Self-Care Behaviours and Heart Failure: Does Experience with Symptoms Really Make a Difference?

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

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.

Self-care Practices of Patients With Heart Failure Using Wearable Electronic Devices: A Systematic Review

BACKGROUND

Heart failure (HF) is the fastest growing cardiovascular condition globally; associated management costs and hospitalizations place an immense burden on healthcare systems. Wearable electronic devices (WEDs) may be useful tools to enhance HF management and mitigate negative health outcomes.

OBJECTIVE

We aimed to perform a systematic review to examine the potential of WEDs to support HF self-care in ambulatory patients at home.

METHODS

Five databases were searched for studies published between 2007 and May 2022, including OVID MEDLINE, EMBASE (OVID), APA PsycINFO (OVID), Cochrane Central Register of Controlled Trials (OVID), and CINAHL Plus with Full Text (Ebsco). After 6210 duplicates were removed, 4045 records were screened and 6 were included for review (2 conference abstracts and 4 full-text citations). All studies used WEDs as 1 component of a larger intervention.

RESULTS

Outcome measures included quality of life, physical activity, self-efficacy, self-care, functional status, time to readmission, social isolation, and mood. Studies were of moderate to high quality and mixed findings were reported. Enhanced exercise habits and motivational behavior to exercise, as well as decreased adverse symptoms of fatigue and dyspnea, were identified in 2 studies. However, improvements in exercise capacity and increased motivational behavior did not lead to exercise adherence in another 2 studies.

CONCLUSIONS

The findings from this review suggest that WEDs may be a viable health behavior improvement strategy for patients with HF. However, studies of higher quality, with the primary intervention being a WED, and consistent outcome measures are needed to replicate the positive findings of studies identified in this review.

Factors associated with poor self-management documented in home health care narrative notes for patients with heart failure

BACKGROUND

Patients with heart failure (HF) who actively engage in their own self-management have better outcomes. Extracting data through natural language processing (NLP) holds great promise for identifying patients with or at risk of poor self-management.

OBJECTIVE

To identify home health care (HHC) patients with HF who have poor self-management using NLP of narrative notes, and to examine patient factors associated with poor self-management.

METHODS

An NLP algorithm was applied to extract poor self-management documentation using 353,718 HHC narrative notes of 9,710 patients with HF. Sociodemographic and structured clinical data were incorporated into multivariate logistic regression models to identify factors associated with poor self-management.

RESULTS

There were 758 (7.8%) patients in this sample identified as having notes with language describing poor HF self-management. Younger age (OR 0.982, 95% CI 0.976-0.987, p < .001), longer length of stay in HHC (OR 1.036, 95% CI 1.029- 1.043, p < .001), diagnosis of diabetes (OR 1.47, 95% CI 1.3-1.67, p < .001) and depression (OR 1.36, 95% CI 1.09-1.68, p < .01), impaired decision-making (OR 1.64, 95% CI 1.37-1.95, p < .001), smoking (OR 1.7, 95% CI 1.4-2.04, p < .001), and shortness of breath with exertion (OR 1.25, 95% CI 1.1-1.42, p < .01) were associated with poor self-management.

CONCLUSIONS

Patients with HF who have poor self-management can be identified from the narrative notes in HHC using novel NLP methods. Meaningful information about the self-management of patients with HF can support HHC clinicians in developing individualized care plans to improve self-management and clinical outcomes.

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.

Investigating the Effect of Family-Centered Self-Care Program based on Home Visits Regarding Dietary and Medication Regimen Adherence of Discharged Patients with Acute Coronary Syndrome

Background

Dietary and medication regimen adherence in patients with history of Acute Coronary Syndrome (ACS) is very important in preventing readmission and reducing the complications of the disease. The objective of the present study was to investigate the effect of the family-centered self-care program based on home visits dietary and medication regimen adherence in patients with ACS discharged from Shahid Chamran Hospital during 2017-2018.

Materials and Methods

This clinical trial was conducted on 80 ACS patients. The samples by using the random numbers table, were randomly divided into control and experimental groups. The routine interventions were administered for the control group, and family-centered self-care was conducted on patients of the experiment group. In order to obtain the quantitative data of this study, three questionnaires were used including demographic characteristics, Morisky questionnaire, and dietary adherence.

Results

The difference between the mean score of medication and diet regimen adherence in both groups before the intervention was not significant (p > 0.05). data was demonstrated that scores of medication and diet regimen adherence were significantly higher immediately and 6 weeks after the intervention; (f = 64.06, p < 0.001).

Conclusions

Family-centered self-care program based on home visits can be used as an effective method to increase the dietary and medication regimen adherence in ACS patients.

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).

