EMPIRICAL STUDIES
12324
Factors associated with quality of life in Arab patients with
heart failure
Fawwaz Alaloul PhD, MPH, RN (Assistant Professor)1, Mohannad E. AbuRuz PhD, RN (Assistant Professor)2,
Debra K. Moser PhD, RN, FAAN (Professor)3, Lynne A. Hall DrPH, RN (Professor)1 and Ahmad Al-Sadi
MSN, RN, CNS (Lecturer)4
1
School of Nursing, University of Louisville, Louisville, KY, USA, 2College of Nursing, Applied Science University, Amman, Jordan, 3College
of Nursing, University of Kentucky, Lexington, KY, USA and 4School of Nursing, University of Hail, Hail, Saudi Arabia
Scand J Caring Sci; 2016
Factors associated with quality of life in Arab patients
with heart failure
The aim of this study was to examine the relationships
of demographic characteristics, medical variables and per-
ceived social support with quality of life (QOL) in Arab
patients with heart failure. A cross-sectional study was
conducted to identify factors associated with QOL in
Arab patients with heart failure. Participants with heart
failure (N = 99) were enrolled from a nonprofit hospital
and an educational hospital. Data were collected on QOL
using the Short Form-36 survey. Perceived social support
was measured with the Medical Outcomes Study Social
Support Survey. The majority of the patients reported
significant impairment in QOL as evidenced by subscale
scored. Left ventricular ejection fraction was the stron-
gest correlate of most QOL domains. Tangible support
Heart failure (HF) affects circulatory, neural and hor-
monal functions resulting in many signs and symptoms
(1). Approximately 5.7 million adults in the United States
had HF in 2008 (2) while 10 million adult had HF in
Europe in 2005 (3). In the United States, the number of
new cases is 550 000 yearly (4) which costs over $33 bil-
lion annually (5). The estimated population in Jordan is
5 611 202. The extrapolated prevalence of HF in Jordan
is 99 021; the estimated incidence is 8251 annually (6).
Patients with HF commonly experience fatigue, dry
mouth, shortness of breath, insomnia, drowsiness,
oedema, depressive symptoms and anxiety (7, 8). Heart
failure adversely affects all aspects of patients’ physical,
social, psychological, emotional (9, 10) and economic (8)
well-being as well as their QOL (8, 9). Poor QOL con-
tributes to an increase in hospital admissions, high
Correspondence to:
Fawwaz Alaloul, School of Nursing, University of Louisville, 555 S.
Floyd St., K Building, Louisville, KY 40202, USA.
E-mail: f0alal02@louisville.edu
© 2016 Nordic College of Caring Science
doi: 10.1111/scs.
was significantly associated with most QOL domains.
Other social support dimensions were not significantly
related to QOL domains. Most patients with heart failure
had significant disrupting pain and limitations in per-
forming activities which interfered with their usual role.
Due to the importance of understanding QOL and its
determinants within the context of culture, the outcomes
of this study may provide valuable guidance to health-
care providers in Arabic countries as well as Western
society in caring for these patients. Further studies are
needed to explore the relationship between social sup-
port and QOL among patients with heart failure in the
Arabic culture.
Keywords: quality of life, heart failure, Arabs, culture,
social support.
Submitted 6 April 2015, Accepted 30 November 2015
mortality (11) and economic burden (9). A major focus
of HF treatment is optimisation of QOL (12).
Identification of factors associated with changes in QOL
among patients with HF could help in determining
patients in need of health services (12). Demographic
characteristics (e.g. age, sex, educational level), medical
factors (e.g. left ventricular ejection fraction [LVEF], New
York Heart Association (NYHA) functional class, duration
of HF, number of comorbidities) and social factors (e.g.
social support) could influence HF patients’ QOL (12, 13).
Most of the research to date on the effect of HF on QOL
was conducted among Western patient populations. Cul-
ture is important in understanding and facilitating mean-
ing in life in health and in sickness (14). The World
Health Organization Group (15) defined QOL as ‘Individu-
als’ perception of their position in life in the context of the
culture and value systems in which they live and in rela-
tion to their goals, expectations, standards and concerns’.
Jordan is an Arabic and Islamic country. Because the
culture of Arabic and Islamic countries differs in social
structure, religious beliefs and healthcare delivery
1
2 F. Alaloul et al.
systems, outcomes of research conducted in the Western
culture may or may not apply to these individuals (16,
17). Specific characteristics of the Arab Muslim popula-
tion that differ from Western countries include strong
family and community relations, abiding faith, reticence
to disclose personal matters in public (18) and male dom-
inance (19). Men in Arabic culture are responsible for
family members’ safety and supporting them financially.
They are also responsible for making final decisions after
discussion with family members (19, 20). Men in the
