*4.1.2.2 Comorbidities*

Comorbidities such as hypertension, diabetes mellitus, respiratory problems, osteoarthritis, and gastrointestinal disorders affect the self-care process. As the management of advanced heart failure and comorbidities requires the referral of patients to more than one different medical branch, different laboratory tests, and many drugs to be taken, it is a difficult and tiring process. As each disease has its own dynamics, this makes it difficult for patients to manage the symptoms and comply with treatment [19].

#### *4.1.2.3 Financial pressure*

The process of managing advanced heart failure, especially when there are additional comorbidities, creates a financial burden for patients and their primary carers. In addition to the costs of accessing healthcare services, periodic doctor visits, laboratory tests, drugs, specific diets, and frequent hospitalisations, there may also be loss of employment. The fall in income and increased outgoings during the course of the disease can limit the capabilities of patients for self-care [3].

### *4.1.3 Inadequate support systems*

The third main category of barriers to self-care of patients with advanced heart failure is inadequate support systems. There are three subcategories of insufficient social support, lack of attention to self-care by healthcare providers, and limited access to healthcare providers.

#### *4.1.3.1 Insufficient social support*

Both the presence of symptoms and the treatment of advanced stage heart failure require a long and tiring process. There is a need in this process for family, state, healthcare, and social support in physical, psychosocial, and financial aspects [3].

### *4.1.3.2 Lack of attention to self-care by healthcare providers*

The starting point of self-care is healthcare centres and healthcare professionals in the centre. For the patient to be able to perform effective self-care, healthcare professionals should enable the patient to systematically apply awareness and knowledge. Specialisation in the field of advanced stage heart failure is an important criterion for healthcare professionals undertaking the provision of effective self-care [21].

The main reasons for the lack of attention to self-care by healthcare professionals in the hospital environment are a heavy workload, limited professional autonomy, a medical treatment-focused approach, a limited time for patient education, and a lack of comprehensive hospital discharge programmes. The responsibilities of healthcare professionals discharging patients are limited. That there is no separate unit for home healthcare service for the follow-up of patients with advanced heart failure is one of the conditions weakening the self-care process.

#### *4.1.3.3 Limited access to healthcare services*

In addition to the diagnosis of advanced heart failure, elderly patients who live alone or far from the hospital and have financial problems experience difficulties in accessing healthcare services.

### **4.2 Self-care evaluation**

Heart failure self-care is defined as the process of healthcare and disease management in which the stability of decisions and behaviours is maintained, defined by changes in the patient's condition and for which correct applications are provided. Studies in the field of heart failure have shown the need for healthy lifestyle behaviours, the follow-up and management of symptoms, and determination of the level at which the patient can take responsibility, in addition to treatment compliance.

The international scales used for heart failure patients include the Self-Care of Heart Failure Index, the European Heart Failure Self-Care Behaviour Scale, and the Minnesota Living with Heart Failure Questionnaire [MLWHFQ ].

The Self-Care of Heart Failure Index [SCHFI], which is the most comprehensive evaluation scale, has been translated into 22 languages and has been modified several times over the years in accordance with evidence-based practices. The SCHFI version 7.2 consists of four sections of self-care [10 items], symptom perception [11 items], self-care management [8 items], and self-belief [10 items] [22].

The European Heart Failure Self-Care Behaviour Scale is a short self-reported scale of 9 items. The questionnaire includes items related to self-care behaviours of heart failure, consisting of questions directly measuring behaviours associated with fluid and weight management [23].

The Minnesota Living with Heart Failure Questionnaire [MLWHFQ ] is a quality of life questionnaire comprising two dimensions [physical and emotional subdimensions] and 21 patient-specific questions. It was designed to measure the effect on the quality of life of heart failure and the treatment received. To date, the questionnaire has been translated into 33 languages, and validity and reliability studies have been conducted [24].
