Abstract
Introduction
Although self-care has a therapeutic effect on heart failure (HF), patients experience a marked reduction in physical and executive function, resulting in poor quality of life (QoL). A literature review revealed limited evidence regarding the possible relationship between self-care and QoL in HF patients. Therefore, this scoping review aimed to identify scientific evidence that examines the extent of self-care, QoL, and relationship between self-care and QoL in patients with HF.
Methods
Full-text research published from March 23, 2010, to March 23, 2020, written in English, that had content on both self-care and QoL among adult patients with HF was included. A literature search of electronic databases and web searches was conducted for published articles. Four databases were used: MEDLINE, Scopus, Web of Science, and the Cochrane Library. Studies collected from Google and Google Scholar web searches were also included.
Results
Of 1,537 papers identified by the search, 12 were included. The reviewed studies included 3,127 patients. Ten articles used a cross-sectional study design, whereas the remaining articles used a longitudinal and quasi-experimental design. This review found that the extent of self-care practices among patients with HF was inadequate, a significant proportion of patients enrolled in the reviewed studies had a moderate QoL, and higher self-care practices were associated with a better QoL. Self-care behavior and QoL were affected by social support, sex, age, educational level, place of residence, illness knowledge, presence of comorbidities, and functional classification of HF.
Conclusion
Self-care behavior was positively correlated with QoL in patients with HF. Self-care and QoL in these patients have been reported to be affected by several factors. Further research with a rigorous study design is recommended to investigate the influence of self-care practices on QoL in patients with HF.
Introduction
Cardiovascular disease (CVD) is a major cause of morbidity and mortality (Li et al., 2021). Of all CVD, heart failure (HF) accounts for most deaths, especially in adults over the age of 65 years, and poses a significant burden to health systems (Savarese & Lund, 2017). Worldwide, in Europe, and in the United States, HF affects more than 64.3, 15, and 6 million people, respectively (Groenewegen et al., 2020; Lippi & Sanchis-Gomar, 2020; Network, 2020; Virani et al., 2021).
Studies have also demonstrated that HF negatively affects the quality of life (QoL) (McHorney et al., 2021; Molla et al., 2021; Yeh & Shao, 2021). The World Health Organization (WHO) defines 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, concerns, and standard (Wulfovich et al., 2022). In healthcare settings, the concept of QoL refers to a patient's view of the overall effect of their clinical conditions and treatment on their lives (Comin-Colet et al., 2016). Specifically, it measures physical, psychological (emotional and cognitive), and social functioning (Seid, 2020). Poor QoL is consistently linked to HF-related outcomes in patients with HF, including higher mortality, frequent hospitalization, and poor self-care adherence (Molla et al., 2022; Seid et al., 2022; Wisnicka et al., 2022).
Self-care is the practice of maintaining one's health through preventative and health-promoting behaviors (Jaarsma et al., 2021). Self-care for HF encompasses a range of activities, including limiting alcohol intake, sodium and fluid restriction, cessation of smoking, adherence to the treatment schedule, daily weight monitoring, regular physical activity, diet, prompt identification and monitoring of signs and symptoms of disease exacerbation, and the search for an adequate response to possible deterioration (Asadi et al., 2019; Jaarsma et al., 2021; Jiang & Wang, 2021; Lee et al., 2018; Vellone et al., 2017). Self-care maintenance, self-care management, and self-care confidence are the three main concepts of self-care in HF. Self-care maintenance reflects routine symptom monitoring and treatment adherence. Self-care management is a process initiated by symptom recognition and evaluation which stimulates the use of self-care treatments, while self-care confidence is thought to mediate the effect of self-care on various outcomes (Bidwell et al., 2015; Riegel & Dickson, 2008).
Studies have shown that HF patients who received self-care interventions showed a decrease in rehospitalization, morbidity, and mortality rate (Jonkman et al., 2016; Ruppar et al., 2016; Toukhsati et al., 2019). Furthermore, patients with HF who engage in effective self-care experience better health outcomes than those who do not (Jaarsma et al., 2021; Pobrotyn et al., 2021).
However, despite the growing importance of good self-care practices in improving QoL, many patients with HF find it difficult to perform self-care activities which could be due to a lack of formal initiatives to empower people with HF to adopt self-care, perceived need for self-care, understanding of the influence of self-care on QoL, motivation, support from healthcare providers, and the complexity of self-care (Jaarsma et al., 2017; Network, 2020).