Arabic culture do not express their emotions and control
their responses to maintain their traditional norms of the
male role in terms of strength and control (21). Women
integrate and adjust their needs and interests to satisfy all
family members’ needs including themselves (22).
Islam, whether practiced in the Western countries or
Jordan, can have a major impact on an individual’s
health and involvement with the healthcare system (16).
For example, although Muslims understand the impor-
tance of seeking medical treatment, some Muslims may
delay or refuse certain diagnostic tests or be less adherent
to treatment based on their religious belief in God’s heal-
ing power. Although Muslims with certain illness are
excused from fasting during their Holy month (Rama-
dan), some Arab Muslim patients with HF may prefer to
fast, thus interfering with their treatment schedule.
Social support has a beneficial effect on a wide range
of health outcomes. Social support reduces mortality
(23), contributes to a healthy lifestyle (24) and improves
QOL (25). The Arabic and Islamic culture is characterised
by extended families who provide the individual with
physical and psychological social support during wellness
and illness (18). Families and other relatives in Arabic
culture make a concerted effort to provide patients with
continuous support. According to the beliefs of the Islam
and Arabic culture, individuals should visit and provide
support to others in times of sickness to get rewards from
God and meet social obligations (18). Being physically
available may or may not provide the patient with the
appropriate support. Examination of the relationships of
a variety of dimensions of social support with QOL in
patients with HF is essential to determine those that are
most critical for patients’ well-being.
Understanding the factors associated with domains of
QOL for patients with HF is important for determining
their needs, developing interventions and evaluating the
outcomes of interventions. In addition to improving the
care of Arab Muslims who reside in their country of ori-
gin, findings of this study may have the potential to assist
healthcare providers in Western countries, including Eur-
ope, to provide appropriate care for Arab Muslim patients
with HF. The specific aims of this study were to: (i) iden-
tify demographic characteristics (age, gender, education
level) and medical variables (LVEF, HF duration, pres-
ence of diabetes mellitus and hypertension) associated
with QOL of adults with HF, (ii) evaluate the relation-
ships of multiple dimensions of perceived social support
with QOL, and (iii) identify predictors of QOL, given
demographic and medical variables and dimensions of
social support.
Methods
Design, sample and setting
A cross-sectional study of 99 outpatients with HF
recruited from a nonprofit hospital and an educational
hospital was conducted. The inclusion criteria were as
follows: (i) HF diagnosis, (ii) not known to have another
chronic disease that might affect QOL (e.g. cancer, liver
failure, kidney failure), (iii) no major psychiatric prob-
lems that could interfere with the completion of the
questionnaires or that might affect QOL, and (iv) able to
read and write Arabic.
Measures
SF-36 Survey, Version 2. Quality of life was defined as a
multidimensional construct that addresses the physical,
psychological and social aspects of life as perceived by
the individuals. It was measured using the Short Form-
36 version 2, a 36-item multiple-response option ques-
tionnaire with eight scales: physical functioning (10
items), role physical functioning (four items), role emo-
tional functioning (three items), vitality (four items),
mental health (five items), social functioning (two
items), body pain (two items) and general health (five
items) (26). All are measured on a 0–100 scale. Higher
scores indicate better QOL in each domain. Domain
scales of the SF-36 were analysed using norm-based scor-
ing methods in accordance with the 1998 US general
population. Quality of life domain scores below 47 are
considered below the average general population score
and indicate impairment in this domain (27). This instru-
ment has been translated into Arabic and had satisfactory
psychometric properties (28). Cronbach’s alphas for the
eight scales in this study were: 0.88 for physical function-
ing, 0.94 for role physical, 0.82 for social functioning,
0.95 for role emotional, 0.91 for bodily pain, 0.71 for
general health, 0.84 for vitality and 0.82 for mental
health.
Medical outcomes study social support survey (MOS-SSS). The
MOS-SSS is a 19-item self-report questionnaire designed
to assess perceived social support (29). The first 18 items
form four subscales: emotional/informational support
(eight items), affectionate support (three items), tangible
support (four items) and positive social interaction (three
items). Respondents indicate how often support is avail-
able, if needed, on a five-point Likert scale ranging from
© 2016 Nordic College of Caring Science
 Factors associated with quality of life 3

