Measuring self-care in patients with heart failure: A review of the psychometric properties of the European Heart Failure Self-Care Behaviour Scale (EHFScBS)

Cognitive impairment and limited health literacy are associated with poor health outcomes among patients with heart failure residing in rural areas

BACKGROUND

Cognitive impairment and limited health literacy are prevalent among patients with heart failure, particularly those residing in rural areas, and are linked to poor health outcomes. Little is known about the intricate relationships among cognitive function, health literacy, and rehospitalization and death in rural patients with heart failure.

OBJECTIVES

To determine the relationships among cognitive function, health literacy, and cardiac event-free survival (ie, heart failure hospitalizations and cardiac mortality) in rural patients with heart failure.

METHODS

This was a secondary data analysis of a randomized controlled trial of 573 rural patients with heart failure. Cognitive function was measured using the Mini-Cog test. Health literacy was measured by the Short Test of Functional Health Literacy in Adults. Cardiac event-free survival was followed for 2 years. Survival analyses (ie, Kaplan-Meier plots with log-rank test and Cox regression) were used.

RESULTS

Cognitive impairment was associated with limited health literacy. Cognitive impairment and limited health literacy predicted worse cardiac event-free survival (P<.05). Patients with both cognitive impairment and limited health literacy had a 2.24 times higher risk of experiencing a cardiac event compared to those without cognitive impairment and with adequate health literacy (P<.001).

CONCLUSIONS

Patients with cognitive impairment and limited health literacy were at the highest risk of experiencing a cardiac event. It is important to screen rural patients with heart failure for cognitive impairment and limited health literacy. Interventions to improve outcomes need to be developed to target rural patients who have heart failure with cognitive impairment and limited health literacy.

Mediating Effects of Depressive Symptoms and Uncertainty on Physical Symptoms and Self-Care in Korean Older Men With Heart Failure

BACKGROUND

Heart failure is prevalent among aging populations. Given the increasing median age in many countries, sustainably improving self-care behaviors in heart failure patients is crucial. Physical symptoms predict self-care in patients with heart failure, whereas psychological factors such as depressive symptoms and uncertainty negatively affect disease management efficacy.

PURPOSE

The mediating and indirect effects of depressive symptoms and disease uncertainty regarding the relationship between physical symptoms and self-care behaviors were examined in older South Korean men with heart failure.

METHODS

A descriptive correlational survey design was used to collect data from 185 older men with heart failure. Data were obtained from medical records and self-reported questionnaires addressing physical symptoms, depressive symptoms severity (Patient Health Questionnaire-9), illness uncertainty (Mishel Uncertainty in Illness Scale-Community Form), and self-care behaviors (European Heart Failure Self-care Behavior Scale). The mediating effects of depressive symptoms and disease uncertainty were assessed using a bootstrapping method via PROCESS Model 4, a parallel mediation model, in SPSS.

RESULTS

The mean age of the participants was 77.41 ( SD = 5.35) years. Half (50.8%) had a diagnosis of New York Heart Association Class II heart failure, and 21.6% had a diagnosis of New York Heart Association Class III/IV heart failure. Self-care behaviors were found to correlate negatively with physical symptoms, depressive symptoms, and uncertainty. Depressive symptoms ( B = -0.10, 95% confidence interval [CI] [-0.18, -0.01]) and uncertainty ( B = -0.05, 95% CI [-0.09, -0.01]) were found to mediate the relationship between physical symptoms and self-care behaviors.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The findings reveal depressive symptoms and disease uncertainty significantly mediate the relationship between physical symptoms and self-care behaviors in older South Korean men with heart failure. In light of this, cardiovascular nurses should join in targeted educational initiatives tailored to address the unique needs of older men with heart failure that consider psychological factors such as depressive symptoms and uncertainty as well as physical symptom management.

Prevalence and predictors of poor self-care behaviors in patients with chronic heart failure

Despite the indispensable role of self-care behavior in managing heart failure, the practice of self-care behavior remains poor, especially in developing countries. There is a scarcity of research focusing on poor self-care behavior and its determinants within our specific context. Therefore, the objective of this study was to investigate the prevalence and predictors of poor self-care behavior among ambulatory heart failure patients. A facility-based cross-sectional study was conducted at a tertiary care hospital in Ethiopia, involving patients with heart failure. We utilized the European Heart Failure Self-Care Behavior Scale (EHFScBS-9) to evaluate adherence to self-care behaviors. Data were gathered through patient interviews and a review of medical records. A binary logistic regression analysis was performed to identify predictors of poor self-care behavior in heart failure patients. We included a total of 343 participants in the final analysis of this study. The findings revealed that a majority of the patients (73.8%) demonstrated poor overall self-care behavior. Specifically, the majority of patients did not engage in regular exercise (76.1%), failed to consult doctors in case of rapid weight gain (75.6%), did not monitor weight daily (71.5%), did not restrict fluid intake (69.9%), and did not contact doctors in case of experiencing fatigue (68.6%). Additionally, 32.4% of patients did not reach out to doctors when experiencing shortness of breath, 30% did not restrict salt intake, 29% did not adhere to prescribed medication, and only 7% did not consult doctors if edema occurred. Our findings indicated that rural residence (AOR: 5.76, 95% CI: 2.47-13.43), illiteracy (AOR: 2.64, 95% CI: 1.52-6.31), prior hospitalization (AOR: 2.09, 95% CI: 1.21-3.61), and taking five or more medications (AOR: 1.83, 1.01-3.33) were significant predictors of poor self-care behavior. In conclusion, a majority of the participants in our study demonstrated poor self-care behavior. Risk factors for this behavior included rural residence, illiteracy, prior hospitalization, and taking five or more medications. Therefore, it is crucial to prioritize these high-risk patients and implement interventional programs aimed at improving self-care behaviors and overall treatment outcomes in heart failure patients.

