Self-care confidence mediates the relationship between perceived social support and self-care maintenance in adults with heart failure

Effects of Social Isolation and Loneliness on Heart Failure Self-care: A Cross-sectional Analysis

BACKGROUND

Patients with heart failure (HF) who engage in effective HF self-care have better quality of life, and lower risks of all-cause and HF-related hospital readmission and mortality. It is unclear whether social isolation and loneliness, which are prevalent among patients with HF and known to affect other self-care behaviors, can predict HF self-care.

OBJECTIVE

The aim was to explore the relationship between social isolation, loneliness, and HF self-care.

METHODS

This was a cross-sectional secondary analysis (n = 49) of the GEtting iNTo Light Exercise for HF randomized controlled trial, a 6-month home-based live group gentle exercise intervention for patients with HF. Measures included the following: 6-item Lubben Social Network Scale for social isolation, Patient-Reported Outcomes Measurement Information System Social Isolation survey for loneliness, Self-Care of Heart Failure Index, and Patient-Reported Outcomes Measurement Information System Depression survey. Multiple linear regression modeling was used to examine the relationships of 4 HF self-care processes to social isolation and loneliness, adjusting for depression and grouping (control group or intervention group).

RESULTS

Scores indicating less social isolation predicted higher self-care maintenance (B = 0.937, P = .015), monitoring (B = 0.799, P = .041), and management (B = 1.812, P < .001). Loneliness did not predict HF self-care.

CONCLUSIONS

To our knowledge, this is the first study to predict HF self-care using distinct measures for social isolation and loneliness. Patients who were less socially isolated engaged in better HF self-care; loneliness had no relationship with HF self-care. Prospective studies are needed to investigate causal relationships between social isolation and HF-self-care engagement to determine the effect on outcomes such as hospital readmission and mortality.

Family Support and Type 2 Diabetes Self-management Behaviors in Underserved Latino/a/x Patients

BACKGROUND

Latino/a/x families experience persistent Type 2 diabetes mellitus (T2DM) disparities, including higher rates of diagnosis and mortality due to disease complications than their non-Hispanic White counterparts. Though greater social support is associated with improved disease outcomes for Latino/a/x patients with diabetes, research has yet to identify the specific pathways through which social support, and specifically family support, influences self-management.

PURPOSE

This study tested a theoretical model highlighting the mechanisms and pathways linking social support and physical health. Specifically, self-efficacy and depression were tested as psychological pathways connecting family support to diabetes self-management behaviors and diabetes morbidity in Latino/a/x patients with T2DM.

METHODS

Data from 177 patients were analyzed using structural equation modeling. Measures included diabetes-specific family support needed and received, depressive symptoms, self-efficacy in diabetes management, diabetes self-management behaviors, health appraisal, and hemoglobin A1c.

RESULTS

Greater diabetes-specific family support was significantly associated with more frequent engagement in diabetes self-management behaviors, both directly (p < .001) and through diabetes self-efficacy's partial mediation of this relationship (p = .013). Depression was not significantly associated with either family support (support received, p = .281; support needed, p = .428) or self-management behaviors (p = .349).

CONCLUSIONS

Family support and diabetes self-efficacy may be important modifiable psychosocial factors to target via integrated care interventions aimed at supporting Latino/a/x patients with T2DM. Future research is needed to test empirically based, culturally adapted interventions to reduce T2DM-related health disparities in this population.

What are key characteristics of adults with advanced heart failure discharged from ICU?

BACKGROUND

As the number of people with heart failure and treatment complexity increases, many hospitals are implementing Advanced Heart Failure Intensive Care Units (AHFICU). However, little evidence concerning the clinical characteristics of people admitted to AHFICUs exists. Understanding the clinical characteristics of people admitted to the AHFICU will assist nurses with implementing tailored interventions to ensure high-quality care delivery.

AIM

The purpose of this study was to describe the clinical characteristics of people who are admitted to and discharged from an AHFICU.

STUDY DESIGN

Baseline data from a longitudinal descriptive study were collected on adults (N = 43) admitted to an AHFICU. Heart failure severity, self-management ability, cognition, sleep quality, and other clinical characteristics were assessed.

RESULTS

Most study participants were New York Heart Association functional class IV (n = 24) or class III (n = 14), indicating poor functional capacity. Over half had mild cognitive impairment and poor sleep quality was prevalent (92.7%). Participants had adequate levels of heart failure knowledge, but low levels of heart failure self-management decision-making and ability.

CONCLUSIONS

Interventions to address the unique clinical characteristics of AHFICU patients include sleep hygiene, integration of cognitive, sleep, and self-management assessments into the electronic medical record. Addressing the unique clinical needs of people with heart failure will lead to patient-centered, evidence-based, and safe care.

RELEVANCE TO CLINICAL PRACTICE

Understanding characteristics of this population addresses this evidence gap and targeted clinical interventions to address unique discharge needs of this population are proposed. Sleep quality education should be done throughout hospitalization on sleep strategies and self-management coaching to facilitate adoption of new sleep routines. Healthcare providers should ensure each patient has care support upon discharge and take cognitive status into consideration during teaching. Addressing self-management readiness should include providing scenarios as part of discharge preparation. Providers must include addressing comorbidities and how they may affect heart failure self-management, such as teaching about sleep apnea device use and encouraging compliance.

Relationships of person-related, problem-related, and environment-related factors to self-care behaviours and the mediating role of self-confidence among patients with heart failure: Cross-sectional analysis of structural equation modelling

BACKGROUND

Promoting self-care behaviours in heart failure management is an important goal and challenge for healthcare systems worldwide. Using the situation-specific theory of heart failure self-care, this study examined the relationships of person-related, problem-related, and environment-related factors to self-care behaviours and the mediating role of self-care confidence in these relationships.

METHOD

We analysed the baseline data from a previous randomised controlled trial study involving 213 patients with heart failure. Structural equation modelling was used to test our hypothesised model that included age, income, education, depression, anxiety, number of comorbidities, social support, self-care confidence, and self-care behaviours. Depression and anxiety were measured by the Hospital Anxiety and Depression Scale. Social support was measured by the Short Form of the Social Support Questionnaire satisfaction subscale. The Self-Care of Heart Failure Index (version 6.2) was used to assess self-care confidence and self-care behaviours (i.e., self-care maintenance and self-care management).

