- 1-Assessment of Congestive Heart Failure Patients Knowledge and Compliance in Kirkuk بلقلا زجع ىضرم مازتلاو فراعم مییقتيناقتحلإايفةنیدمكوكرك

Background: Heart failure is an increasing cause of morbidity and mortality, especially in people aged above 65 years .Year after year, heart failure (HF) affects and kills an increasingly large number of people , the nurses educating of Heart Failure patients about diagnosis and treatment of their diseases have fewer hospital readmissions and a better quality of life Aim of the study:In order to assessment patients knowledge and compliance with congestive heart failure in Kirkuk city . as well as to find out the relationship between patients knowledge and some as age and gender , residence , educational level . Methodology A descriptive study of a quantitative design was conducted in Kirkuk hospitals( Kirkuk general hospital, Azadi teaching hospital and Dakuk hospital) throughout the period from 1 of June 2012 to 31 of July 2013 . A non-probability (purposive) sample of (75) patients who admitted to Cardiac care units and ward of internal medicine at ( Kirkuk general hospital, Azadi teaching hospital and Dakuk hospital) . In order to collect the study information, a questionnaire was constructed. The questionnaire which contain of ( 54) items .Demographic data include ( 9 ) items , knowledge of the Patients include (36) items , practice of the Patients include (9) items . 3-likert scale option was used in the rating scale as: (3) for yes , (2 ) for uncertain ,and ( 1 ) for no . Content validity was determined by presenting the questionnaire to a panel of (10) experts Frequencies and percentage were used to describe and to analyze the data the present study and inferential statistical data analysis (chi-square). Results The findings of the study indicate that a high percentage 56% of patients was from four age group (51and more) years. Its also appears that more than half (61%) of patients was male. With regard to their educational level, a high percentage (37%) from less than secondary school. The data indicate that (60%) were married. It had been noted that the majority of patients (70%) were retired. As for address, it is obvious that a high percentage (62%) of the patients were from the city. The data indicates that the most of these patients (72%) were had chronic diseases. The data analysis revealed that a high percentage (72%) of the patients were use medications. Its also appears that (53%) were no smoking. Conclusions : A socio demographic characteristic tends to have clearly effect on the knowledge of the patients and nursing staff , also the study concluded high percentage from patients have poor knowledge and practice about disease , while nurses staff have poor knowledge and need to update about congestive heart failure . Recommendation According to the results of the study, the study recommended the following items, concentrates should be on the health education for our society who may be had risk factors to heart diseases, more studies conducting about heart disease.


Abstract
Background: Heart failure is an increasing cause of morbidity and mortality, especially in people aged above 65 years .Year after year, heart failure (HF) affects and kills an increasingly large number of people , the nurses educating of Heart Failure patients about diagnosis and treatment of their diseases have fewer hospital readmissions and a better quality of life Aim of the study:-In order to assessment patients knowledge and compliance with congestive heart failure in Kirkuk city .as well as to find out the relationship between patients knowledge and some as age and gender , residence , educational level .Methodology A descriptive study of a quantitative design was conducted in Kirkuk hospitals( Kirkuk general hospital, Azadi teaching hospital and Dakuk hospital) throughout the period from 1 st of June 2012 to 31 st of July 2013 .A non-probability (purposive) sample of (75) patients who admitted to Cardiac care units and ward of internal medicine at ( Kirkuk general hospital, Azadi teaching hospital and Dakuk hospital) .In order to collect the study information, a questionnaire was constructed.The questionnaire which contain of ( 54) items .Demographic data include ( 9 ) items , knowledge of the Patients include (36) items , practice of the Patients include (9) items .3-likert scale option was used in the rating scale as: (3) for yes , (2 ) for uncertain ,and ( 1 ) for no .Content validity was determined by presenting the questionnaire to a panel of (10) experts Frequencies and percentage were used to describe and to analyze the data the present study and inferential statistical data analysis (chi-square).

Results
The findings of the study indicate that a high percentage 56% of patients was from four age group (51and more) years.Its also appears that more than half (61%) of patients was male.With regard to their educational level, a high percentage (37%) from less than secondary school.The data indicate that (60%) were married.It had been noted that the majority of patients (70%) were retired.As for address, it is obvious that a high percentage (62%) of the patients were from the city.The data indicates that the most of these patients (72%) were had chronic diseases.The data analysis revealed that a high percentage (72%) of the patients were use medications.Its also appears that (53%) were no smoking.Conclusions : A socio demographic characteristic tends to have clearly effect on the knowledge of the patients and nursing staff , also the study concluded high percentage from patients have poor knowledge and practice about disease , while nurses staff have poor knowledge and need to update about congestive heart failure .Recommendation According to the results of the study, the study recommended the following items, concentrates should be on the health education for our society who may be had risk factors to heart diseases, more studies conducting about heart disease.Keywords:-Heart failure , practice, Knowledge .

