Heart failure (HF) is one of the most common discharge diagnoses among patients 65 years or older.1 Although there has been no national mortality rate from HF reported in Taiwan, heart diseases are the second leading cause of death in Taiwan.2 The heart disease mortality rate was 67.7 per 100000 in 2011, which has been increasing over the years.2 Heart failure is a gradually progressive disease characterized by a decline in physical function. Patients with HF often experience symptoms such as weakness, fatigue, shortness of breath, activity intolerance, and edema.1 These symptoms can further decrease physical activities in patients with HF.3
Adequate physical activity is believed to help stabilize heart rate variability,4 reduce acute exacerbations, decrease the progression of HF,5 and finally decrease readmission and improve quality of life.6 It is suggested that patients in stable condition should perform adequate physical activity starting 1 month after discharge from hospital.7 Understanding the predictors of physical activity of patients with HF 1 month after discharge can help nurses design a discharge-planning program when patients are still hospitalized.
In Asian countries, especially in Taiwan, people usually assume that patients should do nothing but rest while recovering from illness. This belief might limit physical activity of patients with HF in Taiwan. Understanding the predictors of physical activity of patients with HF in Taiwan could provide more knowledge about the physical activity of patients with HF in different countries.
Physical activity is defined as any bodily movement produced by skeletal muscles. Such movement results in different levels of energy expenditure (EE). Physical activity requires extra EE above the basal metabolic rate.8 Physical activity can occur during work at an individual’s occupation and during domestic tasks, sport, and leisure time physical activities.9
The metabolic equivalent (MET) is used to measure EE. Physical activity can be categorized into 5 levels: sleep (1 MET), sedentary activity (about 1.5 METs, ranging from 1.0 to 2.9 METs), moderate activity (about 4 METs, ranging from 3.0 to 5.0 METs), strenuous activity (about 6 METs, ranging from 5.1 to 6.9 METs), and intense activity (about 10 METs, ≥7.0 METs).10
Garet et al11 investigated the daily EE (DEE) of 105 French patients with HF and New York Heart Association (NYHA) classes from I to IV. They found that patients with HF spent most of their time in the low physical activity level, with 22.55% of total DEE below 3 METs, 12.71% of total DEE between 3 and 5 METs, and only 1.01% of total DEE above 5 METs. Another study of 39 French patients with HF also demonstrated that patients with HF had low levels of physical activity.4 Only 9.63% of total DEE was spent in physical activities between 3 and 5 METs, and 0.7% of total DEE was spent in physical activities above 5 METs.
Few studies have explored the physical activity of Asian patients with HF. By using the Seven-day Physical Activity Recall questionnaire, the total DEE of 193 Taiwanese patients with HF was approximately 7998.01 ± 2709.73 kJ 24 h−1.12 Taiwanese patients with HF had relatively low physical activity levels as compared with French patients (11127.52 ± 3051.83 kJ 24 h−1).12
Demographic characteristics might affect the physical activity of patients with HF. For example, younger age,11,13 higher educational level, and male gender12 are associated with higher levels of physical activity level. Marital status14 and body mass index (BMI) also are related to physical activity levels.15
Similarly, clinical characteristics affect physical activity level. Functional status, as measured by the NYHA classification, was negatively correlated to physical activity level.13 Left ventricle ejection fraction (LVEF) was found to be positively correlated with physical activity at the third and fifth days of hospitalization.16 Symptom distress is defined as the degree of perceived physical or mental upset, anguish, or suffering from the specific symptom being experienced.17 Patients with HF often experience symptoms of lack of energy, dry mouth, shortness of breath, and drowsy feeling. The greater the degree of symptom distress, the lower the performance of physical activity of patients with HF.13,18
Personal characteristics also affect physical activity, and self-efficacy is often strongly correlated with engagement in physical activity. Self-efficacy is the belief in one’s ability to perform a task and is considered important to predict individual behaviors.19 Patients with HF with better exercise self-efficacy had higher levels of physical activity.13,20 Self-efficacy for physical activity was positively correlated with physical activity level both at discharge and 6 months after discharge among patients with HF.21 Knowledge affects both an individual’s behavior and whether he/she will perform behaviors suggested by others.22 Patients with HF who had better knowledge had better physical activity.23
Many previous studies have examined the factors related to physical activity of patients with HF by cross-sectional design. Longitudinal designs often provide a better estimation of the predictive ability of patient characteristics for some desired outcome. Thus, the purpose of this study was to explore important baseline predictors of physical activity 1 month after discharge of patients with HF in Taiwan.