RESULT

The final model included age, depression, social support, and self-care confidence as independent variables. Age had a direct relationship with self-care maintenance (β = 0.235, p < 0.001) but not self-care management (β = 0.067, p = 0.179); better social support was directly associated with higher levels of self-care confidence (β = 0.267, p < 0.001); and higher levels of self-care confidence were associated with better self-care maintenance (β = 0.573, p < 0.001) and self-care management (β = 0.683, p < 0.001). The result showed an indirect relationship between social support and self-care maintenance through the mediator of self-care confidence (β = 0.153, p < 0.001), as well as an indirect relationship between social support and self-care management through self-care confidence (β = 0.182, p < 0.001).

CONCLUSION

Satisfactory social support can increase self-care confidence, thereby increasing self-care maintenance and management. The findings of this study also implied that self-care maintenance can increase with increasing age. Future interventions directly targeting assessment and management of self-care confidence, available social support, and the age of patients may help enhance their heart failure self-care behaviours.

Experiences of what influences physical activity adherence in Iranian patients with heart failure: A qualitative study

BACKGROUND

Heart failure (HF) is becoming one of the important health care problems around the world. Physical activity as the foundation of the cardiac rehabilitation program is poorly adhered by patients with HF. This study aimed to understand the experiences of patients with HF in terms of adherence to physical activity.

MATERIALS AND METHODS

This study was conducted using conventional qualitative content analysis. Data were collected by semistructured telephone interviews with 25 patients with HF through open-ended questions. Data were collected from patients with HF in Birjand and Mashhad hospitals and heart departments from December 2021 to March 2022. Data were analyzed using Max-QDA10 and data analysis was continuous, comparative, and simultaneous with data collection.

RESULTS

After data analysis, three main categories were identified: (1) patient-related barriers and facilitators, (2) support system-related barriers and facilitators, and (3) environmental barriers and facilitators. These categories were subdivided into two main themes: (1) threatening disease and (2) challenging disease.

CONCLUSION

The results showed that beyond patient-related, support system-related, and environmental categories, perceiving the disease as a challenge or a threat is crucial in the activity of patients with HF. Nurses and other health care providers can train problem-solving behaviors to patients with HF to improve their physical and mental well-being. It is suggested that theoretical-behavioral approaches can be used in future clinical trials to improve adherence to physical activity.

Race Moderates the Relationship Between Perceived Social Support and Self-care Confidence in Patients With Heart Failure

BACKGROUND

African Americans are at the highest risk of developing heart failure (HF) compared with other races and are hospitalized at 7 to 8 times the rate of Whites. Poor overall self-care, low self-care confidence, and lower levels of perceived social support are factors related to increased risk for hospitalizations in HF. Yet, limited evidence is available regarding the factors that may differentially impact self-care confidence by race in patients with HF.

OBJECTIVE

The aim of this study was to examine to what extent race moderates the relationship between perceived social support and self-care confidence.

METHOD

This is a secondary analysis of cross-sectional data from African American and White patients with HF in North America (n = 429). Patients completed the Multidimensional Scale of Perceived Social Support and the Self-Care Confidence Scale of the Self-Care of Heart Failure Index. A moderation analysis was conducted using hierarchal linear regression.

RESULTS

Sample mean age was 60.8 ± 11.5 years, 22.4% were African American, and 54.7% were in New York Heart Association class I or II. Moderation analyses yielded a significant interaction of perceived social support and race, showing White patients, not African Americans, have significantly different self-care confidence scores depending on level of social support: White, b = 0.224, 95% confidence interval [0.046-0.094], t = 5.65, and P < .001; African American, b = -0.776, 95% confidence interval [-0.049 to 0.060], t = 0.212, and P = .832.

CONCLUSIONS

Our findings show a variable effect of perceived social support on self-care confidence as a function of race, suggesting the need for further research to develop and test interventions tailored to race and levels of social support in HF.

Effects of multidisciplinary exercise management on patients after percutaneous coronary intervention: A randomized controlled study

Objectives

To explore the effectiveness of the mobile app-based multidisciplinary exercise management on patients who receive percutaneous coronary intervention (PCI).

Methods

From January to October 2020, 54 patients after PCI were randomly assigned to the intervention group (n = 27) and the control group (n = 27). The intervention group received the mobile app-based multidisciplinary exercise management, whereas the control group received routine care. The patients after PCI began to take intervention one month after the operation, and the intervention lasted for two months. Before and after the intervention, 6-Minute Walking Distance was used to evaluate the patient’s exercise tolerance, and the patient’s exercise compliance was evaluated according to the patient’s exercise status recorded by the mobile app. The cognitive questionnaire on knowledge about PCI treatment for Coronary Heart Disease, the Self-efficacy for Chronic Disease Scale and the Perceived Social Support Scale were used to evaluate patients’ disease-related cognition, self-efficacy and perception of social support. This study was registered on Clinical Trials.gov with registration number ChiCTR2000028930.

Results

Totally 51 patients after PCI who completed this study (25 patients in the intervention group and 26 patients in the control group) were included in the analysis. After 2 months of intervention, the exercise compliance of patients in the intervention group was better than that in the control group. And 6-Minute Walking Distance (469.36 ± 57.48 vs. 432.81 ± 67.09), and the scores of knowledge of PCI treatment for coronary heart disease (52.64 ± 9.82 vs. 42.42 ± 8.54), Self-efficacy for Chronic Disease Scale (42.40 ± 8.04 vs. 36.88 ± 7.73) and Perceived Social Support Scale (74.04 ± 5.73 vs. 66.69 ± 6.86) in the intervention group were higher than those in the control group with statistical significance (P < 0.05).

Conclusions

The multidisciplinary exercise management based on the mobile app can effectively improve exercise tolerance, exercise compliance, disease-related cognition, self-efficacy, and perception of social support during exercise training for patients after PCI.

The Situation-Specific Theory of Heart Failure Self-care: An Update on the Problem, Person, and Environmental Factors Influencing Heart Failure Self-care

Many studies of heart failure (HF) self-care have been conducted since the last update of the situation-specific theory of HF self-care.