Effects of a Transitional Telehealth Program on Functional Status, Rehospitalization, and Satisfaction With Care in Thai Patients with Heart Failure

Limited functional status is a common health problem in patients living with heart failure (HF), which often requires rehospitalization.Home-based transitional telehealth programs (TTPs) focused on health monitoring, education, promotion of self-management, and multidisciplinary team consultation have been shown to improve functional status and satisfaction with care while reducing rehospitalization rates in this population. Nonetheless, these variables and outcomes have yet to be assessed in a Thai patient with HF. Thus, the aim of this study was to investigate the effectiveness of a TTP on functional status, rehospitalization, and satisfaction with care in Thai patients with HF. Eligible participants (N = 146) were randomly assigned to either the control or TTP group. The TTP included in-hospital discharge planning and 6-week telemonitoring via a mobile phone application to provide follow-up home care. Data on the outcome variables were collected at 6 and 8 weeks post-enrollment and analyzed by descriptive statistics, independent t-tests, repeated measures ANOVA, and Z-tests. Functional status and satisfaction with care scores in the TTP group were significantly higher than those of the control group, and rehospitalization rates in the TTP group were significantly lower than those of the control group at 6 and 8 weeks post-enrollment. Thus, the TTP effectively improved functional status, increased satisfaction with care, and reduced rehospitalization rates in Thai patients with HF. TTP implementation could be considered to improve the quality of transitional care in Thailand.

Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness

The Middle-Range Theory of Self-Care of Chronic Illness has been used widely since it was first published in 2012. With the goal of theoretical refinement in mind, we evaluated the theory to identify areas where the theory lacked clarity and could be improved. The concept of self-care monitoring was determined to be underdeveloped. We do not yet know how the process of symptom monitoring influences the symptom appraisal process. Also, the manner in which self-care monitoring and self-care management are associated was thought to need refinement. As both of these issues relate to symptoms, we decided to enrich the Middle-Range Theory with knowledge from theories about symptoms. Here, we propose a revision to the Middle-Range Theory of Self-Care of Chronic Illness where symptoms are clearly integrated with the self-care behaviors of self-care maintenance, monitoring, and management.

Self-Efficacy of Exercise in Older Adults with Diabetes: A Concept Analysis

Introduction: Self-efficacy is defined as a person’s own judgment of their capabilities to perform a specific activity to attain a particular outcome. The concept of self-efficacy of exercise in older adults with diabetes may still be unclear, so it is essential to elucidate its meaning for better understanding in this concept. This paper aims to explore the meaning of self-efficacy with regard to exercise in older adults with diabetes.Methods: Using the Walker and Avant concept analysis, it discusses cases showing diabetic Thai people and how they manage their health behavior changes, such as with exercise.Results: Analysis of the concept of self-efficacy in terms of its defining attributes, antecedents, consequences, and empirical referents provides information related to clinical usefulness. It helps healthcare professionals communicate the same notion when discussing self-efficacy and can distinguish this concept from other related concepts.Conclusion: Analysis of the concept of self-efficacy provides information related to exercise in older adults and can assist healthcare professionals in communicating the same notion when discussing the concept. 

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.

Toma de decisiones para el manejo de los síntomas de falla cardíaca: protocolo de intervención

Objetivo: dar a conocer el diseño,implementación y evaluación de una intervención de enfermería: “Toma de decisiones para el manejo de los síntomas en adultos con falla cardíaca”.Métodos: se realizó un proceso sistemático propuesto por Sidani yBraden que contempla cuatro fases: diseño de la intervención, operacionalización de la intervención en un manual de intervención, estudio de aceptabilidad, viabilidad y efectividad de la intervención y traducción de la intervención.Resultados: se diseñó la intervención según los postulados de la teoría de situación específica autocuidado en falla cardíaca, centrada en la toma de decisiones para el manejo de los síntomas en adultos con falla cardíaca. Los expertos (n = 5) evaluaron satisfactoriamente el nivel teórico del protocolo (índice de cumplimiento 90 %). La tasa de reclutamiento de los participantes fue exitosa (91,6 %). En una muestra final para el análisis (n = 105) se halló una mejora significativa en el grupo de intervención (n = 53) en el mantenimiento del autocuidado [F (1,103) = 719,6; p = 0,000; 𝜂2𝑝 =0,88 ( = f de Cohen ́s = 2,65)] y en lagestión del autocuidado [F (1,74) = 23501,07;p = 0,000; 𝜂2𝑝 = 0,97 ( = f de Cohen ́s = 5,6)] comparado con el grupo de control(n = 52) que recibió la atención habitual.Conclusiones: se demuestra la fidelidad teórica y operacional, la factibilidad y efectividad del protocolo de una intervención de enfermería para mejorar el autocuidado en adultos con falla cardíaca con un tamaño de efecto grande.

Relationship between self-care behaviors and quality of life in patients with heart failure

Background

It has been generally agreed that cardiac failure is one of the common and devastating diseases due to its morbidity, mortality and rates of disability. Moreover, it has negative impacts on quality of life among sufferers. Meanwhile, improving quality of life among heart failure patients is essential. It can be suggested that people with self-care ability have a better quality of life. However, this issue may be affected by some cultural issues. Regarding a paucity of information on this aspect in Iran, this study aims to explore the relationship between self-care behaviors and quality of life in patients with heart failure.

