A Multi-Methods Study Of Social Determinants And Self-Care In Adults With Heart Failure

Social determinants of health (SDH) include the social, economic, and built environmental resources that define health. Inequitable distribution of these resources results in disparate health outcomes. Disadvantaged population groups experience limited access to health-promoting resources that further marginalize them from mainstream society and increase their predisposition to chronic cardiovascular diseases (CVD) such as heart failure (HF). Although prior research has linked social disadvantage to CVD risk, few studies have explored the mechanism underlying the social determinants – health outcomes relationship. The overall goal of this dissertation was to develop scholarship surrounding the relationship between SDH and HF self-care, and explore operational mechanisms underlying that relationship. Using a three-article dissertation format, chapter two of this dissertation presents a synthesis of existing literature on marginalization and situates the concept of marginalization in the SDH framework. Chapter three reports the findings of a secondary data analysis that explored the relationship between sociodemographic indicators of SDH and self-care maintenance in adults with HF. Chapter four presents the findings of a mixed methods study of SDH and HF self-care. The first aim of the study addressed the relationship between SDH and self-care in community dwelling adults with HF. The second aim explored participants’ perceptions, beliefs, and experiences surrounding SDH and self-care behavior using one-on-one in-depth interviews. In integration, differences and/or similarities in the self-reported SDH in relation to participants’ self-care behavior were described. Major findings of this dissertation were: 1) Disparities and inequity in health promoting resources increase with increased distance from mainstream society, 2) Social position serves as the link between SDH and marginalization, 3) Socio-political, economic, cultural and religious influences accentuate the marginalization of vulnerable population groups, further limiting their access to health promoting resources, 4) Race, education and marital status were associated with self-care maintenance, 5) Social connections, individual lived experiences, and type of insurance coverage are possible mechanisms underlying the SDH-Self-care relationship. This dissertation adds to current literature on the relationship between SDH and HF self-care. Knowledge gained will inform future research, clinical and policy interventions that facilitate self-care, reduce disparities, and enhance equity

Marginalization: Conceptualizing patient vulnerabilities in the framework of social determinants of health: An integrative review

Scientific advances in health care have been disproportionately distributed across social strata. Disease burden is also disproportionately distributed, with marginalized groups having the highest risk of poor health outcomes. Social determinants are thought to influence health care delivery and the management of chronic diseases among marginalized groups, but the current conceptualization of social determinants lacks a critical focus on the experiences of people within their environment. The purpose of this article was to integrate the literature on marginalization and situate the concept in the framework of social determinants of health. We demonstrate that social position links marginalization and social determinants of health. This perspective provides a critical lens to assess the societal power dynamics that influence the construction of the socio‐environmental factors affecting health. Linking marginalization with social determinants of health can improve our understanding of the inequities in health care delivery and the disparities in chronic disease burden among vulnerable groups

Patterns of adherence to diuretics, dietary sodium and fluid intake recommendations in adults with heart failure

Background: Three behaviors advocated to minimize fluid-related hospitalizations in patients with heart failure (HF) are restricted sodium and fluid intake and consistent oral diuretic use. Adherence to behaviors intended to decrease risk of hospitalization is believed to vary over time, but surprisingly little research has addressed patterns of adherence in HF patients. Objective: To describe patterns over time of 3 recommended self-care behaviors (i.e., diet, fluid intake, and diuretic dosing) in adults with HF and to determine how time and behavior influenced adherence rates. Methods: We enrolled 24 adults hospitalized for a HF exacerbation and discharged on a loop diuretic into a descriptive, longitudinal pilot study. Over 3-months, diuretic use was measured using electronic event monitoring, and participants were telephoned regularly to assess sodium and fluid intake. Data were summarized for each 2-week intervals. Results: The overall adherence rates were 42.4% for low sodium diet, 96.4% for fluid restriction, and 84.7% for the diuretic regimen. Early after hospital discharge, medication adherence was the highest, and dietary adherence was the lowest, but adherence to diet and diuretic use decreased significantly over time. Conclusion: Although participants were just discharged from the hospital after an acute exacerbation of HF, all three behavioral patterns decreased markedly over the 3-month follow-up period

Sociodemographic indictors of social position and self-care maintenance in adults with heart failure

Social determinants of health (SDH) are known to influence health. Adequate self-care maintenance improves heart failure (HF) outcomes. However, the relationship between self-care maintenance and SDH remains unclear. Explore the relationship between sociodemographic indicators of social position and self-care maintenance in adults with HF. This was a secondary analysis of data from a cross-sectional descriptive study of 543 adults with HF. Participants completed the Self-Care of HF Index and a sociodemographic survey. We used multiple regression with backward elimination to determine which SDH variables were determinants of self-care maintenance. Marital status (p = .02) and race (p = .02) were significant determinants of self-care maintenance. Education (p = .06) was highest in Whites (35.6%). These variables explained only 3.8% of the variance in self-care maintenance. Race, education, and marital status were associated with HF self-care maintenance. SDH is complex and cannot be explained with simple sociodemographic characteristics

A mixed methods study of symptom perception in patients with chronic heart failure

Background,br> Early heart failure (HF) symptoms are frequently unrecognized for reasons that are unclear. We explored symptom perception in patients with chronic HF. Methods We enrolled 36 HF out-patients into a longitudinal sequential explanatory mixed methods study. We used objectively measured thoracic fluid accumulation and daily reports of signs and symptoms to evaluate accuracy of detected changes in fluid retention. Patterns of symptom interpretation and response were explored in telephone interviews conducted every 2 weeks for 3-months. Results In this sample, 44% had a mismatch between objective and subjective fluid retention; younger persons were more likely to have mismatch. In interviews, two patterns were identified: those able to interpret and respond appropriately to symptoms were higher in decision-making skill and the quality of social support received. Conclusion Many HF patients were poor at interpreting and managing their symptoms. These results suggest a subgroup of patients to target for intervention