Measuring Self-care in Chronic Heart Failure: A Review of the Psychometric Properties of Clinical Instruments

Validation of Psychometric Properties of Partners in Health Scale for Heart Failure

Background: Congestive heart failure (CHF) is a complex chronic disease, and it is associated with a second comorbid condition in more than half of cases. Self-management programs can be specific to CHF or generic for chronic diseases. Several tools have been validated for CHF. Presently, there are no established generic instruments that are validated for measuring self-management in CHF. Objective: This study aims to evaluate the internal reliability and construct validity (psychometric properties) of the Partners in Health (PIH) scale for patients with congestive heart failure, a generic chronic disease self-management tool. Methods: The study included 210 adult CHF patients [120 with heart failure with reduced ejection fraction (HfrEF), 90 with preserved ejection fraction (HfpEF)], from Community Cardiology Outpatients in West Melbourne, Australia, who were treated in community cardiology and were included between May 2022 and Jan 2024. The screened patient population were diagnosed with CHF and were eligible for an SGLT-2 inhibitor. Cohort analysis used the Bayesian confirmatory factor analysis to evaluate the a priori four-factor structure. Omega coefficients and 95% credible intervals (CI) were used to assess internal reliability. Results: In the CHF (HFrEF) and preserved ejection fraction (HFpEF) cohorts, participants' mean [standard deviation (SD)] age was 66.8 (13.5) and 71.3 (9.76) years. Description of study sociodemographics highlighted that 88% and 52% of patients were male, there was a BMI > 50% in both cohorts, eGFR > 60 mL/min were 59% and 74%, and LVEF < 40% and > 50% were 99% and 100%, respectively. Model fit for the hypothesised model was adequate (posterior predictive p = 0.073) and all hypothesised factor loadings were substantial (>0.6) and significant (p < 0.001). Omega coefficients (95% CI) for the PIH subscales of Knowledge, Partnership, Management and Coping were 0.84 (0.79-0.88), 0.79 (0.73-0.84), 0.89 (0.85-0.91) and 0.84 (0.79-0.88), respectively. Conclusion: This study is original in confirming the dimensionality, known-group validity, and reliability of the PIH scale for measuring generic self-management in outpatients with CHF syndrome.

Evaluating a New Short Self-Management Tool in Heart Failure Against the Traditional Flinders Program

Background/Objective: Heart failure (HF) is a complex syndrome, with multiple causes. Numerous pathophysiological pathways are activated. Comprehensive and guideline-derived care is complex. A multidisciplinary approach is required. The current guidelines report little evidence for chronic disease self-management (CDSM) programs for reducing readmission and major adverse cardiovascular events (MACE). CDSM programs can be complex and are not user-friendly in clinical settings, particularly for vulnerable patients. The aim of this study was to investigate whether a simplified one-page CDSM tool, the SCReening in Heart Failure (SCRinHF), is comparable to a comprehensive Flinders Program of Chronic Disease Management, specifically in triaging self-management capabilities and in predicting readmission and MACE. Methods:SELFMAN-HF is a prospective, observational study based on community cardiology. Eligible patients, consecutively recruited, had HF with left ventricular ejection fraction <40% and were placed on sodium-glucose co-transporter-2 inhibitors (SGLT2-i) within 3 months of recruitment. SGLT2-i is the newest of the four HF treatment pillars; self-management skills are assessed at this juncture. CDSM was assessed and scored independently via the long-form (LF) and short-form (SF) tools, and concordance between forms was estimated. The primary endpoint is the 80% concordance across the two CDSM scales for predicting hospital readmission and MACE. Results: Of the 117 patients, aged 66.8 years (±SD 13.5), 88 (75%) were male. The direct comparisons for SF versus LF patient scores are as follows: "good self-managers", 13 vs. 30 patients (11.1% vs. 25.6%); "average", 46 vs. 21 patients (39.3% vs. 17.9%), "borderline", 20 vs. 31 patients (17.1% vs. 26.5%), and "poor self-managers" (vulnerable), 38 vs. 35 patients (32.5% vs. 29.9%). These findings underscore the possibility of SF tools in picking up patients whose scores infer poor self-management capabilities. This concordance of the SF with the LF scores for patients who have poor self-management capabilities (38 vs. 35 patients p = 0.01), alongside readmission (31/38 vs. 31/35 p = 0.01) or readmission risk for poor self-managers versus good self-managers (31/38 vs. 5/13 p = 0.01), validates the simplification of the CDSM tools for the vulnerable population with HF. Similarly, when concurrent and predictive validity was tested on 52 patients, the results were 39 (75%) for poor self-managers and 14 (27%) for good self-managers in both groups, who demonstrated significant correlations between SF and LF scores. Conclusions: Simplifying self-management scoring with an SF tool to improve clinical translation is justifiable, particularly for vulnerable populations. Poor self-management capabilities and readmission risk for poor self-managers can be significantly predicted, and trends for good self-managers are observed. However, correlations of SF to LF scores across an HF cohort for self-management abilities and MACE are more complex. Translation to patients of all skill levels requires further research.

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.

Instruments Measuring Self-Care and Self-Management of Chronic Conditions by Community-Dwelling Older Adults: A Scoping Review

Given the high prevalence of chronic conditions and multimorbidity in older adults, there is a need to better conceptualize and measure self-care and self-management to promote a person-centered approach. This scoping review aimed to identify and map instruments measuring self-care and self-management of chronic conditions by older adults. We searched six electronic databases, charted data from the studies and tools and reported the results in accordance with the PRISMA-ScR guidelines. A total of 107 articles (103 studies) containing 40 tools were included in the review. There was substantial variation in the tools in terms of their aims and scope, structure, theoretical foundations, how they were developed, and the settings in which they have been used. The quantity of tools demonstrates the importance of assessing self-care and self-management. Consideration of the purpose, scope, and theoretical foundation should guide decisions about tools suitable for use in research and clinical practice.

