865587

research-article2019
TCNXXX10.1177/1043659619865587Journal of Transcultural NursingMassouh et al.

Research

Journal of Transcultural Nursing

Determinants of Self-Care in Patients

2020, Vol. 31(3) 294­–303
© The Author(s) 2019
Article reuse guidelines:
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DOI: 10.1177/1043659619865587
https://doi.org/10.1177/1043659619865587

Developing Country in the Middle East journals.sagepub.com/home/tcn

Angela Massouh, PhD, RN1 , Huda Abu Saad Huijer, PhD, RN, FEANS, FAAN1,
Paula Meek, PhD, RN, FAAN2, and Hadi Skouri, MD, FESC, FACP, FACC, FHFA1

Abstract
Introduction: Self-care is recognized as a means for improving outcomes of heart failure (HF), yet studies have not
addressed what predicts successful self-care in collectivist cultures like Lebanon. Methodology: Self-care was measured,
using the Arabic Self-Care of HF index, in 100 participants with HF (76% males; mean age 67.59) recruited from a tertiary
medical center. Results: Self-care was suboptimal, with mean scores of 67.26, 66.96, and 69.5 for self-care maintenance,
management, and confidence. Better HF knowledge, social support, and self-care confidence and lower New York Heart
Association score predicted better self-care maintenance. Better knowledge, social support, and self-care maintenance, no
recent hospitalization, and being unemployed predicted better self-care confidence. Better self-care confidence, maintenance,
and HF knowledge predicted better self-care management. Discussion: HF self-care in Lebanon is suboptimal. Nurses
need to identify facilitators of and barriers to self-care particular to this population. Interventions targeting HF knowledge,
confidence, and caregiver support are expected to improve self-care in Lebanese patients.

Keywords
heart failure, cardiovascular, clinical areas, self-care, symptom management, social support, self-care confidence

