Heart Failure Research Paper

JAN
ORIGINAL RESEARCH

JOURNAL OF ADVANCED NURSING

A randomized controlled trial of self-management programme improves health-related outcomes of older people with heart failure
Jung-Hua Shao, Anne M. Chang, Helen Edwards, Yea-Ing Lotus Shyu & Su-Hui Chen
Accepted for publication 2 February 2013

Correspondence to Su-Hui Chen: e-mail: [e-mail] Jung-Hua Shao PhD RN Assistant Professor School of Nursing, College of Medicine, Chang Gung University, Taiwan Anne M. Chang PhD RN Professor, Professor of Clinical Nursing School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia Helen Edwards PhD RN OAM Professor, Head of School School of Nursing, Queensland University of Technology, Brisbane, Queensland,
Australia Yea-Ing Lotus Shyu PhD RN Professor School of Nursing, College of Medicine, Chang Gung University, Taiwan Su-Hui Chen PhD RN Associate Professor Department of Nursing, Chang Gung University of Science and Technology, Taiwan

SHAO J.-H., CHANG A.M., EDWARDS H., SHYU Y.-I.L. & CHEN S.-H. (2013)

A randomized controlled trial of self-management programme improves healthrelated outcomes of older people with heart failure. Journal of Advanced Nursing 00(0), 000–000. doi: 10.1111/jan.12121

Abstract
Aims. This paper is a report on the effectiveness of a self-management programme based on the self-efficacy construct, in older people with heart failure. Background. Heart failure is a major health problem worldwide, with high mortality and morbidity, making it a leading cause of hospitalization. Heart failure is associated with a complex set of symptoms that arise from problems in fluid and sodium retention. Hence, managing salt and fluid intake is important and can be enhanced by improving patients’ self-efficacy in changing their behaviour. Design. Randomized controlled trial. Methods. Heart failure patients attending cardiac clinics in northern Taiwan from October 2006–May 2007 were randomly assigned to two groups: control (n = 46) and intervention (n = 47). The intervention group received a 12-week self-management programme that emphasized self-monitoring of salt/fluid intake and heart failure-related symptoms. Data were collected at baseline as well as 4 and 12 weeks later. Data analysis to test the hypotheses used repeated-measures ANOVA models. Results. Participants who received the intervention programme had significantly better self-efficacy for salt and fluid control, self-management behaviour and their heart failure-related symptoms were significantly lower than participants in the control group. However, the two groups did not differ significantly in health service use. Conclusion. The self-management programme improved self-efficacy for salt and fluid control, self-management behaviours, and decreased heart failure-related symptoms in older Taiwanese outpatients with heart failure. Nursing interventions to improve health-related outcomes for patients with heart failure should emphasize self-efficacy in the self-management of their disease. Keywords: heart failure, nurse, nursing, older adult, randomized controlled trial, self-efficacy, self-management

© 2013 Blackwell Publishing Ltd

1

J.-H. Shao et al.

Introduction
Heart failure (HF), a major worldwide public health problem, is the end stage of heart disease and has been linked with an increased risk of death (Rich 2005).
Furthermore, HF is associated with older age and, given the dramatic increase in the population of older people worldwide, the prevalence of HF is increasing among older persons in the United States (American Heart Association 2008) and in Taiwan (Department of Statistics 2006). In Europe, a survey of 24 countries revealed that 24% of patients admitted with confirmed or suspected HF were readmitted to hospital (Clelanda et al. 2003). In fact, HF is one of the leading causes of hospitalization and readmission in the US (American Heart Association 2008). In Taiwan, HF was found to be a leading cause of morbidity and to place a large economic burden on society, particularly as the readmission rate for patients with HF is steadily increasing (Department of Statistics 2006). As HF is a progressive condition, patients often experience a high level of symptom burden (Zambroski et al. 2005) and significant decreases in functional status (American Heart Association 2008). Most HF-related symptoms are greatly influenced by fluid overload with sodium retention, which in turn leads to higher rates of readmission (Welsh et al. 2002). Many of these early readmissions for HF may be preventable with improvements in HF management (Str€mberg et al. o 2003, Sisk et al. 2006). Thus, better efforts are needed to manage and decrease these
symptoms and the amount of sodium and fluid retention in patients with HF. Evidence supports self-management as an approach to care for those with long-term illness as it increases self-efficacy, decreases HF patients’ hospitalization, and healthcare costs, and enhances patients’ quality of life (Lorig & Holman 2003). A central concept in self-management is self-efficacy, which provides an effective model for promoting behavioural change (Burckhardt 2005, Weng et al. 2010). Self-efficacy has long been shown to be a powerful predictor of health-related behaviours (Bandura 1977b) and is an important adjunct to assisting people to change their behaviours and achieve better health (Bandura 1977a). Thus, selfefficacy links knowledge and action because belief in one’s ability to do something is a prerequisite for self-management. In addition, although self-management has been shown to help maintain and improve the health-related behaviours and health status of HF patients in the US (Naylor et al. 2004), few studies have examined the effectiveness of self-management for Taiwanese people with HF. Therefore, the purpose of this study was to develop and test a selfmanagement programme, based on Bandura’s self-efficacy
2

model, in facilitating behaviour change in older patients with HF in Taiwan.