Relación entre nivel de adherencia al tratamiento y apoyo social en pacientes con falla cardiaca

Introducción: La falla cardiaca (FC) es una de las enfermedades cardiovasculares con mayor índice de hospitalizaciones en la unidad de cuidado intensivo. En esta enfermedad es imperativo determinar aquellos factores asociados con el reingreso, como la adherencia al tratamiento y el apoyo social. Objetivo: determinar la relación entre la adherencia al tratamiento y el apoyo social de pacientes con falla cardiaca. Método: se realizó un estudio correlacional, con muestreo no probabilístico; el tamaño de la muestra fue de 64 pacientes con diagnóstico de FC. Para la medición del nivel de adherencia, se utilizó la escala para evaluación de comportamientos de adherencia con un alfa Cronbach de 0,72, para medir la percepción del apoyo social; se empleó la escala Medical Outcomes Study Social Supportsurvey (MOS) con una alfa de Cronbach de 0,94. Se realizó un análisis descriptivo y, para establecer la relación del nivel de adherencia con el apoyo social, se aplicó la prueba de independencia de distribuciones categóricas de Fisher. Resultados: Los participantes, en su mayoría, se encontraron adheridos al tratamiento (56,2 %); el índice global de apoyo social (media: 76,18) y sus dimensiones se encontraron en un rango medio. En cuanto a la asociación entre la adherencia al tratamiento, el apoyo social emocional (p: 0,006336) y el apoyo afectivo (p: 0,03025), esta fue moderada. Conclusiones: Existe asociación entre la adherencia y el apoyo social, por lo que es fundamental que el profesional de enfermería incluya la evaluación e intervención del apoyo social previo al alta del paciente, para optimizar los niveles de adherencia.

Psychometric Characteristics of the Caregiver Contribution to Self-care of Heart Failure Index in a South American Population

BACKGROUND

Caregivers can contribute enormously to the self-care of patients with heart failure (HF). The Caregiver Contribution to Self-care of Heart Failure Index (CC-SCHFI) measures these contributions across 3 scales: self-care maintenance, which evaluates caregiver contributions to symptom monitoring and treatment adherence; self-care management, which evaluates caregiver contributions in dealing with symptoms; and caregiver confidence, which assesses caregiver self-efficacy in managing all contributions to self-care. Although the CC-SCHFI has been used in several investigations, only 1 study has evaluated its psychometric characteristics.

OBJECTIVE

The aim of this study was to evaluate the psychometric properties of the CC-SCHFI in Brazil.

METHODS

A cross-sectional design was used in this study. Confirmatory factor analysis was used to assess construct validity, and factor score determinacy coefficients were computed to evaluate internal consistency reliability.

RESULTS

The sample comprised 99 caregivers of patients with HF. Most were women (73%), with a mean age of 48 ± 14 years; 57% were patients' spouses. Confirmatory factor analysis confirmed the original factor structure of the instrument, with supportive fit indices for all 3 scales (comparative fit index, 0.95-1.00; root-mean-square error of approximation, 0.00-0.057). Reliability estimates were adequate for each CC-SCHFI scale (0.77-0.96).

CONCLUSIONS

The CC-SCHFI is a valid and reliable scale to measure caregiver contributions to self-care maintenance, caregiver contributions to self-care management, and caregiver confidence in HF.

The Influence of Caregiver Preparedness on Caregiver Contributions to Self-care in Heart Failure and the Mediating Role of Caregiver Confidence

BACKGROUND

Caregiver contributions (CC) to heart failure (HF) self-care maintenance (ie, CC to maintaining HF stability) and management (ie, CC to dealing with HF signs and symptoms) improve patient outcomes, but it is unknown whether caregiver preparedness influences CC to self-care and whether caregiver confidence mediates this process.

OBJECTIVES

We evaluated the influence of caregiver preparedness on CC to HF self-care maintenance and management and the mediating role of caregiver confidence.

METHODS

This is a secondary analysis of the MOTIVATE-HF study. Patients were 18 years or older, with a diagnosis of HF in New York Heart Association classes II to IV, who had insufficient self-care and did not have severe cognitive impairment. Patients' informal caregivers were those people inside or outside the family who gave most of the informal care to the patients. We used the Caregiver Preparedness Scale and the Caregiver Contribution to Self-Care of HF Index. We tested a path analysis model and the indirect effects.

RESULTS

Caregivers (n = 323) were 55 (SD, 15) years old on average and predominantly female (77%). The path analysis showed that higher scores in caregiver preparedness were associated with higher scores in caregiver confidence. In turn, higher caregiver confidence was associated with higher CC to self-care maintenance and management. Caregiver confidence mediated the association between caregiver preparedness and CC to self-care maintenance and management.

CONCLUSIONS

Caregiver confidence may play a role in CC to self-care. Interventions to improve CC to HF self-care should not only be focused on improving caregiver preparedness but also should consider the role of caregiver confidence.

Risk factors for low self-care self-efficacy in cancer survivors: Application of latent profile analysis

Aim

To identify subgroups of cancer patients with distinct self‐care self‐efficacy profiles and to explore factors that can be used to predict those at risk of low self‐efficacy.

Design

A secondary analysis of data pooled from two cross‐sectional surveys was performed.

Methods

In total, 1,367 Chinese cancer survivors were included in the analysis. Latent profile analysis (LPA) was performed to categorize participants into latent subgroups with distinct self‐efficacy profiles. Multinomial logistic regression was conducted to identify predictors of self‐care self‐efficacy subgroup classification.

Results

We identified three distinct subgroups: low, medium and high self‐care self‐efficacy. Patients with the “low” profile, which was characterized by a low education level, single marital status, complications, late cancer stage and a lower level of social support, had the poorest self‐care behaviour.

Self-care status in patients with heart failure: Systematic review and meta-analysis

Aim

To systematically review the status of self‐care in patients with heart failure through the Self‐Care of Heart Failure Index scale.

Design

A systematic review and meta‐analysis.

Methods

Following national and international databases were searched to retrieve eligible studies: PubMed, Web of Science, Embase, Google Scholar, Scientific Information Database and Magiran. The studies were screened and selected by two researchers. Data analysed through the random‐effects model, and the I² index was used to assess heterogeneity. Stata software version 12.0 was used for analysis. The PRISMA statement was used to report systematic review and meta‐analysis.

Results

Of the 5,953 articles initially identified, 39 studies were included. The average score was estimated at 58.16 (CI: 54.39–61.94) for self‐care maintenance, 53.11 (CI: 49.17–57.05) for self‐care management and 58.66 (CI: 54.32–63.00) for self‐care confidence. Despite the high heterogeneity of the studies, the results indicated that self‐care practice is inadequate in all the three dimensions of self‐care (maintenance, management and confidence).