Psychometric properties of self-reported measures of self-management for chronic heart failure patients: a systematic review

AIMS

The aim of this study is to identify and assess the psychometric properties of patient-reported outcome measures (PROMs) of self-management for chronic heart failure (CHF) patients.

METHODS AND RESULTS

Eleven databases and two websites were searched from the inception to 1 June 2022. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias checklist was used to assess the methodological quality. The COSMIN criteria were used to rate and summarize the psychometric properties of each PROM. The modified Grading of Recommendation Assessment, Development, and Evaluation was used to assess the certainty of evidence. In total, 43 studies reported on the psychometric properties of 11 PROMs. Structural validity and internal consistency were the parameters evaluated most frequently. Limited information was identified on hypotheses testing for construct validity, reliability, criterion validity, and responsiveness. No data regarding measurement error and cross-cultural validity/measurement invariance were achieved. High-quality evidence on psychometric properties was provided for Self-care of Heart Failure Index (SCHFI) v6.2, SCHFI v7.2, and European Heart Failure Self-care Behavior Scale 9-item (EHFScBS-9).

CONCLUSION

Based on the findings from the included studies, SCHFI v6.2, SCHFI v7.2, and EHFScBS-9 could be recommended to evaluate self-management for CHF patients. Further studies are necessary to evaluate more psychometric properties, such as measurement error, cross-cultural validity/measurement invariance, responsiveness, and criterion validity, and carefully evaluate the content validity.

REGISTRATION

PROSPERO CRD42022322290.

Psychometric Testing of the Chinese Version of the Self-care of Heart Failure Index Version 7.2

BACKGROUND

Self-care is essential in patients with heart failure (HF).

OBJECTIVE

Our objective was to test psychometric properties of the Chinese version of the Self-care of Heart Failure Index version 7.2 (SCHFI v7.2-C).

METHODS

The English version of SCHFI v7.2 was translated into Chinese using the modified Brislin translation model. Psychometric tests of the SCHFI v7.2-C were performed in 320 Chinese patients with HF. Content validity, confirmatory factor analysis, convergent validity, concurrent validity, discriminant validity, internal consistency, and test-retest reliability were examined to determine validity and reliability of the questionnaire. Validity and reliability were assessed for the self-care maintenance, symptom perception, and self-care management scales. SPSS 25.0 and Mplus 8.3 were used for data analysis.

RESULTS

Mean (SD) age of the sample was 61.2 (14.20) years. Scale content validity index ranged from 0.93 to 0.97 across the 3 scales. Results of confirmatory factor analysis supported structural validity of the 3 scales. Self-care was significantly associated with quality of life, and those with more HF experience had significantly better self-care than those with less experience, supporting construct validity. The SCHFI v7.2-C was associated with the 12-item European Heart Failure Self-care Behavior Scale. Cronbach α coefficients for the self-care maintenance, symptom perception, and self-care management scales were 0.79, 0.89, and 0.77, respectively; their test-retest reliability was 0.76, 0.78, and 0.75, respectively.

CONCLUSION

The SCHFI v7.2-C is a valid and reliable instrument that can be used in Chinese patients with HF.

Effectiveness of daily activity record-based self-monitoring intervention for patients with chronic heart failure: A study protocol

Background

The prevention of recurrent readmission among heart failure (HF) patients requires support for appropriate self-care behaviors to prevent exacerbation of HF and self-monitoring to allow for patients’ early perception of physical changes during exacerbations. Such support may enable patients to seek early consultation. This study developed a self-monitoring intervention that aimed at increasing the perception of patient-unique physical sensations caused by HF, based on daily activity records of patients.

Method

A parallel two-arm randomized controlled trial is being conducted with 68 HF patients early after their discharge. Participants in both groups wear a wristwatch activity tracker from time-of-discharge. Participants in the self-monitoring intervention group receive support to reflect on their actual daily activities and the associated physical sensations they experienced, based on their daily activity records. The primary outcome is participants’ “Asking for Help” dimension of self-care behavior, measured using the European Heart Failure Self-Care Behavior Scale at one month follow-up after intervention.

Conclusion

This study is the first trial to use an activity tracker as a tool for symptom perception among HF patients. The problem of delayed consultations during exacerbations may be resolved by assisting patients in improving their perception of their unique physical sensations associated with specific daily activities, based on their daily activity records. If the effect is clarified, it could lead to the construction of new nursing interventions for continuous disease management that aim towards re-hospitalization prevention.

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This is the first trial using an activity tracker for symptom perception in HF.

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Intervention focuses on physical sensations perception along with daily activities.

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Trial will test intervention's effect on early consultation behavior and readmission.

Validation of the ELAN-HF Score and self-care behaviour on the nurse-led heart failure clinic after admission for heart failure

AIM

To validate the predictive value of the European coLlaboration on Acute decompeNsated Heart Failure (ELAN-HF) score, and to assess the effect of self-care behaviour on readmission and mortality in patients after admission with acute decompensated heart failure (ADHF).