Factors related to self-care behaviors among hospitalized patients with heart failure in Japan, based on the European Heart Failure Self-Care Behaviour Scale

[Purpose] The characteristics of heart failure in hospitalized patients with poor self-care behaviors are unknown. We investigated factors associated with self-care behaviors by using the European Heart Failure Self-Care Behaviour Scale (EHFScBS) in heart failure patients based on three comprehensive concepts. [Participants and Methods] This was a cross-sectional single-center study of heart failure patients hospitalized at a tertiary-care hospital. We investigated age, gender, family living together/apart, employment, and the Specific Activity Scale (SAS). A physical therapist provided the EHFScBS one time to determine the patients’ pre-hospital self-care behavior status. The 12 items of the EHFScBS were classified into the following three categories: Maintenance, Monitoring, and Management. [Results] The median age of the 39 consecutive patients was 81 years. A multiple regression analysis revealed that the factors exhibiting significant associations were the SAS score (β=0.504) for Management and age (β=−0.403) for the total EHFScBS score (adjusted by the number of hospitalizations for heart failure). Maintenance and Monitoring were not significantly associated with the survey items. [Conclusion] These data indicate that self-care education for hospitalized patients with heart failure leads to individualized approaches based on characteristics such as age and physical activity capacity.

Feasibility of patient-performed lung ultrasound self-exams (Patient-PLUS) as a potential approach to telemedicine in heart failure

Aims

Patient‐performed lung ultrasound (LUS) in a heart failure (HF) telemedicine model may be used to monitor worsening pulmonary oedema and to titrate therapy, potentially reducing HF admission. The aim of the study was to assess the feasibility of training HF patients to perform a LUS self‐exam in a telemedicine model.

Methods and results

A pilot study was conducted at a public hospital involving subjects with a history of HF. After a 15 min training session involving a tutorial video, subjects performed a four‐zone LUS using a handheld ultrasound. Exams were saved on a remote server and independently reviewed by two LUS experts. Studies were determined interpretable according to a strict definition: the presence of an intercostal space, and the presence of A‐lines, B‐lines, or both. Subjects also answered a questionnaire to gather feedback and assess self‐efficacy. The median age of 44 subjects was 53 years (range, 36–64). Thirty (68%) were male. Last educational level attained was high school or below for 31 subjects (70%), and one‐third used Spanish as their preferred language. One hundred fifty of 175 lung zones (85%) were interpretable, with expert agreement of 87% and a kappa of 0.49. 98% of subjects reported that they could perform this LUS self‐exam at home.

Conclusions

This pilot study reports that training HF patients to perform a LUS self‐exam is feasible, with reported high self‐efficacy. This supports further investigation into a telemedicine model using LUS to reduce emergency department visits and hospitalizations associated with HF.

Effectiveness of health education in the self-care and adherence of patients with heart failure: a meta-analysis

OBJECTIVE

to evaluate in the literature the effectiveness of the health education interventions in self-care and adherence to treatment of patients with Chronic Heart Failure.

METHOD

a systematic review with meta-analysis. Studies were selected that compared health education interventions with the usual care to assess the outcomes of adherence and self-care. The quality of the methodological evidence was assessed by the Grading of Recommendations, Assessment, Development and Evaluation system.

RESULTS

the educational interventions were more effective in relation to the usual care in the outcome of adherence (fixed effect=0-3841; p-value <0.001). There was no statistical difference in the outcome of self-care (fixed effect=0.0063; p-value=0.898).

CONCLUSION

the educational interventions improved the outcome of adherence, though not self-care in the patient with Heart Failure.

Self-Care in Heart Failure Inpatients: What Is the Role of Gender and Pathophysiological Characteristics? A Cross-Sectional Multicentre Study

Heart failure is often characterised by low exercise capacity and a great impairment of performance in the activities of daily living. The correct management of the disease can prevent the worsening of symptoms and promote a better quality of life. The aims of this study are to understand the relationship of gender and pathophysiological characteristics with self-care behaviour and to evaluate the self-care behaviour in a sample of Portuguese heart failure inpatients, using the Self-Care of Heart Failure Index (SCHFI). A cross-sectional multicentre study enrolling 225 heart failure inpatients from eight hospitals from Portugal was performed. At admission, each patient’s functional capacity was evaluated as well as their self-care behaviour, using the SCHFI Portuguese v6.2. A comparison between self-care behaviour with gender was performed. The patients’ mean age was 68.4 ± 10.7 years old, 68% were male and 82.3% had reduced ejection fraction. A mean value of 47.9, 35.6 and 38.8 points was found in the SCHFI score of the sections self-care maintenance, self-care management and self-care confidence, respectively. Heart failure inpatients present inadequate levels of self-care behaviour. The results do not suggest a relationship between gender and pathophysiological characteristics with self-care behaviour.

Psychometric properties of patient-reported outcome measures of self-management for cancer survivors: a systematic review protocol using COSMIN methodology

INTRODUCTION

Self-management is an important strategy for cancer survivors. Evaluating self-management is essential for planning nursing interventions that promote self-management and for measuring the contribution of nursing to health outcomes. Many patient-reported outcome measures (PROMs) have been designed and used to assess self-management in cancer survivors. However, it is unclear which PROM has the best reliability and validity. Therefore, the goal is to systematically review the psychometric properties of existing self-management PROMs and determine which PROM is best for cancer survivors.

