AdherenceWhat matters to patients with heart failure? The influence of non-health-related goals on patient adherence to self-care management
Introduction
Ineffective self-care among patients with heart failure (HF) is the leading cause of frequent hospital readmissions, high morbidity and mortality rates, as well as costly health expenditures [1], [2], [3], [4], [5]. The term ‘self-care’ refers to patient-initiated practices that help maintain and optimize physical wellbeing [6], [7]. HF practice guidelines in the US [8] and Europe [9] stipulate that patients should engage in the following self-care behaviors: (1) restricting salt and fluid intake, (2) daily weighing, and (3) balancing physical activity with rest. However, a recent study [10] of HF patients across 15 countries indicated that 50–80% of individuals never or rarely adhere to these recommendations. Given that self-care is central to the successful management of HF [4], it is crucial to elucidate factors that underlie patient non-compliance [11].
Health behavior models are commonly used to explain patient adherence [12]. These models include the Health Belief Model (HBM) [13], [14], [15], the Common Sense Model of Self-Regulation (CSM; [16], [17]) and the Theory of Planned Behavior/Theory of Reasoned Actions (TPB/TRA; [18]). Although each theory differs somewhat in the construal and labeling of constructs, all models underscore the importance of patient knowledge and self-efficacy for health behavior [12]. A recurrent finding in the HF literature is that adherence is not solely driven by these cognitive factors [19], [20], [21], [54]. That is, several qualitative studies suggest that HF patients’ decisions to follow self-care recommendations are driven by whether they value the prescribed behavior and perceive it to be an integral part of their lives [21], [22], [23], [24], [25], [26]. For example, one study found that among patients with similar knowledge of self-care recommendations, those who prioritized HF management above other life events (e.g., a job transition) were more proficient at self-care [22].
Despite the evidence that assessing patient goals and values can advance the understanding of HF self-care adherence, few studies have examined this process. The main exceptions are interventions that incorporate motivational interviewing (MI) strategies, which direct patients’ awareness to the discrepancies between their current actions and desired goals [27]. Yet, the impact of MI on self-care adherence has been suboptimal [28], [29], [30], arguably because MI programs advocate for HF-related goals (e.g., undertaking physical activity) that are not necessarily important to some patients. As a case in point, a qualitative study found that patients have difficulty prioritizing HF management when they have to attend to other pressing matters, such as taking care of a sick spouse [31]. It is possible that capitalizing on a broad range of patient life-goals and charting their compatibility and incompatibility with self-care regimens may be more conducive to understanding health behavior change.
The phenomenon whereby one goal interferes with the achievement of another is termed goal incompatibility [33]. In non-HF populations, it has been shown that conflicts between personal and exercise goals predict non-compliance with a physical activity regimen [33], [34], [35]. For example, one study [36] asked undergraduate students to list goals for school, home, community or leisure, and rate the extent to which these goals facilitated or conflicted with physical activity. The perceived compatibility of exercise with personal goals predicted physical activity above and beyond self-efficacy and behavioral intention. This suggests that the motivation to perform a health behavior is driven not only by the commitment to a single health goal but also by the interrelations between multiple goals from different life domains.
Examining the dynamic process between competing goals may help to operationalize the construct of motivation in health behavior theories [37], and also serve as a useful clinical approach. To date, no quantitative research has examined whether patients’ competing life priorities influence their self-care practice or whether goal compatibility has a similar degree of impact on adherence as other known predictors of self-care in health behavior frameworks, namely, knowledge and self-efficacy.
As such, the overall aim of the current study was to enhance the understanding of patient motivation for self-care through the examination of their goals. The first objective was to gauge the importance patients accorded to managing HF relative to priorities in other life domains. The second objective was to determine whether the perceived incompatibility of HF self-management with non-health-related goals predicted adherence above and beyond the explanatory power of knowledge and self-efficacy.
Section snippets
Participants
Participants were HF patients who received their care from a hospital outpatient heart failure clinic in London, Ontario, Canada. Patients were invited to participate in the study during their scheduled appointment with a HF specialist. Inclusion criteria were: (1) the ability to speak and read English; (2) adequate mental status (as gauged by the attending physician); (3) mild to moderate HF symptoms as identified by the New York Heart Association functional (NYHA) Class II and III guidelines
Participant characteristics
Of the 289 patients screened at the clinic, 88 met the inclusion criteria and 40 (77.0% male; M age = 66.2; SD = 10.0) participated in the study (see Fig. 2). Sample characteristics are presented in Table 3. The majority of the sample met the criteria for NYHA Class II HF (65.0%) and reported being diagnosed with a comorbid disease (70.0%). On average, participants had lived with HF for 5.7 (SD = 3.9) years, were highly educated (mean years = 13.4, SD = 3.8) and were unemployed due to HF (24.3%) or
Discussion
The primary goal of this study was to determine whether considering patients’ broad range of goals could advance the understanding of HF self-care adherence. This study was among the first to elucidate patient priorities outside of HF care in a quantitative manner, and to report on the importance of illness-management when juxtaposed against other goals.
Our results showed that the majority of HF patients’ valued goals related to functional autonomy. The most common top-5 goals chosen by half of
Conflicts of interest
The authors declare no conflicts of interest.
Acknowledgements
This study was supported by the MITACS Accelerate Program, in collaboration with Sykes Assistance Services Corporation Internship reference number IT00658. The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources.
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