“Teach to Goal”: Theory and Design Principles of an Intervention to Improve Heart Failure Self-Management Skills of Patients with Low Health Literacy

Self-management is vital for achieving optimal health outcomes for patients with heart failure (HF). We sought to develop an intervention to improve self-management skills and behaviors for patients with HF, especially those with low health literacy. Individuals with low health literacy have difficulty reading and understanding written information and comprehending numerical information and performing calculations, and they tend to have worse baseline knowledge, short-term memory, and working memory compared to individuals with higher health literacy. This paper describes theoretical models that suggest methods to improve the design of educational curricula and programs for low literate audiences, including cognitive load theory and learning mastery theory. We also outline the practical guiding principles for designing our intervention, which includes a multi-session educational strategy that teaches patients self-care skills until they reach behavioral goals (“Teach to Goal”). Ourintervention strategy is being tested in a randomized controlled trial to determine if it is superior to a single-session brief educational intervention for reducing hospitalization and death. If this trial shows that the “Teach to Goal” approach is superior, this would support the value of incorporating these design principles into educational interventions for other diseases

The Effect of Progressive, Reinforcing Telephone Education and Counseling vs. Brief Educational Intervention on Knowledge, Self-Care Behaviors and Heart Failure Symptoms

The optimal strategy for promoting self-care for heart failure (HF) is unclear

A single-item self-report medication adherence question predicts hospitalisation and death in patients with heart failure

To determine whether a single-item self-report medication adherence question predicts hospitalization and death in patients with heart failure (HF)

Low Literacy Is Associated with Increased Risk of Hospitalization and Death Among Individuals with Heart Failure

BACKGROUND: Low literacy increases the risk for many adverse health outcomes, but the relationship between literacy and adverse outcomes in heart failure (HF) has not been well studied. METHODS: We studied a cohort of ambulatory patients with symptomatic HF (NYHA Class II-IV within the past 6 months) who were enrolled in a randomized controlled trial of self-care training recruited from internal medicine and cardiology clinics at four academic medical centers in the US. The primary outcome was combined all-cause hospitalization or death, with a secondary outcome of hospitalization for HF. Outcomes were assessed through blinded interviews and subsequent chart reviews, with adjudication of cause by a panel of masked assessors. Literacy was measured using the short Test of Functional Health Literacy in Adults. We used negative binomial regression to examine whether the incidence of the primary and secondary outcomes differed according to literacy. RESULTS: Of the 595 study participants, 37 % had low literacy. Mean age was 61, 31 % were NYHA class III/IV at baseline, 16 % were Latino, and 38 % were African-American. Those with low literacy were older, had a higher NYHA class, and were more likely to be Latino (all p < 0.001). Adjusting for site only, participants with low literacy had an incidence rate ratio (IRR) of 1.39 (95 % CI: 0.99, 1.94) for all-cause hospitalization or death and 1.36 (1.11, 1.66) for HF-related hospitalization. After adjusting for demographic, clinical, and self-management factors, the IRRs were 1.31 (1.06, 1.63) for all-cause hospitalization and death and 1.46 (1.20, 1.78) for HF-related hospitalization. CONCLUSIONS: Low literacy increased the risk of hospitalization for ambulatory patients with heart failure. Interventions designed to mitigate literacy-related disparities in outcomes are warranted

Comparison of a one-time educational intervention to a teach-to-goal educational intervention for self-management of heart failure: design of a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Heart failure (HF) is common, costly and associated with significant morbidity and poor quality of life, particularly for patients with low socioeconomic status. Self-management training has been shown to reduce HF related morbidity and hospitalization rates, but there is uncertainty about how best to deliver such training and what patients benefit. This study compares a single session self-management HF training program against a multiple session training intervention and examines whether their effects differ by literacy level.</p> <p>Methods/Design</p> <p>In this randomized controlled multi-site trial, English and Spanish-speaking patients are recruited from university-affiliated General Internal Medicine and Cardiology clinics at 4 sites across the United States. Eligible patients have HF with New York Heart Association class II-IV symptoms and are prescribed a loop diuretic. Baseline data, including literacy level, are collected at enrollment and follow-up surveys are conducted at 1, 6 and 12 months</p> <p>Upon enrollment, both the control and intervention groups receive the same 40 minute, literacy-sensitive, in-person, HF education session covering the 4 key self-management components of daily self assessment and having a plan, salt avoidance, exercise, and medication adherence. All participants also receive a literacy-sensitive workbook and a digital bathroom scale. After the baseline education was completed, patients are randomly allocated to return to usual care or to receive ongoing education and training. The intervention group receives an additional 20 minutes of education on weight and symptom-based diuretic self-adjustment, as well as periodic follow-up phone calls from the educator over the course of 1 year. These phone calls are designed to reinforce the education, assess participant knowledge of the education and address barriers to success.</p> <p>The primary outcome is the combined incidence of all cause hospitalization and death. Secondary outcomes include HF-related quality of life, HF-related hospitalizations, knowledge regarding HF, self-care behavior, and self-efficacy. The effects of each intervention will be stratified by patient literacy, in order to identify any differential effects.</p> <p>Discussion</p> <p>Enrollment of the proposed 660 subjects will continue through the end of 2009. Outcome assessments are projected to be completed by early 2011.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov <url>http://www.clinicaltrials.gov/</url> NCT00378950</p

