An Integrative Review of the Symptom Perception Process in Heart Failure

Illness perceptions of people living with chronic heart failure and limited community disease management

AIM

To explore the cognitive representations and emotional responses to living with chronic heart failure of people receiving limited community disease management.

BACKGROUND

Individuals living with heart failure face self-care and emotional challenges due to the overwhelming nature of adapting to lifestyle changes, particularly in subtropical areas.

DESIGN

Qualitative descriptive. We applied Leventhal's Common Sense Model of Self-Regulation as the framework for interviews and analyses.

METHODS

Twenty patients with chronic heart failure were interviewed during a hospital admission for exacerbation of their condition in a tertiary hospital in Thailand.

RESULTS

Analysis of the components of Leventhal's model of cognitive representations of illness revealed two themes relating to Illness Identity: (1) lack of knowledge of the diagnosis and how to recognise symptoms of the disease, and (2) recognition of symptoms of an exacerbation of CHF was based on past experience rather than education. These resulted in delays responding to cardiac instability and confusion about the intent of treatment. Participants recognised the chronicity of their disease but experienced it as an unrelenting cycle of relative stability and hospitalisations. Perceived Controllability was low. Two themes were: (1) Low perceived trust in the efficacy of medical treatment and lifestyle changes, and (2) Low perceived trust in their ability to comply with recommended lifestyle changes. The Consequences were significant emotional distress and high burden of disease. The two themes of emotional responses were (1) Frustration and hopelessness with the uncertainty and unpredictability of the disease, and (2) Sense of loss of independence, functional capacity and participation in life's activities.

CONCLUSION

Chronically ill patients need support to understand their illness and make better treatment and lifestyle decisions. Improving patients' self-efficacy to manage treatment and symptom fluctuations has the potential to improve their mental well-being and minimise the impact of their condition on suffering and participation in employment and community.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Leventhal's Common Sense Model of Self-Regulation can be used to examine cognitive and emotional elements of illness perceptions, which link to individuals' ability to make informed decisions about disease management and influence health behaviours. Understanding illness perceptions underpins strategies for enhancing and sustaining self-management behaviours.

IMPACT

The study findings accentuate the need to establish long-term condition support programs in low-middle income countries where the burden of heart failure is increasing exponentially.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline was used to explicitly and comprehensively report our qualitative research.

PATIENT OR PUBLIC CONTRIBUTION

Patients contributed to the conduct of the study by participating in the data collection via face-to-face interviews.

Treatment burden in multimorbidity: an integrative review

BACKGROUND

People living with multimorbidity experience increased treatment burden, which can result in poor health outcomes. Despite previous efforts to grasp the concept of treatment burden, the treatment burden of people living with multimorbidity has not been thoroughly explored, which may limit our understanding of treatment burden in this population. This study aimed to identify the components, contributing factors, and health outcomes of treatment burden in people with multiple diseases to develop an integrated map of treatment burden experienced by people living with multimorbidity. The second aim of this study is to identify the treatment burden instruments used to evaluate people living with multimorbidity and assess the comprehensiveness of the instruments.

METHODS

This integrative review was conducted using the electronic databases MEDLINE, EMBASE, CINAHL, and reference lists of articles through May 2023. All empirical studies published in English were included if they explored treatment burden among adult people living with multimorbidity. Data extraction using a predetermined template was performed.

RESULTS

Thirty studies were included in this review. Treatment burden consisted of four healthcare tasks and the social, emotional, and financial impacts that these tasks imposed on people living with multimorbidity. The context of multimorbidity, individual's circumstances, and how available internal and external resources affected treatment burden. We explored that an increase in treatment burden resulted in non-adherence to treatment, disease progression, poor health status and quality of life, and caregiver burden. Three instruments were used to measure treatment burden in living with multimorbidity. The levels of comprehensiveness of the instruments regarding healthcare tasks and impacts varied. However, none of the items addressed the healthcare task of ongoing prioritization of the tasks.

CONCLUSIONS

We developed an integrated map illustrating the relationships between treatment burden, the context of multimorbidity, people's resources, and the health outcomes. None of the existing measures included an item asking about the ongoing process of setting priorities among the various healthcare tasks, which highlights the need for improved measures. Our findings provide a deeper understanding of treatment burden in multimorbidity, but more research for refinement is needed. Future studies are also needed to develop strategies to comprehensively capture both the healthcare tasks and impacts for people living with multimorbidity and to decrease treatment burden using a holistic approach to improve relevant outcomes.

TRIAL REGISTRATION

DOI: https://doi.org/10.17605/OSF.IO/UF46V.