1 (none of the time) to 5 (all of the time). Raw scale MOS-SSS subscale scores. An independent-samples t-test
scores can be standardised by transforming them into a was used to determine if there were differences in the
0–100 scale. Item number 19 measures the availability of QOL domain scores of male and female HF patients. To
people with whom the respondent can do things. Higher identify the potential of multicollinearity among the
scores for the subscales and the overall support index independent variables, the Variance Inflation Factor
indicate a higher level of support (29). The MOS-SSS has (VIF) and tolerance statistics were computed. Stepwise
been tested in a sample of 2987 patients with chronic regression analysis was used to evaluate the strength of
conditions and found to be reliable and valid (29). This association of demographic characteristics (age, gender
instrument was translated into Arabic by the principal and level of education), medical variables (LVEF, dura-
investigator and had good internal consistency in a sam- tion of HF and the presence of hypertension or diabetes)
ple of 63 Arabic stem cell transplant survivors; Cron- and the four social support subscales with each of the
bach’s alphas ranged from 0.79 to 0.87 (30). Cronbach’s eight SF-36 subscales scores.
alphas for the subscales in this study were: 0.88 for tangi-
ble support, 0.88 for emotional–informational support,
Results
0.96 for affectionate support and 0.87 for positive social
interaction support.
Demographic, medical variables, perceived social support and
QOL domains
Demographic and medical characteristics. Data were col-
lected on participants’ age, sex, marital status, educa- A total of 111 patients with HF were assessed to deter-
tional status, employment status and annual income. mine their eligibility for the study. Of these, nine were
Medical variables including time since diagnosis, LVEF not eligible and three patients refused to participate.
and presence of diabetes or hypertension were obtained Ninety-nine patients agreed to participate in this study
from patients’ medical records. and provided written consent. The mean age of the par-
ticipants was 56.9 years (SD = 11.3, range = 29–80).
Other demographic characteristics of the participants are
Procedure
shown in Table 1. The patients’ duration of HF ranged
Institutional ethics committee approval (the equivalent of from 1 to 11 years, with a mean of 3.62 years. Their
institutional review board approval) was obtained from a mean ejection fraction was 37.9% (SD = 5.8,
nonprofit hospital and an educational hospital in Jordan. range = 20–48). Seventy per cent of participants were
The principal investigator met with administrators, physi- hypertensive and 35% were diabetic. Data on perceived
cians and nursing directors to describe the purpose and social support are presented in Table 2. The dimension of
nature of the study. Consecutive HF patients who met the the emotional/informational support had the lowest
inclusion criteria were contacted by two nurse research mean score and the highest was for affectionate support.
assistants during their visit to the outpatient clinic. A The mean scores for the QOL domains are presented in
detailed explanation of the study including the purpose, Table 3. Overall, the patients’ scores were low for all
risks, benefits and procedures was provided to participants
verbally and in written form. Signed, informed consent Table 1 Demographic characteristics of the Arabic patients with
was obtained from patients who agreed to participate. A heart failure (N = 99)
quiet place was provided for participants at the hospital.
Two trained nurse research assistants obtained patient Characteristics n (%)
age, time since diagnosis, LVEF and information about
Gender
other comorbidities (e.g. cancer, liver failure, kidney fail-
Male 64 (64.6)
ure, major psychiatric problems) from patients’ medical
Marital status
records. Data were collected over a 12-month period. Married 85 (85.9)
Divorced/widowed 14 (14.1)
Employment
Data analysis
Employed 37 (37.43)
Data were analysed using the Statistical Package for the Educational level
Social Sciences (SPSS) for Windows 21.0 (SPSS Inc., Chi- School degree 75 (75.8)
cago, IL, USA). This sample size provided 80% power Diploma 15 (15.2)
based on an alpha of 0.05, 11 independent variables and University degree 9 (9.1)
Annual income
an estimated effect size of 0.2 (31). Alpha was set at
Less than $3500 16 (16.2)
<0.05 for all analyses. Descriptive statistics were used to
$3500–$8600 64 (64.6)
describe the demographic and medical characteristics of More than $8600 19 (19.2)
the sample, the eight domains of the SF-36, and the

