Neglect of self-care in patients with heart failure: Instrument Development and Psychometric Properties

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The purpose of this study was to develop a valid and reliable measure for the neglect of self-care in patients with heart failure. Methods The study was methodological research. A three-stage mixed methods study was conducted: (a) in-depth interviews with patients with heart failure were analyzed to extract key themes; (b) these themes, combined with a literature review, informed the development of a 55-item preliminary instrument; and (c) the instrument's content, face, and construct validity were assessed using content validity ratio, content validity index, and exploratory factor analysis. Results Subscales in the final instrument Drug negligence", "Nutritional negligence", "Sexual negligence", "Environmental negligence", "Physical activity negligence", "Informational-communicational negligence” and “Negligence in prioritizing self-care”. Reliability of the instrument was .92. Conclusions The final 35-item “neglect of self-care in patients with heart failure “demonstrated strong psychometric properties. Clinical trial number: Not applicable Psychometric Properties Instrument Development Self-Care Neglect Heart Failure Figures Figure 1 Background One of the most common chronic diseases is cardiovascular disease. According to the World Health Organization, cardiovascular diseases are the leading cause of death worldwide, with 82% of these deaths occurring in developing countries, and it is predicted that they will remain the leading cause of death in the world by 2030 [ 1 ]. Heart failure (HF) is one of the most common heart diseases [ 2 ]. HF occurs when the heart cannot pump sufficient blood to fulfill the body's metabolic requirements [ 1 ]. Dorothy Orem introduced the concept of self-care in 1959 through her self-care theory, defining it as the actions individuals take to maintain and improve their health, well-being, and to prevent or treat illness [ 3 ]. Self-care in HF includes adhering to a specific diet and medication plan, restricting sodium and fluid intake, managing activity levels, tracking daily weight, and making informed treatment decisions as the disease advances [ 4 ]. Evidence shows that HF patients often engage in poor self-care. A study highlights that most of these patients exhibit inadequate self-care behaviors and neglect essential practices [ 5 ]. Neglect refers to forgetting, carelessness, ignorance, and inattention despite being aware [ 6 ]. In chronic illnesses, this neglect can exacerbate the condition and reduce quality of life [ 7 ]. Patients with heart failure often experience symptom exacerbation and repeated hospitalizations due to self-care neglect, including medication neglect, dietary neglect, activity and sports neglect, information acquisition neglect [ 8 – 9 ]. A 2012 study found that chronic patients often neglect self-care, including diet, medication, daily activities, exercise, and stress management [ 8 ]. A study identified key barriers to self-care in HF patients, including knowledge deficits, inadequate social support, complicated treatment regimens, limited access to treatment, and high costs [ 9 ]. Another study reported that financial issues, treatment costs, and lack of insurance as barriers to self-care among heart patients [ 10 ]. Similarly, a study attributed patients’ non-participation in self-care to their social and economic status [ 11 ]. In 2012, a study reported that Orem’s theory does not address cases of neglect in self-care and strategies for reducing it [ 12 ]. Database searches revealed that no instrument has been specifically designed and validated to evaluate self-care neglect in HF patients; most existing tools focus on self-neglect among the elderly. A study developed and validated the Self-Neglect Scale for Polish elderly, which assesses self-neglect in basic and psychological needs over the past year. The 12-item scale has scores ranging from 0 to 12, with higher scores indicating greater self-neglect. The scale focuses on identifying the presence and severity of self-neglect in older people living independently in the community [ 13 ]. These questionnaires only examine self-neglect in the elderly and cannot be used for chronic diseases, including HF, which have multiple symptoms and complications. As most HF patients are elderly and face life-threatening symptoms, they often resort to self-medication, leading to exhaustion in their self-care efforts. Also, many patients with heart failure are hospitalized several times a year due to neglect of self-care. Therefore, it is essential to develop a valid and reliable tool to measure neglect in self-care and its related dimensions, enabling effective educational and support interventions to enhance self-care among these patients. The design of this tool will help doctors and nurses to measure the level of neglect of self-care in patients with heart failure and try to eliminate it. Methods Study design A methodological research study was conducted between October 2024 and February 2025 on patients with class I to IV heart failure who, based on a cardiologist’s diagnosis, were either hospitalized or received outpatient care in the cardiology departments of public and private hospitals in Kashan and Tehran Heart Center. Data collection In the first phase of the study, the item pool was developed through 19 interviews conducted with 15 patients with heart failure, a cardiologist, a nurse, and a patient's child and spouse. The main interview question was: 'Please describe a typical day in your life since your HF diagnosis.' The interview then continued with specific questions based on the research objectives, such as: 'Please describe the problems you have encountered with your illness that have led you to seek additional care,' 'What have you done to manage your symptoms,' 'What aspects of your treatment have you not followed,' 'In what areas do you not take self-care seriously,' 'What is the role of your family in your treatment and care,' and 'What consequences has neglecting self-care had for you?' Based on the participants’ responses, exploratory and clarifying questions such as 'Can you explain more?' were also asked. Each interview lasted between 45 and 60 minutes. In addition, a literature search was conducted in ProQuest, PubMed, Scopus, CINAHL, Ovid, Google Scholar, and Elsevier using keywords related to heart failure, cardiovascular disease, neglect, self-care, inattention, and limitations in care. Articles published between 2015 and 2025 relevant to the tool were reviewed. Items were obtained from both the literature and related instruments. Ultimately, 365 codes and six main themes—drug negligence, nutritional negligence, sexual negligence, environmental negligence, physical activity negligence, and informational-communicational negligence—were extracted from the interviews and literature review [ 14 ]. These categories and subcategories were used to generate the initial item pool for the Neglect of Self-Care in Patients with Heart Failure Scale (NSC-HF). The available literature and instruments will continue to inform item generation. In the second phase of the study, the initial scale was developed with 55 items. A 5-point Likert scale was used for scoring, with the following options: (1 = not at all important, 5 = very important). Higher scores obtained by participants indicated a greater neglect of self-care. Following the development of the initial scale, its psychometric properties were systematically evaluated. These included face validity (both quantitative and qualitative), content validity (both quantitative and qualitative), structural validity, and reliability. To assess both the qualitative and quantitative aspects of face validity, the scale was administered to 12 patients with heart failure. Participants were asked to evaluate the clarity and relevance of each item in relation to the overall purpose of the scale, as well as to identify any ambiguities or difficulties in wording [ 15 ]. Additionally, they rated the importance of each item using a 5-point Likert scale, ranging from 1 (not important at all) to 5 (very important). Subsequently, the impact score for each item was determined using the following formula: Item Impact = Importance × Frequency (%). Items with a score equal to or above 1.5 were retained in the scale. At this stage, two items fell below the threshold of 1.5 and were therefore excluded from the final version. To