DESIGN

Quantitative, prospective, single centre, cohort study.

METHODS

N-Terminal pro-B-type natriuretic peptide (NT-proBNP) levels were measured on admission and discharge, and were used together with clinical and laboratory parameters to calculate the ELAN-HF score. Patients were stratified into four risk groups (low, intermediate, high, very high) according to their ELAN-HF score. The performance of the ELAN-HF score was evaluated and compared to the original study. Self-care behaviour was assessed by the European Heart Failure Self-care Behaviour Scale (EHFScBS-9). Survival analysis was used to estimate the association between both scores and re-admission for HF and/or all-cause mortality within 180 days.

RESULTS

88 patients were included. The median age of the study population was 75 years (IQR 69-83), 43% was female. NYHA III/IV functional class was present at discharge in 68 patients (85%) and 27 patients (34%) had a left ventricular ejection fraction < 40%. Complete data and 180 day follow up was available for 80 patients. 55% reached the endpoint of readmission and/or all-cause mortality. There was a significant association between the ELAN-HF score and re-admission and/or mortality < 180 days (HR = 1.25, 95% CI 1.08-1.45, p = 0.003). The median EHFScBS-9 score was 68.1 (IQR 58.3 - 77.8). There was no significant association between the EHFScBS-9 score and readmission and/or mortality < 180 days (HR = 1.01, 95% CI 0.99-1.03, p = 0.174).

CONCLUSION

This study confirms the validity and therefore the potential of the ELAN-HF score to triage patients with ADHF before discharge. Using this score may optimize the follow-up treatment on the nurse-led heart failure clinic in order to decrease readmission and mortality. Self-care behaviour was non-significantly associated with readmission and/or mortality in our study population.

TRIAL REGISTRATION

This study has been registered with the ethics committee MEC-U (Nieuwegein, The Netherlands), registration nr: V.160999/W18.208/HG/mk.

Psychometric properties of the Persian version of the European heart failure self-care behavior scale

Objective

To investigate the psychometric properties of the self-care behavior scale in heart failure (HF) patients. The development of self-care behaviors is one of the goals of non-pharmacological care management programs.

Methods

After translating the European Heart Failure Self-care Behavior scale (EHFScBS), validity was assessed through explanatory factor analysis; additionally, reliability was assessed through Cronbach alpha and test–retest. The samples comprised of 120 HF patients admitted to hospitals in Tehran during 2017–2018.

Results

The mean age of the samples was 67.3 ± 14.04 years. Fifty-four patients (45%) were female. All items of the scale had an acceptable factor loading. Cronbach alpha coefficient was 0.72. The intra-cluster correlation coefficient (ICC) was 0.69.

Conclusions

Nurses and clinicians could benefit from the Persian version of HF self-care scale since it would enable them to rapidly assess patients’ self-care behaviors and to evaluate the effectiveness of the HF management.

Predictors of Effective Self-care Interventions Among Jordanians With Heart Failure

Jordan has dramatic increases in the prevalence of risk factors for heart failure. However, there are few studies addressing heart failure self-care in Jordan. Identifying predictors of heart failure self-care among Jordanian patients is crucial in providing comprehensive care including addressing risk factors. The study aimed to identify predictors of self-care behaviors among Jordanians with heart failure. A cross sectional study with a convenience sample of 300 Jordanian patients was performed in an educational hospital in the north of Jordan. Differences in the level of self-care between selected sociodemographic and clinical variables were identified using univariate statistics, and multiple regression was used to adjust estimates for covariates. The predictors of self-care were insomnia (p ≤ .001) and marital status (p = .018). Identifying factors influencing self-care can assist with addressing the causes of insomnia to ensure effective treatment, providing patients with social support, and eventually promoting heart failure self-care.

Temporal Trends and Factors Associated With the Inclusion of Patient-Reported Outcomes in Heart Failure Randomized Controlled Trials: A Systematic Review

Background

Patient‐reported outcomes (PROs) are important measures of treatment response in heart failure. We assessed temporal trends in and factors associated with inclusion of PROs in heart failure randomized controlled trials (RCTs).

Methods and Results

We searched MEDLINE, Embase, and CINAHL for studies published between January 2000 and July 2020 in journals with an impact factor ≥10. We assessed temporal trends using the Jonckheere‐Terpstra test and conducted multivariable logistic regression to explore trial characteristics associated with PRO inclusion. We assessed the quality of PRO reporting using the Consolidated Standards of Reporting Trials (CONSORT) PRO extension. Of 417 RCTs included, PROs were reported in 226 (54.2%; 95% CI, 49.3%–59.1%), with increased reporting between 2000 and 2020 (P<0.001). The odds of PRO inclusion were greater in RCTs that were published in recent years (adjusted odds ratio [aOR] per year, 1.08; 95% CI, 1.04–1.12; P<0.001), multicenter (aOR, 1.89; 95% CI, 1.03–3.46; P=0.040), medium‐sized (aOR, 2.35; 95% CI, 1.26–4.40; P=0.008), coordinated in Central and South America (aOR, 5.93; 95% CI, 1.14–30.97; P=0.035), and tested health service (aOR, 3.12; 95% CI, 1.49–6.55; P=0.003), device/surgical (aOR, 6.66; 95% CI, 3.15–14.05; P<0.001), or exercise (aOR, 4.66; 95% CI, 1.81–12.00; P=0.001) interventions. RCTs reported a median of 4 (interquartile interval , 3–6) of a possible of 11 CONSORT PRO items.

