gms | German Medical Science

Background: Heart failure (HF) is a serious debilitating clinical syndrome that occurs when the pump action of the heart is unable to meet the body’s metabolic demands. There are an estimated 23 million people with HF worldwide. In the general population, HF prevalence amounts to 2% and over 16% among people aged 75 years and above. The German Federal Office of Statistics reported 317.000 cases of HF requiring hospitalization. The Robert Koch Institute released figures indicating that 2.7 billion Euros were spent on HF treatment; around 70% of these costs were attributed to in-patient care. Adherence to self-care including dietary adherence, medication taking and symptom monitoring is vital in HF patients. International guidelines recommend on-going self-care; yet patients frequently fail to adhere to self-care recommendations. Efforts to develop sound interventions to enhance self-care are critical in order to reduce hospital (re-)admissions. To date, single qualitative studies provide varied reasons why patients do not engage in self-care activities. However, they are frequently limited by the range of population groupings and study settings. Thus, synthesizing the findings of multiple qualitative studies in a qualitative meta-synthesis is an ideal approach to addressing these limitations.

Research question: From the perspective of people with HF living at home and who had no active research intervention at the time of the interview, what are the barriers and facilitators to self-care recommendations?

Method: We applied Sandelowski and Barroso’s comprehensive procedure for conducting a qualitative meta-synthesis. Qualitative studies of patients with HF were chosen as the method case. We searched the literature databases MEDLINE, EMBASE, PsycINFO, CINAHL, ASSIA, BASE and DART Europe without language restriction. Searches were undertaken from 2010 to July 2015. Out of 2810 papers identified, 31 studies were included in the meta-synthesis. Individual studies were appraised using the 14-item reading guide to extract information about content, orientation and structure of every study. We used the ‘typology of qualitative findings’ to discern similarities and differences between findings. Out of the 31 reports, a total of 415 statements relating to barriers and facilitators to self-care recommendations were extracted. Findings were edited by staying close to the words of the authors while clarifying them so that they are meaningful on their own. We then grouped findings of the same topic to see how they were related to each other. In the abstraction process, statements were further reduced until we finally had a set of concise statements that reflected the content of all the findings.

Results: Influences for effective self-care in patients with HF arose in different sectors and levels. On the personal level we found influential factors like food preferences, ethnic socialisation, financial constraints and self-efficacy, comorbidities, self-care adverse effects and social relationships to be of significant relevance. On the task level the following factors influencing self-care were identified: knowing the diagnosis, communication of the complex and time consuming recommendations, (lack of) knowledge or understanding of self-care recommendations and misinterpretations, recognising and interpreting symptoms, experiences with self-care activities and deciding to act adequately. The interaction of these factors is complex and can lead to better or worse self-care. While expressing challenges to integrate self-care into daily life, patients developed strategic plans to facilitate this integration process. Stable social support, good communication between patients and caregivers and a sense for the importance of healthy behaviour alleviated this development.

Discussion: This meta-synthesis highlights the key themes recurring in qualitative studies of people with HF regarding their self-care competences. This work elucidates inhibiting and supporting factors for self-care and how these can both facilitate or impede efforts to manage HF self-care.

Practical implication: In line with the Medical Research Council (MRC) framework, this current project lays the foundation stone for developing a prospective evidence-based complex intervention with the aim of enhancing self-care recommendations in HF patients to reduce hospital (re-)admissions.