Methods

This study is carried out using a descriptive - analytical method. The sample size consists of 77 patients who consented to participate in the study and had ejection fraction <40%. The tools were demographic checklist, European heart failure self-care behavior scale, and SF-36 quality of life questionnaire. Data was gathered from the heart center of Imam Ali in Kermanshah-Iran. Data analysis was done using independent t-test, Mann Whitney, ANOVA, and Kruskal-Wallis tests by SPSS-24 software.

Findings

The study sample was 77 participants, of which 45 were female and 51 lived in an urban area. The mean of self-care score was 39.42 ± 7.04, and most of the patients (67.5%) were in moderate level. The mean and SD of quality of life was estimated as 38.45 ± 17.28. The spearman correlation test showed no correlation between self-care and quality of life. However there was a correlation between marital status and self-care ability, in which it shows the higher scores in unmarried people (K2 = 7.75, P = 0.021), and the results indicated better quality of life in male (t = 2.68, P = 0.009), educated patients at the level of university (F = 7.60, P < 0.001), free job (F = 6.21, P < 0.001) and lived in the urban area (Z = 2.05, P = 0.04).

Conclusion

In this study, there is no correlation between self-care behaviors and quality of life in which, this may be attributed to Iranian cultures and perspectives such as valuing live with the children and importance of their attention to elderly patients, which demanded more studies.

An exploration of learning needs: identifying knowledge deficits among hospitalized adults with heart failure

The current study examined the learning needs of hospitalized patients with chronic heart failure (CHF) by identifying their current CHF self-care behaviors and knowledge levels, while identifying relationships between clinical variables, and their learning needs. A descriptive, cross-sectional design was utilized to examine a convenience sample of 42 hospitalized patients with CHF. Self-care behaviors and knowledge levels were measured using the Self Care of Heart Failure Index V. 6.2, and the Japanese Heart Failure Knowledge Scale. Descriptive statistics were used to describe the learning needs and sociodemographic data and Pearson product moment correlation examined relationships between the learning needs and clinical variables. The mean scores of self-care were 38.6% (maintenance), 41.6% (management) and 17.8% (confidence). The participant's mean knowledge level score was 74.9%. Multiple CHF hospital readmissions had a significant negative correlation with CHF knowledge scores (r = −0.358, p < 0.05), suggesting the lower the knowledge score, the higher the prevalence of CHF readmissions. There were significant positive correlations between self-care maintenance (r = 0.525, p < 0.05), management (r = 0.435, p < 0.05), confidence (r = 0.366, p < 0.05), knowledge level (r = 0.752, p < 0.05) and not living alone. Thus, indicating that living with family support is correlated with better self-care and greater knowledge. The presence of multiple comorbidities revealed significant positive correlations (p < 0.05) with self-care scores (maintenance [r = 0.391], management [r = 0.438], and confidence r = 0.504), indicating a higher number of comorbidities, yielded lower self-care behaviors. Findings revealed poor self-care behaviors in all three areas (maintenance, management, confidence). These findings suggested that patients had difficulty implementing knowledge into self-care. By identifying knowledge deficits and contributing factors to suboptimal self-care, the chronic care model can be used as a guideline for ideal CHF education and management. Improving self-care behaviors can be obtained by initiating an active engagement between health care teams and the patient.

Determinants of Self-Care in Patients With Heart Failure: Observations From a Developing Country in the Middle East

Introduction: Self-care is recognized as a means for improving outcomes of heart failure (HF), yet studies have not addressed what predicts successful self-care in collectivist cultures like Lebanon. Methodology: Self-care was measured, using the Arabic Self-Care of HF index, in 100 participants with HF (76% males; mean age 67.59) recruited from a tertiary medical center. Results: Self-care was suboptimal, with mean scores of 67.26, 66.96, and 69.5 for self-care maintenance, management, and confidence. Better HF knowledge, social support, and self-care confidence and lower New York Heart Association score predicted better self-care maintenance. Better knowledge, social support, and self-care maintenance, no recent hospitalization, and being unemployed predicted better self-care confidence. Better self-care confidence, maintenance, and HF knowledge predicted better self-care management. Discussion: HF self-care in Lebanon is suboptimal. Nurses need to identify facilitators of and barriers to self-care particular to this population. Interventions targeting HF knowledge, confidence, and caregiver support are expected to improve self-care in Lebanese patients.

Self-Care Practices of Primary Health Care Patients Diagnosed with Chronic Heart Failure: A Cross-Sectional Survey

Chronic heart failure patients require self-care behaviors and active monitoring of signs and symptoms to prevent worsening. Most patients with this condition are attended in primary healthcare centers. This study aimed to evaluate the endorsement of and adherence to self-care behaviors in primary health care patients with chronic heart failure. We conducted a multicenter cross-sectional study. We randomly included chronic heart failure patients from 10 primary healthcare centers in the Barcelona metropolitan area (Spain). Patients completed the European Heart Failure Self-Care Behaviour Scale, a health literacy questionnaire. Differences between groups were studied using ANOVA tests. We included 318 patients with a mean age of 77.9 years, mild limitations in functional activity New York Heart Association scale (NYHA) II = 51.25%), and a low health literacy index of 79.6%. The endorsement of self-care behaviors was low in daily weighing (10.66%), contacting clinicians if the body weight increased (22.57%), and doing physical exercise regularly (35.58%). Patients with lower educational levels and a worse health literacy had a lower endorsement. The screening of individual self-care practices in heart failure patients might improve the clinician follow-up. We suggest that primary healthcare clinicians should routinely screen self-care behaviors to identify patients requiring a closer follow-up and to design and adapt rehabilitation programs to improve self-care.