Conclusions

Just over half of all heart failure RCTs published in high impact factor journals between 2000 and 2020 included PROs, with increased inclusion of PROs over time. Trials that were large, tested pharmaceutical interventions, and coordinated in North America / Europe had lower adjusted odds of reporting PROs relative to other trials. The quality of PRO reporting was modest.

Human-Centred Design Of A Digital Health Tool To Promote Effective Self-Care In Heart Failure Patients: Mixed Methods Study (Preprint)

Background

Objective

Methods

Results

Conclusions

Effectiveness of telemonitoring on self-care behaviors among community-dwelling adults with heart failure: a quantitative systematic review

OBJECTIVE

This review examined the effectiveness of telemonitoring versus usual care on self-care behaviors among community-dwelling adults with heart failure.

INTRODUCTION

Heart failure is a global health crisis. There is a body of high-level evidence demonstrating that telemonitoring is an appropriate and effective therapy for many chronic conditions, including heart failure. The focus has been on traditional measures such as rehospitalizations, length of stay, cost analyses, patient satisfaction, quality of life, and death rates. What has not been systematically evaluated is the effectiveness of telemonitoring on self-care behaviors. Involving patients in self-care is an important heart failure management strategy.

INCLUSION CRITERIA

This review included studies on adult participants (18 years and older), diagnosed with heart failure (New York Heart Association Class I - IV), who used telemonitoring in the ambulatory setting. Studies among pediatric patients with heart failure, adult patients with heart failure in acute care settings, or those residing in a care facility were excluded.

METHODS

Eight databases, including CINAHL, Cochrane Central Register of Controlled Trials, Embase, MEDLINE, Epistemonikos, ProQuest Dissertations and Theses, PsycINFO, and Web of Science were systematically searched for English-language studies between 1997 and 2019. Studies selected for retrieval were assessed by two independent reviewers for methodological quality using critical appraisal checklists appropriate to the study design. Those meeting a priori quality standards of medium or high quality were included in the review.

RESULTS

Twelve publications were included in this review (N = 1923). Nine of the 12 studies were randomized controlled trials and three were quasi-experimental studies. Based on appropriate JBI critical appraisal tools, the quality of included studies was deemed moderate to high. In a majority of the studies, a potential source of bias was related to lack of blinding of treatment assignment. Telemonitoring programs ranged from telephone-based support, interactive websites, and mobile apps to remote monitoring systems and devices. Self-care outcomes were measured with the European Heart Failure Self-care Behaviour Scale in nine studies and with the Self-care of Heart Failure Index in three studies. Telemonitoring improved self-care behaviors across 10 of these studies, achieving statistical significance. Clinical significance was also observed in nine of the 12 studies. All studies utilized one of two validated instruments that specifically measure self-care behaviors among patients with heart failure. However, in some studies, variation in interpretation and reporting was observed in the use of one instrument.

CONCLUSIONS

Overall, telemonitoring had a positive effect on self-care behavior among adult, community-dwelling patients with heart failure; however, there is insufficient and conflicting evidence to determine how long the effectiveness lasts. Longitudinal studies are needed to determine the sustained effect of telemonitoring on self-care behaviors. In addition, the limitations of the current studies (eg, inadequate sample size, study design, incomplete statistical reporting, self-report bias) should be taken into account when designing future studies. This review provides evidence for the use of telemonitoring, which is poised for dramatic expansion given the current clinical environment encouraging reduced face-to-face visits.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019131852.

The Impact of Motivational Interviewing on Self-care and Health-Related Quality of Life in Patients With Chronic Heart Failure

BACKGROUND

Self-care is an integral component of successful chronic heart failure (HF) management. Structured educational programs have already been shown to be effective in improving self-care, but some patients show resistance and little motivation for change.

OBJECTIVE

The objective of this study was to compare efficacy in improving self-care and health-related quality of life (HRQoL) for an educational intervention based on motivational interviewing (MI) compared with a conventional educational intervention.

METHODS

This experimental pretest-posttest study with an equivalent historical control group included 93 patients in the intervention group and 93 matched patients in the control group. Participants attended a first visit after HF hospitalization discharge and 6 to 7 follow-up visits during 6 months. The European Heart Failure Self-care Behavior scale and the Minnesota Living with Heart Failure Questionnaire were used to assess self-care and HRQoL, respectively. Data on mortality and hospital readmissions were collected as adverse events.

RESULTS

Self-care improved significantly more in the MI-based intervention group than in the control group (P = .005). Although both self-care and HRQoL improved in both groups over time (P < .05), there was no significant between-group difference in terms of HRQoL improvement over time (P = .13).

CONCLUSIONS

Our findings suggest that MI delivered by MI-trained nurses is effective in significantly improving self-care by patients with HF. Nonetheless, further studies are required to evaluate the impact of MI on other outcomes, such as HRQoL and adverse clinical events.

The relationship between self-care, long-term mortality, and heart failure hospitalization: insights from a real-world cohort study

AIMS

The assumption that improved self-care in the setting of heart failure (HF) care necessarily translates into improvements in long-term mortality and/or hospitalization is not well established. We aimed to study the association between self-care and long-term mortality and other major adverse HF events (MAHFE).