Self-care research: How to grow the evidence base? (reprint)

BACKGROUND AND OBJECTIVE

The number of studies in the area of self-care is growing and international researchers are increasingly developing self-care interventions to improve outcomes of individual patients and communities. However, growth of the evidence is still slow due to challenges with designing and testing self-care interventions. In this article we address major methodological challenges with regard to the definition of self-care, use of theory, and research design, intended to provide guidance to researchers in this field.

METHOD

During the inaugural conference of the International Center for Self-Care Research held in Rome, Italy in June 2019 we identified important issues in existing self-care research. Discussion and literature review lead to eight recommendation for future self-care research.

RESULTS

In preparation, begin with a theoretically sound definition of self-care. In planning the intervention, build on and extend previous studies. Use theory to develop self-care interventions and consider translational models to guide development, evaluation and implementation of complex self-care interventions. Employ a study design that fits the current phase and objectives of the research and measure self-care and related factors carefully. In reporting, describe the sample and setting sufficiently so that others can draw conclusions about generalizability and applicability to their practice and patient population. In interpretation, describe how the intervention is assumed to work (causal assumptions) and its key components.

CONCLUSION

Our review of existing self-care research clearly illustrates that the recommendations we provide are needed if we are to substantially grow the evidence base supporting self-care. Embracing a core set of principles will allow us to build on each other's work. Tweetable abstract: A core set of methodological principles is needed to substantially grow the evidence base supporting self-care.

Development of an informational support questionnaire of transitional care for aged patients with chronic disease

OBJECTIVES

We developed an informational support questionnaire of transitional care (ISQTC) for aged patients with chronic disease and investigated its reliability and validity.

SETTING

This study was conducted in three large general hospitals in Nantong, Jiangsu Province, China.

PARTICIPANTS

A total of 130 aged patients with chronic diseases, admitted into outpatient and inpatient departments from three hospitals in China, participated in the study. The inclusion criteria were: (1) patients must provide consent to participate; (2) being 60 years and above; (3) being diagnosed with at least one chronic disease and hospitalised more than two times within the last 1 year; (4) being able to listen, speak, read and write. The exclusion criteria were: (1) refusing to participate; (2) language expression and communication barriers (and having no caregiver to assist in participation); (3) being in intensive care or long-term hospitalisation.

PRIMARY AND SECONDARY OUTCOME MEASURES

The developed questionnaire was validated and tested for reliability. The content validity of the questionnaire was determined through experts' interviews and Delphi expert consultation, and the structure validity of the questionnaire was determined by performing exploratory factor analysis. The coefficient of reliability of the questionnaire was measured using Cronbach's alpha.

RESULTS

Through Delphi expert consultation and exploratory factor analysis, the questionnaire was reduced from four dimensions and 12 items to three dimensions and 11 items. A total of 130 patients responded to the questionnaire. The alpha coefficient was 0.747.

CONCLUSION

The ISQTC is a reliable and valid instrument for evaluating aged patients with chronic disease in transitional care.

TRIAL REGISTRATION DETAILS

ChiCTR1900020923. The trial was registered on 22 January 2019.

The Contribution of Living Arrangements, Social Support, and Self-efficacy to Self-management Behaviors Among Individuals With Heart Failure: A Path Analysis

BACKGROUND

Living arrangements, social support, and self-efficacy have significant implications for self-management science. Despite the theoretical linkages among the 3 concepts, there is limited empirical evidence about their interplay and the subsequent influence on heart failure (HF) self-management.

OBJECTIVE

The aim of this study was to validate components of the Individual and Family Self-management Theory among individuals with HF.

METHODS

This is a secondary analysis of cross-sectional data generated from a sample of 370 individuals with HF. A path analysis was conducted to examine the indirect and direct associations among social environment (living arrangements), social facilitation (social support) and belief (self-efficacy) processes, and self-management behaviors (HF self-care maintenance) while accounting for individual and condition-specific factors (age, sex, race, and HF disease severity).

RESULTS

Three contextual factors (living arrangements, age, and HF disease severity) had direct associations with perceived social support and self-efficacy, which in turn were positively associated with HF self-management behaviors. Living alone (β = -.164, P = .001) was associated with lower perceived social support, whereas being an older person (β = .145, P = .004) was associated with better support. Moderate to severe HF status (β = -.145, P = .004) or higher levels of perceived social support (β = .153, P = .003) were associated with self-efficacy.

CONCLUSIONS

Our results support the Individual and Family Self-management Theory, highlighting the importance of social support and self-efficacy to foster self-management behaviors for individuals with HF. Future research is needed to further explore relationships among living arrangements, perceived and received social support, self-efficacy, and HF self-management.

The role of health literacy, depression, disease knowledge, and self-efficacy in self-care among adults with heart failure: An updated model

BACKGROUND

Patients with inadequate health literacy and heart failure face high healthcare costs, more hospitalizations, and greater mortality. To address these negative consequences, patients need to improve heart failure self-care. Multiple factors may influence self-care, but the exact model by which they do so is not fully understood.

OBJECTIVES

The objective of this study was to examine a model exploring the contribution of health literacy, depression, disease knowledge, and self-efficacy to the performance of heart failure self-care.

METHODS

Using a cross-sectional design, patients were recruited from a heart failure clinic and completed validated assessments of their cognition, health literacy, depression, knowledge, self-efficacy and self-care. Patients were separated into two groups according to their health literacy level: inadequate/marginal and adequate. Differences between groups were assessed with an independent t-test. Hypothesized paths and mediated relationships were estimated and tested using observed variable path analysis.

RESULTS

Participants (n = 100) were mainly male (67%), white (93%), and at least had a high school education (85%). Health literacy was associated with disease knowledge (path coefficient=0.346, p = 0.002), depression was negatively associated with self-efficacy (path coefficient=-0.211, p = 0.037), self-efficacy was positively associated with self-care (path coefficient=0.402, p<0.0005), and there was evidence that self-efficacy mediated the link between depression and self-care. There was no evidence of: mediation of the link between health literacy and self-care by knowledge or self-efficacy; positive associations between knowledge and self-efficacy or self-care; or mediation of the disease knowledge and self-care relationship by self-efficacy. Further, depression was associated with self-care indirectly rather than also directly as hypothesized.

CONCLUSIONS

Self-efficacy and depression are associated with heart failure self-care. Data generated from the model suggest that healthcare professionals should actively engage all patients to gain self-efficacy and address depression to positively affect heart failure self-care.