evaluate the qualitative and quantitative content validity, ten experts in cardiac nursing and clinical instrumentation were invited to review the items. They provided feedback on grammar, clarity, word appropriateness, and the suitability of the scoring scale. Additionally, they assessed the necessity of each item using a 3-point Likert scale (3 = necessary, 2 = useful but not necessary, 1 = not necessary). The content validity ratio (CVR) was calculated for each item based on Lawshe’s method. According to the Lawshe table, items with a CVR below 0.51 were excluded [ 15 ]. Among the 55 initial items, 47 achieved a CVR of 0.57 or higher, resulting in the elimination of 8 items. Subsequently, 15 experts were asked to evaluate the relevance of each item using a 4-point Likert scale (1 = not relevant, 2 = somewhat relevant, 3 = relevant, 4 = highly relevant). Based on their ratings, the content validity index (CVI) was calculated for each item. Items with a CVI above 0.80 were considered acceptable [ 16 ]. All remaining items had CVI values of 0.87 or higher, and therefore, no further items were removed. Additionally, the scale-level content validity index (S-CVI) was determined by averaging the item-level CVI scores (I-CVI). An S-CVI value above 0.90 is considered acceptable [ 16 ], and the S-CVI for this scale was 0.97, indicating excellent overall content validity. Construct validity of the scale was assessed through a cross-sectional study using exploratory factor analysis (EFA). Participants were selected via convenience sampling from both inpatient and outpatient populations with heart failure at Shahid Beheshti Hospital in Kashan and the Tehran Heart Center. Based on Harrington’s recommendation (2009), a sample size of 300 or more is appropriate for conducting EFA [ 17 ]. In this study, questionnaires, and consent forms were distributed to 421 patients with heart failure. All questionnaires were returned, with 390 completed, resulting in a response rate of 81%. Following data collection, exploratory factor analysis (EFA) was conducted to identify the underlying constructs of the OHI-SSS scale. Principal component analysis (PCA) was used as the extraction method, along with varimax rotation to enhance interpretability of the factor structure. Prior to conducting exploratory factor analysis (EFA), the Kaiser–Meyer–Olkin (KMO) test was performed to assess sampling adequacy, with a threshold of ≥ 0.6. Factor retention decisions were guided by multiple criteria: eigenvalues exceeding 1, visual analysis of the scree plot (Graph 1), and a minimum acceptable factor loading of 0.40 for each item. The reliability of the scale was assessed using Cronbach’s alpha coefficient, with values above 0.70 considered acceptable [ 16 ]. To evaluate temporal stability, a test–retest procedure was conducted. The questionnaire was administered to 20 heart failure patients on two occasions, spaced two weeks apart. The intraclass correlation coefficient (ICC) was calculated for the overall scale and its subscales. ICC values exceeding 0.75 were interpreted as indicating satisfactory stability [ 18 ]. Data analyses "Data analysis was performed using SPSS version 16 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were applied to summarize the participants’ demographic information. Construct validity was assessed through exploratory factor analysis (EFA). Additional statistical procedures included Pearson correlation, as well as paired and independent samples t-tests. The Kaiser–Meyer–Olkin (KMO) measure was also utilized to evaluate the adequacy of the sample size for factor analysis. Results The results indicated that the mean age of the participants was 68.6 ± 26.91 years. The majority were male (57.2%) and married (60.3%). In terms of occupation, most were either retired (25.9%) or employed (25.1%). Regarding education level, the majority had less than a high school diploma (37.2%). More than half of the patients (54.9%) had underlying medical conditions. Additionally, most participants (90.5%) resided in urban areas (Table 1 ). Table 1 The participants’ characteristics to evaluate the construct validity Variable Number (%) Sex Male 223 (57.2) Female 167 (42.8) Marital status Married 235 (60.3) Single 69 (17.7) Widow 53 (13.5) Divorced 33 (8.5) Occupation Employee 98 (25.1) Retired 101 (25.9) Homemaker 81 (20.8) Self-employed 110 (28.2) Education Illiterate 40 (10.3) Under diploma 145 (37.2) Diploma 110 (28.2) Higher education 95 (24.3) Residence Urban 353 (90.5) Rural 27 (9.5) Underlying disease Yes 214 (54.9) No 176 (45.1) Age Mean ± SD 68.26 ± 6.91 The 47 items retained from the previous phase were included in the current analysis. The Kaiser–Meyer–Olkin (KMO) measure confirmed the adequacy of the sample size for conducting exploratory factor analysis, yielding a value of 0.904. Additionally, Bartlett’s test of sphericity was statistically significant (χ² = 8640.438, p < 0.001), indicating that the correlations among variables were sufficiently strong to justify factor analysis (Table 2 ). Table 2 Bartlett spherical test and KMO Sampling Adequacy Test KMO 0.904 Bartlett’s test of Sphericity Chi-Square 8640.438 Df 630 p p < 0.001 Note. KMO = Kaiser–Meyer–Olkin Exploratory factor analysis, applying varimax rotation and retaining factors with eigenvalues greater than 1, resulted in the identification of 7 factors comprising 35 items. These extracted factors accounted for 63.75% of the total variance. The factor loadings of the items ranged from 0.40 to 0.88. Based on the concepts inferred from the items loaded onto each factor, the final instrument was developed, consisting of 7 subscales and 35 items. These 7 factors were considered subscales in the final instrument and included: Drug Negligence (9 items), Informational-Communicational Negligence (7 items), Nutritional Negligence (6 items), Physical Activity Negligence (4 items), Environmental Negligence (3 items), Sexual Negligence (3 items), and Negligence in Prioritizing Self-Care (3 items). Each item was evaluated using a 5-point Likert scale, ranging from "not at all" to "always." Cronbach’s alpha total scale was 0.92. The ICC tools and their subscales were calculated with the two‑way mixed model of the absolute agreement type, which with 95% confidence, the coefficients were between 0.71 and 0.89 (Table 3 ). Table 3 Factor Analysis and Internal Reliability of the Neglect of Self-Care in Patients with Heart Failure Scale Question Questionnaire items and subscale names Factor Loading 1 Factor Loading 2 Factor Loading 3 Factor Loading 4 Factor Loading 5 Factor Loading 6 Factor Loading 7 Subscale 1: Drug negligence (9 items) 1. I am negligent in taking my medications regularly .834 2. I postpone taking my medication in the presence of others. .742 5. I am not careful about taking medications that look similar. .718 10. I use traditional methods (opium, various herbal teas, etc.) to relieve the symptoms of my illness. .700 3. I arbitrarily change the dosage of my medications when side effects occur. .694 4. When medication side effects occur, I arbitrarily discontinue it. .666 8. I take expensive medications irregularly (due to high cost). .555 7. If I do not have access to foreign medicines, I will refrain from using Iranian medicines. .527 9. Too many medications make us careless when taking them. .512 Subscale 2: Informational-communicational negligence (7 items) 44. Lack of cooperation from family members causes me to neglect self-care. .888 42. I am negligent in updating my information about medications (their effects and side effects) .871 45. I reduce my social interactions when my symptoms worsen. .733 43. I am negligent in updating my dietary information. .710 41. I am negligent in updating my information regarding medication and dietary regimen. .562 38. I ignore the accuracy of information searched online about my illness .478 39. I fail to report new or worsening symptoms to the treatment team. .465 Subscale 3: Nutritional negligence (6 items) 14. I have salty, fried eating habits. .856 17. I eat forbidden foods when family members are not present. .712 13. In some situations (parties, ceremonies, etc.), I neglect to follow my heart-healthy diet. .660 19. I ignore medical advice regarding diet when my symptoms subside. .605 18. I neglect my regular weighing. .484 16. I fail to provide nutritional counseling related to my illness. .408 Subscale 4. Physical activity negligence (4 items) 27. I don't have enough time to do sports activities. .818 28. Despite dyspnea, I carry out my daily