METHODS AND RESULTS

We conducted an observational, prospective, cohort study of 1123 consecutive patients with chronic HF. The primary endpoint was all-cause mortality. We used the European Heart Failure Self-care Behaviour Scale 9-item version (EHFSCBS-9) to measure global self-care (overall score) and three specific dimensions of self-care including autonomy-based adherence, consulting behaviour and provider-based adherence. After a mean follow-up of 3.3 years, all-cause death occurred in 487 patients (43%). In adjusted analysis, higher EHFScBS-9 scores (better self-care) at baseline were associated with lower risk of all-cause death [hazard ratio (HR) 0.993, 95% confidence interval (CI) (0.988-0.997), P-value = 0.002], cardiovascular (CV) death [HR 0.989, 95% CI (0.981-0.996), P-value = 0.003], HF hospitalization [HR 0.993, 95% CI (0.988-0.998), P-value = 0.005], and the combination of MAHFE [HR 0.995, 95% CI (0.991-0.999), P-value = 0.018]. Similarly, impaired global self-care [HR 1.589, 95% CI (1.201-2.127), P-value = 0.001], impaired autonomy-based adherence [HR 1.464, 95% CI (1.114-1.923), P-value = 0.006], and impaired consulting behaviour dimensions [HR 1.510, 95% CI (1.140-1.923), P-value = 0.006] were all associated with higher risk of all-cause mortality.

CONCLUSION

In this study, we have shown that worse self-care is an independent predictor of long-term mortality (both, all-cause and CV), HF hospitalization, and the combinations of these endpoints in patients with chronic HF. Important dimensions of self-care such as autonomy-based adherence and consulting behaviour also determine the risk of all these outcomes in the long term.

Thirst distress in outpatients with heart failure in a Mediterranean zone of Spain

Aims

This study aimed to evaluate psychometric properties of the Spanish version of the Thirst Distress Scale for patients with Heart Failure (TDS‐HF) and to describe thirst distress‐associated factors in outpatients at a heart failure (HF) clinic in Spain. Thirst is common in patients with HF, but thirst distress has rarely been addressed and may significantly decrease quality of life.

Methods and results

A cross‐sectional study was performed assessing perceived thirst distress by patients with HF during the preceding 3 days, with the TDS‐HF (scores 8 to 40). Univariable and multivariable linear regression analyses were performed to identify variables independently associated with thirst distress. Three‐hundred two HF outpatients were included (age 67 ± 12 years, 74% male, HF duration 82 ± 75 months, left ventricular ejection fraction 42 ± 14%). Most patients were on treatment with fluid restriction (99%), sodium restriction (99%), and diuretics (70%). The psychometric evaluation of the Spanish version of the TDS‐HF showed satisfactory item‐total and inter‐item correlations (range from 0.77 to 0.85 and 0.60 to 0.84, respectively), and internal consistency was 0.95 (Cronbach's alpha). The majority perceived mild to moderate thirst distress, and 18% perceived it as high or severe. The mean score obtained was 16.2 ± 9.3 (median 13, Q1–Q3 8–20). Higher serum urea {beta coefficient 1.6 [95% confidence interval (CI) 0.267 to 2.92], P = 0.019} and lower potassium [beta coefficient −3.63 (85% CI −6.32 to −0.93), P = 0.009] remained significantly associated with thirst distress in the multivariable analysis, together with the dose of diuretics [beta coefficient 2.98 (95% CI 1.37 to 4.59), P < 0.001]. Treatment with angiotensin receptor blocker showed an independent protective effect [beta coefficient −3.62 (95% CI −6.89 to −0.345), P = 0.03].

Conclusions

The psychometric evaluation of the Spanish version of the TDS‐HF showed good psychometric properties. One in five patients experienced severe distress by thirst, but the majority had mild to moderate thirst distress. The dose of diuretics and angiotensin receptor blocker treatment influence thirst distress and could be clinically important targets to relieve thirst distress in patients with HF.

Methodological quality of studies assessing validity and reliability of the European Heart Failure Self-care Behaviour Scale: a systematic review using the COSMIN methodology

AIMS

The European Heart Failure Self-care Behaviour Scale (EHFScBS) is frequently used to assess self-care behaviours in patients with heart failure. This scale has been translated into several languages. The COnsensus-based Standards for the selection of health status Measurement INstrument (COSMIN) Risk of Bias checklist for a systematic review has recently been published. The aim of the study was to assess the methodological quality of studies reporting on psychometric evaluations of the EHFScBS using the COSMIN methodology.

METHODS AND RESULTS

To identify relevant studies, a systematic literature search was performed using PubMed and CINAHL databases in December 2019 and the search was updated in June 2020. The COSMIN Risk of Bias checklist was used to assess the methodological quality. In total, 21 relevant studies were rated. The overall methodological quality of content validity was rated as inadequate in 17 studies and a main reason of the inadequate rating was a lack of patient involvement. Structural validity was adequately addressed in 12 studies, internal consistency in seven, and eight of 11 studies reporting on construct validity and had good methodological quality.

CONCLUSION

Although the use of the EHFScBS has grown rapidly and the validity and reliability are reported to be good, the methodological quality of studies reporting on psychometric properties of the scale is not optimal. Further studies are necessary to strengthen the evidence on validity and reliability of the EHFScBS.

