≥ 60 years.18

A systematic review and meta-analysis of 60 studies after the screening of 5423 studies showed a change in survival with chronic heart failure with an improvement in 5-year HF survival.19 In our study, the number of years patients had been living with HF was 8.49 ± 4.59 years. This number is not yet representative of the population of HF patients due to the small sample size and convenient sampling. However, it has contributed to the proof that patients with HF live longer thanks to the progress in HF diagnosis and treatment in the province and Vietnam. This is accompanied by a trend of increasing life expectancy, raising concerns about the quality of life of patients with HF, and a genuine need to improve the quality of life of HF patients.

The overall MLHFQ score of HF patients in our study was 67.19 ± 13.31 points (Table 1). A potential source of bias could be the sample size. The small sample size could limit the generalizability of our findings. Additionally, the use of self-reported surveys could lead to bias, as patients might overreport or underreport their symptoms. Finally, the researchers’ personal beliefs or interests could also influence the results, highlighting the need for transparency and ethical conduct in research. Evaluating and addressing these potential sources of bias is crucial to ensure the validity and reliability of the study, thus providing accurate information for healthcare providers to improve health outcomes for patients with chronic heart failure in Vietnam. According to the classification of Behlouli et al.,9 HF patients with MLHFQ scores > 45 points were considered to have poor QoL. In other words, although the study was the first to assess the QoL at a provincial hospital, it revealed a very low level of QoL, which needs to be addressed to improve accompanied advances in diagnosis and treatment. In comparison with the MLHFQ scores of HF patients in studies recently published, the MLHFQ score in our study was quite similar to the MLHFQ score of 74.16 ± 3.78 points in the study of Zhang et al. (2019) in China.20 Meanwhile, it was much higher (i.e., much poorer QoL) than the MLHFQ score of 35.8 ± 21.4 points in the study of Fonseca et al. (2021) in Europe.21 These differences might be explained by the study of Fonseca et al., which measured the QoL among HF patients in France, Germany, Italy, Spain, and the United Kingdom, where better care deliveries have been available and in contrast, Vietnam and China are populated countries where in general, people’s living conditions have been limited. They feel it is harder to live with HF’s condition. Regarding the classification of quality of life, in our study, the majority (89.9%) of patients had a poor QoL (MLHFQ score > 45 points, based on the classification of Behlouli et al.9), the remaining small number of patients (10.1%) had a moderate level of QoL. None had a high QoL (MLHFQ score < 24 points), which was also consistent with a common situation as mentioned in the study by Moradi et al. (2020)5 and in the study by Polikandrioti et al. (2019).6

Table 1. Quality of life scores of HF patients in the study.

Domain scoreScale scoreN (%)Quality of life scores Mean ± SDMin–Max
Total(0–105)89 (100)67.19 ± 13.3133–98
High(<24)0 (0)
Moderate(24–45)9 (10.1)
Poor(>45)80 (89.9)
Physical(0–40)25.78 ± 5.9812–37
Emotional(0–25)16.80 ± 4.1907–25

As seen in Table 2, the female patients had poorer QoL (i.e., higher MLHFQ scores) than the male patients. Regarding the QoL of female and male patients, it is likely to see different results in different studies. For example, the study of Polikandrioti M et al.1 in 100 HF patients found no difference in the MLHFQ scores between male and female patients. In comparison, Fonseca A.F. et al.21 studied 804 HF patients. The results showed that the MLHFQ score of female patients (n = 223) was higher than that of male patients (n = 401) detailed (37.9 ± 20.9 points vs. 34.6 ± 21.6 points; p = 0.0481). In Vietnam, in terms of cultural traditions, the majority of women, besides working to earn, also have to shoulder a lot of responsibility, including raising children and housework, even for the logistics of family, relatives, and clan events. Their life becomes more complicated when having an illness, especially with chronic heart failure, resulting in feeling that their QoL is poor, which may be a reasonable explanation for the poorer QoL in female HF patients than in male patients HF patients in this study. Table 2 also shows that the group of patients in single, divorced, and widowed conditions had poorer QoL than those in the married group. The group of patients living alone had poorer QoL than those living with their families. Persons living in conditions of single, divorced, widowed, and alone, together with Vietnamese customs, are likely to be disadvantaged and vulnerable. Naturally, bearing the burden of chronic heart failure without supporting/sharing with a wife/husband or family members will make them feel complicated and worse about life. These findings should be considered when planning and delivering care to HF patients.