activities .800 29. I fail to do sports .547 25. If I am very busy, I will remove my sports activities .511 Subscale 5. Physical activity negligence (4 items) 23. I am negligent in improving my home environment (repairing stairs, etc.) in accordance with the conditions of my illness. .922 24. Despite the doctor's advice, I prefer using a squat toilet to a sitting toilet. .912 32. I do not have access to the necessary facilities (diagnostic and treatment centers, etc.) where I live to periodically follow up on my treatment. .593 .889 Subscale 6. Sexual negligence (3 items) 30. I arbitrarily use sexual enhancement drugs to solve my problems. .889 31.I avoid discussing sexual problems with health care providers. .854 33. I use opiates to solve my sexual problems .620 Subscale 7. Negligence in prioritizing self-care (3 items) 35. I give priority to taking care of my children compared to taking care of myself .803 36. I give priority to taking care of my wife compared to taking care of myself .775 34. I prioritize taking care of the house over taking care of myself. .719 Cronbach’s alpha for each subscale 0.89 0.89 0.84 0.86 0.84 0.76 0.71 ICC 0.89 0.87 0.83 0.85 0.87 0.71 0.74 ICC: Intraclass correlation coefficient Discussion This study aimed to develop and analyze the psychometric properties of a new instrument for assessing self-care neglect in HF patients. A qualitative interview with patients with HF and a comprehensive literature review were conducted. Using content analysis, six main themes were extracted as types of neglect in self-care. The final instrument, validated for content and construct validity and reliability, included 35 items across seven subscales: Drug negligence, Informational-communicational negligence, Nutritional negligence, Physical activity negligence, Environmental negligence, Sexual negligence, and Negligence in prioritizing self-care. Factor analysis revealed that drug negligence was the most important subscale, extracted in the first stage of the study. A study reported that one of the causes of readmission of HF patients is neglect in taking medications and non-adherence to treatment [ 19 ]. The results of a study showed that neglecting diet in heart patients causes aggravation of their symptoms, repeated hospitalization, and even death of patients [ 14 ]. These results are consistent with the Nutritional negligence subscale in the present study. A study reported that lack of physical activity disrupts oxygen delivery to the heart of HF patients, leading to a worsening of their symptoms [ 20 ]. The results of the Jaressma study support the Physical Activity Neglect subscale in the present study. Another study showed that fear of injury during physical activity and exercise causes neglect in HF patients [ 21 ]. Paneroni et al. (2022) reported that modifying the living environment, such as stair modification, is important in improving the lifestyle of HF patients [ 22 ], which is in line with the Environmental Neglect subscale. A study reported that HF patients do not talk about their sexual problems with their nurses and doctors due to shame and modesty [ 5 ], which is consistent with the Sexual Neglect subscale. Regarding the Negligence in prioritizing self-care subscale, a study showed that although heart patients were aware of their health, hygiene, psychological, and educational needs, they did not prioritize them [ 23 ]. No instrument was found that directly measures self-care neglect in heart failure. So, questionnaire assessing self-care limitations were compared with the current instrument. Holden et al. (2015) developed a 25-item tool to measure self-care limitations in patients with heart failure [ 9 ]. The tool identifies 27 barriers across six subscales: patient-related, task-related, tool-related, health-related, social-related, and physical-related barriers. Patient-related barriers include comorbidities, limited mobility, mood disturbances, insufficient self-care knowledge, and memory impairment; these limitations are reflected in the instrument. The Holden tool's task-related barriers subscale includes factors like side effects, complexity, time consumption, and lack of benefit from self-care, some of which are mirrored in the current tool. This overlap stems from the chronic nature of heart failure, making these limitations inherent to the disease and consistent across socio-cultural contexts. In the Holden study, the tool-related barriers subscale reflects the absence of tools needed for self-care; however, it's not applicable to the present study's tool design because the patients with heart failure in the current study lacked prior self-care experience. The subscale of organizational barriers refers to encompassing resource limitations and insurance issues, are addressed in the current instrument. While interruption of care at events is covered, travel-related obstacles are not. The researcher believes that inadequate drug insurance coverage and a lack of socio-economic support in Iran hinder patients with heart failure ability to afford and maintain self-care. The Holden tool's social barriers subscale includes issues like family caregiver problems, food culture, and social inactivity. While the current tool addresses food culture and caregiver issues, it lacks items covering other social barriers. The researcher believes that insufficient support systems in Iranian society place a disproportionate burden on families caring for patients with heart failure. This can lead to caregiver fatigue and reduced support. The situation is further complicated by additional family illnesses or when the patient is also a caregiver, leaving them with insufficient time for self-care. The physical barriers subscale includes weather conditions, distance to medical centers, and stairs in the residence. The self-care assessment tool covers all but weather conditions. Patients with heart failure in this study had no experience with the other barriers listed in the Holden tool, so those items are not included [ 9 ]. The tool developed in this study differs from the Holden tool in several aspects. Our tool includes items related to herbal medicine use, medicine scarcity, and delays in seeking medical care, which are absent in the Holden tool. These items reflect the specific cultural context of our study population, explaining their absence in Holden et al.'s findings. Conversely, our tool lacks items addressing social immobility, a barrier reported by Holden et al [ 9 ]. This absence is likely due to the geographical and cultural context of our study, where participants did not report social immobility as a barrier. Limitations This study was limited by the potential for social desirability bias in self-reported data, although anonymity was implemented to mitigate this. Furthermore, the novelty of the "Neglect of self-care in patients with HF " instrument necessitates further research to establish its validity and reliability. Conclusion The study confirms the psychometric properties of the "Neglect of self-care in patients with HF" instrument, a validated 35-item tool assessing neglect of self-care in patients with heart failure across seven subscales: Drug negligence, Informational-communicational negligence, Nutritional negligence, Physical activity negligence, Environmental negligence, Sexual negligence, and Negligence in prioritizing self-care. Abbreviations HF Heart failure Neglect of Self-Care in Patients with Heart Failure Scale NSC-HF Content validity ratio CVR Content validity index CVI Scale-level content validity index S-CVI Item-level CVI scores I-CVI Exploratory factor analysis EFA Principal component analysis PCA Kaiser–Meyer–Olkin KMO Intraclass correlation coefficient ICC Declarations Ethics approval and consent to participate The study was approved by the ethics committee of Kashan University of Medical Sciences, Iran (IR.KAUMS.NUHEPM.REC.1402.034). The participants were assured that their information would remain confidential. Informed consent was obtained from all individual participants included in the study. We confirm that that all methods were performed in accordance with the Helsinki Declaration. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding Kashan university of medical sciences, Iran. Author Contribution NMA conceptualized the study, led the instrument design process, and supervised all stages of data collection and analysis. NMA, AZ, PSB, contributed to the literature review, item generation, and participated in qualitative data coding and theme extraction. FSIA was responsible for statistical analysis, including validity and reliability testing, and contributed to drafting the manuscript. NMA, PSB coordinated participant recruitment, managed ethical approvals, and assisted in revising the final manuscript for publication. All authors reviewed and approved the final version of the manuscript. Acknowledgement This article stems from a doctoral dissertation in nursing and is based on an approved research project (Code: 402083), overseen by the Trauma Nursing Research Center at Kashan University of Medical Sciences. The authors extend their sincere appreciation to the esteemed Vice Chancellor for Research, the Development and Clinical Research Unit at Shahid Beheshti Hospital in Kashan, and all the patients who generously contributed to this study. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request **.** References Sinnenberg L, Givertz MM. Acute heart failure. Trends Cardiovasc Med. 2020;30(2):104–12. Tomasoni D, Adamo M, Lombardi CM, Metra M. Highlights in heart failure. ESC Heart Fail. 2019;6(6):1105–27. Tok Yildiz F, Kaşikçi M. Impact of training based on Orem’s theory on self-care agency and quality of life in patients with coronary artery disease. J Nurs Res. 2020;28(6):e125. Awoke MS, Baptiste DL, Davidson P, Roberts A, Dennison-Himmelfarb C. A quasi-experimental study examining a nurse-led education program to improve knowledge, self-care, and reduce readmission for individuals with heart failure. 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Eckerblad J, Klompstra L, Heinola L, Rojlén S, Waldréus N. What frail, older patients talk about when they talk about self-care—a qualitative study in heart failure care. BMC Geriatr. 2023;23(1):818. https://doi.org/10.1186/s12877-023-04538-1 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 27 Oct, 2025 Editor invited by journal 01 Oct, 2025 Editor assigned by journal 22 Sep, 2025 Submission checks completed at journal 22 Sep, 2025 First submitted to journal 06 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7549181","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":539447581,"identity":"4ef33aec-750f-45c3-a1a5-ab2fe81cdc85","order_by":0,"name":"Parisa Sadat Bahrodi","email":"","orcid":"","institution":"Kashan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Parisa","middleName":"Sadat","lastName":"Bahrodi","suffix":""},{"id":539447582,"identity":"9db10964-9fa6-4c3b-a68f-777def2941a7","order_by":1,"name":"Fatemeh Sadat Izadi Avanji","email":"","orcid":"","institution":"Kashan University of 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Ajorpaz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYDACZgY2IHkAxGR82AAXNiBOC7MhcVoYEFrYJBvwKoQC3XbeZw9+/LojZ97Ae6xyRs3haPkG5ocfGAru4dRidpjd3LC375mxzAG+tJsbjh3O3XCAzViCwaAYjxY2NgnensOJMxh4zG4+YANqAQoC/ZKAV4vk357D9SAthQ/+Hc6d38D+jaAWaZ4fhxMkgFoYN7Ydzm04wEPQFnZj2YbDhkBbjCVn9qXnbjjMUyyRgE/L+WNsD9/8OSwPtMXwY88369z57e0bP3z4g1sLGDC2AQn5B1AeMxAT0AAEfwiqGAWjYBSMgpEMAKH/UuKuaXx1AAAAAElFTkSuQmCC","orcid":"","institution":"Kashan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Neda","middleName":"Mirbagher","lastName":"Ajorpaz","suffix":""}],"badges":[],"createdAt":"2025-09-06 07:38:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7549181/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7549181/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95203400,"identity":"736f9a58-5584-407a-bf6e-42d069e53a0a","added_by":"auto","created_at":"2025-11-05 12:50:47","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":67015,"visible":true,"origin":"","legend":"","description":"","filename":"article6Autosaved12.docx","url":"https://assets-eu.researchsquare.com/files/rs-7549181/v1/f061f4f1ea11f9725c583532.docx"},{"id":95203402,"identity":"9cfa0c95-6af0-43c9-904c-c439bc63f93d","added_by":"auto","created_at":"2025-11-05 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12:50:48","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":99814,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7549181/v1/555abe43a8fcf278081bfe32.html"},{"id":95203403,"identity":"2a1b6dd5-7e94-4349-b787-513496bae624","added_by":"auto","created_at":"2025-11-05 12:50:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":15792,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eGraph 1: Scre\u003c/em\u003ee plot of the neglect of self-care in patients with heart failure scale\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7549181/v1/94c3476884fef6aa002cbb13.png"},{"id":95230706,"identity":"42a9e4c5-53c2-4248-a614-6b027d6941b9","added_by":"auto","created_at":"2025-11-05 16:38:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1188670,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7549181/v1/bee08d16-6e1c-4d85-98aa-66f45a2a4e0d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Neglect of self-care in patients with heart failure: Instrument Development and Psychometric Properties","fulltext":[{"header":"Background","content":"\u003cp\u003eOne of the most common chronic diseases is cardiovascular disease. According to the World Health Organization, cardiovascular diseases are the leading cause of death worldwide, with 82% of these deaths occurring in developing countries, and it is predicted that they will remain the leading cause of death in the world by 2030 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Heart failure (HF) is one of the most common heart diseases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. HF occurs when the heart cannot pump sufficient blood to fulfill the body's metabolic requirements [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDorothy Orem introduced the concept of self-care in 1959 through her self-care theory, defining it as the actions individuals take to maintain and improve their health, well-being, and to prevent or treat illness [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Self-care in HF includes adhering to a specific diet and medication plan, restricting sodium and fluid intake, managing activity levels, tracking daily weight, and making informed treatment decisions as the disease advances [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEvidence shows that HF patients often engage in poor self-care. A study highlights that most of these patients exhibit inadequate self-care behaviors and neglect essential practices [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNeglect refers to forgetting, carelessness, ignorance, and inattention despite being aware [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In chronic illnesses, this neglect can exacerbate the condition and reduce quality of life [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Patients with heart failure often experience symptom exacerbation and repeated hospitalizations due to self-care neglect, including medication neglect, dietary neglect, activity and sports neglect, information acquisition neglect [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A 2012 study found that chronic patients often neglect self-care, including diet, medication, daily activities, exercise, and stress management [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A study identified key barriers to self-care in HF patients, including knowledge deficits, inadequate social support, complicated treatment regimens, limited access to treatment, and high costs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Another study reported that financial issues, treatment costs, and lack of insurance as barriers to self-care among heart patients [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Similarly, a study attributed patients\u0026rsquo; non-participation in self-care to their social and economic status [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In 2012, a study reported that Orem\u0026rsquo;s theory does not address cases of neglect in self-care and strategies for reducing it [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Database searches revealed that no instrument has been specifically designed and validated to evaluate self-care neglect in HF patients; most existing tools focus on self-neglect among the elderly.