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Abstract |
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• Objectives To identify the stage of readiness for change in 6 lifestyle behaviors important in heart failure and to determine differences in signs and symptoms of heart failure, self-reported knowledge of the disease, and self-reported behavior between patients who have taken action and patients who have not.
• Method A mail survey of 250 patients with heart failure.
• Results Most respondents reported consistent avoidance of tobacco (90.6%), alcohol (87.9%), sodium (81%), and excess fluid (72.6%) and regular participation in exercise (67.1%) and trying to lose weight (64.7%). Yet only 38.7% had a regular exercise program, and 94.2% had eaten high-sodium foods in the preceding 24 hours. Knowledge of heart failure was low (mean score, 67.4%) and did not differ by stage of change. Only 30.4% of the respondents were at their desired weight, and most overweight subjects had been trying to lose weight for more than 6 months.
• Conclusions Although respondents thought they were consistently adhering to recommended guidelines for changes in lifestyle, actual reported behaviors did not always support this evaluation. Use of the stage of change tool to assess stage of readiness to make lifestyle changes may not work well in patients with heart failure, perhaps because of the number and complexity of the changes needed.
At any given moment, only about 20% of at-risk populations are ready to take meaningful action to change a health behavior, and 40% of those with a problem are in a stage of change marked by denial and resistance.10 The Transtheoretical Model is a framework for assessing and addressing readiness for changes in behavior. The constructs of the model have been supported in numerous studies of addiction cessation and lifestyle change related to diet,11–13 smoking,14–16 weight loss,17,18 alcohol abuse,19 and exercise.20–27 After 2 decades of research, it has become one of the most influential models in healthcare psychology.
The Transtheoretical Model was first proposed by Prochaska, DiClemente, and Norcross28–30 and consists of 3 dimensions:
In the Transtheoretical Model, a change in behavior is viewed as a 5-stage process that may progress in a linear fashion but most often progresses in a spiral pattern, including relapse to previous stages, recycling through the stages, and learning from mistakes before the changed behavior becomes stable. One of the critical assumptions of the model is that chronic behavioral patterns are under some combination of biological and social influence and self-control.30 Interventions designed within the model are targeted to enhance self-control.
The 5 stages of change within the model30 are
Application of the Transtheoretical Model to specific dietary and other changes required for successful behavior modification in patients with heart failure has not been reported. Understanding how the model works in patients with heart failure may yield insight into why some patients make changes in response to advice from healthcare providers and others do not. The purposes of this pilot study were to determine
The changes in behavior studied were avoiding dietary sodium and excess fluid intake, exercising regularly, avoiding use of alcohol and tobacco, and losing weight, if overweight.
| Patients are often admitted for decom-pensated heart failure because they do not adhere to changes in lifestyle.
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Methods |
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The Survey Tool
The survey questionnaire was developed by us from tools used in previous research with the Transtheoretical Model and from content in the literature on heart failure. The format was prepared in accord with recommendations set forth by Dillman.31 The tool consisted of a section on demographic and personal data, a series of questions to determine stage of change for the 6 behaviors, and the part on knowledge of the disease and self-reported behavior. The survey was reviewed by 2 cardiovascular nurse practitioners who were asked to assess it for accuracy and relevance to information patients with heart failure need in order to self-manage the condition and behaviors that would indicate the patients were doing so. A readability expert, using PROSE readability analysis (MicroBrothers Software, Boulder, Colo), found it to be at the grade 7.45 reading level, consistent with recommendations for materials distributed to patients. It was evaluated by a statistician for ease of data entry and then pretested on 10 patients with heart failure, revised, and retested. In its final form, it was 11 pages long, had 143 response items, and took about 20 minutes to complete.
In addition to the usual demographic data on age, sex, race/ethnic background, and education, personal data included signs and symptoms of heart failure experienced in the preceding month, comorbid conditions, the subject’s current height and weight so that body mass index could be calculated, and a self-reported measure of functional status or cardiovascular ability, the Specific Activities Scale.32 The Specific Activities Scale has greater interrater reliability than does the New York Heart Association functional classification32,33 and is more valid than the New York Heart Association classification when concurrently compared with treadmill performance.32 The scale has been used in other research on heart failure.34,35
Stage of readiness for change for each of the 6 behaviors was determined by using a single-item algorithm consisting of a question and 5 response items representing the operational definition of each of the stages of change (Table 1
). This method has been used for decades by Prochaska and colleagues at the Cancer Prevention Research Center.20 Although multi-item tools have been proposed for assessing stage of change,36 the format recommended by the investigators at the Cancer Prevention Research Center, who have published most of the research supporting the Transtheoretical Model, is the 1-item algorithm with a 5-choice Likert-response format37 because of its simplicity in survey research. Wording of the questions and response options were identical with wording on tools published in the literature on the Transtheoretical Model.