Table 2. MLHFQ scores and personal characteristics.

CharacteristicsN (%)MLHFQ scores Mean ± SDp-value
Age (years):
≤406 (6.8)64.67 ± 13.600.627
41–5926 (29.2)65.54 ± 12.88
≥6057 (64.0)68.21 ± 13.59
Gender:
Male41 (46.1)66.80 ± 15.020.032
Female48 (53.9)67.52 ± 11.80
Job:
Farmer51 (57.3)69.53 ± 12.750.200
Worker13 (14.6)63.31 ± 16.20
Office8 (9.0)60.88 ± 13.24
Business5 (5.6)60.20 ± 7.60
Retired/elderly12 (13.5)68.58 ± 12.77
Educational level:
Unlettered18 (20.2)70.11 ± 9.220.071
Primary school15 (16.9)60.40 ± 13.37
Secondary school38 (42.7)67.29 ± 13.73
High school13 (14.6)73.85 ± 11.75
Vocational college5 (5.6)59.75 ± 20.32
Marital status:
Married74 (83.1)65.27 ± 20.110.000
Single/divorced/widowed15 (16.9)67.58 ± 11.62
Living status:
Living with family80 (89.9)66.50 ± 13.040.014
Living alone9 (10.1)73.33 ± 14.95

As shown in Table 3, patients with HF living with longer HF, more severe HF, more severe depression, and lower levels of social support had poorer QoL. Other studies, for example, the study of Audi,22 the study of Nesbitt et al.,17 and the study of Erceg et al.,16 also had similar results. It is reasonable for these results because heart failure tends to worsen over time with increasing severity of symptoms, which may initially have only a slight effect on patients’ activities, gradually reduce the patient’s independence in daily living activities, and seriously affect the patient’s life.23 These findings should be considered when planning care for HF patients, taking into account factors that worsen the patient’s QoL to improve the patient’s quality of life with appropriate support.

Table 3. MLHFQ scores and features related to HF status.

FeaturesN (%)MLHFQ scores Mean ± SDp-value
Years of heart failure
≤521 (23.6)54.90 ± 14.340.000
6–1043 (48.3)65.14 ± 07.73
>1025 (28.1)81.04 ± 05.85
Stages of heart failure
Stage-II15 (16.9)51.80 ± 8.900.000
Stage -III45 (50.5)69.38 ± 2.97
Stage -IV29 (32.6)71.76 ± 4.60
Depression (BDI-II)
Mild (14–19 points)2 (02.2)39.29 ± 4.070.000
Moderate (20–29 points)7 (07.9)44.50 ± 0.71
Severe (30–63 points)80 (89.9)70.20 ± 10.24
Level of social support (MSPSS)
Low (12–48 points)77 (86.5)70.39 ± 10.290.000
Moderate (49–68 points)10 (11.3)47.10 ± 13.69
High (69–84 points)2 (2.2)44.50 ± 0.71

Conclusion

This study showed a poor QoL of the HF patients with the MLHFQ score of 67.19 ± 13.31 points and factors those made the HF patients’ QoL worse such as gender, marital and living status, HF duration, NYHA classification, depression, and social support. Health professionals need to understand and focus more on the quality of life (QoL) of patients with chronic heart failure to plan effective interventions and provide them with beneficial and holistic care.

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Ngo HH, Tran LTH, Nguyen NT and Mai ATL. Quality of life among patients with chronic heart failure in Nam Dinh Province, Vietnam [version 1; peer review: 1 not approved]. F1000Research 2023, 12:740 (https://doi.org/10.12688/f1000research.134898.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 19 Apr 2024
Konstantinos Giakoumidakis, Department of Nursing, Hellenic Mediterranean University, Heraklion, Greece 
Not Approved
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Dear authors,
I would like to thank you for submitting your work to the journal. According to my evaluation, many concerns have been raised, so I have made the following comments:
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Giakoumidakis K. Reviewer Report For: Quality of life among patients with chronic heart failure in Nam Dinh Province, Vietnam [version 1; peer review: 1 not approved]. F1000Research 2023, 12:740 (https://doi.org/10.5256/f1000research.147989.r208217)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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