\u003c/p\u003e\u003cp\u003eA study developed and validated the Self-Neglect Scale for Polish elderly, which assesses self-neglect in basic and psychological needs over the past year. The 12-item scale has scores ranging from 0 to 12, with higher scores indicating greater self-neglect. The scale focuses on identifying the presence and severity of self-neglect in older people living independently in the community [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These questionnaires only examine self-neglect in the elderly and cannot be used for chronic diseases, including HF, which have multiple symptoms and complications. As most HF patients are elderly and face life-threatening symptoms, they often resort to self-medication, leading to exhaustion in their self-care efforts. Also, many patients with heart failure are hospitalized several times a year due to neglect of self-care. Therefore, it is essential to develop a valid and reliable tool to measure neglect in self-care and its related dimensions, enabling effective educational and support interventions to enhance self-care among these patients. The design of this tool will help doctors and nurses to measure the level of neglect of self-care in patients with heart failure and try to eliminate it.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e\u003cp\u003eA methodological research study was conducted between October 2024 and February 2025 on patients with class I to IV heart failure who, based on a cardiologist\u0026rsquo;s diagnosis, were either hospitalized or received outpatient care in the cardiology departments of public and private hospitals in Kashan and Tehran Heart Center.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData collection\u003c/h2\u003e\u003cp\u003eIn the first phase of the study, the item pool was developed through 19 interviews conducted with 15 patients with heart failure, a cardiologist, a nurse, and a patient's child and spouse. The main interview question was: 'Please describe a typical day in your life since your HF diagnosis.' The interview then continued with specific questions based on the research objectives, such as: 'Please describe the problems you have encountered with your illness that have led you to seek additional care,' 'What have you done to manage your symptoms,' 'What aspects of your treatment have you not followed,' 'In what areas do you not take self-care seriously,' 'What is the role of your family in your treatment and care,' and 'What consequences has neglecting self-care had for you?' Based on the participants\u0026rsquo; responses, exploratory and clarifying questions such as 'Can you explain more?' were also asked. Each interview lasted between 45 and 60 minutes.\u003c/p\u003e\u003cp\u003eIn addition, a literature search was conducted in ProQuest, PubMed, Scopus, CINAHL, Ovid, Google Scholar, and Elsevier using keywords related to heart failure, cardiovascular disease, neglect, self-care, inattention, and limitations in care. Articles published between 2015 and 2025 relevant to the tool were reviewed. Items were obtained from both the literature and related instruments. Ultimately, 365 codes and six main themes\u0026mdash;drug negligence, nutritional negligence, sexual negligence, environmental negligence, physical activity negligence, and informational-communicational negligence\u0026mdash;were extracted from the interviews and literature review [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These categories and subcategories were used to generate the initial item pool for the Neglect of Self-Care in Patients with Heart Failure Scale (NSC-HF). The available literature and instruments will continue to inform item generation.\u003c/p\u003e\u003cp\u003eIn the second phase of the study, the initial scale was developed with 55 items. A 5-point Likert scale was used for scoring, with the following options: (1\u0026thinsp;=\u0026thinsp;not at all important, 5\u0026thinsp;=\u0026thinsp;very important). Higher scores obtained by participants indicated a greater neglect of self-care.\u003c/p\u003e\u003cp\u003eFollowing the development of the initial scale, its psychometric properties were systematically evaluated. These included face validity (both quantitative and qualitative), content validity (both quantitative and qualitative), structural validity, and reliability.\u003c/p\u003e\u003cp\u003eTo assess both the qualitative and quantitative aspects of face validity, the scale was administered to 12 patients with heart failure. Participants were asked to evaluate the clarity and relevance of each item in relation to the overall purpose of the scale, as well as to identify any ambiguities or difficulties in wording [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Additionally, they rated the importance of each item using a 5-point Likert scale, ranging from 1 (not important at all) to 5 (very important).\u003c/p\u003e\u003cp\u003eSubsequently, the impact score for each item was determined using the following formula: Item Impact\u0026thinsp;=\u0026thinsp;Importance \u0026times; Frequency (%). Items with a score equal to or above 1.5 were retained in the scale. At this stage, two items fell below the threshold of 1.5 and were therefore excluded from the final version.\u003c/p\u003e\u003cp\u003eTo evaluate the qualitative and quantitative content validity, ten experts in cardiac nursing and clinical instrumentation were invited to review the items. They provided feedback on grammar, clarity, word appropriateness, and the suitability of the scoring scale. Additionally, they assessed the necessity of each item using a 3-point Likert scale (3\u0026thinsp;=\u0026thinsp;necessary, 2\u0026thinsp;=\u0026thinsp;useful but not necessary, 1\u0026thinsp;=\u0026thinsp;not necessary).\u003c/p\u003e\u003cp\u003eThe content validity ratio (CVR) was calculated for each item based on Lawshe\u0026rsquo;s method. According to the Lawshe table, items with a CVR below 0.51 were excluded [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Among the 55 initial items, 47 achieved a CVR of 0.57 or higher, resulting in the elimination of 8 items.\u003c/p\u003e\u003cp\u003eSubsequently, 15 experts were asked to evaluate the relevance of each item using a 4-point Likert scale (1\u0026thinsp;=\u0026thinsp;not relevant, 2\u0026thinsp;=\u0026thinsp;somewhat relevant, 3\u0026thinsp;=\u0026thinsp;relevant, 4\u0026thinsp;=\u0026thinsp;highly relevant). Based on their ratings, the content validity index (CVI) was calculated for each item. Items with a CVI above 0.80 were considered acceptable [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. All remaining items had CVI values of 0.87 or higher, and therefore, no further items were removed.\u003c/p\u003e\u003cp\u003eAdditionally, the scale-level content validity index (S-CVI) was determined by averaging the item-level CVI scores (I-CVI). An S-CVI value above 0.90 is considered acceptable [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], and the S-CVI for this scale was 0.97, indicating excellent overall content validity.\u003c/p\u003e\u003cp\u003eConstruct validity of the scale was assessed through a cross-sectional study using exploratory factor analysis (EFA). Participants were selected via convenience sampling from both inpatient and outpatient populations with heart failure at Shahid Beheshti Hospital in Kashan and the Tehran Heart Center. Based on Harrington\u0026rsquo;s recommendation (2009), a sample size of 300 or more is appropriate for conducting EFA [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In this study, questionnaires, and consent forms were distributed to 421 patients with heart failure. All questionnaires were returned, with 390 completed, resulting in a response rate of 81%. Following data collection, exploratory factor analysis (EFA) was conducted to identify the underlying constructs of the OHI-SSS scale. Principal component analysis (PCA) was used as the extraction method, along with varimax rotation to enhance interpretability of the factor structure. Prior to conducting exploratory factor analysis (EFA), the Kaiser\u0026ndash;Meyer\u0026ndash;Olkin (KMO) test was performed to assess sampling adequacy, with a threshold of \u0026ge;\u0026thinsp;0.6. Factor retention decisions were guided by multiple criteria: eigenvalues exceeding 1, visual analysis of the scree plot (Graph 1), and a minimum acceptable factor loading of 0.40 for each item.