Introduction symptom recognition and response (McKinley et al., 2004), and

Chronically ill individuals are encouraged to be involved in
their health through participation in self-management pro-
grams; central to these programs is the concept of self-care.
Self-care is credited for disease prevention, timely detection
of health changes, and improvement in health and quality of
life. In patients with chronic diseases, such as heart failure
(HF), self-care is credited for improvement in clinical out-
comes and reduction in health care costs (Jovicic, Holroyd-
Leduc, & Straus, 2006).
HF self-care is poorer in developing compared with devel-
oped countries (Riegel, Driscoll, et al., 2009). Recognizing
and understanding failed self-care is a global challenge for
health care providers worldwide (Jaarsma, Cameron, Riegel,
& Stromberg, 2017). Despite the substantial representation of
HF self-care in nursing research, little is known about self-
care in the developing world (Riegel, Driscoll, et al., 2009).
Research studies on HF self-care are largely from the United
States and Europe, a few from Asia, and very few if any from
the Middle East and North Africa (MENA) region.
Researchers to date have not documented determinants of HF
self-care in Lebanon or the MENA region.
Country specific challenges that impede self-care include but
are not limited to lack of resources (van der Wal, Jaarsma, Moser,
van Gilst, & van Veldhuisen, 2010), cultural dissimilarities in
migration (Davidson et al., 2007). All of these heighten the com-
plexity of self-care for patients with HF. Mindful of the fact that
perceptions about health and illness are culturally constructed,
culture becomes a fundamental context to consider in self-care
research (Moser et al., 2012).
Literature Review
To date, only two studies on self-care originate from the
MENA region. One qualitative study explored the cultural
perceptions of cardiac illness among Lebanese patients and
reported an overarching cultural theme where Lebanese car-
diac patients were oblivious of the term, concept, and mean-
ing of self-care although they performed some self-care
activities (Dumit, Magilvy, & Afifi, 2015). Another study
from Jordan reported suboptimal self-care in Jordanian HF
patients as well as low HF knowledge scores (Tawalbeh
1
American University of Beirut, Beirut, Lebanon
2
University of Colorado, Denver, CO, USA
Corresponding Author:
Angela Massouh, PhD, RN, Hariri School of Nursing, American University
of Beirut, Riad El Solh 1107 2020, Beirut, Lebanon.
Email: am50@aub.edu.lb
Massouh et al. 295
et al., 2017). Authors highlighted that characteristic of the
cultural, social, and health care environment in the MENA
region may help explain some of the results.
The emphasis on self-care in western communities comes
from a cultural perspective reflecting notions of indepen-
dence and self-responsibility. In contrast, the emphasis in
other cultures, including Lebanon and the Middle East, is on
family interdependence or collectivism. Arabs thrive on a
large repertoire of family relations where the extended fam-
ily is the most powerful social institution of the Middle East
(Lipson & Meleis, 1983). The Lebanese family, in particular,
is classically over protective of the patient and family mem-
bers exchange turns in providing care (Dumit, Abboud,
Massouh, & Magilvy, 2015). The effect of this family struc-
ture on self-care has not yet been addressed.
Arabs maintain a value orientation that is based on a pre-
destined belief system. As such, cultural factors rooted in
religious convictions and practices can have an immeasur-
able impact on health (Yosef, 2008). Additionally, self-care
in Lebanon might be challenging due to the scarcity, or lack
thereof, of resources such as low salt diets, HF specialized
nurses, and multidisciplinary disease management programs.
The Lebanese health care system might not always support
self-care. Patients with HF in Lebanon have direct access to
their cardiologist adding to their overdependence on their
health care providers and potentially hindering self-care.
While in developed countries, patients with HF have easier
access to multidisciplinary clinics that foster independence
and ultimately self-care.
In treating HF patients and addressing their self-care
behaviors, practitioners in Lebanon rely on the knowledge of
determinants of HF self-care generated from international
studies. Such determinants have never been tested on the
Middle Eastern patient population and the characteristics of
this population remain unknown. The primary purpose of
this study was to describe self-care behaviors and the rela-
tionships among clinical and sociodemographic characteris-
tics, functional ability, and psychological status and self-care
in a sample of Lebanese patients with HF. Until we under-
stand self-care behaviors from a cultural perspective, failed
self-care will remain common, with tremendous socioeco-
nomic costs and burdens to the individual, family, and soci-
ety. Knowledge from this study will facilitate clinician
understanding of what factors affect the performance or lack
thereof of self-care in Lebanon and the MENA region and
aid in designing tailored behavioral modification interven-
tions targeting improved HF self-care.
Method
Study Design
A cross-sectional, correlational design was used in this study.
Ethical approval was obtained from the institutional review
board at the data collection site. Data were collected by face
to face interviews of inpatients as well as outpatients in the
cardiology specialty clinics. Medical record review was done
following the interview.
Participants
A sample of 100 HF patients were consecutively recruited
between 2016 and 2017 from the cardiology inpatient and
outpatient units in a tertiary medical center in Lebanon. This
center attracts patients from all over Lebanon and its influ-
ence on the medical sector and on improving people’s lives is
without equal in Lebanon and the region. Assuming a corre-
lation coefficient of .3, a desired statistical power level of .8,
and a probability level of .05 for a correlation, a minimum
sample of 85 was needed (Hulley, Cummings, Browner,
Grady, & Newman, 2013). Additionally, assuming a medium
anticipated effect size of .15, a desired statistical power level
of .8, and a probability level of .05 for a linear regression
with 6 predictors, a minimum sample size of 97 participants
was needed (Soper, 2016).
Potential participants were invited to participate if they
spoke Arabic, were 40 years or older, had confirmed HF
(left ventricular ejection fraction [LVEF] less than 45%),
and were diagnosed at least 3 months prior to inclusion in
the study. Participants were excluded if they were clini-
cally unstable, in an acute exacerbation, and/or had a con-
comitant terminal illness, documented dementia, or severe
psychological illness (excluding depression) or any