Psychometric Testing of the Revised Self-Care of Heart Failure Index

BACKGROUND

Self-care is essential in people with chronic heart failure (HF). The process of self-care was refined in the revised situation specific theory of HF self-care, so we updated the instrument measuring self-care to match the updated theory. The aim of this study was to test the psychometric properties of the revised 29-item Self-Care of Heart Failure Index (SCHFI).

METHODS

A cross-sectional design was used in the primary psychometric analysis using data collected at 5 sites in the United States. A longitudinal design was used at the site collecting test-retest data. We tested SCHFI validity with confirmatory factor analysis and predictive validity in relation to health-related quality of life. We tested SCHFI reliability with Cronbach α, global reliability index, and test-retest reliability.

RESULTS

Participants included 631 adults with HF (mean age, 65 ± 14.3 years; 63% male). A series of confirmatory factor analyses supported the factorial structure of the SCHFI with 3 scales: Self-Care Maintenance (with consulting behavior and dietary behavior dimensions), Symptom Perception (with monitoring behavior and symptom recognition dimensions), and Self-Care Management (with recommended behavior and problem-solving behavior dimensions). Reliability estimates were 0.70 or greater for all scales. Predictive validity was supportive with significant correlations between SCHFI scores and health-related quality-of-life scores.

CONCLUSIONS

Our analysis supports validity and reliability of the SCHFI v7.2. It is freely available to users on the website: www.self-care-measures.com.

Change in Depression, Confidence, and Physical Function Among Older Adults With Mild Cognitive Impairment

BACKGROUND AND PURPOSE

Nearly a quarter of those in the United States older than 71 years experience mild cognitive impairment. Persons with mild cognitive impairment battle depression and progressive disengagement from daily activities, which contribute to participation restriction and activity limitation. Daily engagement in meaningful activity (DEMA) is a tailored intervention designed to benefit persons with mild cognitive impairment and their caregivers through preserved engagement and supported adjustment to cognitive changes. This secondary analysis was guided by the International Classification of Functioning, Disability and Health (ICF) model. Aims were to (i) explore the extent to which change in self-rated activity performance and physical function can predict change in depressive symptoms, (ii) evaluate for difference in confidence and depressive symptoms at ICF levels of activity and participation, and (iii) quantify the impact of daily engagement at the ICF level of participation on physical function.

METHODS

A secondary analysis was conducted using data from the parent study, which was a 2-group randomized trial involving persons with mild cognitive impairment and their informal caregivers participating in the Indiana Alzheimer Disease Center DEMA program. Quantitative analysis (dyads: DEMA N = 20, Information Support N = 20) examined outcomes at posttest and follow-up. Analysis employed linear regression to model the relationship between explanatory and dependent variables and independent t test to examine for difference in confidence, depression, and physical function.

RESULTS AND DISCUSSION

At posttest, change in self-rated performance predicted change in depressive symptoms. Those in the DEMA group who engaged in activity at the ICF level of participation demonstrated a significant increase in confidence and physical function. Although not significant, the control group posttest results showed a mean decrease in confidence.

CONCLUSIONS

Results demonstrate a positive impact of DEMA on depressive symptoms, confidence, and physical function. Change in occupational performance predicted change in depressive symptoms. Confidence significantly improved among those who engaged at the ICF participation level. A larger, randomized controlled longitudinal trial is needed to better assess the impact of DEMA on physical function, activity, participation restriction, and quality of life.

Heart Failure Self-care Within the Context of Patient and Informal Caregiver Dyadic Engagement: A Mixed Methods Study

BACKGROUND

Recent heart failure (HF) patient and informal caregiver (eg, dyadic) studies have either examined self-care from a qualitative or quantitative perspective. To date, the 2 types of data have not been integrated.

OBJECTIVE

The aim of this study was to understand HF self-care within the context of dyadic engagement.

METHODS

This was a cross-sectional, mixed methods (quantitative/qualitative) study. Heart failure self-care was measured with the Self-care of Heart Failure Index (v.6) dichotomized to adequate (≥70) or inadequate (<69). Dyadic symptom management type was assessed with the Dyadic Symptom Management Type scale. Interviews regarding self-care were conducted with both dyad members present. Content analytic techniques were used. Data were integrated using an information matrix and triangulated using Creswell and Plano Clark's methods.

RESULTS

Of the 27 dyads, HF participants were 56% men, with a mean age of 77 years. Caregivers were 74% women, with a mean age of 66 years, representing spouses (n = 14) and adult children (n = 7). Quantitatively, few dyads scored as adequate (≥70) in self-care; the qualitative data described the impact of adequacy on the dyads' behavior. Dyads who scored higher, individually or both, on self-care self-efficacy and self-care management were less likely to change from their life course pattern. Either the patient or dyad continued to handle all self-care as they always had, rather than trying new strategies or reaching out for help as the patient's condition deteriorated.

CONCLUSIONS

Our data suggest links that should be explored between dyadic adequacy and response to patients' symptoms. Future studies should assess dyadic adequacy longitudinally and examine its relationship to event-free survival and health services cost.

Self-care confidence mediates self-care maintenance and management in patients with heart failure

BACKGROUND

Literature highlights the influence of self-care confidence on self-care in patients with heart failure (HF), but little is known whether it explains the influence of other determinants of self-care.

OBJECTIVES

To examine whether confidence explained the associations of social support and HF-knowledge with self-care.

METHODS

In a descriptive, correlational study, 100 patients with HF completed questionnaires on self-care, social support, and HF-specific knowledge. Regression analyses were used to examine associations between perceived support and HF-knowledge and self-care.

RESULTS

Self-care confidence mediated the association between social support and self-care maintenance (path reduced from Beta = 0.713 to 0.395) and HF-knowledge and maintenance (path reduced from Beta = 2.569 to 1.798) and management (path reduced from Beta = -0.272 to -0.144).

CONCLUSION

Self-care confidence explains the influence of social support and knowledge on self-care. Supporting self-care confidence may be a key target for interventions to improve disease management and behaviors in patients with HF.

Gender differences in self-care maintenance and its associations among patients with chronic heart failure

Objectives

To identify the gender differences in self-care maintenance and its associations among chronic heart failure patients using the Information-Motivation-Behavioral Skills model.

Methods

Two hundred and ten patients (54.0% female) with chronic heart failure participated in this cross-sectional study. Self-care, knowledge of heart failure, social support and illness perception were measured using the Self-Care of Heart Failure Index, the questionnaire of heart failure knowledge, the Perceived Social Support Scale, and the Revised Illness Perception Questionnaire, respectively.