METHODS AND ANALYSIS

This systematic review will be conducted according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines for systematic reviews of PROMs. Ten electronic literature databases (PubMed, EMBASE and so on) and two websites for PROMs will be searched from inception to 1 March 2020. Studies testing the psychometric properties of PROMs assessing self-management for cancer survivors, published in either English or Chinese, will be included. Two independent reviewers determined the eligibility of the studies and will independently extract the data. Risk of bias will be assessed using the COSMIN risk-of-bias checklist, and the quality of the results will be assessed using specific COSMIN quality criteria.

ETHICS AND DISSEMINATION

It is not necessary to obtain ethical approval for this systematic review protocol. The results will be published in a peer-reviewed journal and presented at a relevant conference.

PROSPERO REGISTRATION NUMBER

CRD42020149120.

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.

The Self-Care of Heart Failure Index: A psychometric study

BACKGROUND

The Self-Care of Heart Failure Index is an empirically tested instrument to measure self-care of heart failure patients across different populations and cultures.

AIMS

To develop and evaluate the psychometric properties of the Nepali Self-Care of Heart Failure Index.

DESIGN

This psychometric study used a cross-sectional, observational, study design to collect data. The study was guided and reported following the Strengthening the Reporting of Observational Studies in Epidemiology guideline.

METHODS

To develop and culturally validate Nepali Self-Care of Heart Failure Index, a combination of the recommended methods for cross-cultural validation studies were applied such as translation, back translation, expert committee review of the translated version and validity/reliability testing. Face and content validity were ensured using expert review. Construct validity was examined using exploratory factor analysis and confirmatory factor analysis. Composite reliability scores were calculated for each sub-scale of the Nepali Self-Care of Heart Failure Index.

RESULTS

A total of 221 heart failure patients in Nepal were enrolled in the study. Adequate face and content validity were ensured through expert review. Exploratory factor analysis and confirmatory factor analysis supported the original three-factor model. Although the three factors explained only 41% of the variance, confirmatory factor analysis fit indexes and error measures were found reasonable. The composite reliability coefficients for self-care maintenance, management and confidence scale were 0.6, 0.7 and 0.8, respectively.

CONCLUSIONS

The Nepali Self-Care of Heart Failure Index is a theoretically based, culturally acceptable and appropriate instrument for use among Nepali heart failure patients. However, further studies are needed to refine its psychometric properties.

RELEVANCE TO CLINICAL PRACTICE

Access to reliable, valid and culturally appropriate instruments is crucial in describing the state of the problem as well as for developing and evaluating tailored and targeted self-care practice interventions for Nepali patients living with heart failure.

Impact of pharmacist-led heart failure tool kits on patient-reported self-care behaviors in a primary care-based accountable care organization

OBJECTIVE

The goal of this project is to evaluate the impact of a pharmacist-led heart failure (HF) intervention, using an educational toolkit, on patient-reported self-care maintenance, management, and confidence at 30 days.

SETTING

Three Accountable Care Organization (ACO) primary care provider offices in South Florida from January to March 2018.

PRACTICE DESCRIPTION

Each primary care clinic was staffed with at least 1 physician, nurse practitioners, a clinical pharmacy faculty member, pharmacy residents and students, and ancillary staff. Pharmacists spent approximately 2 days per week in clinic.

PRACTICE INNOVATION

At the time of this project, no formalized management program for HF patients existed within the clinics. An educational toolkit was designed, reviewed, and approved by the team of pharmacists and ACO providers before use within the clinics, and included educational material outlining common causes of HF exacerbation, symptoms of HF, symptom management strategies, medication action plan, self-management instructions, medication adherence tips, and a weight-management log sheet.

EVALUATION

A prospective, pretest and posttest observational project was conducted at the 3 clinical sites for eligible patients. The Self-Care for Heart Failure Index (SCHFI, v.6.2) tool was used to evaluate self-care practices and adequacy of maintenance, management, and confidence at baseline as compared with 30 days.

RESULTS

Twelve participants completed the initial interview and 30-day follow-up. SCHFI scores for self-maintenance (63-68, P = 0.04) and self-management (38-58, P = 0.01) significantly improved from baseline, whereas self-confidence scores showed an increase, but was not statistically significant (80-82, P = 0.58). All self-care behaviors saw a nonstatistically significant improvement in percentage of patients achieving adequacy.

CONCLUSION

Pharmacists and educational toolkits in the ACO primary care setting may improve self-maintenance, self-management, and self-confidence behaviors in patients with HF.

Knowledge among patients with heart failure: A narrative synthesis of qualitative research

BACKGROUND

Patients' knowledge of heart failure (HF) is integral to improved outcomes. However, the HF literature has not adequately explored the nature of patients' knowledge of HF as part of their lived experience.

OBJECTIVES

We aimed to characterize the nature of patients' knowledge of HF, in the context of living with the disease.

METHODS

We conducted a narrative synthesis of qualitative studies that addressed patients' knowledge of HF. Studies were systematically searched and retrieved from MEDLINE, CINAHL, PsycINFO and PsycARTICLES databases. Findings were synthesized using an iterative coding process carried out by multiple analysts and reported following Enhancing Transparency in the Reporting of Qualitative Health Research (ENTREQ) criteria.

RESULTS

Analysis of 73 eligible articles produced five themes: the content that comprises HF knowledge; development of HF knowledge over time; application of HF knowledge for decision making; communication of information between clinicians and patients; and patients' experience of knowledge.