impairment that would impede them from performing
self-care. Potential study participants received informa-
tion about the study from their cardiologist or the HF clin-
ical nurse specialist. A preliminary intent to participate
was obtained and the study team was informed. Those
who agreed to participate were given the informed con-
sent and interviewed by the research team at a time conve-
nient to them.
Variables
The theoretical framework that guided this study is the self-
care in chronic illness theory (Riegel, Jaarsma, & Stromberg,
2012). Self-care in this study is defined as a naturalistic deci-
sion-making process that necessitates the adoption of behav-
iors that maintain physiologic homeostasis (maintenance),
enable symptom recognition, and direct the response to those
symptoms (management) (Riegel, Dickson, & Faulkner,
2016). Self-care maintenance, management, and confidence
are three terms used in this study. Self-care maintenance is
defined as behaviors that aim at preserving, maintaining, or
enhancing physical and emotional well-being. Self-
management is described as an active, goal-directed process
of symptom recognition and management, while self-care
confidence is described as one’s ability to carry out self-care
tasks.
296 Journal of Transcultural Nursing 31(3)
Measurement
Tools used in this study were previously translated into
Arabic, validated, tested, and used in previous studies done
in the region. The questionnaire included the below tools in
addition to sociodemographic and clinical characteristics
questions. The Arabic Self-Care in HF index (ScHFI) is a
22-item instrument with three subscales that measure: main-
tenance, management, and confidence (Riegel, Lee, Dickson,
& Carlson, 2009). The Arabic version had composite reli-
ability coefficients of .87 for the maintenance scale, .97 for
the management scale, and .97 for the confidence scale
(Deek et al., 2016). All items use a 4-point format and scores
of each scale are transformed to generate a standardized
score from 0 to 100; higher scores indicate better self-care.
The self-care management subscale is only reported for
patients who have trouble breathing or ankle swelling in the
past month. A cut-point score of greater or equal to 70 has
been suggested as the minimum level of self-care adequacy.
The New York Heart Association (NYHA) functional
classification system is the most common tool used to
describe the impact of HF on a patient’s daily activities
(Bennett, Riegel, Bittner, & Nichols, 2002). This was used to
ascertain the severity of HF symptoms and is based on the
extent to which symptoms limit a patient’s level of physical
activity.
The Charlson comorbidity index (CCI) was used to gather
data about comorbid conditions. Each disease is given a
score of 1 to 6 and weighted scores are summed and com-
bined with age variations. The ability of the CCI to predict
mortality, discharge disposition, complications, length of
hospital stay, acute care resource use, and cost of care pro-
vide evidence for the criterion-related validity (Roffman,
Buchanan, & Alliso, 2016).
The Patient Health Questionnaire–9 (PHQ-9) is a vali-
dated tool to measure depressive symptoms in cardiac
patients with the goal of establishing a symptom severity rat-
ing (Kroenke & Spitzer, 2002). Psychometrics of the PHQ-9
were tested in HF patients (Pressler et al., 2011); criterion
validity was supported, and Cronbach’s alpha coefficient
was reported as .82. The instrument was translated to Arabic
and validated in a study in Saudi Arabia (Becker, Al Zaid, &
Al Faris, 2002).
Social support was measured using the ENRICHD Social
Support Inventory (ESSI), a seven-item measure that evalu-
ates the four defining attributes of social support: emotional,
instrumental, informational, and appraisal (Vaglio et al.,
2004). Individual items, scored on a 5-point Likert-type
scale, are summed for a total score, with higher scores indi-
cating greater social support. Internal consistency for the
ESSI, using Cronbach’s alpha, was .88 and the intraclass cor-
relation coefficient was .94. Despite the lack of psychometric
testing, this scale has been translated to Arabic, validated,
and used in many studies in Lebanese cardiac patients. In this
study, the Arabic version of the ESSI revealed high
reliability and validity estimates; internal consistency for the
ESSI using Cronbach’s alpha was .902.
The Dutch HF Knowledge Scale (DHFK), used to mea-
sure knowledge of HF, consists of 15 multiple choice ques-
tions measuring knowledge of disease process, symptom
recognition, and HF treatment. Cronbach’s alpha of the
knowledge scale in this population was .62 (van der Wal,
Jaarsma, Moser, & van Veldhuisen, 2005). This scale was
translated to Arabic and used in clinical practice in Lebanon.
Despite the lack of psychometric testing, patients using the
Arabic version reported understanding of the terms used as
they are expressions used in patient education and clinical
practice.
Statistical Analysis
Data analysis was performed using the Statistical Package
for the Social Sciences version 24. The level of significance
for statistical tests was set at p < .05. Scores on ScHFI’s
three subscales, self-care maintenance, management, and
confidence, were used to ascertain the level of self-care in
the study sample. These scores were compared across demo-
graphic and clinical characteristics using independent t test
and analysis of variance tests or Pearson r as appropriate.
Scores of the three ScHFI subscales were then used as the
outcome variables to create the best regression model using
significant variables from the univariate analyses.
Results
Sample Characteristics
The sample was predominantly males (76%) with a mean
age of 67.59 ± 12.09 years (Table 1). About 80% of the sam-
ple was married and only four participants lived alone. The
level of education was relatively high with 65% of the par-
ticipants having at least high school education. Most partici-
pants were unemployed (65%) due to early retirement and
35% lived in poverty.
The mean duration of HF in this sample was 8.42 ± 7.11
years (Table 1). About three quarters of the sample lived with
a LVEF between 25% and 45%, and 87% had a New York
Heart Failure (NYHA) functional class II or III. About a
quarter of the sample had a recent hospitalization. The etiol-
ogy of HF in this sample was predominantly ischemic; 83%
had hypertension, 36% had a cardiac resynchronization ther-
apy device inserted, while 41% had an implantable cardio-
verter defibrillator.
Participants had a CCI scores ranging from 1 to 12 with a
mean score of 6.49. All the sample had at least one comor-
bidity and 88% of the sample had a CCI score between 4 and
12. Social support was high in this sample with a mean ESSI
score of 24.72 ± 6.07 and a range of 9 through 31. Depression
scores with the PHQ-9 ranged from 0 to 18, a median of 3,
and a mean of 4.41 ± 4.9. HF specific knowledge DHFK
Massouh et al. 297