© 2016 Nordic College of Caring Science

4 F. Alaloul et al.

Table 2 Medical outcomes study social support survey scores of the Table 4 Stepwise regression analyses for predictors of the SF-36
Arabic patients with heart failure (N = 99)a subscale scores (N = 99)

Possible Actual Standardised

Scale/subscale Mean SD range range Outcomes/predictors b t Model statistics

Emotional/information 65.0 19.8 0–100 6.3–100 Physical functioning

support Age 0.29 3.17**
Tangible support 81.6 23.4 0–100 6.3–100 Male gender 0.31 3.57**
Affectionate support 86.3 23.2 0–100 0–100 LVEF 0.27 2.98**
Positive social interaction 75.4 22.4 0–100 0–100 Tangible support 0.21 2.34* R2 = 0.38;
Total score 73.8 18.1 0–100 15.8–100 F(4,98) = 14.68,
a
p < 0.001
A higher score indicates greater social support.
Role physical
Age 0.22 0.2.36*
Male gender 0.20 2.22*
Table 3 Scores for the SF-36 quality of life domains of the partici- LVEF 0.30 3.19**
pants (N = 99)a Tangible support 0.30 3.26** R2 = 0.34;
F(4,98) = 12.27,
Possible Actual p < 0.001
Scale/subscale Mean SD range range Bodily pain
Male gender 0.20 2.20*
Physical functioning (level of 38.9 23.7 0–100 0–90
LVEF 0.34 3.67**
limitation in physical activities)
Tangible support 0.33 3.70** R2 = 0.27;
Role physical (problems with 36.4 24.6 0–100 0–100
F(3,98) = 11.63,
usual role related to
p < 0.001
physical health)
General health perception
Social functioning (interference 42.8 25.2 0–100 0–100
LVEF 0.27 2.81**
with social activities)
Presence of 0.23 2.40* R2 = 0.14;
Role emotional (problems with 42.3 26.5 0–100 0–100
diabetes F(2,98) = 7.87,
usual role related to
p < 0.001
emotional health)
Vitality
Bodily pain (level of pain) 37.9 21.9 0–100 0–100
LVEF 0.32 3.54**
General health (general 40.8 15.1 0–100 5–95
Tangible support 0.38 4.14** R2 = 0.21;
perception about health)
F(2,98) = 13.09,
Vitality (energy and fatigue) 34.8 19.7 0–100 0–81
p < 0.001
Mental health (level of 47.2 17.3 0–100 0–90
Social functioning
psychological status)
LVEF 0.35 3.87**
a
A higher score indicates better quality of life. Presence of 0.28 3.02**
diabetes
Presence of 0.21 2.23*
domains indicating poor QOL. The lowest mean score hypertension
was for vitality (i.e. lack of energy and presence of fati- Tangible support 0.20 2.19* R2 = 0.27;
gue), whereas their mental health score was the highest. F(4,98) = 8.52,
The patients reported problems with carrying out their p < 0.001
usual role due to poor physical health, significant bodily Role emotional
pain and limitations performing role activities. Education 0.27 2.87**
LVEF 0.26 2.74** R2 = 0.17;
F(2,98) = 9.91,
Multivariate analyses p < 0.001

Multicollinearity was not a problem as VIF values were *p < 0.05.

less than three (32). The findings of the stepwise regres-
sion analyses are presented in Table 4. LVEF was a signif-
icant independent variable for all of the QOL subscales
except mental health. Presence of diabetes mellitus was
associated with low general health perception and low
social functioning QOL domain scores. Tangible support
was a significant independent variable for the subscales
of physical functioning, role physical, bodily pain, vitality
**p < 0.01.
LVEF, left ventricular ejection fraction.
and social functioning. Female sex was negatively associ-
ated with physical functioning, role physical and bodily
pain. Those who were younger and had less tangible sup-
port had better physical functioning. These variables
accounted for the greatest amount of variance in all of

© 2016 Nordic College of Caring Science


the SF-36 subscales. The independent variables explained
the least amount of variance for role emotional and gen-
eral health perception.
Discussion
Heart failure has a negative impact on patients’ QOL,
which may lead to increased healthcare demands and
expenses and contribute to an increase in mortality (9,
12). Because one goal of HF treatment is optimising
QOL, it is important to understand QOL and its determi-
nants within the context of culture to assess patient
needs and improve QOL. In this study, we aimed to
understand the impact of different factors on Arab Mus-
lim HF patients’ QOL. We attempted to understand the
impact of these factors within the context of Arab Mus-
lim culture based on the literature.
Most of the Arab patients with HF participating in this
study reported poor QOL in all domains. They reported
significant disruptive pain and fatigue, interference with
social activities, impaired psychological status, and limita-
tions performing activities associated with their usual
role. Similarly, Turkish patients with HF reported impair-
ment in QOL (33). In other studies conducted in Western
countries (Germany and Sweden) (13, 34) and in Brazil
(35), social functioning, role emotional and mental
health were slightly impaired among patients with HF.
Mental health and pain QOL domains were slightly com-
promised among patients with HF from the Netherlands
(36). Cultural or healthcare system issues are potential
explanations for these differences in emotional, mental,
social and pain QOL domains scores in the current sam-
ple compared to samples from other countries (37). Arabs
prefer not to disclose their emotions during illness in
public (38) and thus, may avoid seeking emotional and
social help from healthcare providers (39). Therefore,
emotional and social issues should be addressed directly
by healthcare providers, not waiting for patients to bring
them up. Among this sample of Arabs with HF, the great-
est impairment in QOL was in vitality. The patients
reported severe fatigue and lack of energy which is con-
sistent with the common clinical manifestations of HF.
Further studies are needed to explore the differences in
QOL among different cultures.
Inconsistent findings on the pain domain of QOL were
found in prior HF studies. In the current study and some
previous studies (40, 41), the pain QOL domain was
impaired while in other studies (35, 42) the pain domain
was not significantly compromised. Differences in patient
perception and expression of pain might be related to
many physical, psychosocial, cognitive, behavioural, spir-
itual, religious and cultural factors (43). In the present
study, the Arabic and Islamic culture may have effected
patients’ expression of pain. For Arab patients, pain is
part of their chronic illness and may be viewed as a way
© 2016 Nordic College of Caring Science
Factors associated with quality of life 5
of purifying their sin, and consequently may interfere
with their seeking pain management (38, 44). For that
reason, it is important for healthcare providers to pay
more attention to pain assessment and management
among Arab patients.
This study also examined the demographic and medical
variables associated with QOL in Arab patients with HF.
The most interesting finding was that LVEF was the
strongest correlate of QOL among Arab patients with HF;
however, this finding is contrary to previous research
(13, 36, 37). Low LVEF, which is an objective clinical
measurement of HF, leads to fluid accumulation in lungs
and lower limbs resulting in fatigue and dyspnoea (45).
Previous studies showed that LVEF is a strong predictor
of mortality (46, 47) and hospital admissions (48) but
not QOL. Effective management of LVEF might improve
patients’ QOL, reduce mortality rate and decrease hospi-
talisation admission. Different pharmacological (49) and
nonpharmacological modalities such as implantable car-
dioverter defibrillator, cardiac resynchronisation therapy
or myocardial revascularisation can be used to improve
LVEF (49, 50). In addition to the disease process, culture
may negatively affect LVEF. Although seeking medical
treatment is considered important in Islam, some Arab
Muslim HF patients may not adhere to their diagnostic
procedure or HF treatment regimen based on their belief
in God’s healing power. Poor adherence may intensify
symptoms and impact disease progression (51). Nurses
are in a unique position to play a major role in educating
patients from different cultures about the importance of
treatment adherence.
Another interesting finding was that none of the vari-
ables in this study was associated with mental health.
Diabetes mellitus was associated with general health per-
ception and social functioning QOL domains. This finding
is consistent with previous studies (52, 53). These results
may signify the importance of collaboration among
health providers in the planning of care for patients with
HF. The role of the primary care specialist is not well
established in Jordan (54). Availability of these health-
care providers may help in coordinating the care of
patients with HF across the care system.
Being older and female were associated with poorer
QOL. Older age is associated with poor physical and role
physical QOL domains. The findings were inconsistent in
prior studies conducted in the Western culture (11, 55).
In this sample, the association between age and QOL
could be due to the adverse changes that occur with age-
ing and limited resources available for them. Arab
women with HF were more impaired in the physical, role
physical and bodily pain QOL domains than Arab men.
Conflicting findings regarding the relationship between
sex and QOL were found among studies conducted in
the Western culture (13, 55, 56). In addition to the phys-
iological differences (57), a possible explanation for
6 F. Alaloul et al.