CONCLUSION

The nature of patients' knowledge of HF is both explicit and implicit, dynamic, and personal. This multidimensional model of knowledge-in-context calls for equally multidimensional research and intervention design.

Association between process performance measures and 1-year mortality among patients with incident heart failure: a Danish nationwide study

Aims

To examine the association between fulfilment of performance measures supported by clinical guidelines recommendations and 1-year mortality among patients with incident heart failure (HF) in Denmark.

Methods and results

A nationwide population-based follow-up study based on the Danish Heart Failure Registry. All Danish hospital departments caring for patients with HF. We identified 24 308 in- and outpatients diagnosed with HF from 2003 to 2010. Quality of care was defined as receiving the guideline recommended processes of care: use of echocardiography, New York Heart Association classification, treatment with angiotensin-converting-enzyme inhibitors/angiotensin-II-receptor blocker, beta blockers, physical training, and patient education. Main outcome measure is 1-year mortality. We used multiple imputation and multivariable Cox proportional hazard regression to compute hazard ratios (HRs) for 1-year mortality adjusted for potential confounding factors. Within 1 year, 17.1% of the patients died and the adjusted HRs ranged from 0.61 [95% confidence interval (CI) 0.55-0.67] for patient education to 0.99 (95% CI 0.90-1.10) for beta blocker therapy. The association between meeting more performance measures and 1-year mortality appeared to follow a dose-response pattern: using 0-25% of fulfilled measures as reference, patients who fulfilled 76-100% of the performance measures had an adjusted HR of 0.43 (95% CI 0.38-0.48), while the adjusted HR was 0.96 (95% CI 0.86-1.07) for patients who fulfilled between 26% and 50% of the performance measures.

Conclusion

Meeting process performance measures, which reflect care in concordance with clinical guideline recommendations, was associated with substantially lower 1-year mortality among patients with incident HF.

Study protocol for a cohort study of patients with advanced heart failure in Singapore

INTRODUCTIO

Understanding the symptom and health expenditure burden among patients with advanced congestive heart failure (CHF) and their family caregivers is essential to reform policy and practice needed to provide quality care to these patients at affordable prices. The proposed cohort study titled Singapore Cohort of Patients with Advanced Heart Failure aims to describe trajectories of quality of life among patients and their primary informal caregivers, quantify healthcare utilisation and expenditures, assess changes in patient and caregiver awareness of and preferences for knowing diagnostic and prognostic information, awareness and utilisation of palliative care services, preferences for treatments and decision making, perceived quality of care, self-care, caregiver psychological distress and caregiver burden.

METHODS

This cohort study will recruit 250 patients with New York Heart Association Classification class III and IV CHF from inpatient wards at two public tertiary healthcare institutions in Singapore. Patients and their primary informal caregiver are being surveyed every 4 months until patients' death; caregivers are followed until 8 weeks postpatient death. Medical and billing records of patients are obtained and merged with patients' survey data.

ETHICS AND DISSEMINATION

The study has been approved by an ethics board. Results from the study will be disseminated through publications and presentations targeting researchers, policy makers and clinicians interested in understanding and improving care for patients with advanced CHF.

TRIAL REGISTRATION NUMBER

NCT03089034.

Self-reported Adherence to a Low-Sodium Diet and Health Outcomes in Patients With Heart Failure

BACKGROUND

Most clinicians rely on patients' self-report of following a low-sodium diet to determine adherence of patients with heart failure (HF). Whether self-reported adherence to a low-sodium diet is associated with cardiac event-free survival is unclear.

PURPOSES

To determine (1) whether self-reported is concordant with adherence to a low-sodium diet measured by food diaries and 24-hour urinary sodium excretion and (2) whether self-reported adherence to a low-sodium diet predicts cardiac event-free survival.

METHODS

Adherence to a low-sodium diet was measured using 3 measures in 119 HF patients: (1) self-reported adherence, 1 item from the Self-care of Heart Failure Index scale; (2) a 3-day food diary; (3) 24-hour urinary sodium excretion. Patients were followed up for a median of 297 days to determine cardiac hospitalization or emergency department visit. One-way analysis of variance and Cox regression were used to address our purposes.

RESULTS

Self-reported adherence was concordant with adherence to a low-sodium diet measured by food diaries and 24-hour urinary sodium excretion. Thirty-one patients who reported they always follow a low-sodium diet had an average sodium intake less than 3 g/d (F = 5.07, P = .002) and 3.3 g of a mean 24-hour urinary sodium excretion (F = 3.393, P = .020). Patients who reported they never or rarely follow a low-sodium diet had 4.7 times greater risk of having cardiac events than did those who always followed a low-sodium diet (P = .017).

CONCLUSION

Self-reported adherence to a low-sodium diet predicted cardiac event-free survival demonstrating clinicians can use this as an indicator of adherence.

Self-care in heart failure patients

Objective:

to describe self-care behavior and its associated factors in a sample of heart failure Brazilian patients.

Method:

descriptive cross-sectional study with non-probabilistic sample of 116 ambulatory patients undergoing heart failure treatment. Self-care was evaluated using the Self-Care of Heart Failure Index, (scores ≥70 points=appropriate self-care). Association tests were applied, considering a descriptive level of 0.05.