It is believed that a full understanding of self-care and its influence on the QoL among patients with HF will help nurses and other healthcare providers develop an effective self-care strategy that improves the unmet needs of patients to maximize their QoL.
A preliminary search of PROSPERO, MEDLINE, Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis databases was conducted, and no current or ongoing scoping or systematic reviews on the topic were identified. Therefore, this scoping review aimed to identify scientific evidence that fills gaps in the literature by focusing on the extent of self-care, QoL, and their relationship among patients with HF.
Review Question
What have been studied regarding the extent of self-care, quality of life, and their relationship and determinants among adult patients with heart failure?
Methodology
This scoping review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews (Peters et al., 2020) and in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) (“PRISMA Extension for Scoping Reviews (Tricco et al., 2018).
Eligibility Criteria
The PCC (participant, concept, and context) strategy was adapted to determine the inclusion criteria. Full-text research published in English from March 23, 2010, to March 23, 2020, was considered. Incomplete articles, such as conference abstracts and those whose full text was not accessible, were excluded.
Participants
This scoping review considered studies that included adult HF patients aged >18 years in which self-care and QoL were included as the main concepts.
Concepts
The concepts considered in this review were self-care, QoL, and HF.
Context
This scoping review considered studies that have been conducted in healthcare facilities of any types, including, but not restricted to, hospitals, medical centers, and long-term care facilities. Studies from any geographical setting were eligible for inclusion.
Information Source
To identify potentially relevant articles, PubMed, Cochrane Central, Scopus, and Web of Sciences databases were searched from March 23, 2010, to March 23, 2020. In addition, the review also considered unpublished gray literature from Google Scholars and OpenGrey. The initial search strategy used when searching the MEDLINE (PubMed) database is presented in Appendix I. Following the search, all identified records were collected and uploaded into EndNote X9 version software, and duplicates were removed.
Search Strategy
The text words contained in the titles and abstracts of the relevant articles and the index terms used to describe the articles were used to develop the full search strategy. An initial limited search of the MEDLINE database was performed to identify articles on the topic. The search strategy, including all the identified keywords and index terms, was adapted for each information source.
The identified keywords were combined with the “OR” operator and then linked the search strategies for the two axes with the “AND” operator to search for studies.
The key terms used for the MEDLINE database searches were ((((((Self-care) OR (“Self Care”)) OR (Self-Care)) OR (Care, Self)) OR (Self Management)) OR (Self-Management)) OR (“Management, Self”) AND ((((“qualit* of life”) OR (“life qualit*”)) OR (“health related qualit* of life”)) OR (“health?related qualit* of life”)) OR (HRQOL) AND
Selection of Sources of Evidence
Following the search and removal of duplicated articles, titles and abstracts were screened by two independent reviewers to assess the inclusion criteria for the review. Potentially relevant studies were retrieved in full text, and their citation details were imported into the software. The reference lists of articles selected for full-text review included in the review were screened for additional papers. Full-text papers that did not meet the inclusion criteria were excluded, and the reasons for their exclusion were provided (see Appendix II). Any disagreements between reviewers were resolved through discussion.
Data Charting Process
Data were charted from the papers included in the scoping review by two independent reviewers, using a data extraction tool developed by the reviewers (see Appendix III). Reviewers independently extracted data from each included article, and any disagreements arose between reviewers were resolved through discussion.
Data Items
The extracted data included specific details about the years in which the studies were published, origin of the study, type of study, methods (study design, sample size, and data analysis technique), key findings relevant to the review question (self-care, QoL, their relationships, and determinants), and limitations of the study.
Synthesis of Results
The charted articles were grouped according to the type of database used in the search and summarized according to the type of concept. Following the search of each database, the citations of searched articles were imported into the group created by the names of the respective databases and then copied into another group created based on the type concepts of the included articles. For example, articles that had content only on self-care, QoL, or both were grouped into different categories. Finally, articles that potentially met the inclusion criteria were grouped together, and data were extracted using the developed data extraction tool. All components of the extracted data are presented in tabular form in a manner that aligns with the objective of this scoping review (Appendix IV).