Persistent effect of nurse-led education on self-care behavior and disease knowledge in heart failure patients

PURPOSE

The guidelines on the management of patients with heart failure support intensive patient education on self-care. The present study aimed to evaluate the short-term and long-term impacts of a structured education provided by a qualified heart failure nurse on patients' self-care behavior and disease knowledge.

METHODS

One hundred fifty patients (66 ± 12 years) hospitalized for heart failure participated in a structured one-hour educational session by a heart failure nurse. Patients completed a questionnaire comprising 15 questions (nine questions from the European Heart Failure Self-Care Behavior Scale [EHFScB-9] and six on the patients' disease knowledge) one day before and one day and six months after the educational session. Possible responses for each question ranged from 1 (complete agreement) to 5 (complete disagreement).

RESULTS

After the educational session, the total EHFScB-9 score improved from 24.31 ± 6.98 to 14.94 ± 6.22, and the disease knowledge score improved from 18.03 ± 5.44 to 10.74 ± 4.30 (both P < 0.001). Scores for individual questions ranged from 1.26 ± 0.81 (adherence to the medication protocol) to 3.66 ± 1.58 (everyday weighing habits) before the education. The greatest improvement after education was observed on response to weight gain (-2.00‬±1.57), daily weight control (-1.77 ± 1.64), and knowledge on the cause of patients' heart failure (-1.53 ± 1.43). At 6-month follow-up, EHFScB-9 score was 17.33 ± 7.23 and knowledge score was 12.34 ± 5.30 (both P < 0.001 compared with baseline). No factor was predictive of an insufficient teaching effect.

CONCLUSIONS

The educational program led by a qualified nurse improves patients' self-care behavior and disease knowledge with a persistent effect at 6-month follow-up. There are no patient characteristics which preclude the implementation of an educational session.

Characteristics of self-care interventions for patients with a chronic condition: A scoping review

BACKGROUND

Self-care is a fundamental element of treatment for patients with a chronic condition and a major focus of many interventions. A large body of research exists describing different types of self-care interventions, but these studies have never been compared across conditions. Examination of heterogeneous interventions could provide insights into effective approaches that should be used in diverse patient populations.

OBJECTIVES

To provide a comprehensive and standardized cross-condition overview of interventions to enhance self-care in patients with a chronic condition. Specific aims were to: 1) identify what self-care concepts and behaviors are evaluated in self-care interventions; 2) classify and quantify heterogeneity in mode and type of delivery; 3) quantify the behavior change techniques used to enhance self-care behavior; and 4) assess the dose of self-care interventions delivered.

DESIGN

Scoping review DATA SOURCES: Four electronic databases - PubMed, EMBASE, PsychINFO and CINAHL - were searched from January 2008 through January 2019.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Randomized controlled trials (RCTs) with concealed allocation to the intervention were included if they compared a behavioral or educational self- care intervention to usual care or another self-care intervention and were conducted in adults. Nine common chronic conditions were included: hypertension, coronary artery disease, arthritis, chronic kidney disease, heart failure, stroke, asthma, chronic obstructive lung disease, and type 2 diabetes mellitus. Diagnoses that are psychiatric (e.g. schizophrenia), acute rather than chronic, or benefitting little from self-care (e.g. dementia) were excluded. Studies had to be reported in English with full-text available.

RESULTS

9309 citations were considered and 233 studies were included in the final review. Most studies addressed type 2 diabetes mellitus (n = 85; 36%), hypertension (n = 32; 14%) or heart failure (n = 27; 12%). The majority (97%) focused on healthy behaviors like physical activity (70%), dietary intake (59%), and medication management (52%). Major deficits found in self-care interventions included a lack of attention to the psychological consequences of chronic illness, technology and behavior change techniques were rarely used, few studies focused on helping patients manage signs and symptoms, and the interventions were rarely innovative. Research reporting was generally poor.

CONCLUSIONS

Major gaps in targeted areas of self-care were identified. Opportunities exist to improve the quality and reporting of future self-care intervention research. Registration: The study was registered in the PROSPERO database (#123,719).

Self-care perception and behaviour in patients with heart failure: A qualitative and quantitative study

Background and objective

Self‐care strategies in heart failure (HF) are effective for disease management, yet adherence in many patients is inadequate. Reasons are presumably multifactorial but remain insufficiently investigated; thus, we aimed to analyse self‐care adherence and associated factors in outpatients with HF.

Methods and results

To measure self‐care levels and explore barriers and facilitators to self‐care adherence in patients with HF, quantitative study using the European Self‐Care Behaviour Scale (EHFScBS‐9) (n = 80; NYHA II–III, mean age 72 ± 10 years, 58% male) and qualitative study using semi‐structured interviews (n = 32; NYHA II–III, mean age 73 ± 11, 63% male) were conducted. We detected lowest adherence to regular exercise (39%) and contacts with healthcare provider in case of worsening symptoms (47%), whereas adherence was highest for regular medication taking (94%). Using the EHFScBS‐9 standardized cut‐off score ≤ 70, 51% of patients reported inadequate self‐care. Binary logistic regression analysis showed significant influence of education (OR = 0.314, 95% CI: 0.103–0.959) and perceived control (OR = 1.236, 95% CI: 1.043–1.465) on self‐care adequacy. According to the situation‐specific theory of HF self‐care, most commonly reported factors affecting the process of self‐care were knowledge about HF self‐care behaviours (84%), experience with healthcare professionals (84%), beliefs about their expertise (69%) and habits related to medication taking (72%). Among values, working responsibilities (53%) and maintenance of traditions (31%) appeared as the most prevalent socially based values affecting motivation for self‐care. Situational characteristics related to the person (self‐confidence, 53%; adaptive coping strategies, 88%), problem (burdensome breathing difficulties, 56%; co‐morbidities, 81%) and environment (practical support from family/caregivers, 59%; financial difficulties, 50%) were also commonly reported.