Results:

the mean age of participants was 57.7 (SD =11.3) years; 54.3% were male; the mean schooling was 5.5 (SD = 4.0) years; and 74.1% had functional class II-III. The mean scores on the subscales of the Self-Care of Heart Failure Index indicated inappropriate self-care (self-care maintenance: 53.2 (SD =14.3), selfcare management: 50.0 (SD = 20.3) and self-care confidence: 52.6 (SD=22.7)) and it was found low frequencies of participants with appropriate self-care (self-care maintenance, 6.9%), self-care management (14.7%) and self-care confidence (19%). Higher scores of the Self-Care of Heart Failure Index were associated with: reduced left ventricular ejection fraction (p=0.001), longer time of experience with the disease (p=0.05) and joint monitoring by physician and nurse (p=0.007).

Conclusion:

investments are needed to improve the self-care behavior and the nursing can play a relevant role in this improvement.

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.

Instruments to assess self-care among healthy children: A systematic review of measurement properties

AIM

To identify, critically appraise and summarize the measurement properties of instruments to assess self-care in healthy children.

BACKGROUND

Assessing self-care is a proper consideration for nursing practice and nursing research. No systematic review summarizes instruments of measurement validated in healthy children.

DESIGN

Psychometric review in accordance with the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) panel.

DATA SOURCES

MEDLINE, CINAHL, PsycINFO, Web of Science and Open Grey were searched from their inception to December 2016.

REVIEW METHODS

Validation studies with a healthy child population were included. Search was not restricted by language. Two reviewers independently assessed the methodological quality of included studies using the COSMIN checklist.

RESULTS

Eleven studies were included in the review assessing the measurement properties of ten instruments. There was a maximum of two studies per instrument. None of the studies evaluated the properties of test-retest reliability, measurement error, criterion validity and responsiveness. Internal consistency and structural validity were rated as "excellent" or "good" in four studies. Four studies were rated as "excellent" in content validity. Cross-cultural validity was rated as "poor" in the two studies (three instruments) which cultural adaptation was carried out.

CONCLUSION

The evidence available does not allow firm conclusions about the instruments identified in terms of reliability and validity. Future research should focus on generate evidence about a wider range of measurement properties of these instruments using a rigorous methodology, as well as instrument testing on different countries and child population.

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

OBJECTIVE

The aim of this study was to review and evaluate the evidence related to psychometric properties of the European Heart Failure Self-Care Behaviour Scale (EHFScBS) that was developed and tested to measure health maintenance behaviours of heart failure (HF) patients and translated into several languages.

METHODS

PRISMA guidelines were used to search major health databases (PubMed, Scopus and ScienceDirect), to identify relevant studies. A literature search was undertaken in November 2015. An integrative review, aiming to bring together all evidence relating to the psychometric properties (validity, reliability) of the EHFScBS was conducted.

RESULTS

13 eligible studies were included. The results showed content, discriminant and convergent validity of the 9- and 12-item scale across the samples, while the factor structure of both versions of the scale was inconsistent. Most commonly used reliability estimates (Cronbach's alpha) of the total scale were satisfactory.

CONCLUSION

Overall, published data demonstrate satisfactory psychometric properties of the EHFScBS, indicating that the scale is a reliable and valid tool for measuring health maintenance behaviours of HF patients.

PRACTICE IMPLICATIONS

Taking the findings regarding the factorial structure of the scale into account, we recommend the use of the total EHFScBS score or scores on specific items.

Factors related to self-care behaviours in heart failure: A systematic review of European Heart Failure Self-Care Behaviour Scale studies

BACKGROUND

Self-care is an important element in the comprehensive management of patients with heart failure. The European Heart Failure Self-Care Behaviour Scale (EHFScBS) was developed and tested to measure behaviours performed by the heart failure patients to maintain life, healthy functioning, and wellbeing.

AIMS

The purpose of this review was to evaluate the importance of factors associated with heart failure self-care behaviours as measured by the EHFScBS.

METHODS

Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines were used to search major health databases (PubMed, Scopus and ScienceDirect). Obtained associating factors of heart failure self-care were qualitatively synthesised and the association levels of most commonly addressed factors were further explored.

RESULTS

We identified 30 studies that were included in the review; a diverse range of personal and environmental factors associated with self-care behaviours in heart failure patients were identified. Age, health-related quality of life, gender, education, New York Heart Association class, depressive symptoms and left ventricular ejection fraction were most often correlated with the EHFScBS score. Consistent evidence for the relationship between self-care behaviours and depression was found, while their association with New York Heart Association class and health-related quality of life was non-significant in most of the studies. Associations with other factors were shown to be inconsistent or need to be further investigated as they were only addressed in single studies.

CONCLUSION

A sufficient body of evidence is available only for a few factors related to heart failure self-care measured by the EHFScBS and indicates their limited impact on patient heart failure self-care. The study highlights the need for further exploration of relationships that would offer a more comprehensive understanding of associating factors.

The impact of a self-management patient education program for patients with chronic heart failure undergoing inpatient cardiac rehabilitation

OBJECTIVE

To evaluate a patient-centred self-management educational group program for patients with chronic systolic heart failure as compared to usual care education during inpatient cardiac rehabilitation.

METHODS

A multicentre cluster randomized controlled trial of 475 patients was conducted. In the intervention condition, patients received the new self-management educational group program whereas in the control condition, patients received a short lecture-based educational program (usual care). The primary outcome was patients' self-reported self-management competence. Secondary outcomes included self-management health behaviour, health-related quality of life, and treatment satisfaction. Patients completed self-reported outcome measures at admission, discharge, and after 6 and 12 months.