higher QOL among Arab men is that men in the Arabic
and Islamic culture try to suppress their feelings to main-
tain their gender role in the community and show their
control over the negative consequences of HF (21). Due
to the significant role of Arab Muslim women in the fam-
ily dynamics, women try to integrate and adjust their
physical and psychological needs and interests to satisfy
all family members’ needs including themselves (22).
Another aim of this study was to describe the associa-
tion of perceived social support with QOL among Arab
patients with HF. In this study, patients reported that
they received a moderate to high level of social support.
This level of perceived support is consistent with previous
studies conducted in the United States and Turkey (25,
58). Turkish HF patients mainly received social support
from their families (25). Patients in the present study
who received more tangible support had lower scores on
the domains of physical functioning, role physical, bodily
pain, vitality and social functioning. This is not surprising
since Arab patients with these compromised domains due
to the disease process and treatment complexity were
more in need of tangible support (17). Other social sup-
port subscales were not significantly related to QOL
domains. The few studies that examined the relationship
between social support and QOL among HF patients
yielded, inconsistent findings (25, 58). The inconsisten-
cies in the current study and previous studies may be
due to the use of different instruments to measure social
support and QOL (58). Further studies are needed to
explore the relationship between social support and QOL
among patients with HF in the Arabic and Islamic
culture.
The cross-sectional nature of this study limits causal
inferences and is a weakness in terms of understanding
factors that affect HF patients’ QOL over time. In this
study, data on physical and depressive symptoms were
not collected. Arab community values discourage the
expression of depression and other mental issues out-
side the family. Further studies are needed to explore
the influence of these factors on QOL in this
population.
to optimising QOL within the context of culture as a
major focus of HF treatment. One of the more signifi-
cant findings was that LVEF had the strongest relation-
ship with QOL among Arab patients with HF. Effective
management of LVEF using pharmacological and non-
pharmacological interventions may improve QOL among
this population. Expansion of the role of the primary
care specialist is important to provide comprehensive
care for patients with chronic diseases. Nurses and other
healthcare providers may need to support Arab patients
in general and male patients specifically to express their
feelings so that their needs can be identified. Further
investigation of the relationship between perceived
social support and QOL among Arab and Western
patients with HF is warranted. While we expect our
findings are relevant to Arab Muslim patients with HF
currently living in Western countries, future research
should focus specifically on understanding the experi-
ence of Arab Muslim with HF residing in Western
countries.
Author contribution
Fawwaz Alaloul, PhD, MPH, RN; Mohannad E. AbuRuz,
PhD, RN; Debra K. Moser, DNSc, RN, FAAN; Lynne A.
Hall, DrPH, RN; and Ahmad Al-Sadi, MSN, RN, involved
in study conception and design. Fawwaz Alaloul, PhD,
MPH, RN, and Ahmad Al-Sadi, MSN, RN, involved in
acquisition of data. Fawwaz Alaloul, PhD, MPH, RN;
Mohannad E. AbuRuz, PhD, RN; Debra K. Moser, DNSc,
RN, FAAN; and Lynne A. Hall, DrPH, RN, involved in
analysis and interpretation of data. Fawwaz Alaloul, PhD,
MPH, RN; Mohannad E. AbuRuz, PhD, RN; Debra K.
Moser, DNSc, RN, FAAN; and Lynne A. Hall, DrPH, RN,
involved in drafting of the manuscript.
Ethical approval
Institutional ethics committee approval (the equivalent of
institutional review board approval) was obtained from
the two hospitals and the Hashemite University in
Jordan.

