Introduction

Chronic heart failure (CHF), the advanced stage of various heart diseases, remains a significant clinical challenge worldwide. It is a major cause of morbidity and mortality, posing substantial health risks globally1. CHF not only results in high direct and indirect healthcare costs but is also a common cause of death2. Over 64 million people globally are affected by CHF, requiring continuous medical care, frequent monitoring, hospitalizations, and intensive treatment plans. These healthcare demands contribute to CHF being a major economic burden, with global expenditures projected to reach USD 400 billion by 20303. In adults, especially older men, CHF prevalence is estimated at around 2%4.

Cardiac rehabilitation (CR) is a cornerstone in heart failure management, providing benefits like improved standardized exercise capacity and walking ability post-rehabilitation4. This multidisciplinary approach includes exercise training, lifestyle coaching, medication supervision, and support for cardiovascular risk reduction, promoting healthier behaviors and psychosocial well-being5. Despite these advantages, CR is underutilized globally6.

Home-based CR (HBCR) was developed to address access limitations related to center-based CR, providing an effective alternative that reduces geographical, logistical, and other access barriers6. HBCR typically includes structured exercise training programs that can be performed at home, educational components delivered through various media (printed materials, online resources, or telehealth platforms), regular remote monitoring of vital signs and symptoms, and scheduled follow-up communications with healthcare providers. These programs are commonly supported by telephone counseling, mobile applications, or web-based platforms to facilitate correct exercise performance and adherence to rehabilitation protocols7. European guidelines on cardiovascular disease prevention recommend home-based rehabilitation, with or without telemonitoring, as a method to increase participation and support behavioral changes8. HBCR has been integrated into healthcare systems in countries like Australia, Canada, and the United Kingdom. A recent study on CR-eligible patients found that nearly half preferred home-based programs over center-based options when given a choice9.

The Knowledge, Attitude, and Practice (KAP) model suggests that knowledge is fundamental to behavioral change, while attitudes and beliefs drive the change10. According to KAP theory, the behavioral change process involves three steps: gaining knowledge, forming attitudes/beliefs, and developing practices/behaviors11. However, acquiring knowledge alone is insufficient to induce behavioral change; it must first alter perceptions, which subsequently influence actions12. In the context of CR, previous studies have shown that improved disease-related knowledge enhances patients’ perceived benefits of rehabilitation, which in turn strengthens their motivation and confidence to adhere to self-care routines. For instance, greater understanding of exercise benefits has been associated with stronger intention to engage in regular rehabilitation exercises. Targeted educational interventions have also been shown to improve both beliefs and health-related behaviors in heart failure patients13,14. Previous studies have applied the KAP framework in cardiac care settings, suggesting that improving patients’ knowledge about HBCR contributes to more favorable attitudes and greater engagement in health-promoting practices13,15. Therefore, in this study, the KAP model was adopted as the conceptual framework to investigate how patients’ knowledge, attitudes, and practices interact in the context of HBCR for chronic heart failure.

Research on patients’ engagement with HBCR has revealed several challenges across the knowledge, attitude, and practice dimensions. In terms of knowledge, patients often demonstrate limited understanding of HBCR benefits and self-management strategies13,14. Regarding attitudes, patients frequently express concerns about the effectiveness of home-based programs compared to center-based rehabilitation, and some doubt the economic advantages of HBCR. In practice, adherence to HBCR among CHF patients remains suboptimal, with common challenges including inconsistent exercise routines, poor self-monitoring of health indicators, and irregular communication with healthcare providers13,16. These barriers are particularly evident in aspects such as psychological management and lifestyle modifications, where patients often struggle to maintain long-term engagement with recommended practices17.

This underutilization is particularly concerning given the mobility and logistical difficulties CHF patients face, which often impede their participation in center-based programs. These challenges highlight the need to investigate patient perceptions and engagement with HBCR. Recent studies have explored various aspects of heart failure management, with emerging interest in home-based care approaches. For instance, a study14 investigated knowledge and self-care practices among heart failure patients, finding significant gaps in patient understanding of disease management strategies. Similarly, a study18 conducted a study focusing on patient education interventions for chronic disease management, demonstrating improvements in all three domains following targeted educational programs. Additionally, a study13 examined adherence predictors for HBCR exercises among CHF patients, revealing that knowledge of exercise benefits significantly influenced practice behaviors. Despite these contributions, research specifically focusing on KAP regarding HBCR in CHF patients remains limited. Existing studies have typically focused on single aspects of heart failure management without comprehensively examining the interconnection between knowledge, attitudes, and practices in the context of HBCR. Furthermore, most studies have not thoroughly investigated how specific demographic and clinical factors influence patients’ KAP towards HBCR, particularly across diverse healthcare settings and populations with varying socioeconomic backgrounds. This gap in understanding the KAP interrelationships and their determinants represents a significant limitation in current approaches to optimize HBCR engagement and outcomes. Therefore, this study aims to address gaps in the literature by examining the KAP regarding HBCR among CHF patients. By understanding these factors, strategies can be developed to improve HBCR accessibility and effectiveness, ultimately enhancing patient adherence and outcomes.