Background
The term ‘self-management’ was first used to describe asthma self-care (Creer et al. 1976) as a treatment process in which the patient was an active participant. Since then, the term self-management has been used extensively, mainly with regard to education programmes for patients with chronic disease. The self-management method differs from the traditional medical process in terms of the roles of both patients and medical professionals (Holman & Lorig 2004). The patient’s role is to monitor symptoms, report them accurately, and manage the disease in their life. The medical professional’s role is to serve as a consultant, resource person and to offer treatment suggestions. Without this partnership, self-managing patients can never reach their highest level of disease control. Self-management methods have been developed based on learning theories/models such as social cognitive theory, stress coping models, and the transtheoretical model (Redman 2004). Theories for the successful management of chronic disease are grounded in the theoretical framework of self-efficacy (Wright et al. 2003, Siu et al. 2007), which provides an effective theoretical model for behavioural change that focuses on self-management (Burckhardt 2005). In fact, self-efficacy has been shown to predict the performance of self-management in patients with chronic disease (Lorig & Holman 2000, Glasgow et al. 2002), particularly patients with chronic HF, where self-efficacy has been highly correlated with actual behaviour change (Schweitzer et al. 2007). Thus, enhanced self-efficacy appears to be one mechanism responsible for the improvements in health status demonstrated by these self-management programmes (Lorig & Holman 2000). The conceptual framework for this study, which was modified from Bandura’s self-efficacy construct (McDowell et al. 2004), proposes that improved self-efficacy facilitates appropriate and effective self-management interventions. Thus, programmes designed to increase efficacy expectations of self-efficacy in one’s abilities to self-manage a chronic disease are more likely to be effective.

The study
Aim
The purpose of this study was to determine the effectiveness of our self-management intervention on self-efficacy for salt and fluid control (SeSFC), HF-related self-management
© 2013 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

Self-management for heart failure

behaviours and symptoms, and health service use in older outpatients with HF in Taiwan.

Design
A randomized controlled trial was used to test the effectiveness of a self-management intervention provided to the experimental group over 12 weeks. Patients in the experimental group received usual care, one home visit, and four phone calls, while the control group received usual care plus three phone calls with no self-management content. The control group received phone calls to overcome the potential effect of attention on participants (Harkness et al. 2005). Data were collected from both groups before the intervention began (baseline or Time 1) and at weeks 4 (Time 2) and 12 (Time 3) following recruitment.

Sample
All HF patients attending cardiac clinics from October 2006–January 2007 at two medical centres in northern Taiwan were invited to participate in this study if they met these inclusion criteria: (i) 65 years and above; (ii) diagnosed with primary or secondary HF; (iii) documented as New York Heart Association (NYHA) functional class I to III; (iv) had been discharged from the cardiology wards of the hospital; and (v) able to speak and understand Chinese or Taiwanese. Patients were excluded from this study if they met these criteria: (i) diagnosed with a terminal illness such as advanced cancer or renal failure, which would affect fluid retention and probably influence the study findings; and (ii) diagnosed with a debilitating psychiatric disorder or living in a long-term care facility, which would affect their self-management ability. The sample size was estimated from the medium effect of a previous experimental study (Bondmass 2002), which reported a significant difference in mean Heart Failure Symptom Distress Scale (HFSD) scores between pre-test (Mean = 32, SD 8Á06) and posttest (Mean = 26 SD 10Á55), assuming a mean baseline HFSD score of 32 (out of a possible score of 68), with 80% power at the 5% level of significance (two-tailed). In the present study, the sample size required to detect a difference of 6 or more units between two groups, with an alpha of 0Á05 and power of 0Á80 was estimated to be 42 subjects per group (Cohen 1992). To account for attrition of HF patients (cite previous studies), the sample size was increased by 28% to 54 per group. Thus, 108 eligible participants were needed. Of 488 HF patients attending these heart clinics between October 2006–January 2007, 352 met eligibility criteria. Of
© 2013 Blackwell Publishing Ltd

these patients, 188 met the exclusion criteria and 56 refused to participate. Thus, 108 eligible participants were randomly assigned to the intervention (n = 54) and control (n = 54) groups. Over the 12-week study, seven participants from the intervention group, and eight participants from the control group withdrew or dropped out. Therefore, only 47 participants in the intervention group and 46 participants in the control group completed this study, for a 14% withdrawal rate. The reasons for attrition are shown in Figure 1, with the majority of participants declining to continue with no reason provided. Patients agreeing to participate in the study were randomly allocated to the two groups according to a computergenerated sequence of random numbers. Each patient who met the inclusion criteria was given a numbered envelope by the author. The envelopes, numbered from 1 to 108, contained the baseline set of questionnaires and a small sealed envelope. This small envelope contained the randomly computer-generated number, with 1 indicating the experimental group and 0 for the control group. After collecting the baseline data from each patient, the researcher opened the small envelope to learn the participant’s group assignment and advised him/her of the next point of contact. This procedure ensured that neither the researcher nor the participant was aware of group assignment until after the baseline questionnaire had been completed. This procedure of random allocation adhered to the principles of the Consolidated Standards of Reporting Trials (CONSORT) flow diagram (Moher et al. 2001).

Intervention
Usual care Both the intervention and control groups received usual care from clinical nurses during the patient’s hospital admission, according to common health education programme teaching patients how to deal with HF, which focused on improving the patients’ general knowledge of HF including the cause, symptoms, complications, medications, and activity and dietary recommendations for those with HF. However, there was no clear strategy provided in the usual care that demonstrated the performance of health-related behaviours and how to evaluate outcomes for usual care. Participants in the control group also received telephone calls at 3, 7, and 11 weeks from the research assistant (RA) using the ‘Telephone guide-control group’, which guided the RA in greeting and listening to control group patients during the phone calls, which differed from the telephone follow-up for the intervention group.
3

J.-H. Shao et al.