Introduction:
Heart failure ( HF ) is a syndrome characterized by high mortality , frequent hospitalization , poor quality of life , and multiple comorbitities ,as a result , heart failure management inevitably involves both a multidimensional assessment process and a complex therapeutic regimen.Heart failure develops over time as the heart's pumping action grows weaker.The condition can affect the right side of the heart only, or it can affect both sides of the heart.Most cases involve both sides of the heart.Right-side heart failure occurs if the heart can't pump enough blood to the lungs to pick up oxygen.Left-side heart failure occurs if the heart can't pump enough oxygen-rich blood to the rest of the body.Right-side heart failure may cause fluid to build up in the feet, ankles, legs, liver, abdomen, and the veins in the neck.Right-side and left-side heart failure also may cause shortness of breath and fatigue (tiredness).The leading causes of heart failure are diseases that damage the heart.Examples include coronary heart disease (CHD), high blood pressure, and diabetes (1) Heart failure is a condition in which the heart is unable to adequately pump blood throughout the body or unable to prevent blood from "backing up" into the lungs When the heart does not pump correctly there is not enough blood circulating through the body to meet the metabolic demands of the body.The inadequate supply of blood to the body results in a subsequent inadequate supply of oxygen to the tissues and symptoms such as fatigue or activity intolerance appear.Additionally, when the blood backs up into the lungs symptoms such as shortness of breath develop (2) .
Heart failure (HF) is an epidemic.Five million people were diagnosed with the disease in 2006 and 550,000 new cases are being reported each year.HF is associated with a decreased quality of life and high mortality rate.It also accounts for 12-15 million office visits and 6.5 million hospitals stays each year.Although there is no known cure for HF, understanding the disease and guidelines put forth by the American Heart Association as well as the Heart Failure Society of America, has been shown to decrease mortality, increase quality of life, and decrease hospital admissions (3) .When the heart does not pump correctly there is not enough blood circulating through the body to meet the metabolic demands of the body.The inadequate supply of blood to the body results in a subsequent inadequate supply of oxygen to the tissues and symptoms such as fatigue or activity intolerance appear.Additionally, when the blood backs up into the lungs symptoms such as shortness of breath develop (4) Objectives of the study: 1-To assess the patients knowledge regarding to Congestive Heart Failure in Kirkuk city.2-To identify the patient's compliance to reduce the burden of Congestive Heart Failure in Kirkuk city.3-To find out the relationship between patients knowledge compliance with age , gender , residence , educational level .

Methodology:-
To achieve the objectives of the study quantitative design (descriptive study) was conducted on congestive heart failure patients between period from 1 st of June 2012 to 31 st of July 2013.To assess congestive heart failure patients knowledge and compliance.The study was conducted in Kirkuk general hospital, (Azadi teaching hospital and Dakuk hospitals).A purposive sample consisted of (75) patients who were admitted in to hospitals in Kirkuk city definitely diagnosed with Congestive heart failure on adult patients who were attended to these hospitals.Through extensive review of relevant literature, a questionnaires was constructed for reach purpose of the study the data was collected by using personal and interview technique.Overall items included in the questionnaire were (54) items.A panel of (8) experts was involved in the determination of the questionnaire content validity.The questionnaire consists of three parts, demographic data which is composed of (9)  items such as (age, gender, level of education, occupation, marital status, chronic disease, treatment history and smoking history) , patients knowledge which comprised of (36) items.That classified as ( general information about heart failure, risk factors, signs and symptoms and treatment of heart failure ), patients Compliance which is composed of (9) items.The data were collected through the utilization of constructed questionnaire, interview technique with the patients with congestive heart failure in cardiac care unit and internal medicine wards in Kirkuk, Dakuk and Azady teaching hospitals.The data Was collected between 17 th of July , 2012 up to the 24 th December , 2012..All items were measured by using 3-likert scale option were used in the rating scale as Yes (3) , uncertain (2) and No (1).Data were analyzed by using descriptive statistics, which include frequency and percentages, were computed.and inferential statistics (chi-square test, t test and anova ), data are prepared, organized and entered into the computer file; Statistical Package for Social Science (SPSS) version ( 17) is used for data analysis at (P.value ≤ 0.05).

