Linda Worrall-Carter

Measuring self-care in chronic heart failure: A review of the psychometric properties of clinical instruments

Background:Improved self-care skills and behaviors are an important outcome of patient education and counseling. Both researchers and health professionals need to utilize instruments that are reliable and valid at measuring this outcome to advance our understanding as to the efficacy of clinical practice directed toward improving self-care. Objective:The aim of this study was to identify instruments that measure chronic heart failure (CHF) self-care and demonstrate their psychometric properties. Methods:A search of Medline, Cumulative Index to Nursing and Allied Health Literature, Medline, PsycArticles, Psychology and Behavioral Sciences Collection, and PsycINFO databases elucidated studies published between January 1980 and February 2009 that measure CHF self-care. The clinical instruments selected were disease-specific measures of CHF self-care behaviors that are promoted in best practice guidelines. Only instruments that reported estimates of reliability and validity were included in this review. Psychometric properties of the instruments were evaluated according to practice guidelines. Results:The literature search identified 14 instruments published in peer-reviewed journals that measured constructs that predict or correlate to self-care rather than self-care itself. Only 2 disease-specific measures of self-care were identified (Self-care Heart Failure Index [SCHFI] and European Heart Failure Self-care Behavior Scale [EHFScBS]) that have undergone rigorous psychometric testing in CHF populations. Five aspects of validity had been demonstrated with EHFScBS, and 6 aspects of validity had been demonstrated with SCHFI. Two of 3 aspects of reliability have been demonstrated in both instruments. Conclusion:Only 2 reliable and valid tools have been developed to specifically measure CHF self-care. Further use of these instruments in the research arena may reduce gaps in our understanding of CHF self-care and further shape clinical practice directed at improving it.

Does cognitive impairment predict poor self-care in patients with heart failure?

Cognitive impairment occurs often in patients with chronic heart failure (CHF) and may contribute to sub‐optimal self‐care. This study aimed to test the impact of cognitive impairment on self‐care.

E-Cigarettes and Smoking Cessation: Evidence from a Systematic Review and Meta-Analysis

Background E-cigarettes are currently being debated regarding their possible role in smoking cessation and as they are becoming increasingly popular, the research to date requires investigation. Objectives To investigate whether the use of e-cigarettes is associated with smoking cessation or reduction, and whether there is any difference in efficacy of e-cigarettes with and without nicotine on smoking cessation. Data Sources A systematic review of articles with no limit on publication date was conducted by searching PubMed, Web of Knowledge and Scopus databases. Methods Published studies, those reported smoking abstinence or reduction in cigarette consumption after the use of e-cigarettes, were included. Studies were systematically reviewed, and meta-analyses were conducted using Mantel-Haenszel fixed-effect and random-effects models. Degree of heterogeneity among studies and quality of the selected studies were evaluated. Results Six studies were included involving 7,551 participants. Meta-analyses included 1,242 participants who had complete data on smoking cessation. Nicotine filled e-cigarettes were more effective for cessation than those without nicotine (pooled Risk Ratio 2.29, 95%CI 1.05-4.97). Amongst 1,242 smokers, 224 (18%) reported smoking cessation after using nicotine-enriched e-cigarettes for a minimum period of six months. Use of such e-cigarettes was positively associated with smoking cessation with a pooled Effect Size of 0.20 (95%CI 0.11-0.28). Use of e-cigarettes was also associated with a reduction in the number of cigarettes used. Limitations Included studies were heterogeneous, due to different study designs and gender variation. Whilst we were able to comment on the efficacy of nicotine vs. non-nicotine e-cigarettes for smoking cessation, we were unable to comment on the efficacy of e-cigarettes vs. other interventions for cessation, given the lack of comparator groups in the studies included in this meta-analysis. Conclusions Use of e-cigarettes is associated with smoking cessation and reduction. More randomised controlled trials are needed to assess effectiveness against other cessation methods.