Effect of Daily Activity Record-Based Self-monitoring Intervention on the Perception of Physical Sensations in Patients With Chronic Heart Failure: A Randomized Controlled Trial

BACKGROUND

To prevent rehospitalization for heart failure (HF), patients need to be able to perceive physical changes that occur at the onset of HF exacerbation and seek early help.

OBJECTIVE

The aim of this study was to evaluate the effect of a self-monitoring intervention on patients' perceptions of physical sensations during daily activities in the context of HF via a randomized controlled trial.

METHODS

Participants (N = 70) were randomly assigned to the intervention (received daily activity record-based self-monitoring intervention support; group A) or control (only explained the measured results from the records; group B) group. Group A reflected on and described the physical sensations in their daily activities within 1 month after discharge. Outcome measures were assessed at 1 month after the intervention using the European Heart Failure Self-care Behavior Scale, Evaluation Scale for Self-Monitoring by patients with Heart Failure, clinical events, physical activity, and sleep.

RESULTS

There was no significant difference in the change in the "asking for help" subscale score of the European Heart Failure Self-care Behavior Scale between the groups (+0.7 vs +0.4 points, P = .716). Group A had improved score on the self-monitoring subscale related to "concern about how movements affect body" from baseline (from 12.7 to 14.0 points, P = .026). There was no significant effect of self-monitoring intervention support on the first rehospitalization related to HF and all-cause death (log-rank χ 2 = 0.432, P = .511). A significant difference in moderate-intensity physical activity between the groups was observed (+4.6 vs -0.5 minutes, P = .029).

CONCLUSIONS

A focused strategy that enables patients to perceive their physical sensations and promotes early help-seeking behavior is needed.

Contribution of informal caregivers to self-care in individuals with heart failure

OBJECTIVES

to evaluate the contribution of informal caregivers to the self-care of individuals with heart failure.

METHODS

a cross-sectional study was conducted with 87 caregivers from March to October 2022 in the city of João Pessoa/PB. The caregivers' contribution was assessed using the Caregiver Contribution to Self-Care of Heart Failure Index instrument. Scores ≥ 70 points indicate adequate contribution. Data were analyzed using descriptive statistics and Spearman's correlation.

RESULTS

the sample consisted of 81.6% female caregivers. Median scores obtained for the self-care contribution scales were: 63.3 for maintenance; 55.5 for management; and 66.6 for confidence. Caregivers never or rarely recommended monitoring body weight, regular physical exercise, extra use of diuretics, and fluid restriction.

CONCLUSIONS

informal caregivers showed inadequate contribution in the areas of maintenance, management, and confidence in self-care of individuals with heart failure.

The symptom perception processes of monitoring, awareness, and evaluation in patients with heart failure: a qualitative descriptive study

AIMS

Patients with heart failure (HF) experience various signs and symptoms and have difficulties in perceiving them. Integrating insights from patients who have engaged in the process of symptom perception is crucial for enhancing our understanding of the theoretical concept of symptom perception. This study aimed to describe how patients with HF perceive symptoms through the processes of monitoring, awareness, and evaluation and what influences the process.

METHODS AND RESULTS

Using a qualitative descriptive design, we conducted in-person semi-structured interviews with a purposeful sample of 40 adults experiencing an unplanned hospitalization for a HF symptom exacerbation. We elicited how patients monitor, become aware of, and evaluate symptoms prior to hospitalization. Data were analysed using directed qualitative content analysis. One overarching theme and three major themes emerged. Patients demonstrated Body listening, which involved active and individualized symptom monitoring tactics to observe bodily changes outside one's usual range. Trajectory of bodily change involved the patterns or characteristics of bodily changes that became apparent to patients. Three subthemes-sudden and alarming change, gradual change, and fluctuating change emerged. Patients evaluated symptoms through an Exclusionary process, sequentially attributing symptoms to a cause through a cognitive process of excluding possible causes until the most plausible cause remained. Facilitators and barriers to symptom monitoring, awareness, and evaluation were identified.

CONCLUSION

This study elaborates the comprehensive symptom perception process used by adults with HF. Tailored nursing interventions should be developed based on the factors identified in each phase of the process to improve symptom perception in HF.

Feasibility, acceptability, and outcome responsiveness of the SYMPERHEART intervention to support symptom perception in persons with heart failure and their informal caregivers: a feasibility quasi-experimental study

BACKGROUND

Symptom perception is an important process of heart failure (HF) self-care that persons with HF need in order to master self-care management. It also leads to better patient outcomes. Symptom perception consists of body observation and analysis, which are both challenging. We aimed to test the feasibility, acceptability, and outcome responsiveness of a novel intervention (SYMPERHEART) delivered to persons with HF with their informal caregiver.

