• „ ORIGINAL ARTICLE

The Revised Self-Care of Heart Failure Index — a new tool for assessing the self-care of Polish patients with heart failure

Natalia Świątoniowska-Lonc1, Jacek Polański2, Iwona Pilarczyk-Wróblewska2, Beata Jankowska-Polańska1

1Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, Wrocław, Poland

2Department of Internal Medicine, Occupational Diseases, Hypertension and Clinical Oncology, Wroclaw Medical University, Wrocław, Poland

3Department of Paediatrics, Faculty of Health Science, Wroclaw Medical University, Wrocław, Poland

INTRODUCTION

Depending on the diagnostic criteria used and the study population, heart failure incidence is 100–900 cases per 100 000 person-years [1]. Despite advances in heart failure diagnosis and treatment, one in two patients globally is rehospitalized within 6 months of discharge, and approx. 300 000 patients die annually due to heart failure decompensation [2, 3]. Poor self-care capabilities and non-adherence to treatment are the primary causes of mortality and rehospitalization in heart failure patients [4].

Self-care is an important part of heart failure management [5–7]. Riegel et al. define self-care in heart failure as a naturalistic decision-making process that influences the actions that maintain physiological stability (maintenance), and facilitate the perception of symptoms (symptom perception) and response to symptoms (management) when they occur. Confidence in one’s ability to perform self-care can improve both self-care maintenance and management [8]. Self-care maintenance activities include daily weighing, salt and fluid intake monitoring, and daily exercise. Self-care management activities may include the following decisions: salt and fluid intake restriction, medication (diuretic) dosage increase, and consultation with a nurse or physician.

One of the most commonly used self-care assessment instruments globally is the Self-Care of Heart Failure Index (SCHFI) [9]. The questionnaire is based on the middle-range theory of self-care of chronic illness, which addresses the process of maintaining health through health-promoting practices. Its key concepts include self-care maintenance, monitoring, and management. The original questionnaire was later modified several times in order to improve its psychometric properties, to ensure that the measured behaviors are evidence-based, and to account for their theoretical foundation [10–14]. The revised theory differs from the original situation-specific theory of self-care in a number of aspects. In the revised theory, symptom perception includes both symptom monitoring and recognition (besides body listening, symptom interpretation, and labeling), with a stricter integration of naturalistic decision-making. In addition, autonomous (associated with non-pharmaceutical symptom control methods) and consultative self-care behaviors (pharmaceutical interventions requiring consultation with a physician) were distinguished in all three self-care processes. The Revised SCFHI the above modifications. As such, the new version comprises self‐care maintenance, self‐care management, and the new component of symptom perception. To date, the questionnaire has been validated in an Italian patient population [13, 15].

In Poland, self-care in heart failure patients has so far been measured using the European Heart Failure Self-Care Behavior Scale (EHFSc-9) [16]. Due to the need to systematically evaluate self-care capabilities in the Polish setting and to implement a useful and reliable research instrument for this purpose, we have decided to perform the translation and cross-cultural adaptation of the Revised SCFHI into Polish, and to evaluate its inter-observer reliability and temporal stability.

METHODS

The current research has a cross-sectional, observational design. Data was collected from October 2019 to December 2020.

Two hundred and three patients treated at the cardiology department of the University Hospital in Wroclaw (Poland) were recruited. Out of the 203 patients, 53 did not meet the inclusion criteria or declined to participate, 23 dropped out without providing a reason, despite having previously consented to participate. Thus, the final study group included 127 patients diagnosed with heart failure and who were receiving medication. The patients completed the questionnaire on paper during their control visits. The patients received information about the aim of the study and could ask questions when filling out the questionnaire. The study was implemented by a properly trained team including a physician specializing in internal medicine and an internal medicine nurse. The personnel were informed about the aim of the study. A study protocol was prepared for the purpose of the study so that the personnel could collect data in the same way. Socio-demographic and clinical data was collected by the personnel. Finally, 127 patients have completed the study.

Inclusion and exclusion criteria

The inclusion criteria were as follows: age ≥18 years, heart failure diagnosed in accordance with the European Society of Cardiology criteria [6], cognitive status allowing the study to be understood and the surveys to be completed without assistance (Mini Mental State Examination score ≥18), and command of Polish allowing the patient to understand the questionnaire items.