Design and Sample
A prospective research design was used. We collected demographic and disease characteristics, symptom distress, self-efficacy for physical activity, and physical activity knowledge on the discharge day of patients with HF. Patients were then followed after discharge and the researcher collected data about physical activity after patients had been discharged from the hospital for 1 month. Data were collected when patients visited the clinic for follow-ups. For those who had not visited clinics within 7 days after they had been discharged for 1 month, the researcher contacted them and interviewed them by telephone. All data were collected by 1 researcher. Data were collected from July 2009 to February 2010.
Patients with HF were recruited from the Department of Cardiology of a medical center in southern Taiwan. Inclusion criteria included (a) being 75 years or younger; (b) having a diagnosis of HF as determined by cardiologists according to the Framingham criteria (simultaneous presence of at least 2 major criteria or 1 major in conjunction with 2 minor criteria) and being in NYHA class I, II, or III24; (c) being able to verbally communicate with healthcare providers; and (d) not readmitted to the hospital during the 1-month follow up period. The sample size was determined based on the correlation coefficient between the variables with an effect size of 0.3,13 a power of 0.80, and an α of .05.25 A sample size of 95 was adequate. Assuming an attrition rate of 10%, a sample size of 105 was required. In total, 115 patients were recruited, of whom 2 died of pulmonary infection and 2 could not be approached. Finally, 111 patients with HF completed the study, with a response rate of 96.5%.
A questionnaire was used to collect data. The content of the questionnaire is as follows.
Memorial Symptom Assessment Scale–Short Form
The Memorial Symptom Assessment Scale–Short Form (MSAS-SF), developed by Portenoy et al,26 was used to assess the symptoms that participants experienced in the last 1 week. Originally, the MSAS-SF assessed 32 physical and psychological symptoms. One symptom, “I don’t look like myself,” was deleted in this study as suggested by experts. Physical symptoms were rated on a 5-point Likert scale, where 0.8 = not at all, 1.6 = a little bit, 2.4 = somewhat, 3.2 = quite a bit, and 4.0 = extremely. Psychological symptoms were rated on a 4-point Likert scale, where 1.0 = hardly ever, 2.0 = occasionally, 3.0 = often, and 4.0 = almost always. If participants had no symptoms, the score was rated 0. Initially validated and tested for reliability in cancer patients, the MSAS-SF has been validated also in patients with HF.27,28 The item mean score was calculated by summing the scores of individual items divided by the total numbers of items. A higher item mean score indicated a higher symptom distress.
Self-efficacy for Physical Activity Scale
The Self-efficacy for Physical Activity Scale developed by Liou et al29 was used to measure self-efficacy for physical activity. The scale measured self-efficacy for basic activities of daily living (SE-BADL) (5 items) and instrumental activities of daily living (SE-IADL) (8 items). Basic daily activities included eating, dressing, bathing, and transferring. Instrumental activities included walking, climbing stairs, doing housework, shopping, using transportation, fast walking, and jogging.29 Response of each item was rated from 0 (not at all confident) to 4 (extremely confident). A higher score indicated better self-efficacy for physical activity. The possible total scores for SE-BADL ranged from 0 to 20; those for SE-IADL ranged from 0 to 32.
Physical Activity Knowledge Scale
A 10-item Physical Activity Knowledge Scale developed by the authors was used to measure physical activity knowledge in participants. The responses were yes, no, or don’t know. If the answer was correct, 1 point was scored; if not, 0 points. The total scores ranged from 0 to 10, with a higher score indicating better physical activity knowledge.