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Adherence to guidelines for recommendations for sodium, fluid restriction, and exercise was assessed by using a series of questions designed to gather data on whether or not the subjects had been advised about the recommendation and how closely they adhered to the recommendations. Avoidance of salty foods was assessed by asking subjects to identify how many foods from a list of 15 common foods with sodium content greater than 800 mg per serving they had eaten in the past 24 hours. Items about how often in the past month subjects avoided these foods, read food labels for sodium content, or weighed themselves were modeled after the survey of Ni et al38 and had Likert-type responses. Items related to restricting fluids, frequency and duration of exercise, and frequency of exercising as advised were also included. Maximum points for these questions were given for adherence with practice guidelines and no points for nonadherence. Degrees of partial adherence were scored between the extremes. Means were determined to quantify the degree of adherence to practice guidelines for subjects who had taken action to change and those who had not. Self-care behavior questions are included in Table 1
. Table 2 summarizes the lifestyle changes and the self-care behaviors addressed in this study.
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Data Analysis
The data were entered into SPSS version 10 for Windows (SPSS Inc, Chicago, Ill). The quality of the data was ensured by specifying acceptable ranges for each field and variable. Outliers were checked against the raw data and were corrected. A random sample of 50 questionnaires was selected for review of the entered data; the error rate was less than 1%. Data were analyzed by using descriptive statistics, independent t tests, and 
2 analysis. The Bonferroni correction for multiple comparisons on the same data resulted in the family-wise error rate being set at .001 for statistical significance.
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Results |
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Table 3 includes information about the sample. In general, subjects were relatively young (mean, 55.6 years) white or African-American men. Most had a high school education (mean, 12.4 years) and were married, disabled, or retired. All functional classes of heart failure were represented. Heart failure had been diagnosed from less than 6 months ago to 35 years ago (mean 6.5 years), and the number of comorbid conditions ranged from 0 to 10 (mean 3.65).
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includes data for the stages of change for each of the lifestyle changes. Subjects were more often in the maintenance stage than in any other stage for each of the 6 lifestyle changes. Because of the small numbers of subjects in the preparation, contemplation, and precontemplation stages, statistical analysis was used to compare those who reported taking action to change (action and maintenance) with those who were not taking action (preparation, contemplation, precontemplation). When those in maintenance were taken together with those in the action stage, subjects reported themselves to be consistently avoiding tobacco (90.6%), alcohol (87.9%), sodium (81%), and excess fluid (72.6%); getting regular exercise (67.1%); and trying to lose weight (64.7%).
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| Most subjects reported appropriate changes in lifestyle, yet more than half did not exercise regularly and almost all had recently eaten high-sodium foods.
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Signs and Symptoms of Heart Failure
Table 5 shows the most frequently reported signs and symptoms of heart failure and the number of subjects taking action (action and maintenance stages) or not taking action (precontemplation, contemplation, and preparation stages) to change dietary and exercise behaviors. Fatigue with less than usual activity (65%) and shortness of breath (49%) were the most frequently reported symptoms. Subjects who regularly exercise and consistently avoid dietary sodium and excess fluid intake might be expected to report fewer occurrences of each sign or symptom; however, 2 x 2 2 analyses for presence or absence of these signs and symptoms in those taking action and those not taking action to change indicated that the differences between the 2 groups were not statistically significant. The hypothesis that patients in the maintenance and action stages would report lower mean numbers of signs and symptoms of heart failure in the past month than would patients who had not taken action to change (preparation, contemplation, and precontemplation) was not supported by independent t tests for any of the lifestyle changes (Table 6).