Patients meeting inclusion criteria, n = 352 Excluded, n = 244 - met exclusion criteria, n = 188 - refused to participate, n = 56

Randomly assigned, n = 108

Allocated to intervention group, n = 54

Allocated to control group, n = 54

Lost to follow up, n = 7 Refused to continue, n = 4 Admitted to hospital, n = 2 Moved to a different city, n = 1

Lost to follow up, n = 8 Refused to continue, n = 7 Wrong phone number given, n = 1

In final analysis, n = 47

In final analysis, n = 46

Figure 1 Flow chart of participants through the trial. who agreed to participate in the study. Once all baseline data had been collected, the participants were randomly assigned to the experimental and the control groups. The RA collected outcomes data for weeks 4 and 12 by telephone using the questionnaire guide for two groups. This RA who collected the data was independent from the author who visited and carried out the intervention, which was of 2-hour duration with the content including the provision of information, motivation of behaviours, and performance of behaviour change such as self-monitoring, management of the symptoms of HF, and selection of appropriate health behaviours for patients in the experimental group. The collection of posttest data by the RA who was blinded to the assignment of participants to experimental or control groups helped to reduce bias that would arise if the author also collected data.

Self-management programme The intervention was designed to enhance self-management by promoting self-efficacy through four primary sources of information: mastery of experience, social modelling, social persuasion, and awareness of physical and emotional states (Bandura 1997). The intervention integrated these sources of information into each of five sessions: home visit within 3 days after enrolment, telephone follow-ups at 1, 3, 7, and 11 weeks, completion of a diary of daily sodium and fluid intake and daily self-recording of weight. The activities in the self-management programme were provided through a home visit and four telephone follow-ups. An outline of all activities in the self-management programme is summarized in Table 1.

Data collection procedure
Data collection commenced following the approval. The patients admitted to the cardiology clinics in each of the medical centres by author, for their potential eligibility in the study. When patients met the inclusion criteria of this study, they were invited to participate. An explanation of the study, the benefits of participating, participants’ rights, and the policy on confidentiality of information were provided. Also, a signed consent was obtained from patients
4

Data collection
Self-efficacy for salt and fluid control The SeSFC scale was modified from a self-efficacy scale for health-related diet (Chiou & Ka 2000). The resulting 15-item SeSFC scale has two subscales that assess HF patients’ self-efficacy for resisting salt (nine items) and fluid (six items) intake. Modification comprised adding one item
© 2013 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

Self-management for heart failure

Table 1 Self-management programme activities outline.
Content Within 3 days: Activities of the Home visit 1. Introduce the programme 2. Brief assessment behaviours 3. Discuss HF-related symptoms 4. Discuss relationship between symptom and daily self-weigh, fluid, and salt restriction behaviours 5. Give patient the booklet:
●

Information source

Mastery of experience Mastery of experience Mastery of experience Social modelling

● ● ● ●

Tell the model of story verbally such as grandmother A-Yun or uncle A-Tu and discuss how the models were successful in looking after her/himself. Persuade the patient about benefits of self-management. Encourage to set attainable objectives.
Mastery of experience Social persuasion

6. Make an action plan:

Goal setting to monitor low salt diet, fluid and weight. To daily record: fluid and salt intake (using the standard cup) and body weight (measuring at the same time of the day).
Social persuasion

7. Discussion & encouragement:
● ●

Inform the family about programme Encourage the patient to discuss with the researcher.
Physical and emotional states Social persuasion Physical and emotional states

Weeks 1, 3, 7, & 11: Activities of Telephone follow-up 1. Ask the patients’ thoughts and feelings about self-management 2. Identify problems and solve these problems 3. Discuss their self-monitoring:
● ●

Provide encouragement and praise for behaviour changes. Set new goals for next week.
Social modelling Mastery of experience

4. Remind patients of the models in the booklet (Reinforcement) 5. Remind patients about using their monitoring behaviours (Reinforcement) HF, heart failure.

‘resisting relapse in reducing salt intake’, resulting in a subscale that measures the intake of a low-salt diet of the selfefficacy in different settings. Modification in the original fluid intake subscale involved adapting three items, e.g. stick to fluid restriction when I have guests at home and adding three items, e.g. stick to record my fluid intake every day. The resulting subscale measures ‘Resisting relapse on reducing fluid intake’, which measured the intake of fluid of the self-efficacy in different settings. Responses to each item on both subscales were rated on a 5-point scale from 1 (I am not sure I can do it)–5 (I am very sure that I can do it), with higher scores reflecting greater self-efficacy in reducing salt intake and fluid control. Heart failure self-management behaviour scale Specific HF-related behaviour was assessed using a scale modified from an instrument that measures 12 self-care behaviours of patients with HF. The original instrument
© 2013 Blackwell Publishing Ltd

was found to be valid, reliable, and practical for evaluating the outcomes of HF management programmes (Jaarsma et al. 2003). For this study, we deleted two items related to influenza vaccination and regular exercise because they were not relevant to this study and had the weakest correlations with the overall score. Thus, the Heart failure selfmanagement behaviour scale (HFSmB) has 10 items from the original scale, with total possible scores ranging 10–50. Responses to each item are rated on a 5-point Likert scale from 1 (I completely agree)–5 (I completely disagree), with lower scores reflecting greater self-management behaviours. Heart failure symptom distress scale Heart failure patients’ symptom distress was measured using the HFSD scale (Bondmass 2002), which includes 17 physical problems/symptoms frequently attributed to HF subjects. The original scale had pre-intervention and post-intervention Cronbach’s alphas of 0Á86 and 0Á92
5

J.-H. Shao et al.

respectively (Bondmass 2002). Responses to items on a 5-point Likert-type scale indicate the extent to which these symptoms occur from 0 (not at all)–4 (all the time). The total HFSD score can range from 0–68, with higher scores indicating more distress from physical symptoms. Health services use Health services use data included patients’ clinical and emergency visits and hospitalizations. These data were collected on all patients for the 12 weeks prior to commencing the study and for the 12-week study period. The 12 weeks pre-study data were collected from the patients’ charts by the medical staff and the data over the period of the study were collected from two episodes of data collection. The number of each type of health service use was calculated and totalled for each participant during the study period.

behaviours by participants with HF, while higher SeSFC scores indicate greater self-efficacy in salt and fluid control.

