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MOTIVATional intErviewing to Improve Self-Care in Heart Failure Patients (MOTIVATE-HF): Study Protocol of a Three-Arm Multicenter Randomized Controlled Trial
Aims Heart Failure (HF) self-care improves patient outcomes but trials designed to improve HF self-care have shown inconsistent results. Interventions may be more effective in improving self-care if they mobilize support from providers, promote self-efficacy, increase understanding of HF, increase the family involvement, and are individualized. All of these elements are emphasized in motivational interviewing (MI); few trials have been conducted using MI in HF patients and rarely have caregivers been involved in MI interventions. The aim of this study will be to evaluate if MI improves self-care maintenance in HF patients, and to determine if MI improves the following secondary outcomes: a) in HF patients: self-care management, self-care confidence, symptom perception, quality of life, anxiety/depression, cognition, sleep quality, mutuality with caregiver, hospitalizations, use of emergency services, and mortality; b) in caregivers: caregiver contribution to self-care, quality of life, anxiety/depression, sleep, mutuality with patient, preparedness, and social support. Methods A three-arm randomized controlled trial will be conducted in a sample of 240 HF patients and caregivers. Patients and caregivers will be randomized to the following arms: 1) MI intervention to patients only; 2) MI intervention to patients and caregivers; 3) standard of care to patients and caregivers. The primary outcome will be measured in patients 3 months after enrollment. Primary and secondary outcomes also will be evaluated 6, 9 and 12 months after enrollment. Conclusion This study will contribute to understand if MI provided to patients and caregivers can improve self-care. Because HF is rising in prevalence, findings can be useful to reduce the burden of the disease.
Clinical and Socio-Demographic Determinants of Self-Care Behaviours in Patients with Heart Failure and Diabetes Mellitus: A Multicentre Cross-Sectional Study
Background Self-care is vital for patients with heart failure to maintain health and quality of life, and it is even more vital for those who are also affected by diabetes mellitus, since they are at higher risk of worse outcomes. The literature is unclear on the influence of diabetes on heart failure self-care as well as on the influence of socio-demographic and clinical factors on self-care. Objectives (1) To compare self-care maintenance, self-care management and self-care confidence of patients with heart failure and diabetes versus those heart failure patients without diabetes; (2) to estimate if the presence of diabetes influences self-care maintenance, self-care management and self-care confidence of heart failure patients; (3) to identify socio-demographic and clinical determinants of self-care maintenance, self-care management and self-care confidence in patients with heart failure and diabetes. Design Secondary analysis of data from a multicentre cross-sectional study. Setting Outpatient clinics from 29 Italian provinces. Participants 1192 adults with confirmed diagnosis of heart failure. Methods Socio-demographic and clinical data were abstracted from patients’ medical records. Self-care maintenance, self-care management and self-care confidence were measured with the Self-Care of Heart Failure Index Version 6.2; each scale has a standardized score from 0 to 100, where a score <70 indicates inadequate self-care. Multiple linear regression analyses were performed. Results Of 1192 heart failure patients, 379 (31.8%) had diabetes. In these 379, heart failure self-care behaviours were suboptimal (means range from 53.2 to 55.6). No statistically significant differences were found in any of the three self-care measures in heart failure patients with and without diabetes. The presence of diabetes did not influence self-care maintenance (p = 0.12), self-care management (p = 0.21) or self-care confidence (p = 0.51). Age (p = 0.04), number of medications (p = 0.01), presence of a caregiver (p = 0.04), family income (p = 0.009) and self-care confidence (p < 0.001) were determinants of self-care maintenance. Gender (p = 0.01), number of medications (p = 0.004) and self-care confidence (p < 0.001) were significant determinants of self-care management. Number of medications (p = 0.002) and cognitive function (p < 0.001) were determinants of self-care confidence. Conclusions Self-care was poor in heart failure patients with diabetes mellitus. This population needs more intensive interventions to improve self-care. Determinants of self-care in heart failure patients with diabetes mellitus should be systematically assessed by clinicians to identify patients at risk of inadequate self-care.
Measures of Self-Care in Heart Failure: Issues with Factorial Structure and Reliability
Dear Editor We read with great interest the recently published paper by Dr Lambrinou and colleagues1 entitled “The Greek version of the 9-item European heart failure self-care behaviour scale: A multidimensional or an uni-dimensional scale?” The paper is one of several papers published on the psychometric properties of the European Heart Failure Self-care Behaviour Scale (EHFScBS) and continues to raise the important questions: (1) Is self-care of heart failure (HF) a multidimensional or an uni-dimensional construct? (2) Is self-care of HF a generalizable construct across countries? (3) Is Cronbach's alpha the best approach to estimate reliability of instruments?
Validity and Reliability of the Caregiver Contribution to Self-Care to 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: χ 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); χ 2 = 14.05, P = .12, CFI = 0.96, NNFI = 0.93 for caregiver contribution to self-care management (first-order CFA); and χ 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.