Nurse-led education for heart failure patients in developing countries

Heart failure readmissions are associated with significant morbidity and mortality. Adequate education on adherence and self-care behaviours can affect readmission rates positively and nurses are at the frontline of patient education. Such education is valuable when establishing heart failure programmes in developing countries, in light of the challenging socioeconomic circumstances in these. This study aimed to evaluate nurses' heart failure knowledge, to assess patients' baseline knowledge, and to evaluate the effectiveness of structured nurse-driven education.

METHODS

a total of 131 cardiac centre-based nurses and 30 chronic heart failure patients participated in the study in Kuwait. Patients were surveyed a second time 3 to 6 months later, while being followed at an advanced heart failure clinic by dedicated heart failure nurses.

RESULTS

the majority of the nurses (80%) had not received heart failure education previously, although they were able to recognise most heart failure symptoms. Significant improvement in patients' knowledge was noted between the initial and follow-up surveys.

CONCLUSION

establishing a dedicated advanced heart failure programme to care for patients in a developing country can result in significant improvement in disease awareness and self-care behaviours when led by well-trained heart failure nurses. More research is needed to determine if these findings are shared by other countries in the Middle-East and other developing countries.

Heart failure self-management and normalizing symptoms: an exploration of decision making in the community

OBJECTIVE

To explore the decision making processes undertaken by community-dwelling individuals with heart failure as they experience symptom changes.

BACKGROUND

Heart failure patients are responsible for daily self-management that includes responding to symptom fluctuations between exacerbations. Despite education, some patients fail to seek timely medical intervention when symptoms change.

METHODS

Semi-structured interviews were conducted with homecare patients after receiving self-management education. Grounded theory methods and qualitative software were used to collect and analyze the data.

RESULTS

Five themes were identified: perceiving symptoms, alleviating actions and control, normalizing symptoms, absence of help seeking behaviors, and decreased functional capacity. Normalizing symptoms included actions taken by participants to mitigate symptom fluctuations. Daily fluctuations were assimilated into normal life resulting in desensitization of symptom recognition and decreased functional capacity.

CONCLUSIONS

Findings support the need to educate on early symptom recognition, the benefits of safe physical activity, and building a system to support self-management patient-physician collaboration.

A mixed methods study of symptom perception in patients with chronic heart failure

BACKGROUND

Early heart failure (HF) symptoms are frequently unrecognized for reasons that are unclear. We explored symptom perception in patients with chronic HF.

METHODS

We enrolled 36 HF out-patients into a longitudinal sequential explanatory mixed methods study. We used objectively measured thoracic fluid accumulation and daily reports of signs and symptoms to evaluate accuracy of detected changes in fluid retention. Patterns of symptom interpretation and response were explored in telephone interviews conducted every 2 weeks for 3-months.

RESULTS

In this sample, 44% had a mismatch between objective and subjective fluid retention; younger persons were more likely to have mismatch. In interviews, two patterns were identified: those able to interpret and respond appropriately to symptoms were higher in decision-making skill and the quality of social support received.

CONCLUSION

Many HF patients were poor at interpreting and managing their symptoms. These results suggest a subgroup of patients to target for intervention.

Self-Efficacy and Health-Related Quality of Life Among Heart Failure Patients in Singapore: A Descriptive Correlational Study

Introduction: Heart failure (HF) accounts for 30% of all global deaths and Asians are likely to suffer from HF 10 years earlier than their Western counterparts. Low self-efficacy and poor health-related quality of life (HRQoL) have been reported in patients with HF. Methodology: A descriptive correlational design was adopted to investigate the associations between self-efficacy and HRQoL in 91 patients with HF in Singapore. Results: Patients with HF demonstrated moderately good self-efficacy ( M = 3.05, SD = 0.61) and HRQoL ( M = 22.48, SD = 18.99). Significant differences were found between total self-efficacy scores and education levels ( p = .05), and between overall HRQoL and smoking status ( p < .05). Self-efficacy was not significantly correlated to HRQoL. Smoking status, HF classification, and self-efficacy in maintaining function predicted HRQoL. Discussion: Health care professionals should assess each patient’s demographics, smoking status, and clinical condition before delivering individualized education to enhance their self-efficacy and, in turn, overall HRQoL.

The Situation-Specific Theory of Heart Failure Self-Care: Revised and Updated

BACKGROUND

Since the situation-specific theory of heart failure (HF) self-care was published in 2008, we have learned much about how and why patients with HF take care of themselves. This knowledge was used to revise and update the theory.

