Ercole Vellone

Comparison of self-care behaviors of heart failure patients in 15 countries worldwide

OBJECTIVE Clinicians worldwide seek to educate and support heart failure patients to engage in self-care. We aimed to describe self-care behaviors of patients from 15 countries across three continents. METHODS Data on self-care were pooled from 5964 heart failure patients from the United States, Europe, Australasia and South America. Data on self-care were collected with the Self-care of Heart Failure Index or the European Heart Failure Self-care Behavior Scale. RESULTS In all the samples, most patients reported taking their medications as prescribed but exercise and weight monitoring were low. In 14 of the 22 samples, more than 50% of the patients reported low exercise levels. In 16 samples, less than half of the patients weighed themselves regularly, with large differences among the countries. Self-care with regard to receiving an annual flu shot and following a low sodium diet varied most across the countries. CONCLUSION Self-care behaviors are sub-optimal in heart failure patients and need to be improved worldwide. PRACTICE IMPLICATIONS Interventions that focus on specific self-care behaviors may be more effective than general educational programs. Changes in some health care systems and national policies are needed to support patients with heart failure to increase their self-care behavior.

Hope and Related Variables in Italian Cancer Patients

Hope, long considered an essential element for life, has been shown to be important among cancer patients in coping, perceived control over the illness, and psychologic adjustment to the illness. The purpose of this study was (a) to describe the level of hope in Italian cancer patients; (b) to compare the levels of hope during and after hospitalization; (c) to determine whether hope was correlated with quality of life and several symptoms; and (d) to determine whether the variables from the international literature also pertain to Italian cancer patients. A descriptive correlational design using repeated measures was chosen to study 80 Italian cancer patients during hospitalization and then at home. The following instruments were used: a Sociodemographic Questionnaire, the Hope Related Variable Questionnaire, the Nowotny Hope Scale, the Rotterdam Symptom Checklist, and the Hospital Anxiety and Depression Scale. Overall, patients were moderately hopeful and the level of hopefulness was similar in the hospital and at home. Hope was positively correlated with quality of life, self-esteem, coping, adjustment to the illness, well-being, comfort in the hospital, satisfaction with information received, relationship with, and support from family, healthcare professional, and friends. Hope was negatively correlated with anxiety, depression, and boredom during hospitalization. Time since diagnosis, illness stage, and knowing or not knowing the diagnosis and treatment were not correlated with hope. Similarities and differences with the international literature are discussed, and implications for caring for Italian cancer patients are drawn.

Validity and Reliability of the Caregiver Contribution to Self-care of Heart Failure Index

Background:Caregivers make an important contribution to the self-care of patients with heart failure (HF), but few instruments are available to measure this contribution. Objective:The objective of this study was to test the psychometric properties of the Caregiver Contribution to Self-care of Heart Failure Index (CC-SCHFI), an instrument derived from the Self-care of Heart Failure Index version 6.2. The CC-SCHFI measures the contribution of caregivers to the self-care maintenance and self-care management of HF patients, as well as their confidence in their ability to contribute to the patients’ HF self-care. Methods:A cross-sectional design was used to study 291 Italian caregivers whose HF patients were cared for in 17 cardiovascular centers across Italy. Caregivers completed the CC-SCHFI and a sociodemographic questionnaire. Caregivers were retested on the CC-SCHFI 2 weeks later to assess test-retest reliability. Results:Most caregivers were women (66%) with a mean age of 59 years. First- and second-order confirmatory factor analysis (CFA) for each CC-SCHFI scale showed good model fit: &khgr;2 = 37.22, P = .08, Comparative Fit Index (CFI) = 0.97, Non-Normed Fit Index (NNFI) = 0.96 for caregiver contribution to self-care maintenance (second-order CFA); &khgr;2 = 14.05, P = .12, CFI = 0.96, NNFI = 0.93 for caregiver contribution to self-care management (first-order CFA); and &khgr;2 = 10.63, P = .15, CFI = 0.99, NNFI = 0.98 for caregiver confidence in contributing to self-care (second-order CFA). The CC-SCHFI was able to discriminate statistical and clinical differences between 2 groups of caregivers who had received or not received HF self-care education. Internal consistency reliability measured by factor score determinacy was more than .80 for all factors and scales except for 1 factor in the caregiver contribution to self-care management scale (.65). Test-retest reliability computed by intraclass correlation coefficient was high (>0.90) for most factors and scales. Conclusion:The CC-SCHFI showed good psychometric properties of validity and reliability and can be used to measure the contribution of caregiver to HF patient self-care.