Results

Mean scores for self-care maintenance were 51.4 ± 14.8 in men and 55.6 ± 14.1 in women (t = -2.066, P < 0.05). Associated factors of self-care maintenance were social support and self-care confidence in men and the knowledge of heart failure, self-care management and self-care confidence in women. The relationship between social support and self-care maintenance was meditated by self-care confidence in men, whereas the relationship between knowledge of heart failure and self-care maintenance was meditated by self-care management and self-care confidence in women.

Conclusions

Self-care maintenance were inadequate in both genders with chronic heart failure. Interventions for enhancing social support and self-care confidence in men patients, and strengthening knowledge of heart failure, self-care management and self-care confidence in women patients, may facilitate self-care maintenance.

A National Study of U.S. Emergency Departments: Racial Disparities in Hospitalizations for Heart Failure

INTRODUCTION

Racial disparities in heart failure hospitalizations are well documented. The majority of heart failure hospitalizations originate from emergency departments, but emergency department hospitalization patterns for heart failure and the factors that influence hospitalization are poorly understood. This gap in knowledge was examined using a nationally representative sample of emergency department visits for heart failure.

METHODS

National Hospital Ambulatory Medicare Care Survey data on 2001-2010 emergency department visits were analyzed in 2015-2017 to examine age-related racial differences in hospitalization patterns for heart failure, using multivariable modified Poisson regression models.

RESULTS

More than 12million adult visits for heart failure to U.S. emergency departments occurred from 2001 to 2010, with 23% of visits by blacks. Overall, 71% of visits resulted in hospitalization (57% to floor beds and 14% to intensive care units). Among floor admissions for higher clinical acuity visits, whites were more likely than blacks to be hospitalized. Whites with higher clinical acuity were more likely to be hospitalized than those with lower clinical acuity (71% vs 63%, p=0.005). This expected pattern was not observed in blacks, particularly those aged ≥65years, who were hospitalized in 71% of lower clinical acuity visits, but only 61% of higher acuity visits. Among adults aged ≥65years, there was a significant interaction between clinical acuity Xrace with regard to hospitalization (p=0.037).

CONCLUSIONS

These results suggest age and racial disparities in hospitalization rates for emergency department patients with heart failure. The reasons for these disparities in hospitalization are unclear. Further studies on emergency department hospitalization decisions, and the impact of emergency department clinical factors, may help clarify this finding.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Social support predicts self-care confidence in patients with heart failure

BACKGROUND

Self-care for patients with heart failure includes engaging in behaviours that maintain medical stability and manage problematic symptoms, as well as the confidence in one's ability to carry out such behaviours. Given the social context of self-care behaviours in heart failure, there has been increasing interest in social support as a predictor of self-care.

AIM

The goal of the present study was to examine the role of social support in self-care across time for persons with heart failure.

METHODS

Using data from an observational study of patients with chronic heart failure ( n = 280), we examined the role of three types of support - instrumental support, emotional support and assistance with self-care - in the longitudinal course of self-care maintenance, management and confidence. Self-report questionnaire data were collected at baseline and at three and six months later.

RESULTS

We found that instrumental and emotional support predicted better self-care confidence on average and that self-care confidence improved at a faster rate for those with less instrumental support. Emotional support was positively associated with self-care management and self-care confidence, and assistance with self-care was positively associated with self-care maintenance.

CONCLUSION

These findings highlight the contribution of social support to self-care in heart failure and provide guidance for future family-based interventions to improve self-care.

Perceived social support and self-care in patients hospitalized with heart failure

BACKGROUND

Rehospitalization of heart failure patients is often considered the result of inadequate self-care yet only one study documents superior outcomes with better self-care.

AIMS

If inadequate self-care is related to hospitalizations, then hospitalized heart failure patients should have lower self-care skills than non-hospitalized patients. The purpose of this study was to evaluate perceived social support and self-care characteristics of patients hospitalized with an exacerbation of heart failure. The self-care of heart failure index (SCHFI) and medical outcomes study of social support (MOS-SS) were the key instruments used in the research.

METHODS AND RESULTS

This descriptive study used t tests and multiple regression to analyze the data. Results were compared with non-hospitalized heart failure patients in another study. Perceived social support ( t=-4.007, df=211, P<0.001) and self-care maintenance ( t=-3.343, df=220, P<0.002) scores were lower in the hospitalized participants than the comparison group. Self-care confidence was the only variable significantly related to perceived social support ( β=0.210, t=2.210, P<0.30).

CONCLUSIONS

This study supports the premise that heart failure rehospitalizations are related to inadequate self-care.

Acute Heart Failure: Alternatives to Hospitalization

Acute heart failure (HF) is a major public health problem with substantial associated economic costs. Because most patients who present to hospitals are admitted irrespective of their level of risk, novel approaches to manage acute HF are needed, such as the use of same-day access clinics for outpatient diuresis and observation units from the emergency department. Current published data lacks a comprehensive overview of the present state of acute HF management in various clinical settings. This review summarizes the strengths and limitations of acute HF care in the outpatient and emergency department settings. Finally, a variety of innovative technologies that have the potential to improve acute HF management are discussed.

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.

[Symptom Management to Predict Quality of Life in Patients with Heart Failure: A Structural Equation Modeling Approach]

PURPOSE

The focus of this study was on symptom management to predict quality of life among individuals with heart failure. The theoretical model was constructed based on situation-specific theory of heart failure self-care and literature review.

METHODS

For participants, 241 outpatients at a university hospital were invited to the study from May 19 to July 30, 2014. Data were collected with structured questionnaires and analyzed using SPSSWIN and AMOS 20.0.

RESULTS

The goodness of fit index for the hypothetical model was .93, incremental fit index, .90, and comparative fit index, .90. As the outcomes satisfied the recommended level, the hypothetical model appeared to fit the data. Seven of the eight hypotheses selected for the hypothetical model were statistically significant. The predictors of symptom management, symptom management confidence and social support together explained 32% of the variance in quality of life. The 28% of variance in symptom management was explained by symptom recognition, heart failure knowledge and symptom management confidence. The 4% of variance in symptom management confidence was explained by social support.

CONCLUSION

The hypothetical model of this study was confirmed to be adequate in explaining and predicting quality of life among patients with heart failure through symptom management. Effective strategies to improve quality of life among patients with heart failure should focus on symptom management. Symptom management can be enhanced by providing educational programs, encouraging social support and confidence, consequently improving quality of life among this population.