Variables
No. % Age 20-30 year - ----------- F= Frequency ; % = Percentage -4 -Table (1) shows that the highest percentage (56% ) of study sample at age group (51 and more ) , while the lowest percentage (12%) their ages ranged from (31-40) years, (61%) of the study sample were males , (37 %) of study sample were less than secondary school , (60%) of the study sample were married , (70%) of the study sample were retired and (62%) of the study sample were from urban.The findings of table 2 shows that the mean of scores for items of knowledge regarding heart failure the table reveals that the mean of score was moderate significant in items ( 2-Heart failure is a serious condition that requires medical care and 4-Heart failure may cause fluid to build up in the feet, ankles, legs, liver, abdomen, and the veins in the neck) and low significant in items (1-Heart failure is a condition in which the heart can't pump enough blood to meet the body's needs , 3-Heart failure causes early death if not treated and 3-Heart failure is an increasing cause of morbidity and mortality, especially in people aged above 65 years ) The findings of table 3 shows that the mean of scores for patients knowledge regarding to Risk factors of heart the table reveals that the mean of score was moderate significant in items (1-Developmental age ,2-Smoking and sedentary living ,3-Excessive dietary intake of sodium , 4-Anemia and hyperthyroid disease , 6-Diabetes mellitus , 7-Hypertension ,8-Psychiatric conditions, 9-Obesity 10 Kidney disease and low significant in items 5-Chronic alcohol abuse .The findings of table 4 shows that the mean of scores for patients compliance regarding to heart failure the table reveals that the mean of score was highly significant in items (2, 3,4,5) (2-Do you take your drugs when pain is begin , 3-Do you eat small, frequent meals ,4-Do you work regular activities ,5-Do you Go to doctors regularity ) and low significant in items (1-Do you stop from work and take rest when pain is begin , 6-Do you restrict fluid and sodium with heart disease , 7-Do you Away from salt and fatty food , 8-Do you changed your food with your disease , and 9-Do you quite from smoking and alcohol ) Table (5) This table shows that there were significant differences between General information , Signs and symptoms , Risk factors , Treatment of heart failure patients and their age at P value ≤ 0.05 .

Table (6) Table (5) Statistical differences Between patients knowledge and their age groups education level . F critical =2.4 Df= 74
Table (6) This table shows that there were significant differences between General information and Signs and symptoms while non significant for Risk factors , Treatment and patients compliance with heart failure and their education level at P value ≤ 0.05

