Development and testing of the Survey of Illness Beliefs in Heart Failure tool

Effects of illness representation-focused patient education on illness representations and self-care in patients with heart failure: A randomised clinical trial

AIMS AND OBJECTIVES

To examine the effect of an illness representation-focused patient education intervention on illness representations and self-care behaviours in patients with heart failure 3 months after discharge from the hospital.

BACKGROUND

Few intervention studies have examined the effect of illness representation-focused interventions on illness representations and self-care in patients with heart failure.

DESIGN

A randomised clinical trial based on the Consolidated Standard of Reporting Trials-CONSORT 2010-guidelines was employed. The Clinical Trial Registry number is TCTR20190903002.

METHODS

One hundred and seven participants were randomly assigned to 2 groups, and 62 participants (n = 30 in the intervention group and n = 32 in the usual care group) completed the baseline and one- and three-month postdischarge follow-up assessments. The instruments included the Survey of Illness Beliefs in Heart Failure and the Self-care of Heart Failure Index. The intervention group received illness representation-focused patient education while hospitalised and telephone follow-ups after discharge. Data were analysed with linear mixed-effects model analysis.

RESULTS

The 107 participants had a mean age of 62.17 years and a mean left ventricular ejection of 53.03%. At baseline, the two groups tended to have accurate illness beliefs but insufficient self-care confidence and self-care maintenance. The analysis showed no significant differences between groups in the illness representation total scores, dimension scores or self-care maintenance scores but did show a significant difference in the self-care confidence scores (F = 3.42, p < .05) over the three months.

CONCLUSION

The study did not show an effect of the intervention on illness representations or self-care maintenance behaviours. However, the intervention did maintain participants' self-care confidence three months after discharge.

RELEVANCE TO CLINICAL PRACTICE

It is necessary to conduct long-term follow-ups of patients' illness representations, discuss the implementation of self-care behaviours with patients, enhance patients' self-care confidence, and involve family members or caregivers in self-care practices when needed.

The Third Time's a Charm: Psychometric Testing and Update of the Atlanta Heart Failure Knowledge Test

BACKGROUND AND OBJECTIVE

Since first being published in 2009, the Atlanta Heart Failure Knowledge Test (AHFKT) has proven a reliable and valid instrument and has been used in multiple studies. Given advances in heart failure (HF) self-care, we proposed to reevaluate the psychometric properties of the AHFKTv2 across these recent studies and update the instrument.

METHODS

Demographic, clinical, and baseline AHFKTv2 data from 4 intervention studies in persons with HF were combined for this analysis (N = 284). The 30 questions of the AHFKT are focused on 5 HF self-care knowledge domains: pathophysiology, nutrition, behavior, medications, and symptoms. Characteristics of the sample were analyzed using descriptive statistics; validity testing with t tests and Mann-Whitney 2-group tests and Pearson r and Spearman ρ correlations; and reliability calculations and factor analysis were performed based on tetrachoric correlations.

RESULTS

Participants were 22 to 84 years of age, 66% were African American, 63% were male, and 94% had New York Heart Association class II to III HF. Mean AHFKT score was 80.6% (±11%). Hypotheses that higher levels of knowledge would be associated with higher education level (t = -2.7, P < .01) and less sodium consumption (ρ = -0.22, P = .03) were validated. Factor analysis revealed 1 general knowledge factor with good reliability, Cronbach's α was .87. Item response analysis identified individual questions requiring review and revision.

CONCLUSION

Comprehensive psychometric evaluation of the AHFKTv2 confirmed its internal consistency reliability and validity and provided direction for production of the AHFKTv3 available for use in research and clinical practice.

Correlates of Health Literacy and Its Impact on Illness Beliefs for Emergency Department Patients With Acute Heart Failure

OBJECTIVES

To study the relationship between health literacy (HL) and socioeconomic, demographic factors and disease-specific illness beliefs among patients who present to the emergency department with heart failure (HF).

BACKGROUND

Maintenance of well-being for patients with HF is partially dependent on appropriate self-care behaviors, which, in turn, are influenced by underlying illness beliefs. HL is a potential modifier of the interaction between behaviors and beliefs. There have been limited investigations studying this relationship among individuals with acute HF.