Ethical considerations
This study was approved by the authors’ university (University Human Research Ethics Committee) and hospital (Medical Foundation Institutional Review Board, Taiwan; 94-1129B).

Data analysis
The data were analysed using SPSS, version 15Á0 (Chicago, IL, USA), with the significance level (a) set at 0Á05. Intention-to-treat analysis was used so all patients randomly assigned to groups at study commencement were included in the analysis. Differences in the outcome variables (SeSFC, HFSmB and HFSD scores) over time and between the two groups were analysed using repeated-measures ANOVA models. As the outcome variable, health service use, did not meet the assumptions for parametric data analysis, differences in this variable were assessed using a non-parametric Mann–Whitney U test.

Reliability and validity
All of the scales were assessed the psychometric properties in this study in two phases. Phase 1: instrument translation, content validity The HFSmB scale and HFSD scale were translated and back-translated between English and Chinese and the translation steps followed the principles of cross-culture translation (Jones et al. 2001). The content validity of SeSFC and HFSmB scales was tested by a panel of five experts in the cardiac field and satisfied content validity index was found in SeSFC and HFSmB scales (0Á9, 0Á9 respectively). Phase 2: testing of reliability and construct validity Reliability of the scale was examined through internal consistency (Cronbach’s alpha) in this study. Cronbach’s alphas for the total SeSFC scale, for the reducing salt intake subscale and reducing fluid intake subscale, were 0Á94, 0Á96, and 0Á95 respectively. The original HFSmB scale had acceptable content validity and reliability (Cronbach’s alpha = 0Á81; Jaarsma et al. 2003). The Chinese version of the HFSmB scale used in this study had a Cronbach’s alpha of 0Á71. Cronbach’s alpha was 0Á67, close to the usual acceptable 0Á70 level for HFSD scale in previous studies. Construct validity was also performed in this study. The European Heart Failure Self-Care Behaviour Scale (EHFScB; Jaarsma et al. 2003) was used to assess the construct validity of the SeSFC scales by measuring the correlation between both of the scales. There was a negative relationship(r = À0Á59, P < 0Á001) between EHFScB and SeSFC scales because lower EHFScB scores reflect greater self-care
6

Results
Participants’ characteristics and outcomes at baseline
Of the total sample (N = 108), the majority was male (n = 73, 68%) with a mean age of 72Á04 years (SD 5Á48, range 65–87). The two study groups did not differ significantly (P > 0Á05) at baseline in terms of demographic or outcome variables (Table 2).

Effectiveness of self-management programme
Overall self-efficacy for self-management In the current study, patients in the intervention group were significantly more likely to perform the self-management behaviours such as the action plans, set goals, record their daily sodium and fluid intake, weigh themselves each day and monitor symptoms. Self-efficacy for salt and fluid control The results of repeated-measures ANOVA indicated significant effects for SeSFC scores over time and by group (Table 3). Post-hoc comparison of the results for the experimental and control groups using Scheffe’s adjustment indicated significant differences in mean SeSFC scores between Time 1 and Time 2 (P < 0Á001), and between Time 1 and Time 3
© 2013 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

Self-management for heart failure

Table 2 Sample characteristics and baseline outcome variables by group. Experimental (n = 54) n (%) Control (n = 54) n (%)

(P < 0Á001), but no significant difference between Time 2 and Time 3 (Table 4).
The experimental group had higher mean SeSFC scores than the control group at Time 2 and Time 3 (Table 4). HF self-management behaviour Repeated-measures ANOVA showed significant effects for HFSmB over time and group, indicating improvement in the intervention group (Table 3). Post-hoc tests using Scheffe’s adjustment for multiple comparisons found significant differences in mean HFSmB scores between Time 1 and Time 2 (P &lt; 0Á001), and between Time 1 and Time 3 (P &lt; 0Á001), but not between Time 2 and Time 3 (Table 4). The experimental group had lower mean HFSmB scores than the control group at Time 2 and Time 3 (Table 4). Heart failure symptom distress Repeated-measures ANOVA indicated significant effects for HFSD over time and according to group (Table 3). Post-hoc tests using Scheffe’s adjustment for multiple comparisons found significant differences in mean HFSD scores between Time 1 and Time 2 (P &lt; 0Á001), and between Time 1 and Time 3 (P &lt; 0Á001), but not between Time 2 and Time 3 (Table 4). The experimental group had lower mean HFSD scores than the control group at Time 2 and Time 3 (Table 4), indicating improvement for HF symptom distress. Health service use The mean rate of health service use in the experimental group decreased significantly from 1Á36 times at pre-test to 1Á34 times at posttest according to Wilcoxon signed rank test (z = À0Á30, P = 0Á76). The mean rates of health service use in
the control group increased from 1Á35 times at pretest to 1Á48 times at posttest, but this difference was not significant difference using the Wilcoxon test (z = À1Á50, P = 0Á13). Similar results were obtained using the Mann– Whitney U test (z = À0Á97, P = 0Á33) and t-test (t = À0Á93, P = 0Á35), showing no significant difference in health service use between the experimental and control groups.