Results
Selection of Sources of Evidence
A total of 1,537 studies in English language were identified using search strategies, of which 1,273 remained after duplicates were removed. Of the remaining, 1,238 articles were excluded after their titles and abstracts were reviewed, leaving 35 studies to be read in full text. Ultimately, 12 eligible articles were included in the final review. The flow of articles from identification to final inclusion is shown in Figure 1.
Search results and study selection and inclusion process (Moher et al., 2009).
Characteristics of Included Studies
In total, 12 primary English-language articles published between 2010 and 2020 were considered in the review. In terms of country of origin, four articles were conducted in the United States (Auld et al., 2018; Britz & Dunn, 2010; Buck et al., 2012; Koirala et al., 2020), two in Italy (Buck et al., 2015; Vellone et al., 2014), and one in the Netherlands (Kessing et al., 2017), China (Liu et al., 2014), Taiwan (Tung et al., 2013), Iran (Asadi et al., 2019), Canada (Seto et al., 2011), and Ethiopia (Seid, 2020).
A total of 3,127 populations were studied in all reviewed articles. The maximum included sample size was 1,192 population (Buck et al., 2015), while the minimum included sample size was 30 patients (Britz & Dunn, 2010). Ten out of 12 articles used a cross-sectional study design (Asadi et al., 2019; Auld et al., 2018; Britz & Dunn, 2010; Buck et al., 2012, 2015; Koirala et al., 2020; Liu et al., 2014; Seid, 2020; Seto et al., 2011; Vellone et al., 2014), while the remaining articles used a longitudinal (Kessing et al., 2017) and quasi-experimental study design (Tung et al., 2013).
The included studies varied widely in terms of the instruments used to measure self-care behavior and QoL in patients with HF. Overall, six different types of instruments were identified in the included studies. Of these, two were used to assess self-care, and the other four were used to measure QoL. Of the total articles, eight utilized the Self-Care of Heart Failure Index (SCHFI) (Auld et al., 2018; Britz & Dunn, 2010; Buck et al., 2012, 2015; Koirala et al., 2020; Seto et al., 2011; Tung et al., 2013; Vellone et al., 2014), and four used the European Heart Failure Self-care Behavior Scale (EHFScBS-9) (Asadi et al., 2019; Kessing et al., 2017; Liu et al., 2014; Seid, 2020), to measure self-care. Among the included articles, QoL was measured using four different types of instruments. Nine out of 12 articles used the Minnesota Living with HF Questionnaire (MLHFQ) (Auld et al., 2018; Britz & Dunn, 2010; Buck et al., 2012, 2015; Kessing et al., 2017; Liu et al., 2014; Seid, 2020; Seto et al., 2011; Tung et al., 2013), one article used the Short Form Health Survey 12 (SF-12) (Vellone et al., 2014), one other article used the Short Form Health Survey 36 (SF-36) (Asadi et al., 2019), and the remaining article used the visual analytic scale (Koirala et al., 2020) (see Appendix IV).
The Extent of Self-Care and Quality of Life Among Patients With Heart Failure
From the included studies, there was a different type of finding in terms of self-care practices among patients with HF. Different types of instruments have been utilized in reviewed articles to measure self-care practice as a result, and different ways of presentation in findings were observed as some of them indicated self-care in terms of the mean score without classifying it as adequate or inadequate practice. However, most of the reviewed articles presented their finding in categorized forms of self-care score (Auld et al., 2018; Britz & Dunn, 2010; Buck et al., 2012, 2015; Kessing et al., 2017; Koirala et al., 2020; Seid, 2020; Seto et al., 2011; Tung et al., 2013).
Of the included studies, the majority found that the extent of self-care practice among patients with HF was inadequate or below the established cut-off point for adequate self-care score (Auld et al., 2018; Britz & Dunn, 2010; Buck et al., 2012, 2015; Kessing et al., 2017; Koirala et al., 2020; Seid, 2020; Seto et al., 2011; Tung et al., 2013). Specifically, approximately 48% of the participants had inadequate self-care practice in Ethiopia (Seid, 2020); in Italy, only 20% of the patients performed adequate self-care practice (Buck et al., 2015); in the United States, HF self-care was poor, with mean scores below the established cut-off for adequate self-care scores, a standardized score of 70 on each subscale of the SCHFI (Koirala et al., 2020) score (Auld et al., 2018; Britz & Dunn, 2010; Buck et al., 2012); and in Canada, patients did not perform adequate self-care as measured with the SCHFI (Seto et al., 2011).