Daily Activity Questionnaire in Heart Failure Scale
The Daily Activity Questionnaire in Heart Failure Scale (DAQIHF), developed by Garet et al,11 was used to assess the DEE of physical activity in each participant. The DAQIHF has been proven reliable, sensitive, and valid for DEE estimation in patients with HF.11 The DAQIHF included 82 items to measure 7 dimensions of physical activities in daily life with added specific consideration for autonomy and/or perceived exertion. The 7 dimensions were sleeping and resting periods, basic everyday activities (eating, toilet), housework activities (chores, repair, child bearing), leisure time physical activities, physical activities at work or other ways of being occupied, social activities, moving about, and miscellaneous activities.15 Activities in the previous 1 week (including weekend) were reported by participants. The participant self-reported time spent on each activity, the number of times the activity was done in a week or a day, and whether it required assistance or was interrupted during practice of said physical activity. The developer of the DAQIHF calculated the DEE (kJ 24 h−1) by multiplying the intensity of the activity (J min−1 kg−1) by the duration of the activity (minutes per day) for this study. The DAQIHF identifies 5 dimensions of DEE from total DEE. There are DEEs for waking period, for rest (sleeping, naps, doing nothing), for low-intensity physical activities (PAlow DEE, strictly <3 METs; eg, housework, chores), for high-intensity physical activities (PAhigh DEE, 3–5 METs; eg, sports, gardening, housework, leisure), and for intensive-intensity physical activities (PAintensive DEE, strictly >5 METs). In this study, we identified the total DEE, PAlow DEE, PAhigh DEE, and PAintensive DEE of each participant.
Demographic and Disease Characteristics
Demographic characteristics included gender, age, spouse (with or without), educational level, and BMI. Clinical characteristics included NYHA functional status classes and LVEF. The NYHA class was evaluated on the day of the patient’s discharge, whereas LVEF data were collected from echocardiography records.
This study was reviewed by the institutional review board of a medical center in southern Taiwan (KMUH-IRB-980113). All patients with HF had the aims of the study and their rights explained and were asked to sign an informed consent form.
Data were analyzed using SPSS for Windows 12.0. An independent t test was used to examine the association between gender, spouse (with or without), and physical activity level. One-way analysis of variance was used to assess the association of educational level and NYHA functional status class with physical activity level. Pearson product-moment correlation coefficient was used to analyze correlations of age, BMI, LVEF, symptom distress, self-efficacy for physical activity, and physical activity knowledge with physical activity level.
Stepwise multiple regression analysis was used to identify important predictors of physical activity level. Gender (0 = women, 1 = men), spouse (0 = without, 1 = with), educational level (0 = illiteracy and elementary, 1 = above or equal junior high), and NYHA class (0 = class I and II, 1 = class III) were coded as dummy variables. Left ventricular ejection fraction, age, BMI, symptom distress, SE-BADL, SE-IADL, and physical activity knowledge were used as continuous variables.
Validity and Reliability
Five experts, including 1 cardiovascular physician, 1 sports medicine specialist, and 3 nursing professionals, examined the validity of the scales for patients in Taiwan. These experts evaluated the appropriateness of the items of scales from “very appropriate” (4 points) to “inappropriate” (1 point). In each scale, the number of items rated from 3 to 4 by the experts was divided by the total number of items, and this was taken as the content validity index. The content validity index for each scale was as follows: symptom distress, 0.93; SE-BADL, 0.98; SE-IADL, 0.99; physical activity knowledge, 0.92; and DAQIHF, 0.91. Modifications were made according to the suggestions of the experts.
Cronbach α was calculated for each scale using data for all participants in the study. The Cronbach α for each scale was as follows: symptom distress, .89; SE-BADL, .89; SE-IADL, .90; physical activity knowledge, .86; and DAQIHF, .82. We performed a test-retest reliability test within 2 weeks in 10 patients with HF who met the inclusion criteria. The intraclass correlation coefficient was used to calculate test-retest reliability. The intraclass correlation coefficients for each scale were as follows: symptom distress, 0.78; SE-BADL, 0.99; SE-IADL, 0.98; physical activity knowledge, 0.78; and DAQIHF, 0.99. Thus, each scale used in this study had acceptable validity and reliability.25
The Distribution of Demographic and Disease Characteristics, Symptom Distress, Self-efficacy for Physical Activity, Physical Activity Knowledge, and Physical Activity Level
The demographic and disease characteristics of participants are summarized in Tables 1 and 2. The mean ± SD scores of symptom distress, total self-efficacy for physical activity, SE-BADL, SE-IADL, and physical activity knowledge are summarized in Table 2.