OBJECTIVE

The purpose of this article was to describe the revised, updated situation-specific theory of HF self-care.

RESULT

Three major revisions were made to the existing theory: (1) a new theoretical concept reflecting the process of symptom perception was added; (2) each self-care process now involves both autonomous and consultative elements; and (3) a closer link between the self-care processes and the naturalistic decision-making process is described. In the revised theory, HF self-care is defined as a naturalistic decision-making process with person, problem, and environmental factors that influence the everyday decisions made by patients and the self-care actions taken. The first self-care process, maintenance, captures those behaviors typically referred to as treatment adherence. The second self-care process, symptom perception, involves body listening, monitoring signs, as well as recognition, interpretation, and labeling of symptoms. The third self-care process, management, is the response to symptoms when they occur. A total of 5 assumptions and 8 testable propositions are specified in this revised theory.

CONCLUSION

Prior research illustrates that all 3 self-care processes (ie, maintenance, symptom perception, and management) are integral to self-care. Further research is greatly needed to identify how best to help patients become experts in HF self-care.

Fostering self-care behaviours through symptom diary use? An exploratory, cross-sectional study about the use of and attitude towards a symptom diary of patients with heart failure

Using health diaries is associated with improved outcomes in patients with heart failure. However, heart failure patients’ attitudes towards using a diary have not been investigated so far. The aim of this study was to investigate heart failure patients’ attitudes towards and the factors influencing diary use. Patients who took part in an educational session to foster self-care behaviours, during which they were given a diary, were asked to participate in this explorative, cross-sectional survey study. The survey took place at least six months after the educational session. Over half of the 53 participants (52.8%) were still using the diary. Reasons for not using it were no perceived need to use it, stable vital signs, and being able to recognise symptoms of exacerbation without the diary. Users and non-users did not differ in their general attitudes towards diary use except regarding the statements ‘Keeping a diary makes no sense’ and ‘Keeping a diary helps to control the disease and the occurrence of symptoms’. Therefore, diary users may be prone to better self-care activities. Age and living situation are influencing diary use. To improve diary adherence, health care providers should stress the advantage of using a diary and the importance of diary adherence.

Tailoring of self-management interventions in patients with heart failure

The effectiveness of heart failure (HF) self-management interventions varies within patients suggesting that one size does not fit all. It is expected that effectiveness can be optimized when interventions are tailored to individual patients. The aim of this review was to synthesize the literature on current use of tailoring in self-management interventions and patient characteristics associated with self-management capacity and success of interventions, as building blocks for tailoring. Within available trials, the degree to which interventions are explicitly tailored is marginal and often limited to content. We found that certain patient characteristics that are associated with poor self-management capacity do not influence effectiveness of a given intervention (i.e., age, gender, ethnicity, disease severity, number of comorbidities) and that other characteristics (low: income, literacy, education, baseline self-management capacity) in fact are indicators of patients with a high likelihood for success. Increased scientific efforts are needed to continue unraveling success of self-management interventions and to validate the modifying impact of currently known patient characteristics.

The Effect of Self-Care Education on the Awareness, Attitude, and Adherence to Self-Care Behaviors in Hospitalized Patients Due to Heart Failure with and without Depression

Background

Cardiovascular diseases are among somatic disorders and psychological factors affect their onset, exacerbation, and treatment. This study was conducted on the hospitalized patients who had heart failure with and without depression. The study criteria was to evaluate the effect of self-care education on awareness, attitude, and adherence to self-care behaviors on these patients.

Materials and Methods

In this quasi-experimental study, seventy patients with heart failure that met the inclusion criteria were recruited through purposive sampling method. They were assigned in to two equal size groups regarding their depression status. First, the eligible patients were selected; then Beck Depression Inventory was done on the patients followed by examination by the clinical psychologist. Patients with average and higher scores were classified in the depressed group and others who got lower than average scores were classified as the non -depressed group. A questionnaire containing items related to awareness, attitude, and adherence to self-care behaviors was used to collect the data. First, self-care behavior was determined and then a four-sessions of educational intervention were held individually for both groups. The second round of questionnaires were completed at patients’ home twelve weeks after the discharge. The Collected data was analyzed using independent-samples and paired-sample t tests, Chi square, and statistical analysis of covariance (ANCOVA) tests through SPSS (version 21, SPSS Inc., Chicago, IL, USA).

Results

After the educational sessions, the statistical analysis showed significant differences in the mean scores of awareness, attitude, and adherence to self-care behaviors between the two groups (P<0.0001).

Conclusion

Self-care behavior education had lower effects on the depressed patients with heart failure. Therefore, before providing education for these patients, it is necessary to consider their psychological problems such as depression.

To adjust and endure: a qualitative study of symptom burden in older people with multimorbidity

CONTEXT

Older people with multimorbidity are vulnerable and often suffer from conditions that produce a multiplicity of symptoms and a reduced health-related quality of life.

OBJECTIVES

The aim of this study is to explore the experience of living with a high symptom burden from the perspective of older community-dwelling people with multi-morbidity.