Screening for mild cognitive impairment in patients with heart failure: Montreal Cognitive Assessment versus Mini Mental State Exam

Background: Cognitive impairments occur frequently in patients with chronic heart failure (CHF), resulting in worse health outcomes than expected. These impairments can remain undetected unless specifically screened. There are limited sensitive screening measures available in nursing practice to identify mild cognitive impairment (MCI). Aim: To compare the Montreal Cognitive Assessment (MoCA) with the Mini Mental State Exam (MMSE) in screening for MCI in CHF patients. Methods: The MMSE and MoCA were administered to 93 hospitalized CHF patients (70±11 years), without a history of neurocognitive problems. Patients with low MoCA scores (<26) were compared to those with low MMSE scores (<27). Two different parameters were examined between the MoCA and the MMSE: level of MCI agreement (Kappa coefficient) and task errors on assessed cognitive domains (χ2 test). Results: Statistically more patients had low MoCA scores compared with low MMSE scores (66 vs. 30, p=0.02). The MoCA classified 38 (41%) patients as cognitively impaired that were not classified by the MMSE. A significantly low level of agreement was found (κ=0.25, p=0.001) between the MMSE and MoCA in identifying patients with scores suggestive of MCI. More task errors were observed on the MoCA cognitive domains compared with the MMSE cognitive domains. In 68% of patients with low cognitive scores, visuospatial task errors were observed on tasks from the MoCA compared with 22% on a similar task of the MMSE. Conclusion: The MoCA, a screening tool for MCI, identified subtle but potentially clinically relevant cognitive dysfunctions with greater frequency than MMSE.

Testing a model of patient characteristics, psychologic status, and cognitive function as predictors of self-care in persons with chronic heart failure

OBJECTIVE Self-care is a key component in the management of chronic heart failure (CHF). Yet there are many barriers that interfere with a patients ability to undertake self-care. The primary aim of the study was to test a conceptual model of determinants of CHF self-care. Specifically, we hypothesized that cognitive function and depressive symptoms would predict CHF self-care. METHODS Fifty consecutive patients hospitalized with CHF were assessed for self-care (Self-Care of Heart Failure Index), cognitive function (Mini Mental State Exam), and depressive symptoms (Cardiac Depression Scale) during their index hospital admission. Other factors thought to influence self-care were tested in the model: age, gender, social isolation, self-care confidence, and comorbid illnesses. Multiple regression was used to test the model and to identify significant individual determinants of self-care maintenance and management. RESULTS The model of 7 variables explained 39% (F [7, 42] 3.80; P = .003) of the variance in self-care maintenance and 38% (F [7, 42] 3.73; P = .003) of the variance in self-care management. Only 2 variables contributed significantly to the variance in self-care maintenance: age (P < .01) and moderate-to-severe comorbidity (P < .05). Four variables contributed significantly to the variance in self-care management: gender (P < .05), moderate-to-severe comorbidity (P < .05), depression (P < .05), and self-care confidence (P < .01). When cognitive function was removed from the models, the model explained less of the variance in self-care maintenance (35%) (F [6, 43] 3.91; P = .003) and management (34%) (F [6, 43] 3.71; P = .005). CONCLUSION Although cognitive function added to the model in predicting both self-care maintenance and management, it was not a significant predictor of CHF self-care compared with other modifiable and nonmodifiable factors. Depression explained only self-care management.

Gender-specific barriers and facilitators to heart failure self-care: A mixed methods study

BACKGROUND Although approximately half of adults with heart failure (HF) are women, relatively little is known about gender differences and similarities in HF self-care. AIMS The aim of this study was to describe HF self-care in men and women and to identify gender-specific barriers and facilitators influencing HF self-care. METHODS A total of 27 adults (8 women) with chronic HF participated in a cross-sectional, comparative mixed methods study. An analysis of in-depth interviews was used to describe gender-specific barriers and facilitators of self-care. After the interview data were analyzed, the results were confirmed in quantitative data obtained from the same sample and at the same time. Concordance between qualitative and quantitative data was assessed. RESULTS There were no consistent gender-specific differences in self-care practices but there were distinct gender differences in the decisions made in interpreting and responding to symptoms. The men were better than the women at interpreting their symptoms as being related to HF and in initiating treatment. These differences were associated with differences in self-care confidence, social support, and mood. CONCLUSION Gender-specific differences in self-care behaviors are minimal. However, gender-specific barriers and facilitators greatly influence the choice of self-care behaviors.

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 (&khgr;2 = 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.

Gender differences in heart failure self-care: a multinational cross-sectional study.

