EMPIRICAL STUDIES

doi: 10.1111/scs.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 perceived 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 strongest correlate of most QOL domains. Tangible support

Heart failure (HF) affects circulatory, neural and hormonal 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 billion 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 contributes 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

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 performing 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 healthcare providers in Arabic countries as well as Western
society in caring for these patients. Further studies are
needed to explore the relationship between social support 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. Culture is important in understanding and facilitating meaning in life in health and in sickness (14). The World
Health Organization Group (15) defined QOL as Individuals perception of their position in life in the context of the
culture and value systems in which they live and in relation 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

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 population that differ from Western countries include strong
family and community relations, abiding faith, reticence
to disclose personal matters in public (18) and male dominance (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 individuals
health and involvement with the healthcare system (16).
For example, although Muslims understand the importance 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 Gods healing power. Although Muslims with certain illness are
excused from fasting during their Holy month (Ramadan), 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 origin, findings of this study may have the potential to assist
healthcare providers in Western countries, including Europe, to provide appropriate care for Arab Muslim patients
with HF. The specific aims of this study were to: (i) identify demographic characteristics (age, gender, education
level) and medical variables (LVEF, HF duration, presence of diabetes mellitus and hypertension) associated

with QOL of adults with HF, (ii) evaluate the relationships 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 problems 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 Form36 version 2, a 36-item multiple-response option questionnaire with eight scales: physical functioning (10
items), role physical functioning (four items), role emotional 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 0100 scale. Higher
scores indicate better QOL in each domain. Domain
scales of the SF-36 were analysed using norm-based scoring 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 instrument has been translated into Arabic and had satisfactory
psychometric properties (28). Cronbachs alphas for the
eight scales in this study were: 0.88 for physical functioning, 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 available, if needed, on a five-point Likert scale ranging from
2016 Nordic College of Caring Science

Factors associated with quality of life

1 (none of the time) to 5 (all of the time). Raw scale
scores can be standardised by transforming them into a
0100 scale. Item number 19 measures the availability of
people with whom the respondent can do things. Higher
scores for the subscales and the overall support index
indicate a higher level of support (29). The MOS-SSS has
been tested in a sample of 2987 patients with chronic
conditions and found to be reliable and valid (29). This
instrument was translated into Arabic by the principal
investigator and had good internal consistency in a sample of 63 Arabic stem cell transplant survivors; Cronbachs alphas ranged from 0.79 to 0.87 (30). Cronbachs
alphas for the subscales in this study were: 0.88 for tangible support, 0.88 for emotionalinformational support,
0.96 for affectionate support and 0.87 for positive social
interaction support.
Demographic and medical characteristics. Data were collected on participants age, sex, marital status, educational status, employment status and annual income.
Medical variables including time since diagnosis, LVEF
and presence of diabetes or hypertension were obtained
from patients medical records.

Procedure
Institutional ethics committee approval (the equivalent of
institutional review board approval) was obtained from a
nonprofit hospital and an educational hospital in Jordan.
The principal investigator met with administrators, physicians and nursing directors to describe the purpose and
nature of the study. Consecutive HF patients who met the
inclusion criteria were contacted by two nurse research
assistants during their visit to the outpatient clinic. A
detailed explanation of the study including the purpose,
risks, benefits and procedures was provided to participants
verbally and in written form. Signed, informed consent
was obtained from patients who agreed to participate. A
quiet place was provided for participants at the hospital.
Two trained nurse research assistants obtained patient
age, time since diagnosis, LVEF and information about
other comorbidities (e.g. cancer, liver failure, kidney failure, major psychiatric problems) from patients medical
records. Data were collected over a 12-month period.

Data analysis
Data were analysed using the Statistical Package for the
Social Sciences (SPSS) for Windows 21.0 (SPSS Inc., Chicago, IL, USA). This sample size provided 80% power
based on an alpha of 0.05, 11 independent variables and
an estimated effect size of 0.2 (31). Alpha was set at
<0.05 for all analyses. Descriptive statistics were used to
describe the demographic and medical characteristics of
the sample, the eight domains of the SF-36, and the
2016 Nordic College of Caring Science

MOS-SSS subscale scores. An independent-samples t-test

was used to determine if there were differences in the
QOL domain scores of male and female HF patients. To
identify the potential of multicollinearity among the
independent variables, the Variance Inflation Factor
(VIF) and tolerance statistics were computed. Stepwise
regression analysis was used to evaluate the strength of
association of demographic characteristics (age, gender
and level of education), medical variables (LVEF, duration of HF and the presence of hypertension or diabetes)
and the four social support subscales with each of the
eight SF-36 subscales scores.