Variable Gender Male Female Marital status Married Not married Education No schooling Elementary school ! Junior school Working status Employed outside home Retired Housewife Enough income No Yes Religious faith No Yes Living arrangement With family Alone Duration of heart failure 1–11 months 1–2 years >2 years Ejection fraction (%) 20 21–40 >40 NYHA class I II III Adhering to low salt diet No Yes Mean Age (years) Weight (kg) Comorbidities SeSFC score HFSmB score HFSD score Health service utilization 72Á20 64Á13 3Á81 41Á02 29Á50 5Á15 1Á31

v2 0Á04

P

36 (66Á7) 18 (33Á3) 35 (64Á8) 19 (35Á2) 23 (42Á6) 23 (42Á6) 8 (14Á8) 10 (18Á6) 27 (50Á0) 17 (31Á5) 15 (27Á8) 39 (72Á2) 6 (11Á1) 48 (88Á9) 48 (88Á9) 6 (11Á1) 22 (40Á7) 22 (40Á7) 10 (18Á5) 3 (5Á6) 39 (72Á2) 12 (22Á2) 6 (11Á1) 36 (66Á7) 12 (22Á2) 37 (68Á5) 17 (31Á5)
SD

37 (68Á5) 17 (31Á5) 38 (70Á4) 16 (29Á6) 22 (40Á7) 22 (40Á7) 10 (18Á5) 8 (14Á8) 28 (51Á9) 18 (33Á3) 17 (31Á5) 37 (68Á5) 4 (7Á4) 50 (92Á6) 47 (87Á0) 7 (13Á0) 23 (42Á6) 18 (33Á3) 13 (24Á1) 5 (9Á3) 37 (68Á5) 12 (22Á2) 2 (3Á7) 35 (64Á8) 17 (31Á5) 38 (70Á4) 16 (29Á6)
SD

0Á84

0Á38

0Á54

0Á28

0Á95

0Á58

0Á45

0Á18

0Á67

0Á44

0Á51

0Á09

0Á77

0Á81

0Á67

0Á55

0Á76

2Á88

0Á24

0Á04

0Á84

Mean 71Á87 63Á61 3Á78 43Á63 29Á31 5Á31 1Á33

t À0Á32 À0Á23 À0Á23 0Á16 1Á37 À0Á28 0Á16

P 0Á75 0Á82 0Á82 0Á17 0Á78 0Á80 0Á88

5Á66 12Á00 0Á85 9Á95 3Á70 3Á60 0Á64

5Á34 11Á65 0Á84 9Á86 3Á16 3Á35 0Á58

Discussion
This study is the first randomized controlled trial of a self-management programme for HF patients in Taiwan. Overall, the self-management intervention was effective in improving the self-efficacy of Taiwanese HF patients for controlling salt and fluid intake, and self-management behaviour and in decreasing HF symptom distress, but not in reducing health service use.
7

NYHA, New York Heart Association; SeSFC, Self-efficacy for Salt and Fluid Control; HFSmB, Heart Failure Self-management Behaviour; HFSD, Heart Failure Symptom Distress. © 2013 Blackwell Publishing Ltd

J.-H. Shao et al.

Table 3 SeSFC, HFSmB, and HFSD scores between and within subjects.
Instrument SeSFC Source of variation Within subjects Between Subjects HFSmB Within Subjects Between Subjects HFSD Within Subjects Time Group 9 Time Group Error (between) Time Group 9 Time Group Error (between) Time Group 9 Time Error (within) Group Error (between) Wilks’ Λ 0Á72 0Á57 F 17Á84 34Á24 d.f. 2 2 Error df 90 90 1935Á10 13876Á33 0Á93 0Á68 3Á16 21Á67 2 2 90 90 407Á49 948Á03 35Á60 88Á50 348Á72 138Á37 2242Á02 1 91 2 2 182 1 91 407Á49 10Á42 17Á80 44Á25 1Á92 138Á37 24Á64 39Á12 9Á29 23Á10 5Á62 1 91 1935Á10 152Á49 12Á69 SS d.f. MS F P 0Á000*** 0Á000*** 0Á001** 0Á047* 0Á000*** 0Á000*** 0Á000*** 0Á000*** 0Á020*

Between Subjects

SeSFC, self-efficacy for salt and fluid control; HFSmB, heart failure self-management behaviour; HFSD, heart failure symptom distress. *P < 0Á05, **P < 0Á01, ***P < 0Á001 (two-tailed).

Table 4 SeSFC, HFSmB, and HFSD mean scores by group at three time points. Experimental, n = 47 Time SeSFC Time1 Time2 Time3 HFSmB Time1 Time2 Time3 HFSD Time1 Time2 Time3 Mean
SD

Control, n = 46 Mean
SD

41Á55 51Á70 50Á83 29Á21 26Á21 27Á15 5Á28 4Á06 3Á04

10Á15 4Á73 5Á35 3Á68 1Á93 2Á50 3Á66 2Á70 1Á98

43Á57 41Á78 42Á94 29Á17 30Á52 30Á13 5Á35 5Á39 5Á87

10Á31 8Á83 8Á09 3Á27 2Á25 1Á68 3Á39 3Á19 3Á28

SeSFC, self-efficacy for salt and fluid control; HFSmB, heart failure self-management behaviour; HFSD, heart failure symptom distress.

Self-efficacy for salt and fluid control
Our results on HF participants’ significantly improved SeSFC which was supported by the effectiveness of the selfmanagement programme. These results confirm the findings of previous studies showing that self-management programmes enhance self-efficacy, a key component for patients’ self-management of chronic disease (Siu et al. 2007, Gallagher et al. 2008). Furthermore, these findings are aligned with the proposal that higher self-efficacy is associated with healthier behaviours (Schweitzer et al. 2007), so that interventions should aim not only to improve
8

health functioning, but also to enhance the self-efficacy of patients with HF. Thus, our intervention, which incorporated the four information sources of Bandura’s model for improving self-efficacy (1991, 1997), promoted participants’ success in self-managing their HF-related behaviours by enhancing their self-efficacy. However, self-management programmes do not always lead to improved self-efficacy. For example, one study found no significant effect of their intervention on HF patients’ self-efficacy for managing HF symptoms (Ross et al. 2004). One possible reason could be that their intervention did not seem to address the four information sources needed to help patients improve their self-efficacy. Their intervention included three components (patients’ secure access to their own medical record, an educational guide and a messaging system), with no mention of a theoretical framework (Ross et al. 2004). While our study demonstrated positive outcomes for HF patients participating in a theoretically based self-management programme, few studies on educational interventions for HF patients have reported using theoretically based programmes (Boyde et al. 2011). Alternatively, intervention programmes may be based on theory, but few report details (Shaw 2007).