\u003c/p\u003e\u003cp\u003eThe reliability of the scale was assessed using Cronbach\u0026rsquo;s alpha coefficient, with values above 0.70 considered acceptable [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. To evaluate temporal stability, a test\u0026ndash;retest procedure was conducted. The questionnaire was administered to 20 heart failure patients on two occasions, spaced two weeks apart. The intraclass correlation coefficient (ICC) was calculated for the overall scale and its subscales. ICC values exceeding 0.75 were interpreted as indicating satisfactory stability [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData analyses\u003c/h3\u003e\n\u003cp\u003e\"Data analysis was performed using SPSS version 16 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were applied to summarize the participants\u0026rsquo; demographic information. Construct validity was assessed through exploratory factor analysis (EFA). Additional statistical procedures included Pearson correlation, as well as paired and independent samples t-tests. The Kaiser\u0026ndash;Meyer\u0026ndash;Olkin (KMO) measure was also utilized to evaluate the adequacy of the sample size for factor analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe results indicated that the mean age of the participants was 68.6\u0026thinsp;\u0026plusmn;\u0026thinsp;26.91 years. The majority were male (57.2%) and married (60.3%). In terms of occupation, most were either retired (25.9%) or employed (25.1%). Regarding education level, the majority had less than a high school diploma (37.2%). More than half of the patients (54.9%) had underlying medical conditions. Additionally, most participants (90.5%) resided in urban areas (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe participants\u0026rsquo; characteristics to evaluate the construct validity\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e223 (57.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e167 (42.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e235 (60.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e69 (17.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWidow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e53 (13.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33 (8.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eOccupation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployee\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e98 (25.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRetired\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e101 (25.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHomemaker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e81 (20.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-employed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e110 (28.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIlliterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40 (10.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnder diploma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e145 (37.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiploma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e110 (28.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigher education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e95 (24.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eResidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e353 (90.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e27 (9.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eUnderlying disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e214 (54.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e176 (45.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68.26\u0026thinsp;\u0026plusmn;\u0026thinsp;6.91\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe 47 items retained from the previous phase were included in the current analysis. The Kaiser\u0026ndash;Meyer\u0026ndash;Olkin (KMO) measure confirmed the adequacy of the sample size for conducting exploratory factor analysis, yielding a value of 0.904. Additionally, Bartlett\u0026rsquo;s test of sphericity was statistically significant (χ\u0026sup2; = 8640.438, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that the correlations among variables were sufficiently strong to justify factor analysis (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBartlett spherical test and KMO\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eSampling Adequacy Test\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eKMO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.904\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eBartlett\u0026rsquo;s test of Sphericity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChi-Square\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8640.438\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDf\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e630\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eNote.\u003c/b\u003e KMO\u0026thinsp;=\u0026thinsp;Kaiser\u0026ndash;Meyer\u0026ndash;Olkin\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eExploratory factor analysis, applying varimax rotation and retaining factors with eigenvalues greater than 1, resulted in the identification of 7 factors comprising 35 items. These extracted factors accounted for 63.75% of the total variance. The factor loadings of the items ranged from 0.40 to 0.88. Based on the concepts inferred from the items loaded onto each factor, the final instrument was developed, consisting of 7 subscales and 35 items. These 7 factors were considered subscales in the final instrument and included: Drug Negligence (9 items), Informational-Communicational Negligence (7 items), Nutritional Negligence (6 items), Physical Activity Negligence (4 items), Environmental Negligence (3 items), Sexual Negligence (3 items), and Negligence in Prioritizing Self-Care (3 items). Each item was evaluated using a 5-point Likert scale, ranging from \"not at all\" to \"always.\" Cronbach\u0026rsquo;s alpha total scale was 0.92. The ICC tools and their subscales were calculated with the two‑way mixed model of the absolute agreement type, which with 95% confidence, the coefficients were between 0.71 and 0.89 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactor Analysis and Internal Reliability of the Neglect of Self-Care in Patients with Heart Failure Scale\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eQuestion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"7\" nameend=\"c8\" namest=\"c2\"\u003e\u003cp\u003eQuestionnaire items and subscale names\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFactor\u003c/p\u003e\u003cp\u003eLoading 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFactor\u003c/p\u003e\u003cp\u003eLoading 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFactor\u003c/p\u003e\u003cp\u003eLoading 3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFactor\u003c/p\u003e\u003cp\u003eLoading 4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFactor\u003c/p\u003e\u003cp\u003eLoading 5\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eFactor\u003c/p\u003e\u003cp\u003eLoading 6\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFactor\u003c/p\u003e\u003cp\u003eLoading 7\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSubscale 1: Drug negligence (9 items)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. I am negligent in taking my medications regularly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.834\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. I postpone taking my medication in the presence of others.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.742\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. I am not careful about taking medications that look similar.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.718\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10. I use traditional methods (opium, various herbal teas, etc.) to relieve the symptoms of my illness.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.700\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. I arbitrarily change the dosage of my medications when side effects occur.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.694\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. When medication side effects occur, I arbitrarily discontinue it.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.666\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8. I take expensive medications irregularly (due to high cost).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.555\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7. If I do not have access to foreign medicines, I will refrain from using Iranian medicines.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.527\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9. Too many medications make us careless when taking them.