A study conducted in Iran showed that the mean score of self-care behavior was 39.42 ± 7.04, and most of the patients (67.5%) were at a moderate level (Asadi et al., 2019), while a study conducted in China indicated that the overall scores for self-care ranged between 15 and 63, with an average of 43.2 ± 9.4. Among the three dimensions of self-care, healthy behaviors in general was found to be the best self-care behavior (mean = 9.8, SD = 3.6) (Liu et al., 2014).
Regarding the QoL among patients with HF, a variety of findings were identified from the included studies. In Ethiopia (Seid, 2020), the total mean score for QoL was 46.4 ± 22.4, while in the United States (Auld et al., 2018), it was 46.9 ± 25.4. As the mean score in both studies falls within the accepted cut-off point for poor QoL, which is above 45, this indicates that the participants’ QoL was low. Moderate QoL was reported by the majority of patients in the other three articles (Britz & Dunn, 2010; Koirala et al., 2020; Seto et al., 2011), and good QoL was reported in two articles (Asadi et al., 2019; Liu et al., 2014). The remaining articles described QoL only in terms of the mean score without classifying it (Kessing et al., 2017; Tung et al., 2013; Vellone et al., 2014).
The Influence of Self-Care on Quality of Life Among Patients With Heart Failure
In most of the reviewed studies, self-care was found to have a positive relationship with QoL among patients with HF (Britz & Dunn, 2010; Buck et al., 2012, 2015; Kessing et al., 2017; Koirala et al., 2020; Seid, 2020; Seto et al., 2011; Tung et al., 2013). For instance, one study conducted in the United States revealed that each 1-point increase in self-care confidence was associated with a decrease in the likelihood of poorer health-related QoL; however, in this study, no significant correlations were found between self-care maintenance or management and health-related QoL (Buck et al., 2012).
Surprisingly, a negative correlation was observed in two other included studies (Auld et al., 2018; Vellone et al., 2014). Specifically, a study conducted by Vellone et al. found that higher self-care was related to lower physical QoL in patients with HF (Vellone et al., 2014). Similarly, another study conducted by Auld et al. identified that better self-care maintenance and management were both independently associated with worse emotional health-related QoL (Auld et al., 2018), and the remaining other studies found that self-care had no influence on or correlation with QoL (Asadi et al., 2019; Liu et al., 2014).
Factors Associated With Self-Care and Quality of Life Among Patients With Heart Failure
Of the included articles, eight of them had assessed the predictors and determinants of self-care behavior and QoL in patients with HF (Asadi et al., 2019; Britz & Dunn, 2010; Buck et al., 2015; Kessing et al., 2017; Koirala et al., 2020; Liu et al., 2014; Seid, 2020; Seto et al., 2011). Of the identified factors, marital status (Asadi et al., 2019), social support, educational level, living status, and HF functional classification were associated with self-care behavior (Koirala et al., 2020). Higher education, better NYHA HF functional class, and higher social support were associated with higher self-care confidence and better self-care (Koirala et al., 2020). In other included articles, factors such as illness knowledge, gender, age, and perceived general health were also found to determine self-care confidence (Britz & Dunn, 2010) and self-care behavior (Liu et al., 2014).
Moreover, the reviewed studies identified several factors that predict the QoL of patients with HF. Gender, age, educational level, smoking, presence of comorbidities, place of residence, self-care behavior, HF functional class, and living status were found to be associated with QoL (Asadi et al., 2019; Buck et al., 2015; Kessing et al., 2017; Liu et al., 2014; Seid, 2020; Seto et al., 2011). The reviewed articles have shown that male sex, older age, living in an urban area, having a university-level education, a free job (Asadi et al., 2019), higher self-care behavior (Seto et al., 2011), illness knowledge (Liu et al., 2014), and the presence of fewer comorbidities (Buck et al., 2015; Seto et al., 2011) were associated with a better QoL. While living in rural areas, inadequate self-care, smoking, and having a lower educational level were found to be predictors of poor QoL in patients with HF (Kessing et al., 2017; Seid, 2020).