Table 1.  Participant Demographic Characteristics and Heart percentage of the sample were confident of the effect the
Failure (HF) Disease Indices. remedy they have tried had.
Demographics/Disease Indices M ± SD/n (%) Data from the self-care confidence subscale indicated that
almost half of the participants were not confident in their
Age in years 67.59 ± 12.09 ability to prevent HF symptoms. In contrast, the majority of
Sex: Male 76 (76) participants were confident of their ability to follow treat-
Marital status: Married 78 (78) ment advice, recognize changes in symptoms, evaluate their
Living status: Living alone 4 (4) importance, and do something that will relieve symptoms.
Level of education: At least high school 65 (65)
Occupational status: Employed 35 (35)
Duration of HF in years 8.42 ± 7.11 Predictor Variables
New York Heart Association Functional Class Scores on the three subscales of ScHFI were compared
 I 12 (12) across demographic and clinical characteristics (gender,
 II 39 (39) marital, living, and occupational status, recent hospitaliza-
 III 48 (48) tion, NYHA classification, comorbidity load, and depressive
 IV 1 (1)
symptoms) using independent t test and analysis of variance
Etiology of HF: Ischemic 69 (69)
tests as appropriate (Table 3).
Left ventricular ejection fraction (LVEF)
Although gender was not a significant predictor of self-
 LVEF < 25% 26 (26)
care, females were found to have better self-care than males.
 25% ≤ LVEF< 35% 43 (43)
 35% ≤ LVEF ≤ 45% 31 (31)
Marital and living statuses did not affect self-care. Participants
Comorbidities and cardiac interventions who were unemployed had higher self-care confidence
 Hypertension 83 (83) (72.45 ± 21.3 vs. 64.02 ± 18.2, p = .05) than those who
  Cardiac resynchronization therapy 36 (36) were currently employed. HF patients who were recently
  Implantable cardioverter defibrillator 41 (41) hospitalized had higher self-care confidence than those who
Recent hospitalization 28 (28) were not (72.90 ± 20.94 vs. 60.76 ± 16.98, p = .007).
Comorbidity load 6.49 (4) Severe multimorbidity was common in 75% of the par-
Depression by patient health questionnaire 4.41 ± 4.9 ticipants with coronary artery disease being the most fre-
Social support by ENRICHED social 24.72 ± 6.07 quent comorbidity. Participants who had a higher
support index comorbidity load had higher NYHA classification (r =
HF knowledge by Dutch HF knowledge 10.25 ± 2.09 .396, p < .001) and were rehospitalized more (r = .371, p
score < .001). Patients with HF and mild, moderate, and severe
comorbidity load did not differ significantly in self-care
maintenance scores, F(2, 97) = 2.943, p = .057; confi-
scale scores ranged between 4 and 14 out of 15 with a mean dence, F(2, 97) = 1.058, p = .351; and management,
of 10.25 ± 2.09 and a median of 11 (Table 1). F(2, 48) = 1.563, p = .220 (Table 3).
The majority of the sample was symptomatic with 88%
Self-Care Maintenance, Management, and having NYHA II or higher. Participants were divided into
NYHA Classes I and II versus III and IV to handle the antici-
Confidence
pated lower number of subjects in Classes I and IV.
Table 2 summarizes the descriptive statistics for self-care Participants with NYHA I and II had significantly higher
maintenance, management, and confidence. Self-care in this self-care maintenance, t(98) = 2.359, p = .020, than those
sample was suboptimal with 42% of participants having ade- with NYHA III and IV. This association was not significant
quate self-care maintenance (scores ≥ 70) and a mean score for self-care confidence, t(98) = 1.946, p = .054, and man-
of 67.26 ± 14.40. Additionally, 55% of the sample who had agement, t(49) = 0.262, p = .795 (Table 3).
either shortness of breath or ankle swelling in the past month About one fifth of the participants had symptoms of mild
(n = 51) had adequate self-care management with a mean depression, about 10% had symptoms of moderate depres-
score of 66.96 ± 21.29, while 47% had adequate confidence sion, and 6% had symptoms of moderately severe or severe
and an average score of 69.50 ± 20.57. depression. Participants with moderately severe and severe
The most common maintenance behaviors performed by symptoms of depression had significantly higher self-care
the participants were provider directed and included using a confidence and management than those with symptoms of
system to help remember medicines, not forgetting medica- moderate depression (Table 3).
tions, and keeping doctor appointments. Management actions Pearson correlation was used to ascertain correlations
repeatedly performed in response to symptoms were calling between variables such as age, years since HF diagnosis, per-
the health care provider followed by reducing salt in the diet. ceived social support, and HF knowledge and scores of
Although less likely, some participants will take an extra ScHFI subscales. There was no correlation between age and
water pill, and a few would reduce their fluid intake. Forty years since HF diagnosis and self-care maintenance,
298 Journal of Transcultural Nursing 31(3)