METHODS

A cross-sectional study of patients with hemodynamically stable acute HF was conducted. Demographic, education, and social support data were obtained from all patients along with self-reported responses to the 36-item STOFHLA survey, a 14 item HF-specific illness belief questionnaire, and a 5-item self-care adherence survey. General association was assessed using the χ or Fisher exact test, and comparisons were made using the Kruskal-Wallis test.

RESULTS

A total of 100 patients (51 females and 49 males) were included, 94% of whom were African-American (mean age [SD]: 57.5 [13.2] years). Inadequate, marginal, and adequate health literacy were present in 35%, 17%, and 48%, respectively, with increasing adequacy among the higher educated (P < 0.001). Overall, HF illness beliefs were considered to be "inaccurate" (mean score [SD] on a 4-point Likert scale: 2.8 [0.3]) but did correlate positively with improved HL (r = 0.26; P = 0.008).

CONCLUSION

In this cohort of relatively young, predominantly African-American patients with acute HF, HL was positively correlated with level of education and negatively associated with age and was an important determinant of disease-specific illness beliefs.

Exploring illness beliefs about diabetes among individuals with type 2 diabetes

Purpose

– The purpose of this paper is to explore illness beliefs among adults with type 2 diabetes (T2DM), studied in a clinical setting in the Indian context. Diabetes management lies primarily in the hands of the patient, which signifies the need for understanding the various dimensions of individuals’ illness beliefs. While past research from abroad has stressed the need for understanding the patient’s perspective in effective illness management, the lack of studies in the Indian context calls for further research in this area.

Design/methodology/approach

– Drawing on the Self-Regulation Model (Leventhal et al., 1980), semi-structured interviews were carried out to understand the beliefs about diabetes among individuals diagnosed to have T2DM. In total, 70 individuals with T2DM were included, taking into account the disease duration, urban-rural, age and gender distinctions. The data were analyzed using content analysis method.

Findings

– The results of the analysis revealed numerous sub-themes related to the perceived consequences of diabetes, control or cure issues, timeline and emotional issues as experienced by the subjects.

Research limitations/implications

– Carrying out a triangulated research with the various stakeholders, namely, diabetologists, general practitioners and other support staff like dieticians could add more value to this exploratory study.

Originality/value

– There is a dearth of research work that explores the illness beliefs that patients’ hold about diabetes, as discussed in the Indian context. It is expected that the insight provided by the study can help the government bodies, healthcare organizations and practitioners design and develop interventions from a patient-centric view. Additionally, such a patient-centric approach will enable individuals to achieve their treatment goals.

Parallel paths to improve heart failure outcomes: evidence matters

Gaps and disparities in delivery of heart failure education by nurses and performance in accomplishing self-care behaviors by patients with advanced heart failure may be factors in clinical decompensation and unplanned consumption of health care. Is nurse-led education effectively delivered before hospital discharge? Nurse leaders must understand the strength of nurses' knowledge base related to self-care principles and important barriers to best practice. Nurses may not be comfortable teaching patients about dry weight, meal planning, heart failure medications, or progressive steps of activity and exercise. Further, clinical nurses may not have time to provide in-depth education to patients before discharge. Equally important, research is needed to learn about factors that enhance patients' adherence to heart failure self-care behaviors, because adherence to recommendations of national, evidence-based, heart failure guidelines improves clinical outcomes. Thus, nurses and patients are on parallel paths related to setting the foundation for improved self-care adherence in advanced heart failure. Through research, we found that nurses were not adequately prepared as heart failure educators and that patients did not believe they were able to control heart failure. In 2 educational intervention studies that aimed to help patients understand that they could control fluid management and follow a strict daily fluid limit, patients had improved clinical outcomes. Thus, misperceptions about heart failure can be overcome with interventions that move beyond communicating "what" self-care behaviors are recommended. Research results reflect that evidence matters! Systems and processes are needed to support nurses' knowledge, comfort, and frequency in delivering self-care education before discharge, increase the accuracy of patients' beliefs about controlling heart failure, and enhance patients' desire to adhere to guideline-recommended heart failure self-care behaviors. This article describes the development of the parallel paths of nurse and patient programs of research and explores translation of findings into practice and development of clinical translational research.

An exploration of illness representations and treatment beliefs in heart failure

AIMS AND OBJECTIVES

To explore the beliefs patients with heart failure hold about their illness and its treatment using the common-sense model of illness cognitions and behaviour as the theoretical framework.

