Knowledge About Heart Failure in Participants and NonParticipants Cardiac Rehabilitation

It is believed that the patient’s lack of knowledge contributes to the worsening in quality of life, social isolation, increased comorbidities, lack of self-care, lack of knowledge of signs and symptoms, and lack of adherence to HF treatment.6,7 These factors are inherent to increasing health costs, as patients' knowledge about their condition is considered a central component of the clinical and rehabilitation treatment of patients with HF.8-10


Introduction
Heart Failure (HF) is a complex systemic clinical syndrome characterized by cardiac dysfunction that leads to an impaired blood supply to meet tissue and metabolic needs. 1,2This syndrome has become a growing problem in public health, as approximately 23 million individuals have HF worldwide. 1,3Furthermore, HF is one of the main causes of hospital admissions worldwide, resulting in great economic impact, as well as on mortality and quality of life. 1,3,4erefore, alternatives have been sought to reduce mortality and morbidity rates caused by HF. 4 Among them is the need for patients to have greater access to knowledge on the development and treatment of the of bringing patients back to their usual activities, accompanied by educational actions aimed at lifestyle changes. 12,13However, the information patients with HF have, which are related to knowledge about the disease are restricted to factors routinely registered by patients who only carry out clinical treatment of the disease, restricting the knowledge about information limitations observed in patients participating in these programs. 2e objective of this study was to compare the level of knowledge about the disease in patients with a diagnosis of HF participants and non-participants in Cardiopulmonary and Metabolic Rehabilitation (CPMR) programs.

Methods
A cross-sectional study was carried out with HF patients, intentionally selected by convenience in two public health institutions in the region of Great Florianópolis, state of Santa Catarina, Brazil, from September to October 2014.
The sample consisted of patients with HF (classes I to IV), participants and non-participants in CPMR programs divided into two groups: CPMR participants (RG) and non-CPMR participants (control group, CG).Patients in both groups met the proposed inclusion criteria, namely: having a clinical diagnosis of HF and age older than 18 years.Patients with cognitive alterations that made it difficult to complete the questionnaire were excluded from the study.The instrument used to assess the level of knowledge was the Disease Knowledge Questionnaire for Patients with HF. 2 The questionnaire consists of 19 multiplechoice items, covering areas related to the concept, pathophysiology, risk factors, signs and symptoms, life habits, diagnosis, medications, treatment, self-care and physical exercise. 2ch item in the questionnaire has four alternatives for answers, one correct, one incomplete, one wrong, and one "I do not know".Patients should check only one alternative in each question, the one which they considered to be correct.The established scores for the alternatives were: 3 if correct; 1 if incomplete; zero if wrong; and zero for "I do not know".The maximum score was established according to the final number of questions answered.The sum of the scores established the patient's total level of knowledge. 2

Statistical analysis
Descriptive statistics were used for data analysis, using mean and standard deviation for the variables with normal distribution, and median and interquartile range for variables with non-normal distribution.The Kolmogorov-Smirnov test was used to test the normality of the data.The t-test for independent samples was used to compare the age and time of diagnosis between the groups.For the variables with non-normal distribution, the Mann-Whitney U test was used to compare continuous variables between the groups, whereas the chi-square test was used for the association of categorical variables between the groups.Spearman's correlation was used to verify the existence of an association between the level of knowledge about the disease and the variables educational level, socioeconomic level, and age.The Statistical Package for Social Sciences (SPSS), version 20.0, was used for all analyses.The level of significance was set at 5% for all tests.

Results
We identified 144 patients with HF (classes I to IV) eligible to participate in the study.Of these, three were excluded according to the established criteria, whereas 18 patients refused to participate for personal reasons.A total of 123 (85.4%) patients, 61 in the RG (56 ± 12 years, 23% of women) and 62 in the CG (57.2 ± 11.1 years, 28% of women) participated in the study.There was no significant difference between patients' ages in both groups (p = 0.394).The time of HF diagnosis was similar between the groups, with the RG with a mean of 7.9 ± 6.8 years and the CG with 6.7 ± 4.4 years (p = 0.225).The other characteristics of the participants are shown in table 1.
Table 2 shows the mean scores by items in each group.Only in item 19 the patients in the CG showed superior knowledge when compared to the RG.When comparing the total score of the questionnaire between the groups, it was observed that the RG showed a median knowledge of 42 (13) points and the CG of 33.5 (18) points, with the RG showing significantly greater knowledge than the CG (p <0.001, U = 1,117.5).When comparing the groups according to the questionnaire factors, the RG showed greater knowledge in comparison to the CG in four of the five factors (Table 3).
Moderate positive correlations were found between the level of knowledge and the sociodemographic variable level of schooling, both for the RG (rho = 0.466, p <0.001) and for the CG (rho = 0.633, p <0.001).A moderate positive correlation between income and level of knowledge was found only in the RG (rho = 0.372, p <0.003), as well as a moderate negative correlation between age and level of knowledge in the CG alone (rho = -0.419,p <0.001).