Results
Demographic, medical variables, perceived social support and
QOL domains
A total of 111 patients with HF were assessed to determine their eligibility for the study. Of these, nine were
not eligible and three patients refused to participate.
Ninety-nine patients agreed to participate in this study
and provided written consent. The mean age of the participants was 56.9 years (SD = 11.3, range = 2980).
Other demographic characteristics of the participants are
shown in Table 1. The patients duration of HF ranged
from 1 to 11 years, with a mean of 3.62 years. Their
mean ejection fraction was 37.9% (SD = 5.8,
range = 2048). Seventy per cent of participants were
hypertensive and 35% were diabetic. Data on perceived
social support are presented in Table 2. The dimension of
the emotional/informational support had the lowest
mean score and the highest was for affectionate support.
The mean scores for the QOL domains are presented in
Table 3. Overall, the patients scores were low for all
Table 1 Demographic characteristics of the Arabic patients with
heart failure (N = 99)
Characteristics
Gender
Male
Marital status
Married
Divorced/widowed
Employment
Employed
Educational level
School degree
Diploma
University degree
Annual income
Less than $3500
$3500$8600
More than $8600

n (%)

64 (64.6)
85 (85.9)
14 (14.1)
37 (37.43)
75 (75.8)
15 (15.2)
9 (9.1)
16 (16.2)
64 (64.6)
19 (19.2)

F. Alaloul et al.

Table 2 Medical outcomes study social support survey scores of the

Arabic patients with heart failure (N = 99)a

Scale/subscale

Mean

SD

Possible
range

Actual
range

Emotional/information
support
Tangible support
Affectionate support
Positive social interaction
Total score

65.0

19.8

0100

6.3100

81.6
86.3
75.4
73.8

23.4
23.2
22.4
18.1

0100
0100
0100
0100

6.3100
0100
0100
15.8100

Table 4 Stepwise regression analyses for predictors of the SF-36

subscale scores (N = 99)

Outcomes/predictors

Standardised
b

Model statistics

Physical functioning
Age
Male gender
LVEF
Tangible support

0.29
0.31
0.27
0.21

3.17**
3.57**
2.98**
2.34*

Role physical
Age
Male gender
LVEF
Tangible support

0.22
0.20
0.30
0.30

0.2.36*
2.22*
3.19**
3.26**

Bodily pain
Male gender
LVEF
Tangible support

0.20
0.34
0.33

2.20*
3.67**
3.70**

General health perception

LVEF
0.27
Presence of
0.23
diabetes

2.81**
2.40*

A higher score indicates greater social support.

Table 3 Scores for the SF-36 quality of life domains of the participants (N = 99)a

Scale/subscale

Mean

SD

Possible
range

Actual
range

Physical functioning (level of

limitation in physical activities)
Role physical (problems with
usual role related to
physical health)
Social functioning (interference
with social activities)
Role emotional (problems with
usual role related to
emotional health)
Bodily pain (level of pain)
General health (general
perception about health)
Vitality (energy and fatigue)
Mental health (level of
psychological status)

38.9

23.7

0100

090

36.4

24.6

0100

0100

42.8

25.2

0100

0100

42.3

26.5

0100

0100

37.9
40.8

21.9
15.1

0100
0100

0100
595

34.8
47.2

19.7
17.3

0100
0100

081
090

A higher score indicates better quality of life.

domains indicating poor QOL. The lowest mean score

was for vitality (i.e. lack of energy and presence of fatigue), whereas their mental health score was the highest.
The patients reported problems with carrying out their
usual role due to poor physical health, significant bodily
pain and limitations performing role activities.

Vitality
LVEF
Tangible support

0.32
0.38

3.54**
4.14**

0.35
0.28

3.87**
3.02**

Social functioning
LVEF
Presence of
diabetes
Presence of
hypertension
Tangible support

0.21

2.23*

0.20

2.19*

Role emotional
Education
LVEF

0.27
0.26

2.87**
2.74**

Multivariate analyses
Multicollinearity was not a problem as VIF values were
less than three (32). The findings of the stepwise regression analyses are presented in Table 4. LVEF was a significant 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

R2 = 0.38;
F(4,98) = 14.68,
p < 0.001

R2 = 0.34;
F(4,98) = 12.27,
p < 0.001

R2 = 0.27;
F(3,98) = 11.63,
p < 0.001

R2 = 0.14;
F(2,98) = 7.87,
p < 0.001

R2 = 0.21;
F(2,98) = 13.09,
p < 0.001

R2 = 0.27;
F(4,98) = 8.52,
p < 0.001

R2 = 0.17;
F(2,98) = 9.91,
p < 0.001

*p < 0.05.
**p < 0.01.
LVEF, left ventricular ejection fraction.

and social functioning. Female sex was negatively associated with physical functioning, role physical and bodily
pain. Those who were younger and had less tangible support had better physical functioning. These variables
accounted for the greatest amount of variance in all of
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Factors associated with quality of life

the SF-36 subscales. The independent variables explained
the least amount of variance for role emotional and general 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 determinants 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 Muslim HF patients QOL. We attempted to understand the
impact of these factors within the context of Arab Muslim 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 limitations performing activities associated with their usual
role. Similarly, Turkish patients with HF reported impairment 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 compromised 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 sample 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 greatest impairment in QOL was in vitality. The patients
reported severe fatigue and lack of energy which is consistent 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, spiritual, 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

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 hospitalisation admission. Different pharmacological (49) and
nonpharmacological modalities such as implantable cardioverter 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 Gods 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 variables in this study was associated with mental health.
Diabetes mellitus was associated with general health perception 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 healthcare 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 ageing 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 physiological differences (57), a possible explanation for

F. Alaloul et al.

higher QOL among Arab men is that men in the Arabic

and Islamic culture try to suppress their feelings to maintain 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 family 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 association 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 support 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 inconsistencies 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 outside 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 significant findings was that LVEF had the strongest relationship with QOL among Arab patients with HF. Effective
management of LVEF using pharmacological and nonpharmacological 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 experience 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
This study addressed QOL in Arab patients with HF and
showed that most Arab patients with HF reported poor
QOL. Healthcare providers need to pay more attention

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2016 Nordic College of Caring Science