BACKGROUND Despite a common view that women are better at self-care, there is very little evidence to support or challenge this perspective in the heart failure (HF) population. OBJECTIVE The purpose of this study was to determine if there are cross-cultural gender differences in self-reported HF self-care and to describe gender differences in the determinants of HF self-care. DESIGN, SETTING, AND PARTICIPANTS A secondary analysis was completed of cross-sectional study data collected on 2082 adults with chronic HF from the United States, Australia and Thailand. METHODS Comparisons were made between men and women regarding self-care maintenance, management and confidence as assessed by the Self-Care of Heart Failure Index, as well as the proportion of subjects engaged in adequate self-care. Multivariate comparisons were made to determine if gender explained sufficient variance in HF self-care and the likelihood of reporting adequate self-care, controlling for nine model covariates. RESULTS The sample was comprised of 1306 men and 776 women. Most (73.5%) had systolic or mixed systolic and diastolic HF and 45% had New York Heart Association class III or IV HF. Although small and clinically insignificant gender differences were found in self-care maintenance, gender was not a determinant of any aspect of HF self-care in multivariate models. Married women were 37% less likely to report adequate self-care maintenance than unmarried women. Comorbidities only influenced the HF self-care of men. Being newly diagnosed with HF also primarily affected men. Patients with diastolic HF (predominantly women) had poorer self-care maintenance and less confidence in self-care. CONCLUSION Differences in HF self-care are attributable to factors other than gender; however, there are several gender-specific determinants of HF self-care that help identify patients at risk for practicing poor self-care.

Relationship between self-care and health-related quality of life in older adults with moderate to advanced heart failure.

Background:Heart failure (HF) patients who follow the treatment regimen and attend to symptoms before they escalate are assumed to have better health-related quality of life (HRQOL) than those with poor self-care, but there are few data available to support or refute this assumption. Objective:The objective of the study was to describe the relationship between HF self-care and HRQOL in older (≥65 years old) adults with moderate to advanced HF. Methods:Self-care was measured using the 3 scales (maintenance, management, and confidence) of the Self-care of Heart Failure Index. Scores range from 0 to 100, with higher numbers indicating better self-care. Health-related quality of life was measured with the Minnesota Living With Heart Failure Questionnaire, a 2-subscale (physical and emotional) instrument. Lower numbers on the Minnesota Living With Heart Failure Questionnaire indicate better HRQOL. Pearson correlations, independent-samples t-tests, and linear and logistic regression modeling were used in the analysis. Results:In 207 adults (72.9 [SD, 6.3] years), New York Heart Association class III (82%) or IV, significant linear associations were observed between self-care confidence and total (r = −0.211; P = .002), physical (r = −0.189; P = .006), and emotional HRQOL (r = −0.201; P = .004). Patients reporting better (below median) HRQOL had higher confidence scores compared with patients reporting above-median HRQOL scores (58.8 [19.2] vs 52.8 [19.6]; P = .028). Confidence was an independent determinant of total (&bgr;s = −3.191; P = .002), physical (&bgr;s = −2.346; P = .002), and emotional (&bgr;s = −3.182; P = .002) HRQOL controlling for other Self-care of Heart Failure Index scores, age, gender, and New York Heart Association class. Each 1-point increase in confidence was associated with a decrease in the likelihood that patients had worse (above median) HRQOL scores (odds ratio, 0.980 [95% confidence interval, 0.963–0.998]) with the same controls. No significant associations were found between self-care maintenance or management and HRQOL. Conclusions:The degree of individual confidence in HF self-care is related to HRQOL, but self-reports of specific maintenance and management behaviors are not. Interventions that improve self-care confidence may be particularly important in older adults with moderate to advanced HF.

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

Background: There are many reasons to explain why achievement of optimal self-care can be difficult for many patients with chronic heart failure (CHF). Aim: To investigate differences in self-care skills between patients with and without experience of CHF symptoms. Methods: On the basis of a confirmed diagnosis and treatment for CHF < 2 months or > 2 months, patients were prospectively designated as “novices” or “experienced”. Administration of the Self-Care Heart Failure Index assessed 3 self-care skills: maintenance, management and confidence. A score > 70% in each scale is considered adequate self care. Hierarchal regression models were built to test three hypotheses. Results: In 143 elderly patients hospitalised with CHF, novices had lower self-care maintenance (63 ± 16 vs. 71 ± 14, p = 0.05) and self-care management scores (48 ± 17 vs. 58 ± 19, p = 0.003) than experienced patients. Novices were less likely to have adequate self-care maintenance (OR, 0.73; 95% CI 0.5 to 0.9, LR < 0.02) and management (OR, 0.3; 95% CI, 0.1 to 0.8, p = 0.02). Patients experienced with CHF had similar confidence levels (66 ± 17 vs. 64 ± 17, p = 0.40) to novices. Conclusion: Level of experience is a determinant of self-care skills suggesting this factor should be considered in determining an individual education plan.