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Sodium and Fluid Restriction
A total of 88% of the subjects had received advice to lower intake of dietary sodium, and, as reported earlier, 81% thought they were consistently doing so by placing themselves in the maintenance or action stage of change. Yet 94.2% of the subjects who said they had been advised to maintain a low-sodium diet reported that they had eaten at least 1 item in the preceding 24 hours from the list of foods with more than 800 mg of sodium per serving (mean, 3.75 items for the sample). Among the respondents, 47% added salt to food when cooking, and 37% had eaten canned vegetables and/or fast food in the preceding 24 hours. We hypothesized that patients in the action and maintenance stages for sodium restriction would report self-care behaviors more consistent with recommendations for patients with heart failure than would patients who had not changed behavior. This hypothesis was supported for avoiding high-sodium foods in the preceding month (t = 6.7, df = 163, P < .001) and for reading food labels to determine sodium content (t = 6.82, df = 168, P < .001). The hypothesis that those who had made a change to limit fluid intake would report behavior more consistent with recommendations for patients with heart failure than would patients who had not made a change was supported for avoiding high-sodium foods (t = 4.43, df = 159, P < .001), reading food labels (t = 3.35, df = 163, P = .001), and drinking less than 2 qt of fluid a day (t = 7.14, df = 161, P < .001). Neither the hypothesis for weighing daily nor the one for exercising as advised was supported.
Getting Regular Exercise
Only 38.7% of the sample reported having a regular exercise program, and only 67.5% of those exercised 3 times a week or more. Compared with patients who did not exercise, those who reported being in the action and maintenance stages were more likely to weigh themselves daily (t = 3.34, df = 164, P = .001), exercise 3 times a week (t = 8.05, df = 128, P < .001), exercise 30 minutes or more at a time (t = 2.9, df = 119, P < .001), and exercise as advised (t = 4.83, df = 121, P < .001).
Losing Weight
Body mass index (BMI; calculated as weight in kilograms divided by the square of height in meters) was determined for subjects who reported their height and weight (n = 171). The BMI for the sample ranged from 16.7 to 51.1, with a mean of 28.7. Among the sample, 68.4% had a BMI of 25 or greater and only 52 (30.4%) were at their desired weight (BMI, 18.5–24.9). A total of 103 subjects (59.9%) thought they weighed too much, and 45% of overweight or obese subjects reported that they had never been advised to lose weight. Table 7 shows the number and percentage of subjects trying to lose weight (n=151) in each BMI category by stage of change for trying to lose weight. Most subjects in the overweight, obese, and morbidly obese categories reported that they were in the maintenance stage.
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Discussion |
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Our data did not suggest this relationship for sodum-containing foods. In general, subjects reported that they were consistently avoiding high-sodium foods yet admitted to eating at least one in the preceding 24 hours. This discrepancy may be explained by a lack of understanding about what they should be doing and the complexity of the behavior. Although a person either does or does not smoke or drink alcohol, behaviors such as exercise or following a low-sodium diet are not dichotomous. Even a fruit or a vegetable is easier to identify than is "salt," which is an invisible ingredient within foods. Following a low-sodium diet requires knowing how to read food labels and knowledge about hidden sources of sodium in foods without labels. A further explanation for lack of knowledge and understanding may be related to the sheer number of changes patients with heart failure are being asked to make. They not only may have to give up cigarettes and lose weight, they may also have to change eating habits related to calories and sodium and begin to exercise regularly for the first time.
Ni et al38 found that among patients who knew they should limit salt intake, only 38% did so. Knowing that one should limit salt and not following through with the action to do it may indicate that one is in the preparation, contemplation, or precontemplation stage of readiness. However, our findings add another piece of information to the picture. Our subjects knew that they should avoid salty foods, appeared not to be avoiding these foods, but thought that they were avoiding them (in maintenance or action stages). This behavior, coupled with their low knowledge scores, further suggests that subjects lacked knowledge about which foods were high in sodium (ie, lacked the information to accurately act to change this behavior). Another explanation is that responses related to consistently avoiding dietary salt were socially desirable responses. We therefore suggest that assessment of readiness to change dietary intake of sodium should be accompanied by assessment of knowledge and actual behavior. Use of a food checklist may be a good way to clinically assess actual adherence to a low-sodium diet and a way to begin or reinforce patients’ specific teaching about sodium by showing food labels and offering alternative foods.