Methods

Study design and participants

This cross-sectional study was conducted between April and July 2024 at Jiangxi Provincial People’s Hospital, involving patients with CHF. The study received approval from the Medical Ethics Committee of Jiangxi Provincial People’s Hospital (Approval number: 2024(23)), and informed consent was obtained from all participants before they began to complete the questionnaire.

The inclusion criteria were: (1) patients diagnosed with CHF according to the “2018 Guidelines for the Diagnosis and Treatment of Heart Failure in China” and (2) voluntary participation with signed informed consent.

Questionnaire

The questionnaire used in this study was carefully developed through a thorough review of the literature and current evidence on HBCR for patients with CHF19. It underwent multiple rounds of review and refinement, incorporating feedback from two experts with over 20 years of experience in the field, and was pretested on a sample of 50 individuals. The reliability of the questionnaire was verified by an overall Cronbach’s α coefficient of 0.903, indicating strong internal consistency. (See questionnaire file)

The finalized Chinese-language questionnaire consisted of four sections: demographic information, knowledge, attitudes, and practices. The demographic section collected information on variables including age, gender, place of residence, education level, marital status, average monthly family income, type of medical insurance, history of cardiovascular disease, other health conditions, duration of CHF, current rehabilitation treatment status, smoking habits, alcohol consumption, and dietary preferences regarding salt and fat intake.

The knowledge section included nine items, scored as 2 points for “very well-informed,” 1 point for “somewhat informed,” and 0 points for “not informed,” with a total possible score of 0 to 18. The attitude section comprised eight questions rated on a five-point Likert scale, ranging from “very important” (5 points) to “very unimportant” (1 point), with a possible score range of 8 to 40. The practice section consisted of ten items, rated from “very positive behavior” (5 points) to “very negative behavior” (1 point), resulting in a score range from 10 to 50. Participants were categorized based on their scores: those scoring above 80% of the maximum were considered to have adequate knowledge, a positive attitude, and proactive practices; scores between 60% and 80% indicated moderate knowledge, attitudes, and practices; and scores below 60% represented inadequate knowledge, negative attitudes, and inactive practices20.

The questionnaires were administered to patients through both online and onsite methods. An electronic version was created on the Wenjuanxing platform, with a questionnaire link sent to randomly selected CHF patients. For those unable to complete the electronic version, a paper-based questionnaire was provided. Trained research assistants offered unbiased explanations to participants with questions or confusion regarding the questionnaire.

Sample size calculation

The sample size was calculated using the following formula:

$$\:\text{n}={\left(\frac{{Z}_{1-\alpha\:/2}}{\delta\:}\right)}^{2}\times\:p\times\:\left(1-p\right)$$

n represents the sample size per group, α is the Type I error rate, set at 0.05, \(\:{Z}_{1-\alpha\:/2}\) is the Z-value for a 95% confidence level, which is 1.96, δ is the allowable error, set at 0.05, p is the estimated proportion, set at 0.5 for maximum variability. The calculated required sample size was 384. Considering an anticipated 80% response rate, we aimed to collect a total of 480 questionnaires.

Statistical analysis

Data analysis was conducted using SPSS 27.0 and AMOS 26.0. Continuous variables were presented as means and standard deviations (SD), while categorical data were expressed as frequencies (n %). The normality of continuous variables was evaluated, with comparisons between two groups performed using the t-test for normally distributed data and the Wilcoxon Mann-Whitney test for non-normally distributed data. To compare knowledge (K), attitude (A), and practice (P) scores across different demographic groups, one-way ANOVA was used for normally distributed continuous variables, and the Kruskal-Wallis test was applied for non-normally distributed data. Relationships between K, A, and practice (P) scores were analyzed using Spearman correlation. Additionally, a path analysis model was applied to examine the interconnections among K, A, and P using structural equation modeling (SEM). All statistical tests were two-sided, with a P-value of less than 0.05 indicating statistical significance.

