{'fraction_non_alphanumeric': 0.039897839442258574, 'fraction_numerical': 0.015186028853454821, 'mean_word_length': 5.054325114918512, 'pattern_counts': {'":': 0, '<': 4, '<?xml version=': 0, '>': 1, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Factors related to self-care behaviors among hospitalized patients with heart failure in Japan, based on the European Heart Failure Self-Care Behaviour Scale

[Purpose] The characteristics of heart failure in hospitalized patients with poor self-care behaviors are unknown. We investigated factors associated with self-care behaviors by using the European Heart Failure Self-Care Behaviour Scale (EHFScBS) in heart failure patients based on three comprehensive concepts. [Participants and Methods] This was a cross-sectional single-center study of heart failure patients hospitalized at a tertiary-care hospital. We investigated age, gender, family living together/apart, employment, and the Specific Activity Scale (SAS). A physical therapist provided the EHFScBS one time to determine the patients’ pre-hospital self-care behavior status. The 12 items of the EHFScBS were classified into the following three categories: Maintenance, Monitoring, and Management. [Results] The median age of the 39 consecutive patients was 81 years. A multiple regression analysis revealed that the factors exhibiting significant associations were the SAS score (β=0.504) for Management and age (β=−0.403) for the total EHFScBS score (adjusted by the number of hospitalizations for heart failure). Maintenance and Monitoring were not significantly associated with the survey items. [Conclusion] These data indicate that self-care education for hospitalized patients with heart failure leads to individualized approaches based on characteristics such as age and physical activity capacity.


INTRODUCTION
There has been a rapid increase in the number of heart failure (HF) patients in Japan, due in part to the super-aging of the population, and because the onset of HF increases geometrically from the age of 65 years; this increase has been called the "heart failure pandemic" 1) . The number of individuals with HF in Japan is projected to reach 1.3 million by 2030 1) . In many HF patients, repeated readmissions due to acute exacerbations are accompanied by gradual declines in cardiac function and exercise tolerance 2) . It is therefore very important to prevent readmissions in HF patients.
Self-care education is essential for the prevention of readmissions among patients with HF 3) . The European Heart Failure Self-Care Behaviour Scale (EHFScBS) is an effective patient-reported questionnaire that measures the self-care behaviors (ScBs) of HF patients 4) . It has been reported that poor ScBs revealed by the EHFScBS are associated with mortality 5) , depression 6) , cognitive function 7) , and health-related quality of life 8) . Since poor ScBs affect a patient's prognosis, it is important to understand problems related to ScBs before HF patients' hospitalization. In the EHFScBS, ScBs comprise a comprehensive concept based on three main categories: Maintenance, Monitoring, and Management 9) . Most of the previous research examined mainly the total score on the EHFScBS [5][6][7]9) . The specific characteristics of HF patients with poor ScBs according to the three categories on the EHFScBS are unknown.
The identification of these characteristics will contribute to the understanding of poor ScBs and will strengthen patient education on disease management. We speculated that HF patients who are elderly and/or who live alone would have poor ScBs in all three EHFScBS categories, and we conducted the present study to examine the factors associated with ScBs in HF patients in light of the three categories.