Exclusion criteria were as follows: concurrent cancer, psychological disorders (such as cognitive impairment [MMSE <18] and pharmacologically treated severe depression), heart failure exacerbation, ischemic heart disease exacerbation, and acute respiratory disease (requiring urgent and intensive treatment at an Intensive Care Unit), due to the complexity of such patients’ clinical status and risk of comorbidities interfering with the self-care level evaluation; lack of consent to participate; or withdrawing consent at any stage of the study.

The Self-Care of Heart Failure Index v 7.2

The revised SCHFI (v 7.2) is used to evaluate the level of self-care in patients with heart failure. It comprises 29 items concerning three areas of self-care — self-care maintenance, symptom perception, and self-care management. In addition, it scores the level of self-care confidence, which is not a component of self-care, but has a powerful influence on it.

The Revised SCHFI uses Likert-type response options. The self-care maintenance domain includes 10 items concerning general health-related behaviors (diet, exercise, follow-up, prevention of infections) and measuring their frequency (from 1 — never to 5 — always). The symptom perception domain comprises 9 items regarding the frequency of heart failure symptoms (dyspnea, edema, weight gain, fatigue, etc.) and 2 items to determine how quickly the patient noticed the symptoms and identified them as heart failure-related. For these 2 items, the responses range from “not applicable” (no symptoms) or 0 (did not recognize the symptom) to 5 (recognized the symptom very quickly). The self-care management domain is composed of 8 items. Seven of them rate how likely the respondent is to try the behaviors commonly used to control heart failure symptoms (1 — unlikely, 5 — very likely). One item asks the patient how sure they are that the treatment most recently used to manage their symptoms helped them. Responses here range from 0 (I did nothing) or 1 (not sure) to 5 (very sure). Scores are standardized to a value between 0 and 100 points, and higher scores indicate a higher level of self-care [13].

The questionnaire is available in many language versions, but validation studies have so far been completed with heart failure patients from the United States and Italy [13,v15]. The Polish version of the questionnaire is available at: https://self-care-measures.com/project/ patient-version-schfi-polish-7-2/.

Translation and adaptation procedure

In accordance with the widely accepted standard methodology [17], the questionnaire validation procedure comprised obtaining consent from the questionnaire’s author, Barbara Riegel, establishing an expert committee, forward translation from English into Polish, synthesis of translation, backward translation, expert committee review and preliminary pilot testing.

Translation of the Revised SCHFI (v 7.2) into Polish was performed by a team of specialists (2 physicians and 2 nurses) fluent in both languages, whose native language was Polish. The text was then discussed and corrected by a team of medical specialists (1 physician and 1 nurse), and the corrected version was sent to a translation agency. Once the translated text had been proofread by the translation agency, the final suggested version was submitted to an expert panel for approval. The resulting Polish version was submitted to an independent team of medical professionals fluent in both Polish and English, whose native language was English, to translate the text back into English (back translation). After a discussion between designated experts and a number of minor corrections regarding style, the resulting text was officially approved. The back-translated English version of the translated questionnaire was submitted to the author for approval (backward–forward translation).

After the translation was approved by the author of the original version, a pilot study was conducted to verify patients’ understanding of the Polish version of the questionnaire. The pilot study included 16 heart failure patients of a cardiology clinic. All patients filled in the questionnaire on their own and did not report any difficulties in understanding or responding to any of the items. The pretested version of the Revised SCHFI was used as the final version for psychometric tests in a population of patients with heart failure in Poland.

Ethical considerations

The study was approved by the local Bioethics Committee (approval no. KB 67/2016). Written informed consent was obtained from each participant prior to their inclusion, and the investigation conformed to the principles outlined in the Declaration of Helsinki. Data confidentiality was assured by using assigned code numbers in lieu of participants’ names.

Statistical analysis

Internal consistency was evaluated using Cronbach’s α and confirmatory factor analysis. In the latter, model fit was assessed using Hu and Bentler’s two-index method. As SCHFI items are expressed on an ordinal scale, and not a continuous one, parameter estimation was performed using Diagonally Weighted Least Squares. The convergent validity of the instrument was assessed by correlating SCHFI and EHFSc-9 scores. All analyses used a significance threshold of 0.05, i.e. all P values of less than 0.05 were interpreted as showing significant associations. The analyses were performed using the R software, version 3.6.0 [18]. The distribution of the analyzed variables was non-normal (this was verified by the Shapiro–Wilk test) and therefore the Mann–Whitney and Kruskalla–Wallis tests and the Spearman correlation coefficient were used.

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