Self-efficacy mediates the relationship of depressive symptoms and social support with adherence in patients with heart failure

Poor self-care is common among adults with heart failure and leads to poor health outcomes. Low self-efficacy, depression, and low social support are associated with poor self-care, but knowledge about these relationships in heart failure is limited. Secondary data analysis of cross-sectional data from 346 adults with heart failure measuring self-efficacy, depressive symptoms, social support, and self-care adherence was conducted. Tests of mediation using multiple linear regressions indicate that self-efficacy fully mediates the relationships between depression and adherence, and social support and adherence. Bolstering self-efficacy may have a greater impact on self-care adherence than targeting either depression or social support alone.

Psychological Determinants of Heart Failure Self-Care: Systematic Review and Meta-Analysis

OBJECTIVE

Psychological distress has been associated with poor outcomes in patients with chronic heart failure (HF), which is assumed to be partly due to poor HF self-care behavior. This systematic review and meta-analysis describes the current evidence concerning psychological determinants of self-care in patients with chronic HF.

METHODS

Eligible studies were systematically identified by searching electronic databases PubMed, PsycINFO, and the Conference Proceedings Citation Index (Web of Science) for relevant literature (1980-October 17, 2014). Study quality was assessed according to the level of risk of bias. Quantitative data were pooled using random-effects models.

RESULTS

Sixty-five studies were identified for inclusion that varied considerably with respect to sample and study characteristics. Risk of bias was high in the reviewed studies and most problematic with regard to selection bias (67%). Depression (r = -0.19, p < .001), self-efficacy (r = 0.37, p < .001), and mental well-being (r = 0.14, p = .030) were significantly associated with self-reported self-care. Anxiety was not significantly associated with either self-reported (r = -0.18, p = .24) or objective self-care (r = -0.04, p = .79), neither was depression associated with objectively measured medication adherence (r = -0.05, p = .44).

CONCLUSIONS

Psychological factors (depression, self-efficacy, and mental well-being) were associated with specific self-care facets in patients with chronic HF. These associations were predominantly observed with self-reported indices of self-care and not objective indices. Methodological heterogeneity and limitations preclude definite conclusions about the association between psychological factors and self-care and should be addressed in future research.

Self-care confidence may be more important than cognition to influence self-care behaviors in adults with heart failure: Testing a mediation model

BACKGROUND

Cognitive impairment can reduce the self-care abilities of heart failure patients. Theory and preliminary evidence suggest that self-care confidence may mediate the relationship between cognition and self-care, but further study is needed to validate this finding.

OBJECTIVES

The aim of this study was to test the mediating role of self-care confidence between specific cognitive domains and heart failure self-care.

DESIGN

Secondary analysis of data from a descriptive study.

SETTINGS

Three out-patient sites in Pennsylvania and Delaware, USA.

PARTICIPANTS

A sample of 280 adults with chronic heart failure, 62 years old on average and mostly male (64.3%).

METHODS

Data on heart failure self-care and self-care confidence were collected with the Self-Care of Heart Failure Index 6.2. Data on cognition were collected by trained research assistants using a neuropsychological test battery measuring simple and complex attention, processing speed, working memory, and short-term memory. Sociodemographic data were collected by self-report. Clinical information was abstracted from the medical record. Mediation analysis was performed with structural equation modeling and indirect effects were evaluated with bootstrapping.

RESULTS

Most participants had at least 1 impaired cognitive domain. In mediation models, self-care confidence consistently influenced self-care and totally mediated the relationship between simple attention and self-care and between working memory and self-care (comparative fit index range: .929-.968; root mean squared error of approximation range: .032-.052). Except for short-term memory, which had a direct effect on self-care maintenance, the other cognitive domains were unrelated to self-care.

CONCLUSIONS

Self-care confidence appears to be an important factor influencing heart failure self-care even in patients with impaired cognition. As few studies have successfully improved cognition, interventions addressing confidence should be considered as a way to improve self-care in this population.

Shared Care Contributions to Self-Care and Quality of Life in Chronic Cardiac Patients

Shared care is an interpersonal interaction system composed of communication, decision making, and reciprocity; it is used by patients and family caregivers (care dyads) to exchange social support. This study’s purpose was to describe the contributions of shared care to outcomes for individuals with cardiac disease. A secondary data analysis was used to answer the following questions. What is the association between elements of shared care and patient outcomes? Do dyad perceptions of shared care differentially contribute to patient outcomes? Participants in this study were 93 individuals with a cardiac disease and 93 family caregivers. Composite index structured equation modeling was the analytic tool. Caregiver communication and reciprocity were related to patient mental quality of life. Patient communication and reciprocity were related to their own mental and physical quality of life and self-care confidence. Findings from this study contribute a better understanding of how care dyads are integral to patient outcomes.

Symptomatology and Coping Resources Predict Self-Care Behaviors in Middle to Older Age Patients with Heart Failure

Background. Symptoms of heart failure (HF) and coping resources, such as social support and social problem-solving, may influence self-care behaviors. Research regarding the influence of HF symptomatology characteristics and components of social support and social problem-solving on self-care is limited. Objective. To identify predictors of HF self-care behaviors using characteristics of HF symptomatology, components of social support and social problem-solving, and demographic and clinical factors. Methods. Using a cross-sectional, correlational predictive design, a convenience sample (N = 201) of outpatients with HF answered self-report surveys. Multiple linear regression with stepwise variable selection was conducted. Results. Six predictors of HF self-care were identified: race, symptom frequency, symptom-related interference with enjoyment of life, New York Heart Association Class HF, rational problem-solving style, and social network (β = 34.265, R² = 0.19, P = 0.001). Conclusions. Assessing the influence of race on self-care behaviors in middle to older age patients with HF is important. Clinical assessment that focuses on symptom frequency, symptom-related interference with enjoyment of life, and HF Class might also impact self-care behaviors in this population. Rational problem-solving skills used and evaluation of the size of and satisfaction with one's social network may be appropriate when assessing self-care.

La influencia del apoyo social en usuarios institucionalizados socialmente vulnerables || The influence of social support on institutionalized socially vulnerable users

El apoyo social se define como un conjunto de transacciones que implican ayuda, afecto y afirmación. Así, el objetivo de la investigación ha sido desarrollar un modelo que explique como el contacto con la familia conlleva a una mayor satisfacción en la población institucionalizada  través de variables como el apoyo social percibido, aislamiento y autoestima Los resultados obtenidos confirman que el apoyo afectivo y las visitas recibidas predicen la satisfacción, pero están mediados por el apoyo informativo. Asimismo, un alto apoyo social conlleva a una mayor autoestima y satisfacción, y la falta de este a un mayor aislamiento social. 