A Dyadic Approach to Managing Heart Failure with Confidence
Background: The majority of heart failure (HF) self-care research remains focused on patients, despite the important involvement of family caregivers. Although self-care confidence has been found to play an important role in the effectiveness of HF self-care management on patient outcomes, no known research has examined self-care confidence within a dyadic context. Objective: The purpose of this study was to identify individual and dyadic determinants of self-care confidence in HF care dyads. Methods: Multilevel modeling, which controls for the interdependent nature of dyadic data, was used to examine 329 Italian HF dyads (caregivers were either spouses or adult children). Results: Both patients and caregivers reported lower-than-adequate levels of confidence, with caregivers reporting slightly higher confidence than patients. Patient and caregiver levels of confidence were significantly associated with greater patient-reported relationship quality and better caregiver mental health. Patient confidence in self-care was significantly associated with patient female gender, nonspousal care dyads, poor caregiver physical health, and low care strain. Caregiver confidence to contribute to self-care was significantly associated with poor emotional quality of life in patients and greater perceived social support by caregivers. Conclusions: Findings are supportive of the need for a dyadic perspective of HF self-care in practice and research as well as the importance of addressing the needs of both members of the dyad to maximize optimal outcomes for both.
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 patient's 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.
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.
The Key Role of Caregiver Confidence in the Caregiver's Contribution to Self-Care in Adults with Heart Failure
Background: Caregivers play an important role in contributing to heart failure (HF) patients’ self-care but no prior studies have examined the caregivers’ contributions to HF patients’ self-care and no prior studies have examined potential determinants of the caregivers’ contribution to HF patients’ self-care. Aims: The purpose of this study was to describe the caregivers’ contribution to HF patients’ self-care and identify its determinants. Methods: The study design involved a secondary analysis of cross-sectional data. Caregivers’ contributions were measured with the Caregiver’s Contribution to Self-care of HF Index (CC-SCHFI) which measures the caregiver’s contribution to self-care maintenance and management and caregiver confidence in contributing to HF patient’s self-care. Potential determinants were measured using a socio-demographic questionnaire completed by caregivers and patients, and patient clinical data was obtained from the medical record. Results: Data from 515 caregiver/patient dyads were analyzed. Most (55.5%) patients were male (mean age 75.6 years) and most (52.4%) caregivers were female (mean age, 56.6 years). The caregivers’ contribution to patients’ self-care maintenance was low in weight monitoring and physical activity but higher in checking ankles, advising on low-salt foods and taking medicines. The caregivers’ contribution to patients’ self-care management was low in symptom recognition. When symptoms were recognized, caregivers advised patients to reduce fluids and salt and call the provider but rarely advised to take an extra diuretic. Caregiver confidence in the ability to contribute to patient self-care explained a significant amount of variance in the caregiver’s contribution. Conclusion: These findings suggest that caregivers in this sample did not contribute meaningfully to HF self-care. Providers should educate both HF patients and caregivers. Interventions that improve caregiver confidence have the potential to successfully increase the caregivers’ contribution to patients’ self-care.
The Problem with Cronbach's Alpha: Comment on Sijtsma and Van der Ark (2015)
Knowledge of a scale's dimensionality is an essential preliminary step to the application of any measure of reliability derived from classical test theory--an approach commonly used is nursing research. The focus of this article is on the applied aspects of reliability and dimensionality testing. Throughout the article, the Self-Care of Heart Failure Index is used to exemplify real-world data challenges of quantifying reliability and to provide insight into how to overcome such challenges.
Development and Psychometric Testing of a Theory-Based Tool to Measure Self-Care in Diabetes Patients: The Self-Care for Diabetes Inventory
Background Self-care is essential for patients with diabetes mellitus. Both clinicians and researchers must be able to assess the quality of that self-care. Available tools have various limitations and none are theoretically based. The aims of this study were to develop and to test the psychometric properties of a new instrument based on the middle range-theory of self-care of chronic illness: the Self-Care of Diabetes Inventory (SCODI). Methods Forty SCODI items (5 point Likert type scale) were developed based on clinical recommendations and grouped into 4 dimensions: self-care maintenance, self-care monitoring, self-care management and self-care confidence based on the theory. Content validity was assessed by a multidisciplinary panel of experts. A multi-centre cross-sectional study was conducted in a consecutive sample of 200 type 1 and type 2 diabetes patients. Dimensionality was evaluated by exploratory factor analyses. Multidimensional model based reliability was estimated for each scale. Multiple regression models estimating associations between SCODI scores and glycated haemoglobin (HbA1c), body mass index, and diabetes complications, were used for construct validity. Results Content validity ratio was 100%. A multidimensional structure emerged for the 4 scales. Multidimensional model-based reliabilities were between 0.81 (maintenance) and 0.89 (confidence). Significant associations were found between self-care maintenance and HbA1c (p = 0.02) and between self-care monitoring and diabetes complications (p = 0.04). Self-care management was associated with BMI (p = 0.004) and diabetes complications (p = 0.03). Self-care confidence was a significant predictor of self-care maintenance, monitoring and management (all p < 0.0001). Conclusion The SCODI is a valid and reliable theoretically-grounded tool to measure self-care in type 1 and type 2 DM patients.