METHOD

A qualitative descriptive design with semi-structured interviews, including 20 community-dwelling older people with multi-morbidity and a high symptom burden. The participants were 79-89 years old with a mean of 12 symptoms per person. Data were analyzed using content analyses.

RESULTS

The experience of living with a high symptom burden revealed the overall theme, "To adjust and endure" and three sub-themes. The first sub-theme was "To feel inadequate and limited". Participants reported that they no longer had the capacity or the ability to manage, and they felt limited and isolated from friends or family. The second sub-theme was "To feel dependent". This was a new and inconvenient experience; the burden they put on others caused a feeling of guilt. The final sub-theme was "To feel dejected". The strength to manage and control their conditions was gone; the only thing left to do was to sit or lie down and wait for it all to pass.

CONCLUSION

This study highlights the importance of a holistic approach when taking care of older people with multi-morbidity. This approach should employ a broad symptom assessment to reveal diseases and conditions that are possible to treat or improve.

Investigation the relationship between self-care and readmission in patients with chronic heart failure

BACKGROUND

Chronic heart failure (CHF) is associated with unpredictably increased prevalence of hospital admissions. Self-care is one of the most important aspects of management for patients with CHF. Self-care adequacy has led to increased satisfaction, independence in daily activities, reduced stress, and morbidity.

OBJECTIVES

We aimed to assess the relationship between self-care behavior and readmission rate in patients with heart failure.

PATIENTS AND METHODS

A total of 287 patients with a diagnosis of systolic CHF with a left ventricular ejection fraction less than 35% admitted for acute heart failure were enrolled. The self-care behavior was assessed using SCHFI questionnaires that have three domains (self-care maintenance, self-care management, and self-care confidence). An acquired score greater than 70 was considered as proper self-care index. The study population was followed over three months after discharge for readmission.

RESULTS

This study showed that self-care behavior was improper in our study population. More than 75% of patients had a score less than 70 in the different domains for self-care. The multivariable regression analyses showed a significant relationship between self-care management (ß = 1.6, P = 0.006, OR (CI) = 2.66 (1.37-5.1) and self-care confidence (ß = 0.9, P = 0.02, OR (CI) = 2.01 (1.1-3.68) and readmission rate.

CONCLUSIONS

We concluded that a good administration program such as education and a surveillance plan for the improvement of self-care behaviors would reduce hospital readmissions in patients with heart failure.

Determinants of self-care decision-making in hospitalised patients with heart failure

AIMS AND OBJECTIVES

To explore the important determinants of self-care decision-making in inpatients with heart failure.

BACKGROUND

Self-care is a natural decision-making process that helps patients to improve clinical outcomes. However, patients with heart failure engage in insufficient self-care. More research studies are needed to identify the determinants of self-care decision-making.

DESIGN

A cross-sectional correlational research design.

METHODS

A questionnaire survey with a non-probability sampling was used. A total of 71 inpatients were interviewed at a medical centre in southern Taiwan. Instruments included a demographic and clinical questionnaire, the Dutch Heart Failure Knowledge Scale and the Self-Care of Heart Failure Index.

RESULTS

Admission frequency was the only significant determinant of self-care maintenance. Heart failure knowledge, admission frequency and type of residence were important determinants of self-care management. Heart failure knowledge, having a spouse and admission frequency were important determinants of self-care confidence.

CONCLUSIONS

The study findings support the presence of ongoing clinical challenges associated with poor heart failure knowledge and improper performance of self-care in patients. Admission frequency was correlated with three self-care variables, while heart failure knowledge was associated with self-care management and self-care confidence.

RELEVANCE TO CLINICAL PRACTICE

More effective strategies, including pre-discharge education, consultation of successful cases, case sharing and patient support groups, should be designed to enhance patients' self-care decision-making. However, clinical nurses may not be able to actually perform this task or provide consultation services after hospital discharge due to their workload. Establishment of heart disease educators and professional consultation services may be helpful to improve patient education.

Process evaluation of an exercise counseling intervention using motivational interviewing

AIM

To describe the results of the process evaluation of an exercise counseling intervention using motivational interviewing (MI).

BACKGROUND

Exercise can safely be incorporated into heart failure self-care, but many lack access to cardiac rehabilitation. One alternative is to provide exercise counseling in the clinical setting.

METHODS

This process evaluation was conducted according to previously established guidelines for health promotion programs. This includes an assessment of recruitment and retention, implementation, and reach.

RESULTS

Desired number of subjects were recruited, but 25% dropped out during study. Good fidelity to the intervention was achieved; the use of MI was evaluated with improvement in adherence over time. Dose included initial session plus 12 weekly phone calls. Subjects varied in participation of daily diary usage. Setting was conducive to recruitment and data collection.

CONCLUSIONS

Evaluating the process of an intervention provides valuable feedback on content, delivery and fidelity.

What puts heart failure patients at risk for poor medication adherence?

