The relationship between self-care maintenance and self-care management: a structural equation modeling

Background. Self-care maintenance (symptom monitoring and treatment adherence) is theorized to be the foundation for success in the overall self-care process. This proposition has not been previously tested. Purpose. The purpose of this study was to test the model of heart failure (HF) self-care (Riegel et al., 2004). In this model the connection between HF self-care maintenance and HF self-care management (symptom recognition and evaluation, and treatment implementation and evaluation) was tested with structural equation modeling. Methods. A cross-sectional design was used to study 357 symptomatic HF patients who had experienced problem breathing or ankle swelling in the last month. Patients were recruited from 16 outpatient clinics across Italy. Data were collected with a sociodemographic and clinical questionnaire and the Self-care of Heart Failure Index v.6.2. Structural equation modeling was performed using MPlus 5.0. Modification indices were used judiciously to improve model fit. Results. Patients were mainly male (56.3%) with a mean age of 72.7 years (SD 11.8). Most patients (62%) were in NYHA class II or III; 12.5% were in NYHA class I and 14.5% were in NYHA class IV. The mean ejection fraction was 42.2% (SD 11.9). The initial model showed poor fit. Three modifications were made that significantly improved model fit: 1) A direct effect of symptom monitoring on treatment implementation (bypassing symptom recognition), 2) symptom recognition on treatment evaluation (bypassing treatment implementation), and 3) a covariance between treatment adherence and treatment evaluation. The final model showed good fit: Chi-Square 4.85, DF 2, p .08, CFI .99, NNFI .94, RMSEA 0.06 (90% CI 0.0 - 0.14), SRMS 0.03. Conclusions. This is the first test of the theoretical structure of Riegel’s HF self-care model. Even though some modifications were needed to fit the model to the data, this study confirms the theoretical underpinnings of the relationship between self-care maintenance (treatment adherence and symptom monitoring) and self-care management (symptom recognition and evaluation, treatment implementation and evaluation). Further testing of this nature will help to identify how best to help HF patients to master the various tasks involved in self-care.