Heart failure self-management behaviour
Our finding of improved self-management behaviour at 4 and 12 weeks in the intervention group is similar to a previous report of significant improvements in self-management behaviours of older people with HF (Siu et al. 2007) after participating in a self-management programme that emphasized Bandura’s four primary sources of information.
© 2013 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

Self-management for heart failure

Our study findings are also consistent with those of a systematic review, which showed that self-management programmes improved patient’s self-management behaviours (Ditewig et al. 2010). On the other hand, the absence of significant improvement in health behaviour in another study (Elzen et al. 2007) suggests a ceiling effect. In that study, participants with chronic diseases such as HF, asthma, arthritis, and diabetes had high baseline levels of self-efficacy and health status, leaving little room for improvement (Elzen et al. 2007). In contrast, the participants in our study had a low baseline level of self-management behaviour, leaving significant room for improvement. Another possible reason for our positive results on selfmanagement behaviours is that we used a scale specific for HF-related behaviours to determine the level of self-management behaviour, whereas the other study used a general scale for self-management behaviour such as exercise, cognitive symptom-management, and communication with a physician (Elzen et al. 2007). These differences indicate the need for further research to conclusively determine the effects of self-management programmes on improving self-management behaviour.

Health service use
The lack of a significant difference in hospitalization rates between the two groups in our study at week 12 is puzzling as it seems implausible that providing a self-management programme would not lead to decreased health service use. Our findings are similar to a report that total health service use of congestive HF patients did not decrease significantly at 6 months after a self-management group programme (Smeulders et al. 2009). In marked contrast, HF patients who participated in nurse-led HF clinics had significantly lower hospitalization rates than the control group (Str€mberg et al. o 2003). These differences warrant consideration. First, with regard to disease progression in the present study, health status and symptoms were more stable than in other studies, and progression was well controlled for most outpatients with HF. For example, just 26Á9% participants in our study were classified as NYHA class III, whereas about 70% of patients in the Str€mberg et al. (2003) study o were NYHA class III. Second, differences in health service use could be attributed to available resources. In Taiwan, most people have public health insurance, but it has limitations (Bureau of National Health Insurance 2010). For example, the number of prescriptions chronic patients can obtain from a clinic at any one time is regulated, with the maximum period for which prescriptions are valid being 3 months. Accordingly, health policy has affected the frequency that patients can use health services. A third reason for the differences in health service use might be the length of the follow-up period. Our study followed up health service use for a relatively short 12 weeks, whereas intervention studies that assessed health service use over a 6-month period did find a reduction (Eastwood et al. 2007, Ditewig et al. 2010). In the future, assessing outpatients’ use of health services over 6 months or longer may be more appropriate for determining the effectiveness of self-management interventions on decreasing hospital use.

Heart failure-related symptoms
The HF-related symptoms of the intervention group decreased consistently over the 12-week study period, whereas the control group showed no decrease. Our results are generally consistent with those of previous studies (Lorig & Holman 2003, Ditewig et al. 2010), showing that self-management significantly reduced symptoms and improved HF patients’ health status. As deterioration of HF symptoms often results in rehospitalization, early recognition of HF-related symptoms is particularly important for HF patients to manage symptoms and adhere to treatment, thus avoiding hospitalization (Ditewig et al. 2010). However, a majority of participants in our study reported poor ability in distinguishing between HF-related symptoms and symptoms for other comorbid diseases such as influenza, respiratory, or liver disease and diabetes, as previously reported (H€gglund et al. 2007, Jurgens et al. 2007). Such a difficulty may delay patients’ seeking help when such action could avert a hospital admission (Smith et al. 2005). Thus, it is important for researchers to develop reliable and sensitive self-report and observer-rated specific measures of HFrelated symptoms as the main component of self-management programmes. Patients’ early recognition of the signs and symptoms of HF would help them manage symptoms and get appropriate treatment soon enough to avert unnecessary hospitalization.
© 2013 Blackwell Publishing Ltd

Limitations of the study
Although the strength of this study was its intervention based on providing information through Bandura’s four primary sources, it also had some limitations. First, we could not conclude which aspects of the self-management intervention were more effective because we could not determine the relative effectiveness of the four information sources. Determining the extent to which each source was effective should be addressed in future studies to develop more effective self-management programmes. Second, the study was limited by the relatively short follow-up for
9

J.-H. Shao et al.

What is already known about this topic?
● Heart failure is one of the leading causes of hospital-

Conclusion
The results of this study indicate that HF patients receiving the self-management intervention improved their self-efficacy for controlling salt and fluid intake, changed HF-related behaviours, and had fewer HF-related symptoms. Thus, this research provides evidence supporting the positive influence of self-management programmes on self-efficacy expectations in the HF population by creating a supportive environment to perform health-related behaviours (mastery experience), providing encouragement and support (social persuasion), providing a booklet with guidance and sharing how other HF patients have successfully performed (social modelling) and providing a realistic assessment of each patient’s abilities (physical and emotional states). On the other hand, health service use by participants in the intervention group suggests the need for improvements in the self-management programme or a longer follow-up period. Further study is needed to determine whether an intervention better targeting self-efficacy could improve patients’ health service use. Moreover, this study shows that nurses could help increase patients’ awareness to manage their disease and prevention of HF symptoms and the early detection of health problems through a self-management programme. In addition, the programme so that it can become public policy and clinics such as self-management programme could be incorporated as a major part of discharge planning. Thereby, these policies will bring an important, sustainable intervention programme to the community for older patients with HF. Finally, the knowledge gained from this theory-based study contributes to understanding of the effect of self-efficacy on facilitating self-management of HF among older patients in Taiwan.

ization and readmission, making it one of the most costly medical syndromes. ● Self-management has been shown in Western countries to help maintain and improve heart failure patients’ health-related behaviour and health status, including fewer symptoms, lower readmission rates, and decreased mortality. ● Self-management, based on the self-efficacy construct in Bandura’s social cognitive theory, is important in assisting people to increase their self-efficacy, thus enabling behavioural change in patients’ lives.