The mean total DEE of participants 1 month after their discharge was 8175.85 ± 2595.12 kJ 24 h−1. Furthermore, 19.12% of total DEE was for PAlow DEE (1562.90 ± 601.27 kJ 24 h−1), 7.20% of total DEE was for PAhigh DEE (588.96 ± 1199.58 kJ 24 h−1), and only 1.42% of total DEE was for PAintensive DEE (115.74 ± 306.12 kJ 24 h−1). About 72.26% of total DEE was for sleeping and resting.
The Relationships Between Demographic and Disease Characteristics, Symptom Distress, Self-efficacy for Physical Activity, Physical Activity Knowledge, and Physical Activity Level
In terms of total DEE, participants who were male, without a spouse, or with higher educational level had significantly higher total DEE than others did (Table 1). Participants of younger age, higher BMI, better SE-BADL, better SE-IADL, or better physical activity knowledge had higher total DEE (Table 2).
In terms of PAhigh DEE, women had significantly higher PAhigh DEE than men did (Table 1). Participants with younger age, higher BMI, better SE-BADL, or better SE-IADL had higher PAhigh DEE (Table 2). In terms of PAintensive DEE, participants without spouse or with lower NYHA classes had higher PAintensive DEE (Table 1). Participants with younger age, higher BMI, lower LVEF, lower symptom distress, better SE-BADL, or better SE-IADL had higher PAintensive DEE (Table 2).
Important Predictors of Physical Activity
Because there was no significant association between independent variables and PAlow DEE, we did not explore important predictors of PAlow DEE. Collinearity diagnostics were assessed by examining tolerance (range, 0.72–1.00) and variance inflation factor (range, 1.00–1.33) before stepwise multiple regression. There was no collinearity among independent variables. As shown in Table 3, important predictors of total DEE were BMI, age, SE-IADL, and educational level, which explained 72.4% of the total variance of total DEE. Important predictors of PAhigh DEE were SE-IADL, gender, and BMI, which explained 29.5% of the total variance of PAhigh DEE. Important predictors of PAintensive DEE were age, BMI, and symptom distress, which explained 19.1% of the total variance of PAintensive DEE.
Few studies have addressed the physical activity level of patients with HF, especially patients in Asia. In this study, total DEE of Taiwanese patients with HF was 8175.85 ± 2595.12 kJ 24 h−1. Compared with limited studies in Western countries, the total DEE of Taiwanese patients with HF is lower than that reported for French patients with HF (11127.52 ± 3051.83 kJ 24 h−1).11 Taiwanese patients with HF spent 19.12% and 1.42% of DEE for PAlow DEE and PAintensive DEE, respectively. The results are similar to those in the study of French patients with HF, which are 22.55% and 1.02% of total DEE for PAlow DEE and PAintensive DEE, respectively.11 However, Taiwanese patients with HF spent only 7.20% of total DEE for PAhigh DEE, which is only one-half of that of French patients (12.71%). Physical activity at the level of 3 to 6 METs is recommended for patients with HF.30 Enhancing practice of high-intensity physical activity should be emphasized for patients with HF.
Although the total DEE of men was significantly higher than that of women, PAhigh DEE in women was significantly higher than that in men. This finding is in line with the study of Seo et al.18 High-intensity physical activities such as household tasks are usually performed by women, which may result in women having higher PAhigh DEE than men do. Nurses can encourage men with HF to perform housework or leisure activity after they have been discharged from hospital.
In this study, age was an important predictor of PAintensive DEE. Intensive activities may need more muscle power. The loss of muscle mass with aging may limit older patients’ ability to perform intensive physical activities. In line with the study of Landi et al,14 patients with spouses had lower PAintensive DEE. Spouses of patients with HF might assist them in performing intensive physical activities because they are concerned about the safety of having the patient perform those activities. Such assistance might restrict patients’ performance of intensive physical activities resulting in debilitation. Healthcare providers should educate spouses of patients with HF to encourage patients to practice intensive physical activities.