Conclusions
Funding
This study addressed QOL in Arab patients with HF and
showed that most Arab patients with HF reported poor Financial support for this research was provided by the
QOL. Healthcare providers need to pay more attention Hashemite University.

References
1 Dobre D, van Jaarsveld CH, Ranchor
AV, Arnold R, de Jongste MJ, Haai-
jer Ruskamp FM. Evidence-based
treatment and quality of life in heart
failure. J Eval Clin Pract 2006; 12:
334–40.
2 Roger VL, Go AS, Lloyd-Jones DM,
Benjamin EJ, Berry JD, Borden WB,
. . . Turner MB. Heart disease and
stroke statistics – 2012 update: a
report from the American Heart
Association. Circulation 2012; 125:
e2–220.
3 Jaarsma T, Stromberg A, De Geest S,
Fridlund B, Heikkila J, Martensson J,
Moons P, Scholte op Reimer W,

© 2016 Nordic College of Caring Science


Smith K, Stewart S, Thompson DR.
Heart failure management pro-
grammes in Europe. Eur J Cardiovasc
Nurs. 2006; 5: 197–205.
4 Martin M, Blaisdell-Gross B, Fortin
EW, Maruish ME, Manocchia M,
Sun X, . . . Ware JE. Health-related
quality of life of heart failure and
coronary artery disease patients
improved during participation in dis-
ease management programs: a longi-
tudinal observational study. Dis
Manag 2007; 10: 164–78.
5 Smith DH, Johnson ES, Blough DK,
Thorp ML, Yang X, Petrik AF, Cris-
pell KA. Predicting costs of care in
heart failure patients. BMC Health
Serv Res 2012; 12: 434.
6 Health Grades Inc. Statistics by Country
for Congestive Heart Failure. 2012,
http://cureresearch.com/c/congestive
_heart_failure/stats-country.htm (last
accessed 8 December 2012).
7 Heo S, Doering LV, Widener J,
Moser DK. Predictors and effect of
physical symptom status on health-
related quality of life in patients with
heart failure. Am J Crit Care 2008;
17: 124–32.
8 Heo S, Lennie TA, Okoli C, Moser
DK. Quality of life in patients with
heart failure: ask the patients. Heart
Lung 2009; 38: 100–8.
9 Heo S, Moser DK, Lennie TA, Zam-
broski CH, Chung ML. A comparison
of health-related quality of life
between older adults with heart fail-
ure and healthy older adults. Heart
Lung 2007; 36: 16–24.
10 Chen HM, Clark AP, Tsai LM, Lin
CC. Self-reported health-related
quality of life and sleep disturbances
in Taiwanese people with heart fail-
ure. J Cardiovasc Nurs 2010; 25: 503–
13.
11 Iqbal J, Francis L, Reid J, Murray S,
Denvir M. Quality of life in patients
with chronic heart failure and their
carers: a 3-year follow-up study
assessing hospitalization and mortal-
ity. Eur J Heart Fail 2010; 12: 1002–8.
12 Son YJ, Song Y, Nam S, Shin WY,
Lee SJ, Jin DK. Factors associated
with health-related quality of life in
elderly Korean patients with heart
failure. J Cardiovasc Nurs 2012; 27:
528–38.
13 Peters-Klimm F, Kunz CU, Laux G,
Szecsenyi J, Muller-Tasch T. Patient-
© 2016 Nordic College of Caring Science
and provider-related determinants of
generic and specific health-related
quality of life of patients with
chronic systolic heart failure in pri-
mary care: a cross-sectional study.
Health Qual Life Outcomes 2010; 8: 98.
doi:10.1186/1477-7525-8-98-108.
14 Padilla GV, Kagawa-Singer M, Ash-
ing-Giwa T. Quality of life, health
and culture. In Quality of Life from
Nursing and Patient Perspectives. (King
GL, Hinds PS eds), 2012, Jones and
Bartlett Publishers, Sudbury, MA,
105–35.
15 The World Health Organization
Group. The World Health Organiza-
tion quality of life assessment (WHO-
QOL): position paper from the World
Health Organization. Soc Sci Med
1995; 41: 1403–9.
16 Silbermann M, Hassan EA. Cultural
perspectives in cancer care: impact of
Islamic traditions and practices in
Middle Eastern countries. J Pediatr
Hematol Oncol 2011; 33(Suppl 2):
S81–6.
17 Tajvar M, Fletcher A, Grundy E,
Arab M. Social support and health of
older people in Middle Eastern coun-
tries: a systematic review. Australas J
Ageing 2013; 32: 71–78.
18 Wehbe-Alamah H. Bridging generic
and professional care practices for