RESULTS

There was a significant small between-group intervention effect on certain dimension of patients' self-management competence (self-monitoring and insight) in short term (p<0.05). Furthermore, significant small effects were observed for treatment satisfaction at discharge as well as symptom monitoring after 6 months (p<0.05) and by trend on symptom monitoring and physical activity after 12 months.

CONCLUSIONS

The patient-centred self-management program might be more effective in certain self-management outcomes than a usual care education in both short-term and long-term periods.

PRACTICE IMPLICATIONS

Therefore, such programs may be considered for dissemination within cardiac rehabilitation.

Self-Care and All-Cause Mortality in Patients With Chronic Heart Failure

OBJECTIVES

This study examined the association of self-care with all-cause mortality in a cohort of patients with chronic heart failure (HF).

BACKGROUND

Although self-care is crucial to maintain health in patients with chronic HF, studies examining an association with clinical outcomes are scarce.

METHODS

Consecutive patients with chronic HF (n = 559, mean age 66.3 ± 9.5 years, 78% men) completed the 9-item European Heart Failure Self-care Behaviour scale. Our endpoint was all-cause mortality. Associations between self-care and all-cause mortality were assessed with Kaplan-Meier analyses and multivariable Cox regression accounting for standard sociodemographic and clinical covariates, psychological distress, and self-rated health.

RESULTS

After a median follow-up of 5.5 ± 2.4 years (range 16 weeks to 9.9 years), 221 deaths (40%) from any cause were recorded. There was no evidence of a mortality benefit in patients high over those low in global self-care (p = 0.71). In post hoc analyses, low self-reported sodium intake was associated with increased mortality (adjusted hazard ratio: 1.47; 95% confidence interval: 1.10 to 1.96; p = 0.01). Other significant predictors of mortality were: male sex, lack of a partner, New York Heart Association functional class III to IV, and increasing comorbid conditions.

CONCLUSIONS

Global self-care was not associated with long-term mortality whereas low self-reported sodium intake independently predicted increased all-cause mortality beyond parameters of disease severity. Replication of findings is needed as well as studies examining the correspondence of subjectively and objectively measured sodium intake and its effects on long-term prognosis in patients with chronic HF.

Self Managing Heart Failure in Remote Australia - Translating Concepts into Clinical Practice

Congestive heart failure (CHF) is an ambulatory health care condition characterized by episodes of decompensation and is usually without cure. It is a leading cause for morbidity and mortality and the lead cause for hospital admissions in older patients in the developed world. The long-term requirement for medical care and pharmaceuticals contributes to significant health care costs. CHF management follows a hierarchy from physician prescription to allied health, predominately nurse-led, delivery of care. Health services are easier to access in urban compared to rural settings. The differentials for more specialized services could be even greater. Remote Australia is thus faced with unique challenges in delivering CHF best practice. Chronic disease self-management programs (CDSMP) were designed to increase patient participation in their health and alleviate stress on health systems. There have been CDSMP successes with some diseases, although challenges still exist for CHF. These challenges are amplified in remote Australia due to geographic and demographic factors, increased burden of disease, and higher incidence of comorbidities. In this review we explore CDSMP for CHF and the challenges for our region.

A review of sedation scales for the cardiac catheterization laboratory

PURPOSE

Sedation scales have the potential to facilitate effective procedural sedation and analgesia in the cardiac catheterization laboratory (CCL). For this potential to become realized, a scale that is suitable for use in the CCL either needs to be identified or developed.

DESIGN

A structured review strategy was applied.

METHODS

To identify sedation scales, a review of Medline and CINHAL was conducted.

FINDINGS

One sedation scale for the CCL, the North American Society for Pacing and Electrophysiology Sedation Scale, and 15 intensive care unit (ICU) scales met the inclusion and exclusion criteria. Analysis of the scale's item structures and psychometric properties was then performed.

CONCLUSION

None of these scales were deemed suitable for use in the CCL. As such, further research is required to develop a new scale. The new scale should consist of more than one item to make it more effective for tracking the patient's response to medications. Specific tests required to conduct a rigorous evaluation of the new scale's psychometric properties are outlined in this article.

Efficacy of a home-based educational strategy involving community health volunteers in improving self-care in patients with chronic heart failure in western Iran: A randomized controlled trial

BACKGROUND

This study aimed to evaluate the effectiveness of a home-based educational strategy using community health volunteers (CHVs) in improving self-care of patients with chronic heart failure (CHF) in comparison with an educational strategy using formal health professionals (FHPs) at hospital, and also with a control group receiving usual care in western Iran.

METHODS AND RESULTS

A three-arm controlled trial randomly allocated 231 patients with CHF into a control group and two intervention groups undertaking two different educational approaches - a face-to-face education program by CHVs at the patients' homes and a formal education program using paid FHPs at hospital. Data obtained through interviewing patients before and two months after interventions were analyzed. Self-care components significantly increased after the intervention in both interventional groups compared to the control group (p<0.001). Differences between the two strategies were not significant, except for self-care confidence being greater in the groups exposed to the health professionals (p=0.004). The mean and standard deviation (SD) of the changes in self-maintenance, self-management and self- confidence score (each with a maximum score of 100) for the CHVs group were 26.2±12.7, 29.4±11 9.5±17; for the health professional group were 29.5±12, 31.3±12, 18.1±17; and for the control group were 2.7±9, 10.2±10, -0.30±11 respectively.

CONCLUSION

The home-based face-to-face education by CHVs improved self-care maintenance and self-care management in patients with CHF as effectively as the education provided by health professionals in a formal health education program, and much better than the usual care.

Determinants of Self-Care in Diabetic Patients Based on Health Belief Model

Introduction:

The aim of this study was to determine self-care predictors in diabetic patients based on health belief model.