PARTICIPANTS AND METHODS
This was a cross-sectional study conducted at a single-center. The participants were HF patients who were admitted to the National Hospital Organization Nagasaki Medical Center (a tertiary-care hospital) between July 2020 and January 2021. The eligibility criteria were: (1) diagnosis of HF, (2) HF stage C or D, (3) undergoing physician-prescribed cardiac rehabilitation, and 4) providing written informed consent to participate. The exclusion criteria were: (1) history of dementia or suspected cognitive impairment, (2) in-hospital death, and (3) visual impairment. The diagnosis of HF was made by a cardiologist based on the Framingham Study criteria 10) . The HF stage was defined according to the American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines 11) . This study was conducted with the approval of the Ethics Committee of Nagasaki Medical Center (approval no. 2020037). Written informed consent was obtained from all enrolled patients.
We collected clinical information on each patient's background, comorbidities, life background, coronary risk factors, blood data, echography, and medications. The Specific Activity Scale (SAS) was administered by a physical therapist to the patients at the initial cardiac rehabilitation evaluation. Heart failure was classified according to Japanese guidelines as follows: a left ventricular ejection fraction (LVEF) <40% was 'heart failure with reduced LVEF (HFrEF)', 50% >LVEF ≥40% was 'heart failure with a mid-range LVEF (HFmrEF)', and LVEF ≥50% was 'heart failure with a preserved LVEF (HFpEF)' 12) .
A physical therapist provided the EHFScBS one time to the patients for the determination of the patients' pre-hospital ScB status, at the beginning of the patient's cardiac rehabilitation. The EHFScBS is a self-administered questionnaire first reported in 2003 that measures ScBs of HF patients with 12 items 13) . It uses a Likert scale with five possible responses for each item, from 1 ('I completely agree') to 5 ('I completely disagree') points. The score range is thus 12-60 points, with higher scores indicating worse ScBs. The concept of the EHFScBS-12 items is based on three dimensions 14) . The first dimension, "adherence to a regimen", consists of six items: daily weight measurement, water restriction, sodium restriction, taking medication(s), influenza vaccination, and regular exercise. The second dimension, "asking for help", consists of four items: shortness of breath, swollen feet, a 2-kg increase in body weight within 1 week, and contacting a physician or nurse if fatigue increases. The third dimension, "adapting activities", consists of two items related to the behavior of adapting one's activity status. The reliability and validity of the Japanese version of the EHFScBS were confirmed in 2008 15) .
The comprehensive concept of ScBs has also been described as consisting of Maintenance, Monitoring, and Management, as the "middle-range theory" 16) . Maintenance is the behaviors used to maintain physical and emotional stability, such as adherence to treatment and healthy behaviors (e.g., medication, exercise, salt-restricted diet, etc.). Monitoring is the process of observing oneself for signs and changes in symptoms, such as daily blood pressure and weight measurements and general signs and symptoms. Management is the response when signs or symptoms occur, such as an adaptation of one's activity level or contact with physicians/nurses 16) . In the three dimensions of the EHFScBS, the "adherence to a regimen" consisting of six items is Maintenance (items 6, 9, 10, 11, and 12) and Monitoring (item 1); "asking for help" and "adapting activities" consisting of six items correspond to Management (items 2, 3, 4, 5, 7, and 8) 17,18) . We therefore classified the ScB concepts in this study into three categories: Maintenance (range 5-25 points on the EHFScBS), Monitoring (range 1-5 points), and Management (score range 6-30 points).
The results of our analyses are presented as numbers, percentages, mean ± SD, or median [25th and 75th percentiles]. The data were tested for normal distribution using the Shapiro-Wilk test. A multiple regression analysis was performed to clarify the relationship between the EHFScBS and the survey items (age, gender, living with family vs. living alone, employment, and SAS result). Due to the small sample size of this study, the selection of independent variables was limited to the prehospital social background of HF patients. The dependent variables in a univariate analysis were the total EHFScBS score, the Maintenance score, the Monitoring score, and the Management score. The independent variables were age, gender, living with family, employment, and SAS with probability (p)-values <0.2. For the univariate analysis, Spearman's correlation coefficient was used for continuous data and the Mann-Whitney U-test was used for qualitative data. The covariate was the number of hospitalizations for HF; the reason for this is that HF patients who are hospitalized for the first time may not be well educated about ScBs. The stepwise method was used for variable selection. To avoid multicollinearity between the independent variables, a variable with a variance inflation factor (VIF) greater than 10 was excluded. We used EZR on R commander (ver. 1.54) for all statistical analyses 19) . All statistical tests were two-tailed, and statistical significance was defined as p<0.05.