BACKGROUND

Medication nonadherence is a major cause of hospitalization in patients with heart failure (HF), which contributes enormously to health care costs. We previously found, using the World Health Organization adherence dimensions, that condition and patient level factors predicted nonadherence in HF. In this study, we assessed a wider variety of condition and patient factors and interactions to improve our ability to identify those at risk for hospitalization.

MATERIALS AND METHODS

Medication adherence was measured electronically over the course of 6 months, using the Medication Event Monitoring System (MEMS). A total of 242 HF patients completed the study, and usable MEMS data were available for 218 (90.1%). Participants were primarily white (68.3%), male (64.2%), and retired (44.5%). Education ranged from 8-29 years (mean, 14.0 years; standard deviation, 2.9 years). Ages ranged from 30-89 years (mean, 62.8 years; standard deviation, 11.6 years). Analyses used adaptive methods based on heuristic searches controlled by cross-validation scores. First, individual patient adherence patterns over time were used to categorize patients in poor versus better adherence types. Then, risk factors for poor adherence were identified. Finally, an effective model for predicting poor adherence was identified based on identified risk factors and possible pairwise interactions between them.

RESULTS

A total of 63 (28.9%) patients had poor adherence. Three interaction risk factors for poor adherence were identified: a higher number of comorbid conditions with a higher total number of daily medicines, older age with poorer global sleep quality, and fewer months since diagnosis of HF with poorer global sleep quality. Patients had between zero and three risk factors. The odds for poor adherence increased by 2.6 times with a unit increase in the number of risk factors (odds ratio, 2.62; 95% confidence interval, 1.78-3.86; P<0.001).

CONCLUSION

Newly diagnosed, older HF patients with comorbid conditions, polypharmacy, and poor sleep are at risk for poor medication adherence. Interventions addressing these specific barriers are needed.

Profiles of self-care management versus consulting behaviors in adults with heart failure

INTRODUCTION

Patients with heart failure (HF) vary in their ability to respond to symptoms when they occur. The goal of this study was to classify common patterns of symptom response behaviors among adults with HF and identify biobehavioral determinants thereof.

METHODS

Consulting behaviors (i.e. contacting a provider for guidance) were measured using the European Heart Failure Self-care Behavior Scale consulting behaviors subscale, and self-care management (i.e. recognizing and engaging in self-initiated treatment of symptoms) was measured with the Self-Care of HF Index self-care management scale in a prospective cohort study. Latent class mixture modeling was used to identify distinct profiles of consulting and of self-care management behaviors.

RESULTS

The mean age (n=146) was 57±13 years, 30% were female, and 59% had class III/IV HF. Two distinct profiles of consulting behaviors (novice and expert) and three distinct profiles of self-care management (novice, inconsistent and expert) were identified. There was a weak association between profiles of consulting behaviors and self-care management (Kendall's tau-b=0.211). Higher levels of anxiety were associated with worse consulting behaviors (β=1.67±0.60) and worse self-care management (β= -5.82±3.12) and lower odds of exhibiting expert level consulting behaviors (odds ratio (OR)=0.50; 95% confidence interval (CI)=0.26-0.95) and self-care management (OR=0.47; 95% CI=0.24-0.92) (all p<0.05). Higher levels of physical symptoms were associated with better self-care management (β=0.50±0.12; OR =1.02, 95% CI=1.00-1.05; both p<0.05).

CONCLUSIONS

Expertise in consulting behaviors does not necessarily confer expertise in symptom self-care management and vice versa. Physical and psychological symptoms are strong determinants of symptom response behaviors.

Describing self-care in Italian adults with heart failure and identifying determinants of poor self-care

BACKGROUND

Self-care improves outcomes in patients with heart failure; however, no studies have been conducted on this topic in Italy.

AIMS

We aimed to describe self-care in Italian adults with heart failure and to identify sociodemographic and clinical determinants of self-care.

METHODS

A cross-sectional design was used to study 1192 heart failure patients enrolled across Italy. We measured self-care using the Self-Care of Heart Failure Index version 6.2, which measures self-care maintenance, management and confidence. Sociodemographic and clinical data were tested as potential determinants of self-care.

RESULTS

The mean age of the sample was 72 (SD = 11) years; 58% were male. In the three areas of self-care, scores ranged from 53.18 to 55.26 and few people were adequate in self-care (14.5% to 24.4% of the sample). Self-care behaviours particularly low in this population were symptom monitoring, exercise, use of reminders to take medicines and symptom recognition. Confidence in the ability to keep oneself free of symptoms and relieve symptoms was low. Taking fewer medications, poor cognition, older age, having a caregiver, being male and having heart failure for a shorter time predicted poor self-care maintenance. Poor cognition, not being employed, being male, and having worse New York Heart Association class predicted poor self-care management. Poor cognition, taking fewer mediations, older age, and male gender predicted poor self-care confidence.

CONCLUSION

Self-care is poor in Italian heart failure patients. Determinants of poor self-care identified in this study can help to target patients' education. Male gender and poor cognition were consistently associated with poor self-care maintenance, management and confidence.