Table 2.  Descriptive Statistics of the Self-Care Heart Failure Index.

Self-Care Maintenance (n = 100; M = 67.26 ± 14.403; Median = 64.99), 42% of participants having adequate self-care maintenance
(scores ≥ 70)

How frequently would you: Never Sometimes Frequently Always

Weigh yourself? 32 34 20 14
Check your ankles for swelling? 7 12 19 62
Try to avoid getting sick? 28 20 13 39
Do some physical activity? 19 23 14 44
Keep doctor or nurse appointments? 1 4 4 91
Eat a low salt diet? 8 24 19 49
Exercise for 30 minutes? 48 16 12 24
Forget to take one of your medicines? 84 13 3 0
Ask for low salt items when eating out? 32 22 12 34
Use system to help remember medicines? 0 1 13 86
Self-Care Management (n = 51; M = 66.96 ± 21.286; Median = 75.00), 55% had adequate self-care management (scores ≥ 70)

How quickly did you: Not Somewhat Quickly Very

Recognize it as a symptom of HF? 5 5 16 18
How likely would you: Not Somewhat Likely Very
Reduce the salt in your diet 7 6 15 23
Reduce your fluid intake 11 11 11 18
Take an extra water pill 15 4 23 9
Call your doctor or nurse for guidance 7 4 5 35
How sure were you: Not Somewhat Sure Very
That the remedy helped or did not? 7 3 13 27
Self-Care Confidence (n = 100; M = 69.50 ± 20.570; Median = 66.72), 47% had adequate confidence (scores ≥ 70)

How confident are you to Not Somewhat Very Extremely

Keep yourself free of HF symptoms? 16 37 24 23
Follow treatment advice you were given? 5 23 34 38
Evaluate the importance of symptoms? 3 25 39 33
Recognize changes in health if they occur? 1 12 37 50
Do something that will relieve symptoms? 1 22 39 38
Evaluate how well a remedy works? 1 11 36 52

confidence, and management (Table 3). Social support was
high (mean score 24.72 ± 6.07) in this sample. There was a
positive and moderate correlation between social support
and self-care maintenance and confidence, while social sup-
port and self-care management were uncorrelated (Table 3).
HF specific knowledge scores ranged between 4 and 14
out of 15 with a median of 11. There was a positive and mod-
erate correlation between HF specific knowledge and self-
care maintenance and confidence. There was a weak positive
correlation between HF specific knowledge and self-care
management (Table 3).
Determinants of Self-Care
Different variables were associated with self-care mainte-
nance, management, and confidence as shown in table 3. In
order to explore relationships within the data more thor-
oughly, the scores of the three ScHFI subscales were used as
the outcome variables to create the best regression model
using significant variables from the univariate analyses
(Table 4). The regression was projected from the conceptual
model that governed this study. Predictors were retained in
the regression model if they contributed significantly to the
model or were conceptually relevant and did not negatively
affect the variance.
Better HF-specific knowledge, self-care confidence, and
social support and lower NYHA functional classification
explained about 26% of the variance in self-care mainte-
nance. Better HF knowledge, self-care maintenance, and
social support, unemployment, and no recent hospitalization
significantly explained about 34% of the variance in self-
care confidence. Finally, about 24% of the variability in
Massouh et al. 299

Table 3.  Predictor Variables.