Results

Basic characteristics of the participants

Among the 591 patients with CHF who participated in this study, 470 had underlying conditions. Specifically, 327 had hypertension or were on long-term antihypertensive therapy, 178 had hyperlipidemia, and 177 had diabetes mellitus (Fig. 1). Confirmatory factor analysis (CFA) was conducted to evaluate the construct validity of the knowledge, attitude, and practice dimensions. The model demonstrated acceptable fit with the following indices: CMIN/DF = 3.850, RMSEA = 0.070, IFI = 0.842, TLI = 0.825, and CFI = 0.841. The Kaiser-Meyer-Olkin (KMO) measure was 0.939 (P < 0.001), indicating excellent sampling adequacy. These results support the construct validity of the questionnaire. Among the participants, 349 (59.05%) were male, with a mean age of 64.43 ± 14.65 years. Additionally, 274 (46.36%) resided in urban areas, 209 (35.36%) had a primary school education or less, and 282 (47.72%) reported a monthly per capita family income of 2000–5000 Yuan. A total of 355 (60.07%) had a history of cardiovascular disease, 207 (35.03%) had CHF for over 12 months, and 175 (29.61%) had participated in cardiac rehabilitation (Table 1).

Fig. 1
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Comorbidities.

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Table 1 Demographic characteristics and KAP scores.
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Knowledge, attitudes, and practices

The mean scores for knowledge, attitude, and practice were 7.27 ± 4.43 (range: 0–18), 29.18 ± 5.31 (range: 8–40), and 34.57 ± 5.57 (range: 10–50), respectively, indicating low knowledge but moderate attitudes and practices. Knowledge scores differed significantly across patients with various marital statuses (P < 0.001), residences (P < 0.001), education levels (P < 0.001), histories of cardiovascular disease (P < 0.001), durations of CHF (P = 0.001), and cardiac rehabilitation participation (P < 0.001). Attitude scores varied significantly by marital status (P < 0.001), education level (P < 0.001), monthly per capita family income (P = 0.023), insurance type (P = 0.017), cardiovascular disease history (P = 0.002), presence of underlying diseases (P < 0.001), alcohol history (P < 0.001), and cardiac rehabilitation participation (P < 0.001). Practice scores showed significant differences based on gender (P < 0.001), marital status (P < 0.001), insurance type (P = 0.032), cardiovascular disease history (P = 0.003), presence of underlying diseases (P = 0.007), smoking history (P < 0.001), alcohol history (P < 0.001), and cardiac rehabilitation participation (P = 0.011) (Table 1).

In the knowledge section, the three questions with the highest percentage of participants selecting “Not informed” were: “Patients should receive a pneumococcal vaccine once and an annual influenza vaccine” (K7) with 57.7%, “Self-management can be guided by the dosage of diuretics, body weight, and urine output changes” (K8) with 42.98%, and “Chronic heart failure refers to the condition where heart failure becomes chronic if it persists for more than three months” (K1) with 39.76% (Table 2).

Table 2 Knowledge.
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In the attitude section, 8.97% of participants disagreed, and 3.55% strongly disagreed with obtaining information from various sources (A2). Additionally, 8.46% disagreed, and 3.89% strongly disagreed that HBCR could reduce patients’ financial burden (A3). Furthermore, 8.46% disagreed, and 4.57% strongly disagreed that HBCR provides a wide range of options for recovery and complication prevention (A4) (Table 3).

Table 3 Attitudes.
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In the practice section, 30.46% of participants reported never taking effective steps to manage their psychological state (P3), and 47.38% only underwent cardiovascular evaluations when they felt unwell (P4). Additionally, 4.91% rarely, and 4.57% never took their medication on time (P9), while 8.12% rarely, and 6.26% never consciously monitored their personal health indicators (P10) (Table 4).

Table 4 Practice.
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The correlation and interaction among KAP

Correlation analysis showed significant positive relationships between knowledge and attitude (r = 0.315, P < 0.001), knowledge and practice (r = 0.329, P < 0.001), and attitude and practice (r = 0.502, P < 0.001) (Table 5). Mediation analysis indicated that knowledge directly influenced attitude (β = 0.408, P = 0.008) and practice (β = 0.206, P = 0.011). Attitude also had a direct effect on practice (β = 0.440, P = 0.008). Additionally, knowledge indirectly influenced practice through attitude (β = 0.179, P = 0.006) (Table 6; Fig. 2).

Table 5 Correlation analysis.
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Table 6 Path analysis.
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Fig. 2
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Path Analysis.

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Discussion

Principal results

Patients with CHF exhibited limited knowledge yet maintained moderate attitudes and practices concerning HBCR, underscoring the urgent need for targeted educational strategies. There were also positive correlations among knowledge, attitude, and practice.

Comparison with prior work

The relationships among knowledge, attitudes, and practices were clarified through correlation analyses and SEM. Knowledge was positively correlated with both attitudes and practices, and attitudes were also significantly correlated with practices. SEM results confirmed these correlations, revealing direct effects of knowledge on attitudes and practices, as well as a significant indirect effect of knowledge on practice through attitudes. These findings align with existing literature indicating that improved knowledge often enhances attitudes and practices, which in turn supports better health outcomes21,22.