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.512\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSubscale 2: Informational-communicational negligence (7 items)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e44. Lack of cooperation from family members causes me to neglect self-care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.888\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e42. I am negligent in updating my information about medications (their effects and side effects)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.871\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e45. I reduce my social interactions when my symptoms worsen.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.733\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e43. I am negligent in updating my dietary information.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.710\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e41. I am negligent in updating my information regarding medication and dietary regimen.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.562\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e38. I ignore the accuracy of information searched online about my illness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.478\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e39. I fail to report new or worsening symptoms to the treatment team.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.465\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSubscale 3: Nutritional negligence (6 items)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14. I have salty, fried eating habits.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.856\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17. I eat forbidden foods when family members are not present.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.712\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13. In some situations (parties, ceremonies, etc.), I neglect to follow my heart-healthy diet.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.660\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19. I ignore medical advice regarding diet when my symptoms subside.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.605\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18. I neglect my regular weighing.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.484\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16. I fail to provide nutritional counseling related to my illness.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.408\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSubscale 4. Physical activity negligence (4 items)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e27. I don't have enough time to do sports activities.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.818\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e28. Despite dyspnea, I carry out my daily activities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.800\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e29. I fail to do sports\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.547\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25. If I am very busy, I will remove my sports activities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.511\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSubscale 5. Physical activity negligence (4 items)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e23. I am negligent in improving my home environment (repairing stairs, etc.) in accordance with the conditions of my illness.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.922\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24. Despite the doctor's advice, I prefer using a squat toilet to a sitting toilet.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.912\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e32. I do not have access to the necessary facilities (diagnostic and treatment centers, etc.) where I live to periodically follow up on my treatment.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.593\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.889\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSubscale 6. Sexual negligence (3 items)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30. I arbitrarily use sexual enhancement drugs to solve my problems.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.889\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e31.I avoid discussing sexual problems with health care providers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.854\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e33. I use opiates to solve my sexual problems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.620\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSubscale 7. Negligence in prioritizing self-care (3 items)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e35. I give priority to taking care of my children compared to taking care of myself\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.803\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e36. I give priority to taking care of my wife compared to taking care of myself\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.775\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e34. I prioritize taking care of the house over taking care of myself.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.719\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCronbach\u0026rsquo;s alpha for each subscale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.74\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eICC: Intraclass correlation coefficient\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to develop and analyze the psychometric properties of a new instrument for assessing self-care neglect in HF patients. A qualitative interview with patients with HF and a comprehensive literature review were conducted. Using content analysis, six main themes were extracted as types of neglect in self-care.\u003c/p\u003e\u003cp\u003eThe final instrument, validated for content and construct validity and reliability, included 35 items across seven subscales: Drug negligence, Informational-communicational negligence, Nutritional negligence, Physical activity negligence, Environmental negligence, Sexual negligence, and Negligence in prioritizing self-care.\u003c/p\u003e\u003cp\u003eFactor analysis revealed that drug negligence was the most important subscale, extracted in the first stage of the study. A study reported that one of the causes of readmission of HF patients is neglect in taking medications and non-adherence to treatment [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The results of a study showed that neglecting diet in heart patients causes aggravation of their symptoms, repeated hospitalization, and even death of patients [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These results are consistent with the Nutritional negligence subscale in the present study. A study reported that lack of physical activity disrupts oxygen delivery to the heart of HF patients, leading to a worsening of their symptoms [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The results of the Jaressma study support the Physical Activity Neglect subscale in the present study. Another study showed that fear of injury during physical activity and exercise causes neglect in HF patients [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Paneroni et al. (2022) reported that modifying the living environment, such as stair modification, is important in improving the lifestyle of HF patients [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], which is in line with the Environmental Neglect subscale. A study reported that HF patients do not talk about their sexual problems with their nurses and doctors due to shame and modesty [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], which is consistent with the Sexual Neglect subscale. Regarding the Negligence in prioritizing self-care subscale, a study showed that although heart patients were aware of their health, hygiene, psychological, and educational needs, they did not prioritize them [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNo instrument was found that directly measures self-care neglect in heart failure. So, questionnaire assessing self-care limitations were compared with the current instrument. Holden et al. (2015) developed a 25-item tool to measure self-care limitations in patients with heart failure [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The tool identifies 27 barriers across six subscales: patient-related, task-related, tool-related, health-related, social-related, and physical-related barriers. Patient-related barriers include comorbidities, limited mobility, mood disturbances, insufficient self-care knowledge, and memory impairment; these limitations are reflected in the instrument. The Holden tool's task-related barriers subscale includes factors like side effects, complexity, time consumption, and lack of benefit from self-care, some of which are mirrored in the current tool. This overlap stems from the chronic nature of heart failure, making these limitations inherent to the disease and consistent across socio-cultural contexts. In the Holden study, the tool-related barriers subscale reflects the absence of tools needed for self-care; however, it's not applicable to the present study's tool design because the patients with heart failure in the current study lacked prior self-care experience.