Variable Self-Care Maintenance Self-Care Confidence Self-Care Management

Gender, M ± SD
 Male 66.22 ± 14.40 68.26 ± 19.97 65.54 ± 20.06
 Female 70.55 ± 14.20 73.44 ± 22.36 70.71 ± 24.64
Marital status, M ± SD
  Not married 67.27 ± 13.48 70.76 ± 18.17 72.69 ± 22.04
 Married 67.26 ± 14.74 69.14 ± 21.29 65.00 ± 20.96
Living status, M ± SD
 Alone 68.33 ± 20.09 56.99 ± 15.97 77.50 ± 16.58
  With someone 67.42 ± 14.59 70.02 ± 20.64 66.06 ± 21.54
Occupational status, M ± SD
  Currently working 67.33 ± 13.45 64.02 ± 18.21* 68.33 ± 22.49
 Unemployed 67.22 ± 14.99 72.45 ± 21.29* 66.39 ± 21.07
Recent hospitalization, M ± SD
 No 68.14 ± 14.79 72.90 ± 20.94** 68.04 ± 21.66
 Yes 64.99 ± 13.35 60.76 ± 16.98** 65.65 ± 21.23
Comorbidity load, M ± SD
  Mild: 1 < CCI < 2 55.99 ± 15.880 61.16 ± 20.804 70.00 ± 21.794
  Moderate: 3 < CCI < 4 72.33 ± 14.512 74.50 ± 19.125 80.83 ± 14.634
  Severe: CCI ≥ 5 66.66 ± 13.927 68.72 ± 20.897 64.76 ± 21.667
NYHA functional class, M ± SD
  NYHA I and II 70.52 ± 13.96* 73.37 ± 20.69 68.13 ± 21.78
  NYHA III and IV 63.87 ± 14.21* 65.47 ± 19.86 66.43 ± 21.37
Age, Pearson’s r .081 .139 −.005
Years since diagnosis, Pearson’s r −.061 −.007 .228
Depressive symptoms, Pearson’s r −.138 .021 .108
Social support, Pearson’s r .300** .299** .121
HF knowledge, Pearson’s r .373** .358** .275*
Self-care confidence, Pearson’s r .442** .507**
Self-care maintenance, Pearson’s r .442** .302*

Note. CCI = Charlson comorbidity index; NYHA = New York Heart Association; HF = heart failure.
*p < .05. **p < .01.

self-care management scores was predicted by higher HF
knowledge and self-care maintenance and confidence.
Discussion
This is the first study to examine self-care behaviors and
their determinants in Lebanon and MENA region with an
exception of a study from Jordan (Tawalbeh et al., 2017).
Results of this study primarily support the findings in the
international literature in terms of the presence of suboptimal
levels of HF self-care, the behaviors patients undertake that
primarily revolve around provider-directed actions, and the
importance of self-confidence, social support, and HF
knowledge on the performance of self-care.
Participants in this sample scored lowest on the self-care
management subscale than the other subscales of the ScHFI
instrument. This is similar to findings of a study carried out
in 15 countries worldwide (Jaarsma et al., 2013) as well as
other developing countries like Taiwan (Tung et al., 2012),
Iran (Zamanzadeh, Valizadeh, Jamshidi, Namdar, & Maleki,
2012), and Lebanon (Deek et al., 2016). Self-care manage-
ment had the highest mean score among the ScHFI subscales
in the Jordanian sample (53.89), but significantly lower than
this sample (Tawalbeh et al., 2017). In Lebanon, expecta-
tions related to what is considered an appropriate response to
escalating symptoms affect the performance of self-care
(Dumit, Magilvy, et al., 2015). The actions most frequently
performed by HF patients to alleviate symptoms related to
difficulty with breathing or ankle swelling in this sample was
calling their doctor or nurse for guidance. This provider–
patient interaction has likely elevated the self-care manage-
ment scores and highlights the paternalistic culture that
dominates health care systems in Lebanon as well as the easy
access to physicians and health care providers in this region.
As such, Lebanese patients may leave decision-making
responsibility to their providers which is consistent with the
paternalistic culture in Lebanon (Dumit, Magilvy, et al.,
2015). Results of this and other studies show that taking an
extra water pill had one of the lowest scores and this is attrib-
uted to either providers not prescribing diuretics to use as
300 Journal of Transcultural Nursing 31(3)

Table 4.  Regression Analysis.