RESULTS
Thirty-nine consecutive Japanese patients with HF were enrolled (Fig. 1) The results of the multiple regression analysis for the EHFScBS total score, Maintenance, Monitoring, and Management are provided in Table 3. In the univariate analysis, the independent variables that resulted in p<0.2 were age for total score (r=−0.296, p=0.067), gender for Maintenance (median, female 14.5 vs. male 12.0 points, p=0.08), and SAS for Management (r=0.411, p=0.016). Independent variables were not clarified for Monitoring. There was no multicollinearity among the independent variables. The items that showed significant differences were age (β=−0.403, p=0.014) for the total EHFScBS score and SAS (β=0.504, p=0.006) for Management (adjusted by the number of hospitalizations for HF). Maintenance and Monitoring were not significantly associated with the survey items.

DISCUSSION
Our analyses clarified the characteristics of HF patients based on the categories of Maintenance, Monitoring and Management, which are related to ScBs as follows: the characteristic related to Management was the SAS score, and the HF patients with higher pre-hospital SAS scores had poorer ScBs. Our study hypothesis, i.e., that elderly HF patients and/or HF patients who live alone would have poor ScBs, was thus not supported by the results of our analyses. In particular, the patients' total EHFScBS scores showed that the ScBs were worse among the younger patients compared to the elderly patients. This is clinically important because (1) Management requires more education, such as contacting physicians and nurses, for HF patients who are more physically active compared to those who are less physically active before admission, and (2) ScB education in general needs to be strengthened more for younger HF patients than elderly patients.
Most of the previous research focused on the total EHFScBS score of HF patients 20) . One study examined the causes of death and hospitalization in relation to 'asking for help' and 'adapting activities' in Management, and its authors reported that only adapting activities were associated with death 21) . Adapting activities include taking a break during the day or resting when shortness of breath occurs due to awareness of HF symptoms. Although our present findings cannot be directly compared with those of previous studies since this study was based on three categories of ScBs, it is important to ensure adequate ScB education because some poor Management practices increase patient mortality. For example, special attention to ScB education should be provided for HF patients with a high pre-hospital capacity for physical activity. This may be due to the tendency of HF patients to hold off on going to the hospital because they are able to walk and perform activities of daily living even when symptoms of HF such as shortness of breath and swelling appear.
It has been recommended that education that will accelerate HF patients' consultation behavior (Management) be provided based on the urgency, with a categorization such as a 'red-alert' zone, 'amber-warning' zone, and 'green-safety' zone 17) . It is necessary to make effective use of such a method. ScB education may be difficult for inpatients with initial HF, but sufficient ScB education for inpatients with HF stage B (i.e., before the onset of HF) may help prevent future readmissions.  The data are mean ± SD or median [25th, 75th percentile]. BI: Barthel Index; BNP: brain natriuretic peptide; eGFR: estimated glomerular filtration rate; HF: heart failure; HFmrEF: heart failure with mid-range ejection fraction; HFpEF: heart failure with preserved ejection fraction; HFrEF: heart failure with reduced ejection fraction; IHD: ischemic heart disease; LVEF: left ventricular ejection fraction; NYHA: New York Heart Association functional classification; RAS: renin-angiotensin system; SAS: Specific Activity Scale.
Our present results revealed that the total score on the EHFScBS was more closely associated with poorer ScBs among the younger HF patients compared to the elderly HF patients. This finding is similar to that of another investigation 22) , although other studies indicated that elderly HF patients had poorer ScBs 23,24) . All of these prior studies examined HF patients with an average age of 60-70 years. By contrast, the median age of the present patient series was 81 years. It is thus possible that the research results differed due to the differences in the attributes of the study participants.
ScBs have been reported to be poor not only at the individual level, but also at the family level (e.g., based on family support, medication management) and at the community level (e.g., access to hospitals, availability of healthy food) 18) . A systematic review of ScBs among HF patients stated that the factors associated with ScBs are inconsistent among studies 20) . Thus, ScBs may be affected in various ways, and it is necessary to investigate the characteristics of HF patients in various settings and regions.
This study has two limitations. First, due to the small sample size, only a few variables could be used as independent variables; many related factors could not be examined. Second, regarding the concept of Monitoring, the measurement accuracy was low because there was only one monitoring-related item in the EHFScBS. In the future, a detailed study of Monitoring using the ScBs of the Heart Failure Index (SCHFI) 25) , another ScB assessment, is needed.