Conclusions

Various factors, including health‐related beliefs, habits and socially based values, need to be taken into account when planning self‐care interventions in patients with HF. A patient tailored approach should be based on adequate patient evaluation, taking into consideration the particular personal and social context.

Self-care, symptom experience, needs, and past health-care utilization in individuals with heart failure: results of a cross-sectional study

AIMS

Self-care in heart failure (HF) is generally sub-optimal and impacts morbidity and mortality. To describe self-care prevalence and explore its relationships with symptom experience, patient needs, and health-care utilization in a Swiss hospital providing regional secondary care.

METHODS AND RESULTS

Cross-sectional study, convenience sample of individuals with HF from four campuses of one regional Swiss hospital. Self-care was assessed via the Self-Care of Heart Failure Index (SCHFI) and the European Heart Failure Self-care Behaviour Scale (EHFScBS), symptom experience via the M.D. Anderson Symptom Inventory-HF (MDASI-HF) and needs via the Heart Failure Needs Assessment Questionnaire (HFNAQ). Healthcare utilization reflected the preceding year's hospitalization incidence. A cut-off level of ≥70% indicated adequate self-care. We analysed SCHFI, EHFScBS, MDASI-HF and HFNAQ scores' relationships with hospitalizations using Spearman's rho correlation; no prior hypotheses were stated. Sample of 310 individuals with HF (37.4% female; mean age 76.8; 55% NYHA III). Adequate self-care maintenance, management, and confidence were reported by 24%, 10%, and 61%. respectively. The sample's mean number of experienced symptoms was 12.8 (SD 4.0) and 14.0 (SD 5.8) for needs. Over the previous year, 269 hospitalizations had occurred (median: 0, IQR 1). Hospitalizations positively correlated with self-care; symptom experience with needs. Neither symptom experience nor needs correlated with hospitalizations.

CONCLUSION

The findings indicated low self-care levels and suggest a need for increased support to maintain physiological stability, manage symptoms and prevent hospitalizations. This study is the first of its kind in Switzerland and among few studies worldwide to report on self-care, symptom experience, needs, and health-care utilization. Interventional studies are warranted considering baseline self-care capabilities, symptoms, and needs of individuals with HF.

Self-Care Monitoring of Heart Failure Symptoms and Lung Impedance at Home Following Hospital Discharge: Longitudinal Study

Background

Self-care is key to the daily management of chronic heart failure (HF). After discharge from hospital, patients may struggle to recognize and respond to worsening HF symptoms. Failure to monitor and respond to HF symptoms may lead to unnecessary hospitalizations.

Objective

This study aimed to (1) determine the feasibility of lung impedance measurements and a symptom diary to monitor HF symptoms daily at home for 30 days following hospital discharge and (2) determine daily changes in HF symptoms of pulmonary edema, lung impedance measurements, and if self-care behavior improves over time when patients use these self-care monitoring tools.

Methods

This study used a prospective longitudinal design including patients from cardiology wards in 2 university hospitals—one in Norway and one in Lithuania. Data on HF symptoms and pulmonary edema were collected from 10 participants (mean age 64.5 years; 90% (9/10) male) with severe HF (New York Heart Association classes III and IV) who were discharged home after being hospitalized for an HF condition. HF symptoms were self-reported using the Memorial Symptom Assessment Scale for Heart Failure. Pulmonary edema was measured by participants using a noninvasive lung impedance monitor, the CardioSet Edema Guard Monitor. Informal caregivers aided the participants with the noninvasive measurements.

Results

The prevalence and burden of shortness of breath varied from participants experiencing them daily to never, whereas lung impedance measurements varied for individual participants and the group participants, as a whole. Self-care behavior score improved significantly (P=.007) from a median of 56 (IQR range 22-75) at discharge to a median of 81 (IQR range 72-98) 30 days later.

Conclusions

Noninvasive measurement of lung impedance daily and the use of a symptom diary were feasible at home for 30 days in HF patients. Self-care behavior significantly improved after 30 days of using a symptom diary and measuring lung impedance at home. Further research is needed to determine if daily self-care monitoring of HF signs and symptoms, combined with daily lung impedance measurements, may reduce hospital readmissions.

Cross-Cultural Adaptation and Reliability of the French–Canadian Version of the European Heart Failure Self-Care Behaviour Scale-9

Background and Purpose

The purposes of this methodological study were to adapt the European Heart Failure Self-care Behaviour Scale-9 to the French–Canadian population and to evaluate its reliability.

Methods

The adaptation process consisted of translation, back-translation, evaluation by an expert committee, and pretesting. Reliability was evaluated with stability criteria (test–retest) and internal consistency.

Results

Pretesting led to testing of two response formats: 5-point Likert scale and the frequency scale. Both demonstrated good levels of agreement between the test–retest, although the values were higher with the frequency format. The Cronbach's alpha coefficients ranged from 0.71 to 0.78 (Likert scale) and 0.70 to 0.83 (frequency scale).