Multisite Randomized Trial of a Single-Session Versus Multisession Literacy-Sensitive Self-Care Intervention for Patients With Heart Failure

Self-care training can reduce hospitalization for heart failure (HF), and more intensive intervention may benefit more vulnerable patients, including those with low literacy

Depressed or not depressed: untangling symptoms of depression in patients hospitalized with coronary heart disease.

BackgroundAssessing depression in patients hospitalized with coronary heart disease is clinically challenging because depressive symptoms are often confounded by poor somatic health.ObjectiveTo identify symptom clusters associated with clinical depression in patients hospitalized with coronary heart disease.MethodSecondary analyses of 3 similar data sets for hospitalized patients with coronary heart disease who had diagnostic screening for depression (99 depressed, 224 not depressed) were done. Depressive symptoms were assessed by using the Hamilton Depression Rating Scale or the Beck Depression Inventory. Hierarchical cluster analysis was performed on 11 symptom variables: anhedonia, dysphoria, loss of appetite, sleep disturbance, fatigue, guilt, suicidal symptoms, hypochondriasis, loss of libido, psychomotor impairment, and nervous irritability. Associations between symptom clusters and presence or absence of clinical depression were estimated by using logistic regression.ResultsFatigue (69%) and sleep disturbance (55%) were the most prevalent symptoms. Guilt (25%) and suicidal symptoms (9%) were the least common. Three symptom clusters (cognitive/affective, somatic/affective, and somatic) were identified. Compared with patients without cognitive/affective symptoms, patients with the cognitive/affective symptom cluster (anhedonia, dysphoria, guilt, suicidal symptoms, nervous irritability) had an odds ratio of 1.41 (P&lt;.001; 95% CI, 1.223-1.631) for clinical depression.ConclusionClinicians should be alert for clinical depression in hospitalized patients with coronary heart disease who have the cognitive/affective symptom cluster

Depressed or not depressed: untangling symptoms of depression in patients hospitalized with coronary heart disease.

BackgroundAssessing depression in patients hospitalized with coronary heart disease is clinically challenging because depressive symptoms are often confounded by poor somatic health.ObjectiveTo identify symptom clusters associated with clinical depression in patients hospitalized with coronary heart disease.MethodSecondary analyses of 3 similar data sets for hospitalized patients with coronary heart disease who had diagnostic screening for depression (99 depressed, 224 not depressed) were done. Depressive symptoms were assessed by using the Hamilton Depression Rating Scale or the Beck Depression Inventory. Hierarchical cluster analysis was performed on 11 symptom variables: anhedonia, dysphoria, loss of appetite, sleep disturbance, fatigue, guilt, suicidal symptoms, hypochondriasis, loss of libido, psychomotor impairment, and nervous irritability. Associations between symptom clusters and presence or absence of clinical depression were estimated by using logistic regression.ResultsFatigue (69%) and sleep disturbance (55%) were the most prevalent symptoms. Guilt (25%) and suicidal symptoms (9%) were the least common. Three symptom clusters (cognitive/affective, somatic/affective, and somatic) were identified. Compared with patients without cognitive/affective symptoms, patients with the cognitive/affective symptom cluster (anhedonia, dysphoria, guilt, suicidal symptoms, nervous irritability) had an odds ratio of 1.41 (P&lt;.001; 95% CI, 1.223-1.631) for clinical depression.ConclusionClinicians should be alert for clinical depression in hospitalized patients with coronary heart disease who have the cognitive/affective symptom cluster