Use of a don’t-know option appeared to work to reduce guessing answers on the knowledge test but may have contributed to the low scores, because this option was used frequently. Of note, recent research39 indicated that nurses themselves may not have proper education in self-care principles for patients with heart failure, and this possibility should be considered as a factor in patients’ low level of knowledge. A high percentage of subjects in our study reported that they had received information, but the information may not have been sufficient. Low knowledge scores for patients, regardless of the reason, support the need for continual reassessment of knowledge after educational interventions and for reinforcement of information during the course of many encounters with patients when assessment indicates the need.
As clinicians, we hope that patients who follow recommendations will have fewer signs and symptoms than do patients who do not follow the recommendations. Yet in this pilot study, patients’ self-reported consistent avoidance of dietary sodium and excess fluid and adherence to exercise recommendations did not result in fewer signs and symptoms of heart failure in the preceding month. Arguably, following sodium restrictions is the most important lifestyle change patients can take to manage signs and symptoms such as shortness of breath, fatigue, paroxysmal nocturnal dyspnea, or edema and sudden weight gain. The fact that those who reported consistent avoidance of high-sodium foods did not have significantly fewer of any of these signs and symptoms than did patients who did not avoid such foods further supports the notion that the first patients really did not follow the recommendation as well as they thought they did. The fact that they were more likely to weigh themselves daily, however, suggests that they were perhaps aware of the relationship between dietary sodium, fluid retention, and signs and symptoms.
The weight of our subjects was of concern for many reasons. First, on the basis of BMI, 68.4% of the subjects weighed more than their optimal weight, and this characteristic may limit their option for transplantation if transplantation becomes necessary. Most of them reported that they had been actively trying to lose weight by dieting for more than 6 months, apparently without complete success. These subjects were conscious of their weight because they were more likely to weigh themselves daily, and most knew they were overweight. However, those overweight, obese, and morbidly obese subjects who reported actively trying to lose weight by dieting were not exercising as advised. This finding suggests that their weight-loss efforts consisted only of dietary means and that they were sedentary in their exercise habits. In fact, only 38.7% of subjects exercised regularly, fewer than reported by Carlson et al34 in a sample of patients with heart failure who were a mean of 13.7 years older than the patients in our sample.
| Subjects may have been unable to change dietary behaviors because they did not know enough about high-sodium foods.
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Although our findings need to be verified in a larger sample, if these subjects could be persuaded to add exercise to their lives, perhaps the ratio of calories in to calories out could be tipped in favor of weight loss. Further, the finding that almost half of those who were overweight perceived that they had never been advised to lose weight has implications for practitioners. Do we give patients direct and clear information about the importance of achieving and maintaining an optimal weight? Do we focus on the reduction of sodium in the diet such that we fail to assess caloric intake? Do we make clear the relationship between exercise and weight loss and try to encourage a method of exercise that is acceptable to the patient? Do we consider an organized cardiac exercise or rehabilitation program for patients who have access to and can afford one? Are we aware that these patients may be in denial about the need to lose weight and may not hear us when we do advise weight loss?
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Limitations |
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In defense of the method, however, mail surveys, compared with face-to-face interviews and telephone interviews, have the least probability of producing socially desirable responses in research.31 The questionnaire developed for use in this study appeared to be understood by the subjects, because data were missing in only a few instances. Also, use of the Dillman method resulted in a high enough rate of return of the surveys for reasonable confidence in the data.
The finding that subjects, after having received information, thought they had made necessary change but probably had not raises questions about the usefulness of the Transtheoretical Model in patients with heart failure. Other research with the Transtheoretical Model has addressed changing one behavior at a time, and fundamental problems with using the Transtheoretical Model with dietary behaviors have been suggested.40 Perhaps the sheer number and complexity of the changes our subjects were asked to make were too overwhelming for accurate and complete learning to occur. Before the stages of change framework is used to develop and test interventions to help patients move through the stages, our findings need to be confirmed or refuted by studying a larger, more geographically diverse and representative sample of patients with heart failure. Further, use of the model with hospitalized patients with heart failure may help address the question of the most appropriate timing for assessment of readiness for change.
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ACKNOWLEDGMENTS |
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This research was supported by Medical University of South Carolina institutional research funds for 2000–2001.
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REFERENCES |
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