What this paper adds
● Our theoretically based self-management programme

improved heart failure-related self-management behaviours and symptoms, particularly self-efficacy for salt and fluid control, in older Taiwanese with heart failure. ● Self-efficacy has been shown to influence self-management abilities and indirect positive effects on the health-related outcomes in Taiwan. ● This individualized self-management programme offered no benefits above usual care with respect to health service use at 12 weeks’ follow-up in Taiwan.

Implications for practice and/or policy
● Our findings suggest that nurses can improve out-

comes for older patients with heart failure in Taiwan by teaching them to self-manage their disease, possibly reducing the serious complications. ● Self- management programmes could be incorporated as part of discharge planning into the community for older people with heart failure. These policies will bring an important, sustainable intervention programme to the community for older patients with heart failure in Taiwan.

Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

measuring study outcomes. A longer period may be needed to gain and maintain the desired changes over time, particularly health service use. Moreover, lack of objective measures to support the difference between the experimental and control groups is another major weakness. Finally, the study sample was selected from two medical centres in northern Taiwan, which limits the generalizability of the findings.
10

Conflict of interest
No conflict of interest has been declared by the authors.

Author contributions
All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]:
© 2013 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH
●

Self-management for heart failure Eastwood C.A., Travis L., Morgenstern T.T. & Donaho E.K. (2007) Weight and symptom diary for self-monitoring in heart failure clinic patients. The Journal of Cardiovascular Nursing 22 (5), 382–389. Elzen H., Slaets J.P.J., Snijders T.A.B. & Steverink N. (2007) Evaluation of the chronic disease self-management program (CDSMP) among chronically ill older people in the Netherlands. Social Science & Medicine 64(9), 1832–1841. Gallagher R., Donoghue J., Chenoweth L. & Stein-Parbury J. (2008) Self-management in older patients with chronic illness. International Journal of Nursing Practice 14, 373–382. Glasgow R.E., Toobert D.J., Hampson S.E. & Strycker L.A. (2002) Implementation, generalization and long-term results of the ‘choosing well’ diabetes self-management intervention. Patient Education and Counseling 48(2), 115–122. H€gglund L., Boman K., Olofsson M. & Brulin C. (2007) Fatigue a and health-related quality of life in elderly patients with and without heart failure in primary healthcare. European Journal of Cardiovascular Nursing 6(3), 208–215. Harkness K., Smith K.M., Taraba L., Mackenzie C.L., Gunn E. & Arthur H.M. (2005) Effect of a postoperative telephone intervention on attendance at intake for cardiac rehabilitation after coronary artery bypass graft surgery. Heart and Lung 34 (3), 179–186. Holman H. & Lorig K. (2004) Patient self-management: a key to effectiveness and efficiency in care of chronic disease. Public Health Reports 119(3), 239–243. Jaarsma T., Str€mberg A., M o artensson J. & Dracup K. (2003) Development and testing of the European Heart Failure Self-Care Behaviour Scale. European Journal of Heart Failure 5(3), 363–370. Jones P.S., Lee J.W., Phillips L.R., Zhang X.E. & Jaceldo K.B. (2001) An adaptation of Brislin’s translation model for crosscultural research. Nursing Research 50(5), 300–304. Jurgens C.Y., Hoke L. & Riegel B. (2007) Symptom distress inadequate stimulus for care-seeking in elders with heart failure. Journal of Cardiac Failure 13(6 Suppl. 2), S157. Lorig K.R. & Holman H. (2000) Self-Management Education: Context, Definition and Outcomes and Mechanisms. Paper presented at the Chronic Disease Self- management Conference, Sydney. Lorig K.R. & Holman H. (2003) Self-management education: history, definition, outcomes and mechanisms. Annals of Behavioral Medicine 26(1), 1–7. McDowell J., Courtney M., Edwards H. & Shortridge-Baggett L. (2004) International collaboration in promoting self-management of chronic disease. In National Chronic Condition SelfManagement Conference Proceedings (Department of Health and Ageing ed.), Commonwealth of Australia, Canberra, pp. 368–371. ISBN No: 0 642 82445 2. Moher D., Schulz K.F. & Altman D.G. (2001) The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. BMC Medical Research Methodology 1(2), 1–7. Naylor M.D., Brooten D.A., Campbell R.L., Maislin G., McCauley K.M. & Schwartz J.S. (2004) Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. Journal of the American Geriatrics Society 52(5), 675.

●

Substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; Drafting the article or revising it critically for important intellectual content.