The analysis of KAP across demographic variables identified patient groups that may benefit from additional focus. For instance, married patients showed better performance across all KAP dimensions. This may be partially explained by greater emotional and logistical support provided by a spouse, which has been suggested to facilitate adherence to health-related behaviors in chronic disease management contexts23,24. Additionally, females exhibited better practice scores than males in our sample. Although the reasons for this difference are unclear, it may reflect gender-based variations in health behavior that require further investigation. Patients with a history of cardiovascular disease also showed higher knowledge, attitudes, and practices scores, likely due to more frequent healthcare interactions, which increase awareness and adherence to recommended practices25. Based on these insights, targeted interventions for single, male, and non-cardiovascular disease history groups could enhance overall engagement with HBCR. Education, residence, and insurance status, key indicators of socioeconomic status, were associated with higher knowledge scores in this study. Individuals with higher education levels and urban residency may have greater opportunities to access health information, and those with insurance coverage might face fewer barriers to obtaining care. However, these knowledge advantages did not appear to consistently translate into improved practices, but additional influencing factors were not assessed in this study and need further exploration25,26,27,28,29. Patients with a history of cardiovascular disease showed notable improvements across all KAP dimensions, likely due to more frequent healthcare interactions and heightened awareness of health risks. This increased engagement with healthcare providers likely promotes both a better understanding and adherence to recommended practices25,28.

The assessment of patients’ knowledge about CHF reveals specific gaps requiring targeted intervention. The poorest responses related to vaccinations, self-management, and the chronic nature of heart failure. Over half of the patients were unaware of the need for pneumococcal and annual influenza vaccinations, nearly 43% lacked understanding of self-management practices involving diuretics, body weight, and urine output, and almost 40% were unaware of the criteria defining chronic heart failure. These findings suggest that patient education should focus on improving awareness in these areas, possibly through tailored educational strategies emphasizing pharmaceutical management, vaccination, and clear explanations of CHF progression. While participants displayed relatively better knowledge in other aspects of the disease, the overall lack of understanding underscores the need for comprehensive educational interventions30,31,32.

Patients’ attitudes toward HBCR were generally positive or neutral; however, certain benefits were less recognized. Nearly 9% of patients disagreed, and 3–4% strongly disagreed with seeking information from various sources (A2) and acknowledging the financial benefits of HBCR (A3). Similarly, a small proportion held negative views on the recovery options and complication prevention provided by HBCR (A4). These findings imply that although most patients recognize the general importance of rehabilitation, certain dimensions—particularly access to information and economic benefits—remain underappreciated and warrant further emphasis. To improve patient attitudes, healthcare providers should highlight these benefits during consultations and consider using strategies like success stories and peer-led support groups to increase patient perception and engagement33,34.

In terms of practices, there is a significant lack of consistent engagement in recommended behaviors, such as exercise and regular health monitoring. Many participants reported only seeking medical evaluations when they felt unwell, with a large portion never undergoing regular check-ups. Additionally, a substantial percentage rarely or never engaged in psychological management practices, such as relaxation or stress management techniques. Practical interventions may involve implementing supervised exercise programs that are readily accessible via community facilities or digital platforms. Furthermore, regular follow-up calls or digital monitoring through apps could remind patients of their exercise routines and health checks, promoting better adherence35,36. Studies support these suggestions, showing that regular professional engagement and reminders can significantly improve compliance with health recommendations37,38.

Limitations

This study has several limitations to consider. First, the cross-sectional design restricts the ability to infer causation between knowledge, attitudes, practices, and rehabilitation outcomes. Although the SEM analysis indicated direct and indirect effects among knowledge, attitude, practice, the association was statistical inference. Second, the use of self-reported data may introduce bias, as participants may overestimate their knowledge or adherence to practices. Third, the study was conducted at a single hospital, which may limit the generalizability of the findings to other settings or populations with different demographics. Additionally, although the questionnaire was developed based on literature review and expert input, it was only pretested in a small sample (n = 50) and has not been validated in prior studies. While CFA was performed post hoc to assess construct validity, this approach remains limited by the study’s cross-sectional design and lack of prior scale validation. This may affect the measurement validity and reliability of the assessed constructs.

Conclusions

In conclusion, CHF patients demonstrated inadequate knowledge, particularly in areas such as recommended vaccinations, self-care strategies, and the chronic trajectory of the disease, despite showing moderate attitudes and practices toward HBCR. Although overall attitudes were generally positive or neutral, some areas, such as financial benefits and variety of rehabilitation options, were less recognized. These findings highlight the necessity of targeted educational interventions aimed at bridging key knowledge gaps and promoting the distinct benefits of HBCR. These efforts should aim to improve patient’s knowledge, foster more favorable attitudes, and promote active engagement in rehabilitation practices.