Self-care confidence may be the key: A cross-sectional study on the association between cognition and self-care behaviors in adults with heart failure

BACKGROUND

Self-care, a key element of heart failure care, is challenging for patients with impaired cognition. Mechanisms through which cognitive impairment affects self-care are not currently well defined but evidence from other patient populations suggests that self-efficacy, or task-specific confidence, mediates the relationship between cognitive functioning and patient behaviors such as self-care.

OBJECTIVE

The aim of this study was to test the mediating role of self-care confidence in the relationship between cognition and self-care behaviors.

DESIGN

A secondary analysis of data from a cross-sectional study.

SETTING

Outpatient heart failure clinics in 28 Italian provinces.

PARTICIPANTS

628 Italian heart failure patients.

METHODS

We used the Self-Care of Heart Failure Index v.6.2 to measure self-care maintenance, self-care management, and self-care confidence. Cognition was assessed with the Mini Mental State Examination. Structural equation modeling was used to analyze the data.

RESULTS

Participants were 73 years old on average (SD=11), mostly (58%) male and mostly (77%) in New York Heart Association functional classes II and III. The mediation model showed excellent fit (comparative fit index=1.0; root mean square error of approximation=0.02): Self-care confidence totally mediated the relationship between cognition and self-care maintenance and management.

CONCLUSION

Cognition affects self-care behaviors indirectly, through self-care confidence. Interventions aimed at improving self-care confidence may improve self-care, even in heart failure patients with impaired cognition.

The role of social support on the relationship of depressive symptoms to medication adherence and self-care activities in adults with type 2 diabetes

AIM

To examine the mediating role of social support on the relationship of depressive symptoms to medication adherence and self-care activities in Korean adults.

BACKGROUND

Recent evidence suggests that higher levels of social support are associated with improved medication adherence and self-care activities; however, the role of social support on the relationship of depressive symptoms to medication adherence and self-care activities is less well understood.

DESIGN

A cross-sectional survey.

METHODS

The data were collected from 311 Korean adults with type 2 diabetes who were taking hypoglycaemic agents in the period 2012-2013. Depressive symptoms, social support, medication adherence and self-care activities were assessed using structured questionnaires. Multiple regression analysis with adjustment for covariates and the Sobel test were used to examine the mediating effect of social support on the relationship of depressive symptoms to medication adherence and self-care activities.

RESULTS

There were statistically significant differences by subgroups with and without depressive symptoms in social support, medication adherence and self-care activities of diet, physical activity and stress management. The Sobel test confirmed that social support mediated the effect of depressive symptoms on medication adherence and self-care activities of diet, physical activity and stress management.

CONCLUSION

The evidence from this study suggests that social support-enhancing interventions that also manage depressive symptoms may be more timely and effective than interventions that target depressive symptoms alone in promoting adherence to medication adherence and self-care activities in this population.

The problem with Cronbach's Alpha: comment on Sijtsma and van der Ark (2015)

Knowledge of a scale's dimensionality is an essential preliminary step to the application of any measure of reliability derived from classical test theory--an approach commonly used is nursing research. The focus of this article is on the applied aspects of reliability and dimensionality testing. Throughout the article, the Self-Care of Heart Failure Index is used to exemplify real-world data challenges of quantifying reliability and to provide insight into how to overcome such challenges.

Family member accompaniment to routine medical visits is associated with better self-care in heart failure patients

OBJECTIVES

To examine the association between frequency of family member accompaniment to medical visits and heart failure (HF) self-care maintenance and management and to determine whether associations are mediated through satisfaction with provider communication.

METHODS

Cross-sectional survey of 150 HF patients seen in outpatient clinics. HF self-care maintenance and management were assessed using the Self-Care of Heart Failure Index. Satisfaction with provider communication was assessed using a single question originally included in the American Board of Internal Medicine Patient Satisfaction Questionnaire. Frequency of family member accompaniment to visits was assessed using a single-item question. We performed regression analyses to examine associations between frequency of accompaniment and outcomes. Mediation analysis was conducted using MacKinnon's criteria.

RESULTS

Overall, 61% reported accompaniment by family members to some/most/every visit. Accompaniment to some/most/every visit was associated with higher self-care maintenance (β = 6.4, SE 2.5; p = 0.01) and management (β = 12.7, SE 4.9; p = 0.01) scores. Satisfaction with provider communication may mediate the association between greater frequency of accompaniment to visits and self-care maintenance (1.092; p = 0.06) and self-care management (1.428; p = 0.13).

DISCUSSION

Accompaniment to medical visits is associated with better HF self-care maintenance and management, and this effect may be mediated through satisfaction with provider communication.

Dimensionality and reliability of the self-care of heart failure index scales: further evidence from confirmatory factor analysis

The Self-Care of Heart Failure Index (SCHFI) is used widely, but issues with reliability have been evident. Cronbach alpha coefficient is usually used to assess reliability, but this approach assumes a unidimensional scale. The purpose of this article is to address the dimensionality and internal consistency reliability of the SCHFI. This was a secondary analysis of data from 629 adults with heart failure enrolled in three separate studies conducted in the northeastern and northwestern United States. Following testing for scale dimensionality using confirmatory factor analysis, reliability was tested using coefficient alpha and alternative options. Confirmatory factor analysis demonstrated that: (a) the Self-Care Maintenance Scale has a multidimensional four-factor structure; (b) the Self-Care Management Scale has a two-factor structure, but the primary factors loaded on a common higher-order factor; and (c) the Self-Care Confidence Scale is unidimensional. Reliability estimates for the three scales, obtained with methods compatible with each scale's dimensionality, were adequate or high. The results of the analysis demonstrate that issues of dimensionality and reliability cannot be separated. Appropriate estimates of reliability that are consistent with the dimensionality of the scale must be used. In the case of the SCHFI, coefficient alpha should not be used to assess reliability of the self-care maintenance and the self-care management scales, due to their multidimensionality. When performing psychometric evaluations, we recommend testing dimensionality before assessing reliability, as well using multiple indices of reliability, such as model-based internal consistency, composite reliability, and omega and maximal reliability coefficients.

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.