References
American Heart Association (2008) Heart disease and stroke statistics – 2008 update. Retrieved from http://www.american heart.org/downloadable/heart/1200078608862HS_Stats%202008. final.pdf on 8 February 2008. Bandura A. (1977a) Self-efficacy: toward a unifying theory of behavioral change. Psychological Review 84(2), 191–215. Bandura A. (1977b) Social Learning Theory. Prentice Hall, Englewood Cliffs, NJ, USA. Bandura A. (1991) Social cognitive theory of self-regulation. Organizational Behavior and Human Decision Processes 50, 248–287. Bandura A. (1997) Self-Efficacy: The Exercise of Control. Freeman, New York, NY, USA. Bondmass M.D. (2002) Outcomes of Home Management Methods for Chronic Heart Failure. Unpublished 3058231, University of Illinois at Chicago, Health Sciences Center, IL, USA. Boyde M., Turner C., Thompson D.R. & Stewart S. (2011) Educational interventions for patients with heart failure: a systematic review of randomized controlled trials. Journal of Cardiovascular Nursing 26(4), E27–E35. Burckhardt C.S. (2005) Educating patients: self-management approaches. Disability and Rehabilitation 27(12), 703–709. Bureau of National Health Insurance (2010) Enforcement rules of the Act of National Health Insurance. Retrieved from http:// www.nhitb.gov.tw/law/file/102_1.doc on 24 March 2008. Chiou C.J. & Ka J.K. (2000) Reliability and validity assessment of self-efficacy scales for health-related diet and exercise behaviour. Nursing Research 8(3), 301–312. In Taiwanese. Clelanda J.G.F., Swedbergb K., Follathc F., Komajdad M., CohenSolale A., Aguilarf J.C., Dietz R., Gavazzi A., Hobbs R., Korewicki J., Madeira H.C., Moiseyev V.S., Preda I., van Gilst W.H. & Widimsky J. (2003) The EuroHeart Failure survey programme-a survey on the quality of care among patients with heart failure in Europe-Part 1: patient characteristics and diagnosis. European Heart Journal 24(5), 442–463. Cohen J. (1992) A power primer. Psychological Bulletin 112(1), 155–159. Creer T.L., Renne C.M. & Christian W.P. (1976) Behavioral contributions to rehabilitation and childhood asthma. Rehabilitation Literature 37(8), 226–232. 247. Department of Statistics. (2006) Population by age in TaiwanFuchien area. Retrieved from http://www.moi.gov.tw/stat/ on 24 April 2008. Ditewig J.B., Blok H., Havers J. & van Veenendaal H. (2010) Effectiveness of self-management interventions on mortality, hospital readmissions, chronic heart failure hospitalization rate and quality of life in patients with chronic heart failure: a systematic review. Patient Education and Counseling 78(3), 297–315.

© 2013 Blackwell Publishing Ltd

11

J.-H. Shao et al. Redman B.K. (2004) Patient Self-Management of Chronic DiseaseThe Health Care Provider’s Challenge. Jones and Bartlett, Sudbury, MA, USA. Rich M.W. (2005) Heart failure in the oldest patients: the impact of comorbid conditions. The American Journal of Geriatric Cardiology 14(3), 134–141. Ross S.E., Moore L.A., Earnest M.A., Wittevrongel L. & Lin C.T. (2004) Providing a web-based online medical record with electronic communication capabilities to patients with congestive heart failure: randomized trial. Journal of Medical Internet Research 6(2), e12. Schweitzer R.D., Head K. & Dwyer J.W. (2007) Psychological factors and treatment adherence behavior in patients with chronic heart failure. Journal of Cardiovascular Nursing 22(1), 76–83. Shaw E.J., Stokes T., Camosso-Stefinovic J., Baker R., Baker G.A. & Jacoby A. (2007) Self-management education for adults with epilepsy. Cochrane Database of Systematic Reviews 18, CD004723. Retrieved from http://www.mrw.interscience.wiley. com/cochrane/clsysrev/articles/CD004723/pdf_fs.html on 24 March 2008. Sisk J.E., Hebert P.L., Horowitz C.R., McLaughlin M.A., Wang J.J. & Ross S.E. (2006) Effects of nurse management on the quality of heart failure care in minority communities. Annals of Internal Medicine 145, 273–283. Siu A.M.H., Chan C.C.H., Poon P.K.K., Chui D.Y.Y. & Chan S.C.C. (2007) Evaluation of the chronic disease self-management program in a Chinese population. Patient Education and Counseling 65(1), 42–50. Smeulders E.S.T.F., van Haastregt J.C.M., Ambergen T., JanssenBoyne J.J.J., van Eijk J.T.M. & Kempen G.I.J.M. (2009) The impact of a self-management group program on health behavior and healthcare utilization among congestive heart failure patients. European Journal of Heart Failure 11, 609–616. Smith C.E., Koehler J., Moore J.M., Blanchard E. & Ellerbeck E. (2005) Testing videotape education for heart failure. Clinical Nursing Research 14(2), 191–205. Str€ mberg A., M o artensson J., Fridlund B., Levin L.- Karlsson A., J.E. & Dahlstr€m U. (2003) Nurse-led heart failure clinics o improve survival and self-care behaviour in patients with heart failure. European Heart Journal 24(11), 1014–1023. Weng L.C., Dai Y.T., Huang H.L. & Chiang Y.J. (2010) Selfefficacy, self-care behaviours and quality of life of kidney transplant recipients. Journal of Advanced Nursing 66(4), 828– 838. Welsh J.D., Heiser R.M., Schooler M.P., Brockopp D.Y., Parshall M.B., Cassidy K.B. & Saleh U. (2002) Characteristics and treatment of patients with heart failure in the emergency department. Journal of Emergency Nursing 28(2), 126–131. Wright C.C., Barlow J.H., Turner A.P. & Bancroft G.V. (2003) Self-management training for people with chronic disease: an exploratory study. British Journal of Health Psychology 8, 465–476. Zambroski C.H., Moser D.K., Bhat G. & Ziegler C. (2005) Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure. European Journal of Cardiovascular Nursing 4(3), 198–206.

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original research reports and methodological and theoretical papers. For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan Reasons to publish your work in JAN:

• High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1·477 – ranked 11th of 95 in the 2011 ISI
Journal Citation Reports (Social Science – Nursing).

• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries worldwide (including over 3,500 in developing countries with free or low cost access).

• • • •

Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan. Positive publishing experience: rapid double-blind peer review with constructive feedback. Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication. Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).

12

© 2013 Blackwell Publishing Ltd