Unstandardized Standardized
R2 Adjusted R2 F Sig. beta beta t Sig.
Self-Care Maintenance
(Constant) .292 .263 9.816 .000 35.011 3.984 .000
NYHA class −4.414 −0.154 −1.726 .088
Social support 0.316 0.133 1.446 .151
HF knowledge 1.668 0.242 2.584 .011
Self-care confidence 0.200 0.286 2.957 .004
Self-Care Confidence
(Constant) .376 .343 11.340 .000 14.928 1.371 .174
Occupational status −11.325 −0.264 −3.108 .002
Recent hospitalization −12.720 −0.279 −3.327 .001
HF knowledge 2.587 0.263 2.931 .004
Social support 0.313 0.092 1.053 .295
Self-care maintenance 0.414 0.290 3.190 .002
Self-Care Management
(Constant) .289 .244 6.383 .001 10.027 7.570 .000
HF knowledge −0.123 −0.139 −1.020 .313
Self-care maintenance −0.010 −0.076 −.532 .597
Self-care confidence −0.041 −0.435 −3.142 .003

Note. NYHA = New York Heart Association; HF = heart failure.

necessary or not educating patients on how to adjust their
diuretic dose (Cocchieri et al., 2015). This is a characteristic
of health care practices in Lebanon where taking an extra
dose of diuretic is not recommended as routine practice. Of
greater concern is that about a quarter of the participants
were unable to detect changes in their symptoms when they
first occurred. Lebanese HF patients participated in self-care
behaviors mainly in response to an acute deterioration. This
may indicate an acute model of HF self-care, where partici-
pants are unable to connect chronic symptoms with their HF
and hence do not perform routine self-care.
The proportion of participants who had adequate self-care
maintenance was lower than expected, consistent with an
acute model of HF, and similar to what has been observed in
international studies (Jaarsma et al., 2013). Provider-directed
maintenance behaviors were expectedly high in this sample
and included compliance with medication and appointment
keeping. Abiding by physician directives is a characteristic
of collectivist cultures like Lebanon and is consistent with
findings of the Iranian study (Zamanzadeh et al., 2012).
Findings of this study were consistent with other studies
confirming that low levels of exercise and excessive sodium
intake are common among HF patients (Cocchieri et al.,
2015; Tung et al., 2012). Item scores on the DHFK scale
reveal that 37% of the participants did not know the rationale
behind weighing themselves and 80% did not know how
often patients with severe HF should weigh themselves.
Lebanon lacks multidisciplinary HF clinics, formal outpatient
nurse follow-up, and patient education, as well as cardiopul-
monary rehabilitation centers. This contributes to lack of
knowledge of and compliance in weighing oneself, exercise,
and dietary restrictions. The frequency of asking for low salt
items when visiting others in this sample was very low and
anecdotal filed notes revealed that Lebanese HF patients see
it as culturally inappropriate and would inconvenience others.
This was consistent with findings of a study in Taiwan (Tung
et al., 2012) and with the cultural context of this study in
Lebanon.
The proportion of participants with adequate self-care
confidence was higher than other studies conducted in devel-
oping countries like Italy, Lebanon, and Iran (Cocchieri
et al., 2015; Deek et al., 2016; Siabani et al., 2016).
Participants in this sample were least confident about keep-
ing themselves free from HF symptoms. This may be
explained by the fact that Lebanese cardiac patients see their
cardiac disease as their destiny and as such passively
accepted their fate (Dumit, Magilvy, et al., 2015).
Although comorbidity was not a determinant of self-care
in this study, a critical trend was observed. HF participants
with moderate comorbidity load had higher mean self-care
scores compared with participants with either mild or severe
comorbidity load. The relationship between mild and moder-
ate comorbidity and self-care is consistent with some studies
(Cocchieri et al., 2015; Schnell-Hoehn, Naimark, & Tate,
2009) and can be explained by the fact that as HF patients
develop more comorbidities, attending to self-care becomes
more crucial to them. Yet in the presence of severe multimor-
bidity, patients might be faced with conflicting self-care
goals that complicate self-care and hinders its performance.
Social support was expectedly high in this sample given the
cultural context of this study being conducted in Lebanon, a
country that thrives on a large repertoire of family relations.
Massouh et al. 301
Family caregiver role was grounded in the sense of obligation
and duty toward the sick family member whereby caregivers
collectively provided care (Dumit, Abboud, et al., 2015). The
importance of social support as a facilitator of self-care was pre-
viously demonstrated in the international literature (Gallagher,
Luttik, & Jaarsma, 2011; Sayers, Riegel, Pawlowski, Coyne, &
Samaha, 2008).
HF-specific knowledge was positively correlated with all
three subscales of self-care. This is consistent with conclu-
sions of other researchers highlighting the role health literacy
plays in lessening the barriers to self-care (Evangelista et al.,
2010). HF knowledge’s value in self-care is also well-docu-
mented as a determinant of self-care (Davis et al., 2012;
Mussi et al., 2013).
Evidence from the international literature on the associa-
tion between physical functioning or symptom severity and
self-care is mixed (Riegel, Lee, & Dickson, 2011). In this