BACKGROUND

Heart failure is a disabling condition, which has a significant impact on individuals, their families and healthcare provision. The common-sense model provides a framework within which lay beliefs about illness and its treatment can be examined. Previous studies have reported a number of misconceptions in relation to the nature of and treatment for heart failure. Inaccurate beliefs are related to limited self-care and nonadherence to medication.

DESIGN

A qualitative research design was used in which thematic analysis was used to interpret interview data.

METHODS

Semi-structured interviews were carried out with twelve patients with chronic heart failure in a community setting in South East England. An interview schedule based on the dimensions of the common-sense model guided data collection. Data were analysed thematically using the framework method.

RESULTS

A cluster of beliefs around a chronic illness with serious consequences was found. However, patients were unable to distinguish between symptoms of heart failure, effects of medication and emotional responses to the illness. The illness was attributed to external factors, especially stressful life events. There was a strong belief in the necessity of medication coupled with the belief that the illness and its symptoms could be controlled by medication. Concerns about drug interactions and side effects were prevalent.

CONCLUSIONS

This study highlights the need for nurses to explore illness representations and treatment beliefs in heart failure. Misconceptions should be corrected to influence behaviour change.

RELEVANCE TO CLINICAL PRACTICE

An understanding of illness representations and treatment beliefs should enable structured interventions to be developed, which improve clinical outcomes in this population.

Relationships between illness representations, treatment beliefs and the performance of self-care in heart failure: a cross-sectional survey

BACKGROUND

Self-care is a key principle in the management of chronic heart failure (HF). The common sense model (CSM) of illness cognitions and behaviour provides a theoretical framework within which relationships between beliefs and behaviour can be examined.

AIM

The aim of this study was to determine relationships between illness representations, treatment beliefs and the performance of self-care in community HF patients.

METHODS

A cross-sectional survey was carried out in 169 patients with HF in South East England. Illness representations, treatment beliefs and self-care were measured using an adapted Revised Illness Perception Questionnaire (IPQ-R); the Beliefs about Medicines Questionnaire (BMQ) and the Looking After Yourself with Heart Failure Questionnaire (LAYHFQ), according to the CSM. Relationships between these specific concepts were determined using Pearson's correlation co-efficients (r) and stepwise multiple regression.

RESULTS

Perceived medication knowledge (r = 0.51, p ≤ 0.01), beliefs about the necessity of medication (r = 0.45, p ≤ 0.01) and illness coherence (r = 0.39, p ≤ 0.01) were moderately correlated with self-care. Multiple regression analysis revealed that 46% of the variance in self-care could be explained by illness representations and treatment beliefs (adjusted R(2) = 0.46, F = 9.93, p = 0.00). Three factors were significant predictors of self-care - medication knowledge (β=0.319, p=0.003), a belief in the illness having serious consequences (β = 0.258, p=0.008) and the impact of medication use on lifestyle (β = -0.231, p = 0.03).

CONCLUSION

Illness representations and treatment beliefs should be explored in patients with HF in order to inform the development of targeted interventions designed to correct misconceptions and enhance self-care. This has the potential to improve clinical outcomes in this population.

Characteristics associated with racial disparities in illness beliefs of patients with heart failure

African Americans have greater misperceptions about heart failure (HF) than Caucasians. We examined socioeconomic and medical history factors to determine if they explain differences in accuracy of HF illness beliefs by race. 519 patients completed an illness beliefs and socioeconomic status survey. After establishing univariate associations by race, linear regression with backward selection was used to identify factors associated with HF illness beliefs accuracy. HF illness beliefs were less accurate among African Americans (p < .01). In multivariate models, race remained a predictor of HF illness beliefs accuracy, as did education level and living status (all ps < or = .01). Illness beliefs of African Americans were inaccurate and independently associated with social support and education level. Health care providers must consider patient education processes as a possible cause of differences and focus on what and how they teach, literacy level, materials used, and family engagement and education.

An update on the self-care of heart failure index

BACKGROUND

The Self-care of Heart Failure Index (SCHFI) is a measure of self-care defined as a naturalistic decision-making process involving the choice of behaviors that maintain physiological stability (maintenance) and the response to symptoms when they occur (management). In the 5 years since the SCHFI was published, we have added items, refined the response format of the maintenance scale and the SCHFI scoring procedure, and modified our advice about how to use the scores.