Psychometric testing of the self‐care of heart failure index version 6.2

The Self-Care of Heart Failure Index Version 6.2 (SCHFI v.6.2) is widely used, but its psychometric profile is still questioned. In a sample of 659 heart failure patients from Italy, we performed confirmatory factor analysis (CFA) to test the original construct of the SCHFI v.6.2 scales (Self-Care Maintenance, Self-Care Management, and Self-Care Confidence), with limited success. We then used exploratory factor analysis to determine the presence of separate scale dimensions, followed by CFA in a separate sub-sample. Construct validity of individual scales showed excellent fit indices: CFI = .92, RMSEA = .05 for the Self-Care Maintenance Scale; CFI = .95, RMSEA = .07 for the Self-Care Management Scale; CFI = .99, RMSEA = .02 for the Self-Care Confidence scale. Contrasting groups validity, internal consistency, and test-retest reliability were supported as well. This evidence provides a new understanding of the structure of the SCHFI v.6.2 and supports its use in clinical practice and research.

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.

Effects of self-care on quality of life in adults with heart failure and their spousal caregivers: testing dyadic dynamics using the actor-partner interdependence model.

Emotions are contagious in couples. The purpose of this study was to analyze the manner in which adults with chronic heart failure (HF) and their informal caregivers influence each other’s self-care behavior and quality of life (QOL). A sample of 138 HF patients and spouses was enrolled from ambulatory centers across Italy. The Actor–Partner Interdependence Model (APIM) was used to analyze dyadic data obtained with the Self-Care of Heart Failure Index (SCHFI), the Caregivers Contribution to the SCHFI, and the Short Form 12. Both actor and partner effects were found. Higher self-care was related to lower physical QOL in patients and caregivers. Higher self-care maintenance in patients was associated with better mental QOL in caregivers. In caregivers, confidence in the ability to support patients in self-care was associated with improved caregivers’ mental QOL, but worsened physical QOL in patients. Interventions that build the caregivers’ confidence are needed.

Patterns and predictors of patient and caregiver engagement in heart failure care: A multi-level dyadic study

BACKGROUND Heart failure is a burdensome clinical syndrome, and patients and their caregivers are responsible for the vast majority of heart failure care. OBJECTIVES This study aimed to characterize naturally occurring archetypes of patient-caregiver dyads with respect to patient and caregiver contributions to heart failure self-care, and to identify patient-, caregiver- and dyadic-level determinants thereof. DESIGN Dyadic analysis of cross-sectional data on patients and their caregivers. SETTING Outpatient heart failure clinics in 28 Italian provinces. PARTICIPANTS 509 Italian heart failure patients and their primary caregivers. METHODS Multilevel and mixture modeling were used to generate dyadic averages and incongruence in patient and caregiver contributions to heart failure self-care and identify common dyadic archetypes, respectively. RESULTS Three distinct archetypes were observed. 22.4% of dyads were labeled as novice and complementary because patients and caregivers contributed to different aspects of heart failure self-care that was generally poor; these dyads were predominantly older adults with less severe heart failure and their adult child caregivers. 56.4% of dyads were labeled as inconsistent and compensatory because caregivers reported greater contributions to the areas of self-care most insufficient on the part of the patients; patients in these dyads had the highest prevalence of hospitalizations for heart failure in the past year and the fewest limitations to performing activities of daily living independently. Finally, 21.2% of dyads were labeled as expert and collaborative because of high contributions to all aspects of heart failure self-care, the best relationship quality and lowest caregiver strain compared with the other archetypes; patients in this archetype were likely the sickest because they also had the worst heart failure-related quality of life. CONCLUSION Three distinct archetypes of dyadic contributions to heart failure care were observed that represent a gradient in the level of contributions to self-care, in addition to different approaches to working together to manage heart failure. Interventions and clinical programs that involve heart failure dyads should tailor strategies to take into consideration these distinct archetypes and their attributes.