Development of the Heart Failure Screening Tool (Heart-FaST) to measure barriers that impede engagement in self-care

BACKGROUND

Screening for self-care capacity is advocated before applying educational strategies. No screening tool has been specifically developed to assess barriers that impede engagement in self-care in people with heart failure. Earlier conceptual work (InCOGNITO) identified NYHA class, mild cognitive impairment and depressive symptoms as barriers that impede engagement in HF self-care.

AIMS

Study aims were: 1) to develop the Heart Failure Screening Tool (Heart-FaST) as a means of assessing three critical barriers to self-care; 2) to assess the content validity of the Heart-FaST; and 3) to test the feasibility of implementing the Heart-FaST in clinical practice.

METHODS

The Heart-FaST was developed from barriers identified in previous research (InCOGNITO) and from expert panel consensus. Content validity was assessed by examining the proportion of experts who scored each item as relevant.

RESULTS

The InCOGNITO study indicated that four cognitive tasks, seven emotional questions and NYHA functional class were significantly correlated with the self-care scales: maintenance, management and confidence. These factors were used to create the Heart-FaST items. Consensus on wording and items to be included in the Heart-FaST was reached after two rounds of panel discussion. All items had an item-level content validity index ≥ 0.78. High scores on each barrier (physical, cognitive and emotional functioning) suggest poor self-care and the need for more intensive disease management efforts.

CONCLUSION

The Heart-FaST measures three critical barriers that impede engagement in self-care. In clinical practice this tool may assist in individually tailoring educational and support strategies to promote effective heart failure self-care.

Social support and self-care behaviors in individuals with heart failure: an integrative review

OBJECTIVES

The purpose of this review is to examine and synthesize recent literature regarding the relationship between social support and self-care behaviors in individuals with heart failure (HF).

BACKGROUND

Self-care is an important factor in maintaining health and well-being for individuals with heart failure. Self-care behaviors are an integral component of self-care, and may be impacted by the disease process of heart failure. However, social support may positively influence an individual's self-care behaviors by assisting with activities associated with symptom management and evaluation, as well as activities associated with maintaining heart failure-related treatment regimens. This review will synthesize the current knowledge related to the influence of social support on heart failure self-care behaviors.

DESIGN AND DATA SOURCES

Using an integrative review method, a review of current empirical literature was conducted utilizing CINAHL, PsycARTICLES, and PubMed computerized databases for a period of January 2000 to December 2012. Thirteen studies were identified that met the inclusion criteria for review and investigated aspects of social support and heart failure self-care behaviors.

RESULTS

Social support appears to have a positive relationship on heart failure self-care behaviors, with an individual's family playing an important role in assisting individuals to maintain positive self-care behaviors. Social support appears to influence both heart failure self-care maintenance and management related behaviors by assisting with maintaining treatment regimens and by participating in the decision-making process related to the management of symptoms, as well as seeking treatment for symptoms of heart failure.

CONCLUSIONS

All four types of social support (i.e., emotional support, instrumental/tangible support, informational support, and appraisal support) are involved in the interactive process between an individual's social network (i.e., family and peers) and the individual with heart failure to maintain self-care behaviors that enhance health and well-being. However, more research is needed, specifically longitudinal and experimental designs, to determine the effectiveness of social support on self-care behaviors in individuals with heart failure, since this review revealed mostly cross-sectional, correlational studies which limits the ability to infer causality.

From novice to expert: confidence and activity status determine heart failure self-care performance

BACKGROUND

In a previous, small, mixed-methods study, heart failure patients were described as novice, expert, or inconsistent in self-care. In that study, self-care types differed in experience, confidence, attitudes, and skill.

OBJECTIVES

The aims of this study were to validate the novice-to-expert self-care typology and to identify determinants of the heart failure self-care types.

METHODS

A cross-sectional descriptive study was performed using data from 689 adults with heart failure (61 ± 2.5 years; 36% female, 50% New York Heart Association class III). Two-step likelihood cluster analysis was used to classify patients into groups using all items in the maintenance and management scales of the Self-care of Heart Failure Index. Multinomial regression was used to identify the determinants of each self-care cluster, testing the influence of age, gender, left ventricular ejection fraction, body mass index, depression, anxiety, hostility, perceived control, social support, activity status (Duke Activity Status Index), and self-care confidence.

RESULTS

Self-care behaviors clustered best into three types: novice (n = 185, 26.9%), expert (n = 229, 33.2%), and inconsistent (n = 275, 39.9%). The model predicting self-care cluster membership was significant (χ2 = 88.67, p < .001); Duke Activity Status Index score and Self-care of Heart Failure Index confidence score were the only significant individual factors. Higher activity status increased the odds that patients would be inconsistent (odds ratio [OR] = 1.02-1.09) or novice (OR = 1.02-1.10) in self-care. Higher self-care confidence increased the odds of being an expert (OR = 1.05-1.09) or inconsistent (OR = 1.01-1.05) in self-care.

DISCUSSION

The three-level typology of heart failure self-care was confirmed. Patients who have fewer limitations to daily activities may not be driven adequately to engage in heart failure self-care and may need extra assistance in developing expertise.