Muslim patients through use of Lei-
ninger’s culture care modes. Contemp
Nurse 2008; 28: 83–97.
19 al-Krenawi A, Graham JR. Culturally
sensitive social work practice with
Arab clients in mental health settings.
Health Soc Work 2000; 25: 9–22.
20 Saca-Hazboun H, Glennon CA. Cul-
tural influences on health care in
Palestine. Clin J Oncol Nurs 2011; 15:
281–6.
21 Vogel DL, Heimerdinger-Edwards SR,
Hammer JH, Hubbard A. “Boys don’t
cry”: examination of the links
between endorsement of masculine
norms, self-stigma, and help-seeking
attitudes for men from diverse back-
grounds. J Couns Psychol 2011; 58:
368–82.
22 Joseph S. Gender and Family in the
Arab World. In Arab Women: Between
Defiance and Restraint. (Sabbah S ed),
1996, Olive Branch Press, New York,
194–202.
23 Eng PM, Rimm EB, Fitzmaurice G,
Kawachi I. Social ties and change in
Factors associated with quality of life 7
social ties in relation to subsequent
total and cause-specific mortality and
coronary heart disease incidence in
men. Am J Epidemiol 2002; 155: 700–
9.
24 Pirie PL, Rooney BL, Pechacek TF,
Lando HA, Schmid LA. Incorporating
social support into a community-
wide smoking-cessation contest.
Addict Behav 1997; 22: 131–7.
25 Barutcu CD, Mert H. The relation-
ship between social support and
quality of life in patients with heart
failure. J Pak Med Assoc 2013; 63:
463–7.
26 Ware JE, Sherbourne CD. The MOS
36-item Short-Form Health Survey
(SF-36). I. Conceptual framework
and item selection. Med Care 1992;
30: 473–83.
27 Ware JE Jr, Kosinski M, Bjorner JB,
Turner-Bowker DM, Gandek B,
Maruish ME. SF-36v2â Health Survey:
Administration guide for Clinical Trial
Investigators. 2008, QualityMetric
Incorporated, Lincoln, RI.
28 Coons SJ, Alabdulmohsin SA, Drau-
galis JR, Hays RD. Reliability of an
Arabic version of the RAND-36
Health Survey and its equivalence to
the US-English version. Med Care
1998; 36: 428–32.
29 Sherbourne CD, Stewart AL. The
MOS social support survey. Soc Sci
Med 1991; 32: 705–14.
30 Alaloul, F. Examination of the validity
of the Arabic version of the Medical Out-
come Study (MOS) Social Support Survey
using confirmatory factor analysis. (Mas-
ter Thesis), 2007, University of Ken-
tucky, Lexington.
31 Soper DS. A-priori Sample Size Calcula-
tor for Multiple Regression [Software].
2015, http://www.danielsoper.com/
statcalc (last accessed 8 January
2015).
32 Shieh G. Clarifying the role of mean
centring in multicollinearity of inter-
action effects. Br J Math Stat Psychol
2011; 64: 462–77.
33 Demir M, Unsar S. Assessment of
quality of life and activities of daily
living in Turkish patients with heart
failure. Int J Nurs Pract 2011; 17:
607–14.
34 Ekman I, Fagerberg B, Lundman B.
Health-related quality of life and
sense of coherence among elderly
patients with severe chronic heart
8 F. Alaloul et al.
failure in comparison with healthy
controls. Heart Lung 2002; 31: 94–
101.
35 Saccomann IC, Cintra FA, Gallani
MC. Health-related quality of life
among the elderly with heart failure:
a generic measurement. Sao Paulo
Med J 2010; 128: 192–6.
36 Hoekstra T, Lesman-Leegte I, van
Veldhuisen DJ, Sanderman R,
Jaarsma T. Quality of life is impaired
similarly in heart failure patients
with preserved and reduced ejection
fraction. Eur J Heart Fail 2011; 13:
1013–8.
37 Huang TY, Moser DK, Hwang SL,
Lennie TA, Chung M, Heo S. Com-
parison of health-related quality of
life between American and Tai-
wanese heart failure patients. J Tran-
scult Nurs 2010; 21: 212–9.
38 Hollins S. Religions, Culture, and
Healthcare: A Practical Handbook for
Use in Healthcare Environments. 2009,
Radcliffe Publishing, Oxford; New
York.
39 Al-Busaidi ZQ. A qualitative study
on the attitudes and beliefs towards
help seeking for emotional distress in
Omani women and Omani general
practitioners: implications for post-
graduate training. Oman Med J 2010;
25: 190–8.
40 Rustoen T, Stubhaug A, Eidsmo I,