Materials and Methods:

The cross-sectional study was conducted on 110 diabetic patients referred to health service centers in Ardakan city, Yazd, Iran. The data was collected by a questionnaire including perceived benefits, barriers, severity, susceptibility, self-efficacy, social support, self-care behaviors and demographic variables.

Results:

Regularly medicine use (mean= 6.48 times per week) and shoes checking (mean= 1.17 times per week) were reported as the highest and the lowest self-care behaviors respectively. Health belief model constructs including perceived benefits, barriers, severity, susceptibility, self-efficacy and social support predicted 33.5% of the observed variance of self-care behaviors. Perceived susceptibility and self-efficacy had positive effect on self-care behavior; whereas perceived barrier’s has negative effect. Self-efficacy, perceived susceptibility and barriers were most powerful predictor respectively.

Conclusion:

The findings approved the efficiency of health belief model in prediction of self-care behaviors among diabetic patients. The findings realized the health belief model structure; therefore, it can be used as a framework for designing and implementing educational interventions in diabetes control plans.

The Greek version of the 9-item European Heart Failure Self-care Behaviour Scale: a multidimensional or a uni-dimensional scale?

OBJECTIVES

To evaluate the dimensionality of the Greek version of the European Heart Failure Self-care Behaviour Scale (Gr9-EHFScBS) in a Greek-Cypriot population.

BACKGROUND

EHFScBS is a valid and reliable scale which is widely used for assessing heart failure (HF) patients' self-care behaviors.

METHODS

EHFScBS was translated into Greek and was administered to 128 Greek-Cypriot HF patients. The internal consistency, construct validity and discriminant validity of the scale were assessed.

RESULTS

Confirmatory factor analysis failed to capture the proposed theoretical structure. Further exploratory factor analysis provided a three-factor solution accounting for 53.35% of the variance, though the scale is better used as a whole. Cronbach's alpha was moderate 0.66, but deletion of any item decreased the alpha coefficient. Discriminant validity was supported by the poor correlation between EHFScBS and Minnesota Living with Heart Failure Questionnaire scores.

CONCLUSION

Even though results do not conform to the multidimensionality of the scale, assessment of the tool provided acceptable validity and reliability measures to support its usage among Greek speaking populations.

Implementing guideline based heart failure care in the Northern Territory: challenges and solutions

The Northern Territory of Australia is a vast area serviced by two major tertiary hospitals. It has both a unique demography and geography, which pose challenges for delivering optimal heart failure services. The prevalence of congestive heart failure continues to increase, imposing a significant burden on health infrastructure and health care costs. Specific patient groups suffer disproportionately from increased disease severity or service related issues often represented as a "health care gap". The syndrome itself is characterised by ongoing symptoms interspersed with acute decompensation requiring lifelong therapy and is rarely reversible. For the individual client the overwhelming attention to heart failure care and the impact of health care gaps can be devastating. This gap may also contribute to widening socio-economic differentials for families and communities as they seek to take on some of the care responsibilities. This review explores the challenges of heart failure best practice in the Northern Territory and the opportunities to improve on service delivery. The discussions highlighted could have implications for health service delivery throughout regional centres in Australia and health systems in other countries.

The European Heart Failure Self-care Behaviour Scale: new insights into factorial structure, reliability, precision and scoring procedure

OBJECTIVE

To evaluate a new factorial structure of the European Heart Failure Self-care Behaviour Scale 9-item version (EHFScBS-9), and to test its reliability, floor and ceiling effect, and precision. To propose a new 0-100 score with a higher score meaning better self-care.

METHODS

A sample of 1192 Heart Failure (HF) patients (mean age 72 years, 58% male) was enrolled. Psychometric properties of the EHFScBS-9 were tested with confirmative factor analysis, factor score determinacy, determining the floor and ceiling effect, and evaluating the precision with the standard error of measurement (SEM) and the smallest real difference (SRD).

RESULTS

We identified three well-fitting factors: consulting behaviour, autonomy-based adherence, and provider-based adherence (comparative fit index=0.96). Reliability ranged from 0.77 to 0.95. The EHFScBS-9 showed no floor and ceiling effect except for the provider-based adherence which had an expected ceiling effect. The SEM and the SRD indicated good precision of the EHFScBS-9.

CONCLUSION

The new factorial structure of the EHFScBS-9 showed supportive psychometric properties.

PRACTICE IMPLICATIONS

The EHFScBS-9 can be used to compute a total and specific scores for each identified factor. This may allow more detailed assessment and tailored interventions to improve self-care. The new score makes interpretation of the EHFScBS-9 easier.

Prospective memory and chronic heart failure

Background

Patients with chronic heart failure (CHF) experience a number of debilitating symptoms, which impact on activities of daily living and result in poor quality of life. Prospective memory, which is defined as memory to carry out future intentions, has not been investigated in this group. However, emerging evidence suggests CHF patients have difficulties with cognitive processes related to prospective memory. Self-care, which partly relies on prospective memory, is essential in symptom management and preventing acute clinical deterioration. This study aims to measure prospective memory in CHF patients, and examine the relationship between prospective memory and CHF self-care.

Methods/Design

A comprehensive neuropsychological assessment will be conducted to assess a range of cognitive functions and psychopathology. The primary focus will be an assessment of prospective memory using a well-established behavioral measure; Virtual Week. Thirty CHF patients attending a nurse-led management program will be recruited from three hospital sites in Melbourne, Australia and their self-care behaviors will be assessed using the Self-care Chronic Heart Failure Index (SCHFI), a validated self-report tool. An additional 30 healthy controls, matched on age, gender, and IQ will be recruited from the general community.