We found that patients with a worse NYHA class performed less intensive activities. Patients with a worse NYHA class have more symptoms that likely interfere with their practicing of intensive physical activities.3 Patients with HF who had higher LVEFs had worse PAintensive DEE in this study. However, the correlation was weak (r = −0.18). The relationship between LVEF and physical activity level needs further study to confirm.
The phenomenon of the “obesity paradox” has been observed in patients with HF.31 Higher BMI seems to be protective of adverse outcome in patients with HF.32,33 This study demonstrated that higher BMI at discharge predicts higher physical activity level 1 month later. Patients with HF who had low BMI may be frail, which may limit their ability to engage in physical activities. More longitudinal studies are needed to confirm these data.
Participants with better physical activity knowledge had higher DEE in this study, which is consistent with the findings of Dunderdale et al.23 Providing knowledge of the importance of physical activity is necessary during patients’ hospitalization. Consistent with the result of a qualitative study,34 SE-IADL was an important predictor of DEE and PAhigh DEE in this study. Activities of PAhigh DEE involve activities such as walking, carrying, or lifting things, which need more effort. It is reasonable that SE-IADL is more important than SE-BADL as a predictor of DEE and PAhigh DEE. A multimedia exercise intervention has been found to increase exercise self-efficacy.35 Nurses can develop multimedia exercise intervention to improve knowledge and self-efficacy for physical activity of patients with HF.
Although the symptom distress of patients with HF in this study was not very high, symptom distress before discharge was an important predictor of PAintensive DEE 1 month after discharge. This finding is consistent with previous research findings.13,18 Interventions that reduce respiratory distress or sleep disorder distress have been demonstrated to improve the physical activity of patients.36 Nurses should identify symptom distress in their patients with HF early and educate patients on how to manage their symptoms before their discharge.
The important predictors addressed in this study explained only 29.5% and 19.1% of the total variance of PAhigh DEE and PAintensive DEE, respectively. Previous studies indicated that oxygen consumption per unit time15 and heart rate variability4 were important predictors of physical activities above 3 METs. To more comprehensively understand the predictors of PAhigh DEE and PAintensive DEE, we need to include oxygen consumption per unit time and heart rate variability as independent variables in the future.
This study has some limitations. The generalizability of the study findings was limited because patients with HF were recruited from a medical center in southern Taiwan. Future studies need to recruit patients with HF from diverse hospitals. We followed the physical activity of patients only after they had been discharged from hospital for 1 month. Future studies should include longer follow-up periods so that we can understand the longitudinal development of physical activity.
Taiwanese patients with HF reported low levels of physical activity with low levels of engagement in high-intensity physical activities (3–5 METs). Factors related to the physical activity of patients with HF in Taiwan were similar to those of Western countries. Nurses should emphasize the importance of physical activity to patients with HF to all patients, but special attention should be given to men, older individuals, those with lower educational level, and those with lower BMI because these patients are at higher risk for low levels of physical activity. Improving self-efficacy for instrumental activities and decreasing symptom distress should be incorporated into discharge planning programs for patients with HF.
What’s New and Important
- Even 1 month after discharge from a hospitalization for HF, patients engaged in low levels of low-intensity activities.
- Better DEE 1 month after discharge was predicted by higher BMI, younger age, higher self-efficacy for instrumental activities, higher educational level, and better knowledge about exercise at discharge.
- Nurses should emphasize the importance of physical activity to high-risk patients with the characteristics identified. Although several of the characteristics were not modifiable, improving self-efficacy for instrumental activities and decreasing symptom distress may improve engagement in physical activity.
We express our appreciation to the 105 adults who participated in this study for their dedication and time and to the Cardiovascular Center and Department of Nursing, Kaohsiung Medical University, Chung-Ho Memorial Hospital, Taiwan.
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Keywords:© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
heart failure; knowledge; physical activity; self-efficacy; symptom distress