METHODS

We designed SYMPERHEART as a complex evidence-informed education and support intervention targeting body observation and analysis. We conducted a feasibility quasi-experimental study with a single group pre-post-test design. We included three subsamples: persons with HF receiving home-based care, their informal caregivers exposed to SYMPERHEART, and home-care nurses who delivered SYMPERHEART during 1 month. We assessed feasibility by recruitment time, time to deliver SYMPERHEART, eligibility rate, and intervention fidelity. We assessed acceptability by consent rate, retention rate, persons with HF engagement in body observation, and treatment acceptability. Outcome responsiveness was informed by patient-reported (PRO) and clinical outcomes: HF self-care and the informal caregivers' contribution to HF self-care, perception of HF symptom burden, health status, caregivers' burden, and HF events. We performed descriptive analyses for quantitative data and calculated Cohen's d for PROs. A power analysis estimated the sample size for a future full-scale effectiveness study.

RESULTS

We included 18 persons with HF, 7 informal caregivers, and 9 nurses. Recruitment time was 112.6 h. The median time to deliver SYMPERHEART for each participant was 177.5 min. Eligibility rate was 55% in persons with HF. Intervention fidelity revealed that 16 persons with HF were exposed to body observation and analysis. Consent and retention rates in persons with HF were 37.5% and 100%, respectively. Participants engaged actively in symptom and weight monitoring. Treatment acceptability scores were high. Symptom perception and informal caregivers' contribution to symptom perception were found to be responsive to SYMPERHEART. We estimate that a sample size of 50 persons with HF would be needed for a full-scale effectiveness study.

CONCLUSIONS

SYMPERHEART was found to be feasible and acceptable. This feasibility study provides information for a subsequent effectiveness study.

TRIAL REGISTRATION

ISRCTN. ISRCTN18151041 , retrospectively registered on 4 February 2021, ICTRP Search Portal.

The association between comorbidities and self-care of heart failure: a cross-sectional study

BACKGROUND

Because heart failure (HF) is a debilitating chronic cardiac condition and increases with age, most patients with HF experience a broad range of coexisting chronic morbidities. Comorbidities present challenges for patients with HF to successfully perform self-care, but it is unknown what types and number of comorbidities influence HF patients' self-care. The purpose of this study was to explore whether the number of cardiovascular and non-cardiovascular conditions are associated with HF self-care.

METHODS

Secondary data analysis was performed with 590 patients with HF. The number of cardiovascular and non-cardiovascular conditions was calculated using the list of conditions in the Charlson Comorbidity Index. Self-care was measured with the European HF self-care behavior scale. Multivariable linear regression was performed to explore the relationship between the types and number of comorbidities and self-care.

RESULTS

Univariate analysis revealed that a greater number of non-cardiovascular comorbidities was associated with poorer HF self-care(β=-0.103), but not of more cardiovascular comorbidities. In the multivariate analysis, this relationship disappeared after adjusting for covariates. Perceived control and depressive symptoms were associated with HF self-care.

CONCLUSION

The significant relationship between the number of non-cardiovascular comorbidities and HF self-care was not independent of perceived control and depressive symptoms. This result suggests a possible mediating effect of perceived control and depressive symptoms on the relationship between HF self-care and the number and type of comorbidities.

Effects of a multidisciplinary management program on symptom burden and medication adherence in heart failure patients with comorbidities: A randomized controlled trial

BACKGROUND

Comorbidities in heart failure (HF) are a complex clinical challenge. There is little data on the benefits of multidisciplinary postdischarge management programs in such patients. This study aimed to examine the effects of a multidisciplinary management program (MMP) on symptom burden and medication adherence in HF patients with comorbidities.

METHODS

In this clinical trial study, 94 HF patients with comorbidities were assigned to intervention (n = 47) and control (n = 47) groups by the stratified-random method. The intervention group underwent MMP supervised by a nurse for two months after discharge, including multi-professional visits, telephone follow-ups, and an educational booklet. Medication adherence and symptom burden were assessed using Morisky Medication Adherence Scale (MMAS) and Edmonton Symptom Assessment Scale (ESAS), respectively, on three occasions: Before discharge, six weeks, and eight weeks after discharge.

RESULTS

Both groups almost matched at the baseline, and the most frequent comorbidities included myocardial infarction (MI), hypertension, peptic ulcer, and depression, respectively. The interactive effect of time in groups showed that mean changes in total scores of symptom burden and medication adherence were significantly different (P < 0.001) at other time points. A significant increase in medication adherence (P < 0.001) and a significant reduction in the burden of all symptoms were observed in the intervention group compared to the control group from Time 1 to Time 3.