Discussion

This is a group comparison study that will provide an evaluation of the prospective memory abilities of CHF patients. The findings of this research will provide insight into whether prospective memory may be hindering patients’ ability to perform adequate self-care.

Evaluation of a self-management patient education program for patients with chronic heart failure undergoing inpatient cardiac rehabilitation: study protocol of a cluster randomized controlled trial

Background

Chronic heart failure requires a complex treatment regimen on a life-long basis. Therefore, self-care/self-management is an essential part of successful treatment and comprehensive patient education is warranted. However, specific information on program features and educational strategies enhancing treatment success is lacking. This trial aims to evaluate a patient-oriented and theory-based self-management educational group program as compared to usual care education during inpatient cardiac rehabilitation in Germany.

Methods/Design

The study is a multicenter cluster randomized controlled trial in four cardiac rehabilitation clinics. Clusters are patient education groups that comprise HF patients recruited within 2 weeks after commencement of inpatient cardiac rehabilitation. Cluster randomization was chosen for pragmatic reasons, i.e. to ensure a sufficient number of eligible patients to build large-enough educational groups and to prevent contamination by interaction of patients from different treatment allocations during rehabilitation. Rehabilitants with chronic systolic heart failure (n = 540) will be consecutively recruited for the study at the beginning of inpatient rehabilitation. Data will be assessed at admission, at discharge and after 6 and 12 months using patient questionnaires. In the intervention condition, patients receive the new patient-oriented self-management educational program, whereas in the control condition, patients receive a short lecture-based educational program (usual care). The primary outcome is patients’ self-reported self-management competence. Secondary outcomes include behavioral determinants and self-management health behavior (symptom monitoring, physical activity, medication adherence), health-related quality of life, and treatment satisfaction. Treatment effects will be evaluated separately for each follow-up time point using multilevel regression analysis, and adjusting for baseline values.

Discussion

This study evaluates the effectiveness of a comprehensive self-management educational program by a cluster randomized trial within inpatient cardiac rehabilitation in Germany. Furthermore, subgroup-related treatment effects will be explored. Study results will contribute to a better understanding of both the effectiveness and mechanisms of a self-management group program as part of cardiac rehabilitation.

Trial registration

German Clinical Trials Register: DRKS00004841; WHO International Clinical Trials: = DRKS00004841

Knowledge is insufficient for self-care among heart failure patients with psychological distress

OBJECTIVE

We conducted a study to identify barriers to, and factors promoting, self-care among heart failure (HF) patients with higher or lower levels of knowledge.

METHOD

Baseline data from 612 patients with HF enrolled in the REMOTE-HF trial were analyzed. Using median splits on the HF Knowledge Scale and the European HF Self-Care Behavior Scale, patients were divided into four groups: (a) low knowledge and good self-care, (b) low knowledge and poor self-care, (c) high knowledge and good self-care, and (d) high knowledge and poor self-care. Characteristics of the groups were compared using ANOVA, Kruskal-Wallis tests, and chi-square tests, followed by pairwise tests with Bonferroni correction. Variables significant in the univariate analyses were evaluated as predictors of self-care using hierarchical multiple linear regression. The potential moderating effect of knowledge was tested with interaction terms.

RESULTS

The four groups did not differ in sociodemographics or health literacy scores, but differed in New York Heart Association (NYHA) class, comorbidities, and scores on depression, anxiety, and perceived control. In post hoc pairwise tests, patients with high knowledge and poor self-care tended to have worse NYHA class, greater depression and anxiety, and lower levels of perceived control than others. In the multivariate analysis, knowledge, depressive symptoms, and perceived control were significant predictors of self-care, as was the interaction between knowledge and anxiety.

CONCLUSIONS

Screening and treatment of depression and anxiety is important in improving self-care among HF patients. HF management programs need to include strategies for increasing patients' perceived control over their heart disease.

Validity and reliability of the European Heart Failure Self-care Behavior Scale among adults from the United States with symptomatic heart failure

BACKGROUND

Heart failure (HF) self-care is an important component of disease management and the focus of many interventions.

AIM

The aim of this study was to evaluate the validity and reliability of the nine-item European HF Self-care Behavior Scale (EHFScB-9) in a sample of 200 adults from the USA with symptomatic HF.

METHODS

Psychometric tests included item and confirmatory factor analyses, convergent and discriminant validity, and internal consistency.

RESULTS

Item-total correlations ranged from 0.25 to 0.65. Many fit indices for the EHFScB-9 and the four-item consulting behaviors scale reached thresholds of acceptability. As expected, the EHFScB-9 was associated with other measures of HF self-care but not with quality-of-life. Coefficient α was 0.80 for the EHFScB-9 and 0.85 for the consulting behaviors subscale.

CONCLUSION

The EHFScB-9 was a valid and reliable measure of HF self-care among English-speaking US adults with symptomatic HF.

Screening for determinants of self-care in patients with chronic heart failure

Heart failure self-care is vital to achieving clinical stability and improved health outcomes. Yet despite the attention it has been given, in both research and clinical practice, effective self-care remains elusive. It is recognised that there are many patient factors that impact on attaining effective self-care skills. Systematic research is warranted to resolve the knowledge gap of how patients process information and develop the necessary self-care skills. In addition, sound screening tools are needed to assess factors that hinder the development of effective heart failure self-care skills. In this manner, education and support strategies can be applied on an individualised needs basis to enhance health outcomes.