Discussion
This scoping review aimed to map available scientific evidence that has been conducted over a 10-year period between March 2010 and March 2020 to answer the question of what have been studied regarding the extent of self-care, QoL, and their relationship and determinants among adult patients with HF.
This review found that self-care practices among patients with HF were inadequate or poor. The current finding is in line with a scientific statement by professionals from the American Heart Association (AHA), which reported that the vast majority of people do not perform self-care (Riegel et al., 2017). Similarly, the present finding was also in line with other studies that showed that patient non-adherence to recommended self-care activities is common throughout the globe (Davis et al., 2015; Jaarsma et al., 2013; Moser et al., 2012; Ok & Choi, 2015).
Despite the fact that the AHA recommends that all patients with HF should strongly engage in adequate self-care activities such as taking prescribed medication on regular bases and on time, routine monitoring of changes in signs and symptoms of HF, a daily diet with 2 to 4 g of sodium, discouraging alcohol or limiting to one drinks per day, weight loss when body mass index (BMI) exceeds 40 kg/m2, routine exercise at levels based on prescriptions, hand washing, smoking cessation, daily dental hygiene, and annual vaccination against influenza (Barbara Riegel et al., 2009), majority of the reviewed articles reported that self-care practice among patients with HF was inadequate, which implies that the majority of the HF patients never or infrequently performed self-care practices in areas such as daily weight monitoring, limiting salt consumption and fluid intake, engaging in minimal physical activity, and taking their medications as prescribed (Siabani et al., 2016).
Inadequate self-care practice could be related to several identified factors that are found to impede self-care practice which include lack of social support, low educational level, depression, in a rural area, poor cognition, older age, poor HF functional classification, lack of recall about basic elements of the nature of HF, and lack of illness knowledge and self-care skill (Britz & Dunn, 2010; Clark et al., 2014; Cocchieri et al., 2015; Graven & Grant, 2014; Harkness et al., 2015; Jaarsma et al., 2017; Kessing et al., 2016; Koirala et al., 2020; Liu et al., 2014; Seid, 2020).
Although the majority of studies included in this review reported a moderate QoL among patients with HF, other studies reported a low QoL (Iqbal et al., 2010; Kozhekenova et al., 2014), and in this review, low QoL was attributed to inadequate or poor self-care behavior and several other aforementioned factors. This finding is also supported by other studies (Hwang et al., 2014; Nesbitt et al., 2014; Sedlar et al., 2017; Vellone et al., 2017).
Moreover, the findings from this review also revealed that HF self-care behavior has a positive influence on the QoL. This finding indicates a positive correlation between self-care behavior and QoL. In other words, the higher the self-care practice, the better is the QoL. Our findings are in line with those of randomized controlled trial studies (Dunbar et al., 2015; Shao et al., 2013). However, based on this study, we could not determine whether this relationship was influenced by other factors. Additionally, most of the included studies were conducted using a cross-sectional design; as a result, it was difficult for reviewers to determine the cause-and-effect relationships between self-care behavior and QoL. Therefore, adequately powered and designed studies are needed to identify possible cause-and-effect relationships between self-care and QoL in patients with HF.
As with all review studies, the findings of this study should be interpreted in light of its limitations. First, most of the included studies had used a cross-sectional design. Therefore, no conclusions could be drawn regarding the causality of the observed relationships. Second, methodological heterogeneity across the reviewed articles resulted in difficulties in drawing strong conclusions about the subject of interest. Third, the majority of the included studies were conducted using a small sample size. Finally, a significant number of the included review results depended on the patients’ self-reporting of self-care. This may result in misinformation and social desirability bias.
Conclusion
Although the methodological heterogeneity across the reviewed articles interfered considerably with drawing strong conclusions, the majority of articles have shown that self-care practices among patients with HF were inadequate, and self-care had a positive correlation with the QoL in patients with HF. Further research with a strong study design is recommended to draw a strong conclusion and investigate the influence of self-care behavior on QoL among patients with HF.