Discussion:-
the present study revealed that the high percentage of patients were of (56%) at age(51-and more) years.The present study is in disagreement with the study conducted about the risk factor of heart failure who found 16.8 % from patients between 51-and more (5) .The result of table (1) show that heart failure is more common in males and constitute (61.31%).Because men may be more susceptible to the process of heart muscle-cell remodeling, a damaging effect of hypertension and lead to heart failure ( 6) .. In the Framingham Study, incidence in males was 2.3_1000 and only 1.4_1000 in females (7) With regard to the educational level It is obvious from the table that most of the patients were able to read and write and constitute about (37.40%), the reason of this marked proportion is that lack of social knowledge.The findings presented high percentage of patients was married and constitute (60%) It appears from the table the majority of the patients was retired and consist (70.60%).With regard to their address (62.70%) of the patients was from urban area .The explanation may be that the faraway of the town narrowed down the numbers for visiting the hospital in the city.Regarding the general information about heart failure and compliance the findings reveals that the mean of score was moderate significant level in items ( 2-Heart failure is a serious condition that requires medical care and 4-Heart failure may cause fluid to build up in the feet, ankles, legs, liver, abdomen, and the veins in the neck) and low significant level in items (1-Heart failure is a condition in which the heart can't pump enough blood to meet the body's needs , 3-Heart failure causes early death if not treated and 3-Heart failure is an increasing cause of morbidity and mortality, especially in people aged above 65 years ) .Wilson (2007) mentioned that Heart failure patients who are educated in their diagnosis and treatment have fewer hospital re-admissions and a better quality of life.For this reason, the importance of heart failure education should not be overlooked.According to the American Heart Association (AHA), the education topics include diet and nutrition, activity restrictions and recommendations, smoking cessation, alcoholic intake limitations, medication therapy, and signs and symptoms of worsening HF.Because of the complexity and importance of such education, it is vital that the nurses educating HF patients know and understand this material well (8) .Albert et al. (2002) state that in order for effective education to take place the educator needs an optimum knowledge base of fundamental HF education guidelines.If the patients fail to understand these guidelines and how to implement such changes, they will not be able to effectively participate in their care when outside a care facility.When patients do not participate in their care or disregard the guidelines, it is likely to lead to hospital re-admission or death (9) Koelling et al., ( 2005) state that Ineffective education for heart failure patients plays a significant role on why patients fail to adhere to the specified guidelines and continue to be readmitted, but it is not known to what extent (10) .
The findings of the study show the mean of scores for items of Risk factors of heart failure the table reveals that the mean of score This table indicates that the mean of score was moderate significant in items was moderate significant in items (1-Developmental age ,2-Smoking and sedentary living ,3-Excessive dietary intake of sodium , 4-Anemia and hyperthyroid disease , 6-Diabetes mellitus , 7-Hypertension ,8-Psychiatric conditions, 9-Obesity 10 Kidney disease and low significant in items 5-Chronic alcohol abuse .Diet and nutrition changes are included in the guidelines to managing heart failure.One change involves decreasing the amount of sodium intake.The average American consumes between four to six grams of sodium daily; heart failure patients must decrease their intake to two to three grams daily Along with sodium restriction, many people also need to restrict their fluid intake to less than two liters per day (11) .Alcohol has been shown to increase blood pressure causing hypertension and cardiomyopathy.Alcoholic cardiomyopathy is a condition in which the heart enlarges and the muscles become thin due to excessive alcohol intake.As the muscles thin and weaken, the heart is not able to pump efficiently and can lead to heart failure cigarette smoking also contributes to heart failure in that the smoke contains toxins that, when inhaled, cause plaque to form in the coronary arteries and leads to coronary artery disease (CAD), which is one of the leading causes of heart failure (12) .
The findings of the study show the mean of scores for items of Patients Practice about heart failure the table reveals that the mean of score was highly significant in items (2, 3,4,5) and low significant in items (1, 6 , 7, 8, 9 ) Albert et al. (2002) (13) .found that only 43.3% of patients weighed themselves on a daily basis.She also states that patients who are unaware of the importance of taking daily weights are less likely to relay such information to their physicians or make necessary changes at home .(table4) Study performed by Koelling et al. (2005) (14) Education related to medication management is another guideline and should include proper use and dosaging instructions as prescribed by the healthcare provider.In a patients exposed to a heart failure education program prior to discharge showed increased compliance rates for taking their HF-related medications.
-8 -Limiting alcohol consumption and abstaining from smoking cigarettes is also included in HF education because the consumption of alcoholic beverages and smoking cigarettes may contribute to heart failure (11) .Dietary guidelines for persons with heart failure include a low sodium diet and, at times, fluid restrictions.When heart failure occurs the pumping action of the heart is inhibited and cardiac output decreases.As the cardiac output decreases there is a 16subsequent reduction in renal perfusion through the complex rennin-angiotensin aldosterone system; this causes the kidneys to hold onto sodium, which then causes the body to retain water in order to maintain a strict osmotic balance (15) .The findings of the study show there were significant differences between General information , Signs and symptoms , Risk factors , Treatment of heart failure patients and their age at P value ≤ 0.05 except for patients practice (table5).According to the National Heart, Lung, and Blood Institute (NHLBI) (16) , the survival rate in men with heart failure is even less than in women.Eighty percent of men less than 65 years of age will die within eight years from HF, while only 70% of women less than 65 years of age will die within eight years from HF .Heart failure can affect anyone at any age, it is predominantly seen in the geriatric population.It is primarily a disease of the elderly and is the most common discharge diagnosis in persons over 65 years, with the number being diagnosed with HF increasing since 1979.Currently, HF affects 6-10% of persons 65 years and older.The increase in life expectancy may be one explanation for the increase in incidence of patients with HF (17) .
The findings of the study show that there were significant differences between General information and signs and symptoms while non significant for Risk factors, Treatment and patients practice with heart failure and their age at P value ≤ 0.05 (table 6)   In ( 2003) conducted study about effects of education and support on self-care and resource utilization in patients with heart failure and conclude the planned education and support by a nurse results in an increase in patients' self-care behaviors and that effects of patient's knowledge (18) .

Conclusions
Most of them were more than fifty two years and most of patients were male , large number of patients were read and write, high percentage of the heart failure patients were married with regard to occupation most of the patients were retired and most of them were from urban area .Also the study finding congestive heart failure patients has inadequate knowledge regarding general information about congestive heart failure .Regarding treatment of congestive, the result shows that congestive heart failure patients in compliance with heart failure .The results show that there is highly significant relation between age and General information and Signs and symptoms while non significant for Risk factors , Treatment and patients compliance with heart failure and their age Recommendation 1-Concentrates should be on the health education for our society who may be had risk factors to heart diseases.2-Constructing an educational program should be designee by nurses to increase people knowledge about etiology, signs and symptom and treatment of heart failure patients .5-Establishing new centers for caring of patients with heart disease .6-Increasing the number of nursing teams to deal with patients with heart disease because suspecting increasing number of patients affected in future.7-Further study has to be conducted in all kirkuk region

Table ( 3): Mean of Scores For Patients Knowledge regarding Risk Factors of heart failure
Chi-square Observed ; df= Degree of freedom ; χ2 crit.= Chi-square critical;