Discussion
This study investigated the level of knowledge about the disease in patients with HF that were participants and non-participants in CPMR programs, a context that, to the best of our knowledge, was assessed for the first time.The results showed that the patients in the RG had greater knowledge about HF when compared to the patients in the CG.[15][16][17] When the questionnaire questions were analyzed alone, it was verified that the RG had greater knowledge than the CG for most items of the questionnaire.These results agree with those in the study by Castro et al., 18 who found that patients with HF that had previous knowledge about their disease were more adherent to non-pharmacological care.
The CG showed superior knowledge about the disease in relation to the RG only for the item concerning the medications used.These findings are rather peculiar, as studies have shown that it is common for HF patients to follow drug treatment without knowing the names or effects of the drugs. 19,20Similar results were found by Freitas et al., 20 who verified that 72% of evaluated outpatients with HF did not know the name and indication of the medications they used.These results indicate insufficient knowledge to understand the problem and, consequently, manage the disease. 20en the tool is analyzed regarding its total score, the RG showed significantly higher knowledge than the CG.According to the ICQ classification, 2 the RG showed "good" knowledge about the disease, while the CG was classified as "acceptable" only.Although it was not the objective of the study, it is speculated that these findings may be derived, in part, from the routine contact of patients from CPMR programs with the health team, receiving more information about their disease. 21,22e CPMR appears, in this context, as an important tool for the education of the patient with HF.In addition to the physical exercise factor, one of the main objectives of the CPMR programs, the continuous contact with the rehabilitation team and other educational actions, facilitate the acquisition of knowledge about the disease.Thus, in addition to the improvement in quality of life and functional status, 2 and the reduction of hospitalizations and overall medical costs, CPMR also influences the patient's educational process, allowing the expansion of knowledge related to HF. 2,[22][23][24][25][26][27] It is noteworthy that, even though there is a difference between the groups, both had minimum knowledge about HF, probably due to the fact that living with the chronic disease affects different habits of life of the patients.[25][26] The patients' knowledge about their disease is part of a successful HF treatment. 2,13By increasing their knowledge about the disease, patients have a higher chance to make correct choices.This is because knowledge about the disease contributes to achieving an adequate perception of their health status, which allows a modification in their daily habits of life. 11e results also showed that patients from the RG with higher family income had a higher level of knowledge about HF.Such findings corroborate previously published studies, in which the socioeconomic level has a direct influence on the acquisition of knowledge related to the disease. 2,13,16Patients from the RG with higher educational levels also had greater knowledge about the disease.These results agree with the current literature, according to which the level of schooling positively influences better patient understanding of the illness. 15,28urthermore, the educational level is an important factor for the acquisition of new knowledge about the disease, 15,28 in addition to benefiting changes in lifestyle, early seeking of medical help, 28 and better treatment understanding and adherence. 11Patients participating in CPMR that have lower income need complementary information on diagnosis and treatment. 23milarly, individuals with low level of schooling tend to have a lower degree of basic knowledge, which may result in decreased understanding of their disease, 2,29,30 thus influencing treatment adherence. 9In this sense, low levels of income and schooling are associated with an increased risk of cardiovascular diseases [27][28][29][30]31 and readmissions, 10,[28][29][30][31][32] in addition to a limitation for compliance with medical recommendations and self-care guidelines.14,24,33 As in the original tool, this study was carried out in a specific region (Southern Region of Brazil) and thus, these results cannot be extrapolated to other regions, and further studies must be performed in other regions of the country. One of te implications of using ICQ in research is its use for clinical and geopolitical purposes.The use of this tool can facilitate the identification of educational needs between different regions and different health organizations.

Conclusions
Patients with heart failure who participated in cardiopulmonary and metabolic rehabilitation programs showed a better level of knowledge about their disease when compared to non-participating patients.
The project was approved by the Human Research Ethics Committee of the State University of Santa Catarina (UDESC), under protocol number 775.993/14.All participants agreed to participate and signed the Free and Informed Consent form, in accordance with Resolution 466/12 of the National Health Council.

Table 2 -Comparison of the mean scores of each questionnaire item between the rehabilitation (RG) and the control (CG) groups
* p< 0.05.IQI: interquartile interval; U: Mann-Whitney U test.