CONCLUSIONS

The MMP (targeting comorbidity) is a promising strategy for managing symptoms and medication adherence in HF patients with comorbidities.

Symptom detection and the relationship with self-care in heart failure

AIM

Patients with heart failure (HF) may have difficulty detecting symptom changes. However, most research has relied on medical record reviews or patient recall. Therefore, it is important to prospectively explore symptom detection in HF and the relationship with self-care. This study aimed at (i) prospectively identifying distinct symptom detection groups and comparing characteristics among the groups and (ii) exploring the association between symptom detection groups and self-care.

METHODS AND RESULTS

One hundred and thirty-two patients rated their shortness of breath (SOB) using the modified Borg scale at four-time points after a 6-min walk test (6-MWT). A trained nurse simultaneously and independently rated patients' SOB using the same scale. Latent class growth modelling was used to identify distinct trajectories of the differences in SOB ratings between the patients and nurses after the 6-MWT. After identifying the symptom detection groups, the characteristics of each group were compared, and the relationship between self-care and the symptom detection groups was examined using the multivariate linear regression. Three distinct symptom detection groups were identified: over-estimation (6.1%), consistent (69.7%), and under-estimation (24.2%) groups. There were no significant sample characteristics among the three symptom detection groups, except for attention. There was no relationship between self-care and symptom detection groups.

CONCLUSIONS

We identified three distinct symptom detection groups, implying that different approaches are needed to improve patients' symptom detection ability. The non-significant relationship between the symptom detection groups and self-care may be because we only measured symptom detection, which is only one aspect of the symptom perception process.

Symptom Recognition as a Mediator in the Self-Care of Chronic Illness

Background

The recognition of a symptom is needed to initiate a decision to engage in a behavior to ameliorate the symptom. Yet, a surprising number of individuals fail to detect symptoms and delay in addressing early warnings of a health problem.

Purpose

The aim of this study was to test the hypothesis that symptom recognition mediates the relationship between monitoring for and management of symptoms of a chronic illness.

Methods

A secondary analysis of existing cross-sectional data. A sample of 1,629 patients diagnosed with one or more chronic conditions was enrolled in the United States (US) (n = 407), Italy (n = 784) and Sweden (n = 438) between March 2015 and May 2019. Data on self-care monitoring, symptom recognition, and self-care management was assessed using the Self-Care of Chronic Illness Inventory. After confirming metric invariance in cultural assessment, we used structural equation modeling to test a mediation model where symptom recognition was conceptualized as the mediator linking self-care monitoring and self-care management with autonomous (e.g., Change your activity level) and consulting behaviors (e.g., Call your healthcare provider for guidance).

Results

Symptom recognition mediated the relation between self-care monitoring and autonomous self-care management behaviors (β = 0.098, β = 0.122, β = 0.081, p < 0.001 for US, Italy, and Sweden, respectively). No mediation effect was found for consulting self-care management behaviors.

Conclusion

Our findings suggests that symptom recognition promotes autonomous self-care behaviors in people with a chronic condition. Self-care monitoring directly affects consulting self-care management behaviors but not through symptom recognition. Further research is needed to fully understand the role of symptom recognition in the self-care process.

Association between Residence Location and Pre-Hospital Delay in Patients with Heart Failure

Rural residents with heart failure (HF) face more challenges than their urban counterparts in taking action when their symptoms worsen due to limited healthcare resources in rural areas. This may contribute to rural residents’ pre-hospital delay in seeking medical care. However, few studies have investigated the relationship between residence locations and pre-hospital delay among patients with HF. Therefore, this study determined whether living in rural areas is associated with pre-hospital delay in patients with HF. A retrospective electronic medical record review was conducted using the data of patients discharged with worsening HF from an academic medical center. Data on postal codes of the patients’ residences and their experiences before seeking medical care were obtained. Pre-hospital delay was calculated from the onset of HF symptoms to hospital arrival. A multivariate linear regression analysis was performed to determine the relationship between residence location and pre-hospital delay. The median pre-hospital delay time of all patients was 72 h (N = 253). About half of the patients did nothing to relieve their symptoms before seeking medical care. Living in urban areas was associated with a shorter pre-hospital delay. Patients with HF waited several days after first experiencing worsening of symptoms before getting admitted to a hospital, which may be related to inappropriate interpretation and responses to the worsening of symptoms. Furthermore, we found that rural residents were more vulnerable to pre-hospital delay than their urban counterparts.