Westheim A, Paul SM, Miaskowski C.
Pain and quality of life in hospitalized
patients with heart failure. J Pain
Symptom Manage 2008; 36: 497–504.
41 Spiraki C, Kaitelidou D, Papakon-
stantinou V, Prezerakos P, Mani-
adakis N. Health-related quality of
life measurement in patients admit-
ted with coronary heart disease and
heart failure to a cardiology depart-
ment of a secondary urban hospital
in Greece. Hellenic J Cardiol 2008; 49:
241–7.
42 Middel B, Bouma J, de Jongste M,
van Sonderen E, Niemeijer MG, Cri-
jns H, . . . van den Heuvel W. Psy-
chometric properties of the
Minnesota Living with Heart Failure
Questionnaire (MLHF-Q). [Validation
Studies]. Clin Rehabil 2001; 15: 489–
500.
43 Goodlin SJ, Wingate S, Pressler SJ,
Teerlink JR, Storey CP. Investigating
pain in heart failure patients: ratio-
nale and design of the Pain Assess-
ment, Incidence & Nature in Heart
Failure (PAIN-HF) study. J Cardiac
Fail 2008; 14: 276–82.
44 Van den Branden S, Broeckaert B.
Necessary interventions: Muslim
views on pain and symptom control
in English Sunni e-Fatwas. Ethical
Perspect 2010; 17: 626–51.
45 King M, Kingery J, Casey B. Diag-
nosis and evaluation of heart fail-
ure. Am Fam Physician 2012; 85:
1161–8.
46 Rizzello V, Poldermans D, Biagini E,
Schinkel AF, Elhendy A, Leone AM,
. . . Bax JJ. Relation of improvement
in left ventricular ejection fraction
versus improvement in heart failure
symptoms after coronary revascular-
ization in patients with ischemic car-
diomyopathy. Am J Cardiol 2005; 96:
386–9.
47 Solomon SD, Anavekar N, Skali H,
McMurray JJ, Swedberg K, Yusuf S,
. . . Pfeffer MA. Influence of ejection
fraction on cardiovascular outcomes
in a broad spectrum of heart failure
patients. Circulation 2005; 112: 3738–
44.
48 Chaudhry SI, McAvay G, Chen S,
Whitson H, Newman AB, Krumholz
HM, Gill T. Risk factors for hospital
admission among older persons with
newly diagnosed heart failure: find-
ings from the Cardiovascular Health
Study. J Am Coll Cardiol 2013; 61:
635–42.
49 Bartos JA, Francis GS. The high-risk
patient with heart failure with
reduced ejection fraction: treatment
options and challenges. [Review].
Clin Pharmacol Ther 2013; 94: 509–18.
50 Kireyev D, Adib K, Pohl KK, Khalil
M, Wilson MF. Viability studies-
comparison of techniques. Am Heart
Hosp J 2011; 9: 107–11.
51 Stamp KD. Women with heart fail-
ure: do they require a special
approach for improving adherence to
self-care? Curr Heart Fail Rep 2014;
11: 307–13.
52 Fotos NV, Giakoumidakis K, Kollia Z,
Galanis P, Copanitsanou P, Pananou-
daki E, . . . Hero B. Health-related
quality of life of patients with severe
heart failure. A cross-sectional multi-
centre study. Scand J Caring Sci 2012;
27: 686–94.
53 Franzen K, Saveman BI, Blomqvist
K. Predictors for health related qual-
ity of life in persons 65 years or
older with chronic heart failure. Eur
J Cardiovasc Nurs 2007; 6: 112–20.
54 Barghouti F, Halaseh L, Said T,
Mousa AH, Dabdoub A. Evidence-
based medicine among Jordanian
family physicians: awareness, atti-
tude, and knowledge. Can Fam Physi-
cian 2009; 55: e6–13.
55 Lewis EF, Lamas GA, O’Meara E,
Granger CB, Dunlap ME, McKelvie
RS, . . . Pfeffer MA. Characterization
of health-related quality of life in
heart failure patients with preserved
versus low ejection fraction in
CHARM. Eur J Heart Fail 2007; 9:
83–91.
56 Rector TS, Anand IS, Cohn JN. Rela-
tionships between clinical assess-
ments and patients’ perceptions of
the effects of heart failure on their
quality of life. J Cardiac Fail 2006;
12: 87–92.
57 Bennett SJ, Perkins SM, Lane KA,
Deer M, Brater DC, Murray MD.
Social support and health-related
quality of life in chronic heart failure
patients. Qual Life Res 2001; 10: 671–
82.
58 Heo S, Moser DK, Chung ML, Len-
nie TA. Social status, health-related
quality of life, and event-free sur-
vival in patients with heart fail-
ure. Eur J Cardiovasc Nurs 2012; 11:
141–9.
© 2016 Nordic College of Caring Science