Footnotes
Author Contribution
All authors made a significant contribution to the work reported, whether in the conception, study design, execution, acquisition of data, analysis, and interpretation or, in all these areas, took part in drafting, revising, or critically reviewing the article; gave the final approval of the version to be published; agreed on the journal to which the article has been submitted; and agreed to be accountable for all aspects of the work.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
APPENDIX I: Medline Search Strategy
Pubmed search conducted on March 23,2020,Time 15:15:33
Appendix II: Studies ineligible following full-text review
Abbasi A, Ghezeljeh TN, Farahani MA. Effect of the self-management
Abbasi A, Najafi Ghezeljeh T, Ashghali Farahani M, Naderi N. Effects of the self-management
Dickson VV, Howe A, Deal J, McCarthy MM. The relationship of work, self-care, and quality of life in a sample of older working adults with
Dunbar SB, Reilly CM, Gary R, Higgins MK, Culler S, Butts B, et al. Randomized clinical trial of an
Evangelista LS, Lee JA, Moore AA, Motie M, Ghasemzadeh H, Sarrafzadeh M, et al. Examining the effects of
Goodman H, Firouzi A, Banya W, Lau-Walker M, Cowie MR.
Grady KL, de Leon CF, Kozak AT, Cursio JF, Richardson D, Avery E, et al. Does
Heidari M, Shahbazi S. Effect of self-care training program on quality of life of
Hua CY, Huang Y, Su YH, Bu JY, Tao HM. Collaborative care model improves self-care ability, quality of life and cardiac function of patients with chronic heart failure. Braz J Med Biol Res. 2017;50(11):e6355.
Jonkman NH, Schuurmans MJ, Groenwold RHH, Hoes AW, Trappenburg JCA. Identifying components of self-management interventions that improve health-related quality of life in
Kim J, Hwang SY, Heo S, Shin MS, Kim SH. Predicted relationships between cognitive function, depressive symptoms, self-care adequacy, and health-related quality of life and major events among patients with heart failure. Eur J Cardiovasc Nurs. 2019;18(5):418-26.
1Koberich S, Lohrmann C, Mittag O, Dassen T. Effects of a hospital-based education programme on self-care behaviour, care dependency and quality of life in patients with heart failure--a randomised controlled trial. J Clin Nurs. 2015;24(11-12):1643-55.
Leavitt MA, Hain DJ, Keller KB, Newman D. Testing the Effect of a Home Health Heart Failure Intervention on Hospital Readmissions, Heart Failure Knowledge, Self-Care, and Quality of Life. J Gerontol Nurs. 2020;46(2):32-40.
Lee CS, Mudd JO, Hiatt SO, Gelow JM, Chien C, Riegel B.
1Lee EH, Lee YW, Moon SH. A
Liou HL, Chen HI, Hsu SC, Lee SC, Chang CJ, Wu MJ. The effects of a self-care program on patients with heart failure. J Chin Med Assoc. 2015;78(11):648-56.
Macabasco-O'Connell A, DeWalt DA, Broucksou KA, Hawk V, Baker DW, Schillinger D, et al. Relationship between literacy, knowledge, self-care behaviors, and heart failure-related quality of life among patients with heart failure. J Gen Intern Med. 2011;26(9):979-86.
Shao JH, Chang AM, Edwards H, Shyu YI, Chen SH. A randomized controlled trial of self-management
Slyer JT, Ferrara LR. The effectiveness of
2Vellone E, Fida R, Ghezzi V, D’agostino F, Biagioli V, Paturzo M, et al. Patterns of self-care in adults with heart failure and their associations with sociodemographic and clinical characteristics, quality of life, and hospitalizations: a cluster analysis. Journal of Cardiovascular Nursing. 2017;32(2):180-9.
Wang SP, Lin LC, Lee CM, Wu SC. Effectiveness of a self-care program in improving symptom distress and quality of life in congestive heart failure patients: a preliminary study. J Nurs Res. 2011;19(4):257-66.
Williams M, Casimir Y, Liang M, Pitakmongkolkul S, Slyer J. The Effectiveness of Patient-Centered Self-Care
Ong-Artborirak P, Seangpraw K. Association Between Self-Care Behaviors and Quality of Life Among Elderly Minority Groups on the Border of Thailand. J Multidiscip Healthc. 2019;12:1049-59.
Appendix III: Data Extraction Tool
S.no.
Authors
Year
Title
origins
Types of research
study design
Sample size
method of analysis
findings
Limitations