OBJECTIVE

The objective of this article was to update users on these changes.

METHODS

In this article, we address 8 specific questions about reliability, item difficulty, frequency of administration, learning effects, social desirability, validity, judgments of self-care adequacy, clinically relevant change, and comparability of the various versions.

RESULTS

The addition of items to the self-care maintenance scale did not significantly change the coefficient alpha, providing evidence that the structure of the instrument is more powerful than the individual items. No learning effect is associated with repeated administration. Social desirability is minimal. More evidence is provided of the validity of the SCHFI. A score of 70 or greater can be used as the cut-point to judge self-care adequacy, although evidence is provided that benefit occurs at even lower levels of self-care. A change in a scale score more than one-half of an SD is considered clinically relevant. Because of the standardized scores, results obtained with prior versions can be compared with those from later versions.

CONCLUSION

The SCHFI v.6 is ready to be used by investigators. By publication in this format, we are putting the instrument in the public domain; permission is not required to use the SCHFI.

Development, psychometric testing, and revision of the Atlanta Heart Failure Knowledge Test

BACKGROUND AND RESEARCH OBJECTIVE

Several heart failure (HF) knowledge tools have been developed and tested over the past decade; however, they vary in content, format, psychometric properties, and availability. This article details the development, psychometric testing, and revision of the Atlanta Heart Failure Knowledge Test (A-HFKT) as a standardized instrument for both the research and clinical settings.

PARTICIPANTS AND METHODS

Development and psychometric testing of the A-HFKT were undertaken with 116 New York Heart Association (NYHA) class II and III community-dwelling HF patients and their family members (FMs) participating in a family intervention study. Internal consistency, reliability, and content validity were examined. Construct validity was assessed by correlating education level, literacy, dietary sodium ingestion, medication adherence, and healthcare utilization with knowledge.

RESULTS

Content validity ratings on relevance and clarity ranged from 0.55 to 1.0, with 81% of the items rated from 0.88 to 1.0. Cronbach alpha values were .84 for patients, .75 for FMs, and .73 for combined results. Construct validity testing revealed a small but significant correlation between higher patient and FM knowledge on sodium restriction questions and lower ingested sodium, r = -0.17, P = .05 and r = -0.19, P = .04, respectively, and between patient knowledge and number of days that medications were taken correctly (diuretics: r = 0.173, P < .05, and angiotensin-converting enzyme: r = 0.223, P = .01). Finally, patients seeking emergency care or requiring hospitalization in the 4 months before study entry were found to have significantly lower FM knowledge using both t test and logistic regression modeling.

CONCLUSIONS

The A-HFKT was revised using the content and construct validity data and is available for use with HF patients and FMs. The construct validity testing indicates that patient knowledge has a significant relationship to aspects of self-care. Furthermore, family knowledge may influence patient adherence with sodium restriction and healthcare utilization behavior.

Patient adherence or patient self-management in transplantation: an ethical analysis

Adherence of patients to transplantation regimens has been problematic. Patient self-management of the chronic diseases that frequently lead to transplantation is now the standard of practice, although that practice has been incompletely implemented. Through its focus on developing patients' skills and confidence in their ability to perform medical management, maintain important life roles, and manage the negative emotions that often accompany chronic conditions, patient self-management has the potential to support effective adherence of patients in an ethically satisfactory way. A professional decision to transplant should carry with it a commitment to help patients self-manage, including patients with low levels of literacy. Viewing adherence as patients' work to be accomplished within a framework of patient self-management offers an option for improving transplant outcomes. Testing this option is an important next step.

Patient Adherence or Patient Self-Management in Transplantation: An Ethical Analysis

Adherence of patients to transplantation regimens has been problematic. Patient self-management of the chronic diseases that frequently lead to transplantation is now the standard of practice, although that practice has been incompletely implemented. Through its focus on developing patients' skills and confidence in their ability to perform medical management, maintain important life roles, and manage the negative emotions that often accompany chronic conditions, patient self-management has the potential to support effective adherence of patients in an ethically satisfactory way. A professional decision to transplant should carry with it a commitment to help patients self-manage, including patients with low levels of literacy. Viewing adherence as patients' work to be accomplished within a framework of patient self-management offers an option for improving transplant outcomes. Testing this option is an important next step.