study, better functional status (lower NYHA score) was asso-
ciated with better self-care maintenance and confidence.
While some researchers found that patients with poor physi-
cal functioning and worsening symptoms were less engaged
in self-care behaviors (Cocchieri et al., 2015), others reported
that patients engage in self-care only when faced with wors-
ening symptoms and substantial functional decline (Cameron,
Worrall-Carter, Page, & Stewart, 2010). Findings of this
study may be attributed to the fact that participants with bet-
ter functional status have more energy to devote to self-care.
They may also believe that being less symptomatic is a con-
sequence of them managing their HF well.
Symptoms of depression had no significant associations
with self-care. Further analysis revealed that participants who
had moderately severe/severe symptoms of depression had
significantly better HF self-care confidence and management
than those with symptoms of moderate depression. This is
consistent with one study finding (Holzapfel et al., 2009) but
broadly inconsistent with the available literature that holds
that depression was significantly associated with lower HF
self-care. One interpretation of this finding could be that
many depressed patients living with HF attribute their symp-
toms to their HF rather than assume a depressive disorder, a
diagnosis with much stigma and marginalization in Lebanon.
As such, patients with moderately severe/severe depression
might experience more vulnerability than those with moder-
ate depression and therefore endorse self-care. Additionally,
patients living with moderately severe/severe symptoms of
depression are usually more dependent on social support and
as such their self-care needs are met by their caregivers. It
may also be that participants with moderately severe/severe
symptoms of depression were more attentive to social desir-
ability and as such responded to questionnaires as they
thought they should rather than as they actually behave.
Limitations
This study was not without limitations. Lack of data on char-
acteristics of HF patients in Lebanon challenged the choice
of theoretically justified HF determinants. This was based on
similar research studies and clinical observations from
experts in HF in Lebanon. The cross-sectional design limited
the ability to infer causality regarding determinants of self-
care in this sample. Self-reporting of self-care may have led
to overreporting. The fact that this study lacked detailed
mental health histories was a limitation as the PHQ does not
exclude somatic items common in depression and HF. The
use of the CCI may not be sufficient as a measure for multi-
morbidity in HF as it may not capture the whole HF patient’s
experience.
Implications for Practice, Research, and Education
To effectively address self-care practices in patients with
HF, health care professionals in Lebanon need to under-
stand facilitators and barriers to self-care. In view of the
effect of knowledge and social support on self-care, nurses
need to provide HF education and implement interventions
to promote self-care in HF patients and their caregivers.
Moreover, efforts to improve self-care confidence in HF
patients may influence engagement in self-care behaviors
more effectively than efforts to increase social support or
decrease depressive symptoms alone; thus, self-efficacy
interventions must be a key component of HF disease man-
agement programs.
Health behaviors are perceived differently across cultures
and this may determine which actions patients take or do not
take in self-care. Research on self-care should address the
notion of individualism in the Western culture and compare
this with collectivist cultures like Lebanon. Although several
determinants of HF self-care were identified in this study, the
amount of variance explained by the three models was low.
This suggests that other variables influence self-care in the
Lebanese patients with HF. A great deal of conceptual work
is still needed to understand HF self-care in developing
countries grounded in a paternalistic hierarchy like Lebanon.
Addressing the role of caregivers in HF self-care and explor-
ing determinants such as cognitive function, self-efficacy,
and somatic awareness is highly needed.
Conclusion
Self-care is recognized for its immeasurable potential to
improve the care of patients with HF; however, the signifi-
cance of and engagement in self-care differs across countries
and cultures. Findings of this study support the notion that
self-care of chronic illnesses is a complex, multifactorial
phenomenon that involves a multitude of determinants
(Siabani et al., 2016). As such, the need to consistently exam-
ine self-care with an anthropological lens that views illness
as a concept that is culturally constructed is imperative.
Acknowledgments
Authors would like to acknowledge Drs. Nancy Lowe and Paul
Cook from the University of Colorado, Denver as well as Dr.
302 Journal of Transcultural Nursing 31(3)
Maurice Khoury and Ms. Dounia Iskandarani from the American
University of Beirut for their contribution to this study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
work was supported by the University Research Board at the
American University of Beirut.
ORCID iD
Angela Massouh https://orcid.org/0000-0002-8766-033X
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