Conclusion

The French–Canadian version of the EHFScB-9, in both formats, demonstrated good evidence of reliability.

Psychometric Properties of the 9-item European Heart Failure Self-care Behavior Scale Using Confirmatory Factor Analysis and Rasch Analysis Among Iranian Patients

BACKGROUND

The 9-item European Heart Failure Self-Care Behavior scale (EHFScB-9) is a self-reported questionnaire commonly used to capture the self-care behavior of people with heart failure (HF).

OBJECTIVE

The aim of this study was to investigate the EHFScB-9's factorial structure and categorical functioning of the response scale and differential item functioning (DIF) across subpopulations in Iran.

METHODS

Patients with HF (n = 380; 60.5% male; mean [SD] age, 61.7 [9.1] years) participated in this study. The median (interquartile range) of the duration of their HF was 6.0 (2.4-8.8) months. Most of the participants were in New York Heart Association classification II (NYHA II, 61.8%); few of them had left ventricular ejection fraction assessment (11.3%). All participants completed the EHFScB-9. Confirmatory factor analysis was used to test the factorial structure of the EHFScB-9; Rasch analysis was used to analyze categorical functioning and DIF items across 2 characteristics (gender and NYHA).

RESULTS

The 2-factor structure ("adherence to regimen" and "consulting behavior") of the EHFScB-9 was confirmed, and the unidimensionality of each factor was found. Categorical functioning was supported for all items. No items displayed substantial DIF across gender (DIF contrast, -0.25-0.31). Except for item 3 ("Contact doctor or nurse if legs/feet are swollen"; DIF contrast, -0.69), no items displayed substantial DIF across NYHA classes (DIF contrast, -0.40 to 0.47).

CONCLUSIONS

Despite the DIF displayed in 1 item across the NYHA classes, the EHFScB-9 demonstrated sound psychometric properties in patients with HF.

Gender differences in prognostic relevance of self-care behaviors on mortality and hospitalization in patients with heart failure - A report from the CHART-2 Study

BACKGROUND

Self-care behaviors (ScB) are associated with symptoms and outcomes in patients with heart failure (HF). However, little is known about gender differences in the prognostic relevance of ScB in HF patients.

METHODS

We examined gender differences in ScB of HF patients regarding its prognostic associations with mortality and HF hospitalization with a reference to ScB dimensions. The European Heart Failure Self-Care Behavior Scale (EHFScBS) was used to evaluate ScB in 2233 patients with Stage C/D HF in the CHART-2 Study.

RESULTS

Male patients (n=1583) were younger (71 vs. 73 yrs) and had lower ScB (median 33 vs. 31) (all p<0.001) than females (n=650). During the median follow-up of 2.57 years, patients with high ScB (score 12-32, n=1090), as compared with low ScB patients (score 33-60, n=1143), had significantly increased all-cause mortality in males [adjusted hazard ratio (aHR) 1.44, p=0.02] but not in females (aHR 0.80, p=0.40) (p for interaction 0.02), while ScB was not significantly associated with incidence of HF hospitalization in both genders. Among the 3 dimensions in EHFScBS, complying with regimen was associated with decreased mortality in females, but not in males (p for interaction 0.003), while asking for help was related with increased incidence of HF hospitalization in males (aHR 1.34, p=0.072) but not in females (aHR 0.98, p=0.931) (p for interaction 0.048).

CONCLUSIONS

There were gender differences in the prognostic relevance of self-care with mortality and incidence of HF hospitalization, suggesting that self-care should be implemented considering gender differences to improve prognosis.

Anxiety and self-care behaviour in patients with chronic systolic heart failure: A multivariate model

BACKGROUND

While comprehensive evidence exists regarding negative effects of depression on self-care behaviours in patients with chronic heart failure (CHF), the relation between anxiety and self-care behaviours in patients with CHF is not clear. The aim of this study was to analyse the interactions between anxiety, depression and self-care behaviours in patients with CHF.

METHODS

The self-care behaviour of CHF outpatients was measured using the European Heart Failure Self-care Behaviour Scale (EHFScBS). The Patient Health Questionnaire (PHQ) was used to assess anxiety, the PHQ-9 was used to measure depression severity. Differences between patients with and without anxiety were assessed with the respective tests. Associations between anxiety, self-care and other predictors were analysed using linear regressions.

RESULTS

Of the 308 participating patients, 35 (11.4%) fulfilled the PHQ criteria for an anxiety disorder. These patients took antidepressants more frequently (11.8% versus 2.3%, p = .02), had had more contacts with their general practitioner within the last year (11.8 ± 16.1 versus 6.7 ± 8.6, p = .02), and had a higher PHQ-9 depression score (12.9 ± 5.7 versus 6.5 ± 4.7, p < .01) than patients without anxiety disorder. Anxiety and self-care were negatively associated (ß = -0.144, r² = 0.021, p = 0.015). The explanation of variance was augmented in a multivariate regression with the predictors age, sex, education, living with a partner, and New York Heart Association (NYHA) class ( r² = 0.098) when anxiety was added ( r² = 0.112). Depression further increased the explanation of variance (ß = -0.161, r² = 0.131, p = 0.019).

CONCLUSIONS

Anxiety is negatively associated with self-care behaviour in patients with CHF. However, this effect disappears behind the stronger influence of depression on self-care. The consideration of mental comorbidities in patients with CHF is important.