Adaptation to Turkish of the Self-Care of Heart Failure Index: A Validity and Reliability Study
1Clinic of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Türkiye
2Clinic of Cardiology, Başakşehir Çam and Sakura City Hospital, İstanbul, Türkiye
3 Public Hospitals 1st District, İstanbul Provincial Health Department, İstanbul, Türkiye
Keywords: Selfcare; heart failure; validity; reliability
Introduction: Heart failure is a chronic and progressive disease with increasing prevalence and incidence worldwide, despite advances in science and technology, and it necessitates long-term follow-up, treatment, and care. Self-care in heart failure is one of the fundamental elements of quality of life and disability-free living. The aim of this study was to assess the validity and reliability of the Turkish version of the Self-Care of Heart Failure Index v.2 (SCHFI).
Patients and Methods: The study sample included 233 patients who presented with a diagnosis of heart failure and volunteered to participate in the research at a training and research hospital. The data were collected using a personal information form and the SCHFI. The SCHFI was translated into Turkish, and the internal consistency coefficient and the item-total points reliability coefficient were analyzed for the reliability study. To determine structure validity, Explanatory Factor Analysis and Confirmatory Factor Analysis were performed.
Results: The adaptation of the SCHFI to Turkish culture was found to have high structure validity and internal consistency in the reliability and validity studies.
Conclusion: We concluded that the Self-Care of Heart Failure Index can be used as a unidimensional scale.
Despite continuing scientific and technological developments in the field of healthcare, heart failure has increasing prevalence and incidence throughout the world and remains one of the most important causes of morbidity and mortality. According to American Heart Association data from 2015, there were approximately 6.2 million heart failure patients aged >20 years in the United States, and with 870.000 new diagnoses per year added, the rate of diagnosed cases is expected to rise by 46 percent by 2030(1,2). According to the HAPPY study, heart failure prevalence in Türkiye is 6.9% and there are 2.000.424 adult heart failure patients(3). As heart failure is a chronic and progressive disease, it requires many years of follow-up, treatment, and care.
The primary aims of heart failure treatment are to reduce mortality and hospital admissions, increase functional capacity, correct symptoms and findings, and improve quality of life. In addition to medical treatment for patients with heart failure, it is necessary to record and strengthen self-care practices to ensure compliance with recommendations related to the management of signs and symptoms that cause mild to severe impairments in daily life due to fatigue, shortness of breath, and other cardiac findings(4). Heart failure self-care is defined as the process of healthcare and disease management in which stability is preserved in decisions and behaviors, changes in the patient’s condition are identified, and correct practices are provided(5,6).
The scales related to Self-Care Behaviours of Patients with Chronic Heart Failure in Türkiye include the “Self-Care Behaviours of Patients with Chronic Heart Failure Evaluation Scale” of 39 items, developed by Durademir in 1998, and the “European Heart Failure Self-Care Behaviour Scale” developed by Jaarasma et al. in 2003, with 12 items, which was then adapted to Turkish by Baydemir et al. in 2013(7-9).
Studies conducted in the field of heart failure have revealed the need to determine the levels which can be attained in healthy living behaviour, follow-up and management of symptoms, treatment adherence, and patient responsibility(10).
The Heart Failure Self-Care and the Self-Care of Heart Failure Indexes are among the most widely used tools worldwide(11,12). The Self-Care of Heart Failure Index (SCHFI) has been translated into 22 languages, and over the years has been modified several times in accordance with evidence-based practices(12). The SCHFI version 7.2 comprises 39 items in four dimensions: self-care (10 items), symptom perception (11 items), self-care management (8 items), and self-belief (10 items)(13).
The aim of this study was to assess the validity and reliability of the Turkish version of the SCHFI v. 2.
Patients and Methods
Study Universe- Sample
The recommended sample size for a scale to be adapted to a different culture is 5-10 times the number of items in the scale(14). Thus, the minimum sample size required for the validity and reliability study of the SCHFI-2, which contains 39 items, was 195 individuals. The sample group of volunteers for this research included 233 patients who presented at a training and research hospital with a diagnosis of heart failure.
The first dimension was used to collect general information such as age, gender, marital status, children, educational level, occupation, current employment status, economic status, and people living in the same home. The second dimension was used as the Turkish version of the SCHFI, which consisted of four dimensions: self-care (10 items), symptom perception (8 items), self-care management (11 items), and self-belief (10 items).
Language Validity of the Scale
The Turkish translation of the SCHFI (version 2) was done by three specialists fluent in both Turkish and English. Two of them were healthcare professionals, and one was a linguist who did not work in the healthcare field. The translated scales were collated and examined by another linguist for language compatibility. A language specialist back-translated the revised form into English, which was then compared for compatibility with the SCHFI-2, and the translation to Turkish was completed(15,16).
The study was carried out with the permission of the Health Sciences Hospital Clinical Research Ethics Committee (Decision No: KAEK/2022.07.230). All procedures were carried out in accordance with the ethical rules and the principles of the Declaration of Helsinki.