Determinants of Heart Failure Self‐Care Maintenance and Management in Patients and Caregivers: A Dyadic Analysis

Disease self-management is a critical component of maintaining clinical stability for patients with chronic illness. This is particularly evident in the context of heart failure (HF), which is the leading cause of hospitalization for older adults. HF self-management, commonly known as HF self-care, is often performed with the support of informal caregivers. However, little is known about how a HF dyad manages the patients care together. The purpose of this study was to identify determinants of patient and caregiver contributions to HF self-care maintenance (daily adherence and symptom monitoring) and management (appropriate recognition and response to symptoms), utilizing an approach that controls for dyadic interdependence. This was a secondary analysis of cross-sectional data from 364 dyads of Italian HF patients and caregivers. Multilevel modeling was used to identify determinants of HF self-care within patient-caregiver dyads. Patients averaged 76.2 (SD = 10.7) years old, and a slight majority (56.9%) was male, whereas caregivers averaged 57.4 (SD = 14.6) years old, and about half (48.1%) were male. Most caregivers were adult children (48.4%) or spouses (32.7%) of patients. Both patients and caregivers reported low levels of HF maintenance and management behaviors. Significant individual and dyadic determinants of self-care maintenance and self-care management included gender, quality of life, comorbid burden, impaired ADLs, cognition, hospitalizations, HF duration, relationship type, relationship quality, and social support. These comprehensive dyadic models assist in elucidating the complex nature of patient-caregiver relationships and their influence on HF self-care, leading to more effective ways to intervene and optimize outcomes.

The experience of quality of life for caregivers of people with Alzheimer's disease living in Sardinia, Italy.

Purpose:This study explored the meaning of quality of life (QOL) for Sardinian caregivers of people affected with Alzheimer’s disease and factors improving and worsening their QOL. Design: The phenomenological method was used to study 41 Alzheimer’s disease caregivers living on the western coast of Sardinia, Italy. Interviews were conducted and analyzed using Cohen, Kahn, and Steeves’s approach. Findings: Extracted themes were the following: unity and cooperation in the family; freedom/independence; having time for themselves; serenity/tranquility; and well-being and health. Caregivers identified factors that they believed worsened or improved their QOL. Family was particularly important for these caregivers. Discussion and Practice Implications: This study reinforces previous research about cultural influence on QOL and emphasizes the importance of nurses being culturally sensitive. Since Sardinia is a rural region, these findings may be useful for nurses working with caregivers in other rural settings.

Predictors of hospitalization and quality of life in heart failure: A model of comorbidity, self-efficacy and self-care

BACKGROUND Comorbidity is associated with decreased confidence or self-efficacy to perform self-care in heart failure patients which, in turn, impairs self-care behaviors. Comorbidity is also associated with increased hospitalization rates and poorer quality of life. Yet the manner in which comorbidity and self-efficacy interact to influence self-care, hospitalization, and quality of life remains unclear. OBJECTIVES The purpose of this study was to test an explanatory model. The research questions were (1) What is the contribution of comorbidity to heart failure self-care behaviors and outcomes (i.e. hospitalization, quality of life)? and (2) Is comorbidity a moderator of the relationship between self-efficacy and heart failure self-care behaviors? DESIGN This was an analysis of an existing dataset of 628 symptomatic, older (mean age=73, standard deviation (SD)=11) male (58%) Italian heart failure patients using structural equation modeling and simple slope analysis. RESULTS Higher levels of self-care maintenance were associated with higher quality of life and lower hospitalization rates. Higher levels of comorbidity were associated with lower levels of self-care management. Comorbidity moderated the relationship between self-efficacy and self-care maintenance, but not self-care management. Post hoc simple slopes analysis showed significantly different slope coefficients (pdiff<.05). Specifically, in patients with less comorbidity, the relationship between self-efficacy and self-care was significantly stronger than in patients with higher comorbidity. CONCLUSIONS Self-efficacy is important in the self-care maintenance process at each level of comorbidity. Because higher comorbidity weakens the strength of the relationship between self-efficacy and self-care maintenance, tailoring interventions aimed at improving self-efficacy to different levels of comorbidity may be key to impacting hospitalization and quality of life.