Data obtained in the analyses were evaluated using IBM SPSS (Statistical Package for Social Sciences) and 20 LISREL software. Descriptive statistics were calculated for all the variables and stated as number (n), percentage (%), mean ± standard deviation (SD) values, skewness, and kurtosis. To evaluate the knowledge of data factors, the Kaiser-Meyer-Olkin (KMO) test, sample sufficiency measurement, and the Bartlett sphericity test were used. Significance of the Bartlett sphericity test (p< 0.000) and 1.00≤ KMO≤ 0.90 showed that there was a sufficient sample to support factor analysis. To determine the structural validity of the scale, Exploratory Factor Analysis (EFA) and then Confirmatory Factor Analysis (CFA) were performed. Internal consistency coefficients (Cronbach alpha) were calculated to examine reliability.
The sociodemographic characteristics of heart failure patients are shown in Table 1.
63.7% of the participants were males and 36.3% were female, with a mean age of 57.59 ± 15.56 years. 74.2% were married, 73.4% had children, 46.8% were primary school graduates, 37.3% were retired, 69.5% had middle income, 72.1% were unemployed, and 90.6% lived together with family. The mean time since diagnosis was 57.25 ± 76.67 months.
In the descriptive analysis of the scale, the skewness and kurtosis values were between -3 and +3, showing normal distribution (Table 2).
Kaiser-Meyer-Olkin (KMO) test was performed to determine whether the sample size was suitable for Exploratory Factor Analysis (EFA). To determine whether or not the data were suitable for Exploratory Factor Analysis (EFA), Bartlett tests were performed (Table 3).
The KMO value was 0.95 and the result of the Bartlett test was significant (x2 = 6.327.631; p= 0.000). For EFA, confirmatory factor analysis was performed with a single factor explaining more than 5% variance according to the explained total variance table and the returned components matrix (Table 4, Table 5). The results showed that the dataset was suitable for EFA. A Scree Plot was obtained as a result of the EFA (Figure 1).
The graph shows that the scale has a single dimension. The single-factor cumulative values in the EFA were found to be >40%, determining a 46.7% variance.
The SCHFI had a single dimension, which seemed to explain 46.7% of the total variance. The factor load values of the items collected under the single dimension varied between 0.46 and 0.84 (Table 6).
To confirm the unidimensional structure obtained with EFA, Confirmatory Factor Analysis (CFA) was performed with the LISREL software (Figure 2).
The scale items were assigned t values. In accordance with the analyses performed, the level representing the implicit variable of all the items (observed oblique) of all the factors was significant at 0.05.
The goodness of fit index (GFI) values of the CFA were Chi-square (x2 ) 1640.27, Degree of Freedom (df) 691, x2 /df 2.37, and Root Mean Square Error of Approximation (RMSEA) 0.007. The Normalized Fit Index (NFI)= 0.96, Non-Normalized Fit Index (NNFI)= 0.97, and GFI= 0.73 (Table 7). The values of the defined fitness indices were above the acceptable values, and the first-level CFA model of the SCHFI generally showed a good fit.
When the reliability coefficients of the SCHFI, which consisted of 39 items, were examined, it was discovered that the reliability coefficient was 0.969 and the sub-dimension reliability coefficients ranged between 0.843 and 0.930. According to these findings, the internal consistency of this scale is high (Table 8).
Self-care and disease management for patients with heart failure generally include the administration of multiple medications, adherence to recommended diet and fluid restrictions, daily exercise, daily monitoring of symptoms and weight, and managing changes in symptoms. In the literature, self-care in heart failure patients is defined as behaviors to protect and maintain health, with a focus on self-care, symptom observation and management, and treatment adherence(17,18).
Previous research on heart failure patients conducted using self-care behavior scales has demonstrated the importance of evaluating factors and behaviors affecting self-care in the development of support mechanisms(19,20).
When the items in the SCHFI version 7.2 are examined, self-care in heart failure can be evaluated in many aspects using the items related to disease prevention(1,7), diet compliance(3,5,6,8,22), exercise(2), fatigue(14), symptom followup(11,16-18,20), psychological compliance(12), treatment compliance(4,5,9-11,13,15,19,23), and taking responsibility(21).
The structure validity and internal consistency were found to be high in this study of the validity and reliability of the Turkish version of the SCHFI version 7.2, which had not previously been validated in Turkish and was revised in accordance with current data in 2019, and evaluates the self-care of heart failure patients in many aspects, as shown in previous studies, but unlike other studies, it was concluded that this could be used as a unidimensional scale(21-23).
Cite this article as: Afşar F, Kayalı S, Kesgin V, Akgün T, Yılmaz H. Adaptation to Turkish of the self-care of heart failure index: A validity and reliability study. Koşuyolu Heart J 2022;25(3):226-234.
This study was approved by Başakşehir Çam ve Sakura City Hospital Clinical Research Ethics Committee (Decision no: 230, Date: 06.07.2022).
This is retrospective study, we could not obtain written informed consent from the participants.
Concept/Design - FA; Analysis/Interpretation - FA; Data Collection - SK, VK; Writing - FA; Critical Revision - FA, HY; Final Approval - TA, HY; Statistical Analysis - FA; Overall Responsibility - FA.
The authors have no conflicts of interest to declare.
The authors declare that this study has received no financial support.
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Figure and Tables