\u003c/p\u003e\u003cp\u003eThe subscale of organizational barriers refers to encompassing resource limitations and insurance issues, are addressed in the current instrument. While interruption of care at events is covered, travel-related obstacles are not. The researcher believes that inadequate drug insurance coverage and a lack of socio-economic support in Iran hinder patients with heart failure ability to afford and maintain self-care.\u003c/p\u003e\u003cp\u003eThe Holden tool's social barriers subscale includes issues like family caregiver problems, food culture, and social inactivity. While the current tool addresses food culture and caregiver issues, it lacks items covering other social barriers. The researcher believes that insufficient support systems in Iranian society place a disproportionate burden on families caring for patients with heart failure. This can lead to caregiver fatigue and reduced support. The situation is further complicated by additional family illnesses or when the patient is also a caregiver, leaving them with insufficient time for self-care.\u003c/p\u003e\u003cp\u003eThe physical barriers subscale includes weather conditions, distance to medical centers, and stairs in the residence. The self-care assessment tool covers all but weather conditions. Patients with heart failure in this study had no experience with the other barriers listed in the Holden tool, so those items are not included [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe tool developed in this study differs from the Holden tool in several aspects. Our tool includes items related to herbal medicine use, medicine scarcity, and delays in seeking medical care, which are absent in the Holden tool. These items reflect the specific cultural context of our study population, explaining their absence in Holden et al.'s findings. Conversely, our tool lacks items addressing social immobility, a barrier reported by Holden et al [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This absence is likely due to the geographical and cultural context of our study, where participants did not report social immobility as a barrier.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis study was limited by the potential for social desirability bias in self-reported data, although anonymity was implemented to mitigate this. Furthermore, the novelty of the \"Neglect of self-care in patients with HF \" instrument necessitates further research to establish its validity and reliability.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study confirms the psychometric properties of the \"Neglect of self-care in patients with HF\" instrument, a validated 35-item tool assessing neglect of self-care in patients with heart failure across seven subscales: Drug negligence, Informational-communicational negligence, Nutritional negligence, Physical activity negligence, Environmental negligence, Sexual negligence, and Negligence in prioritizing self-care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHeart failure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNeglect of Self-Care in Patients with Heart Failure Scale\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNSC-HF\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eContent validity ratio\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCVR\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eContent validity index\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCVI\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eScale-level content validity index\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eS-CVI\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eItem-level CVI scores\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eI-CVI\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eExploratory factor analysis\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEFA\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePrincipal component analysis\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePCA\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKaiser\u0026ndash;Meyer\u0026ndash;Olkin\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKMO\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIntraclass correlation coefficient\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eICC\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e The study was approved by the ethics committee of Kashan University of Medical Sciences, Iran (IR.KAUMS.NUHEPM.REC.1402.034). The participants were assured that their information would remain confidential. Informed consent was obtained from all individual participants included in the study. We confirm that that all methods were performed in accordance with the Helsinki Declaration.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eKashan university of medical sciences, Iran.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eNMA conceptualized the study, led the instrument design process, and supervised all stages of data collection and analysis. NMA, AZ, PSB, contributed to the literature review, item generation, and participated in qualitative data coding and theme extraction. FSIA was responsible for statistical analysis, including validity and reliability testing, and contributed to drafting the manuscript. NMA, PSB coordinated participant recruitment, managed ethical approvals, and assisted in revising the final manuscript for publication. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis article stems from a doctoral dissertation in nursing and is based on an approved research project (Code: 402083), overseen by the Trauma Nursing Research Center at Kashan University of Medical Sciences. The authors extend their sincere appreciation to the esteemed Vice Chancellor for Research, the Development and Clinical Research Unit at Shahid Beheshti Hospital in Kashan, and all the patients who generously contributed to this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request **.**\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSinnenberg L, Givertz MM. Acute heart failure. Trends Cardiovasc Med. 2020;30(2):104\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTomasoni D, Adamo M, Lombardi CM, Metra M. Highlights in heart failure. ESC Heart Fail. 2019;6(6):1105\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTok Yildiz F, Kaşik\u0026ccedil;i M. Impact of training based on Orem\u0026rsquo;s theory on self-care agency and quality of life in patients with coronary artery disease. J Nurs Res. 2020;28(6):e125.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAwoke MS, Baptiste DL, Davidson P, Roberts A, Dennison-Himmelfarb C. A quasi-experimental study examining a nurse-led education program to improve knowledge, self-care, and reduce readmission for individuals with heart failure. Contemp Nurse. 2019;55(1):15\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJaarsma T, Cameron J, Riegel B, Stromberg A. Factors related to self-care in heart failure patients according to the middle-range theory of self-care of chronic illness: a literature update. Curr Heart Fail Rep. 2017;14(2):71\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhormaei F, Gharehchahi M, Yazdani F, Zare S. 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Ann Emerg Med. 2015;66(1):1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCampbell DJ, King-Shier K, Hemmelgarn BR, Sanmartin C, Ronksley PE, Weaver RG, et al. Self-reported financial barriers to care among patients with cardiovascular-related chronic conditions. Health Rep. 2014;25(5):3\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMansourieh N, Pour Sharifi H, Taban Sadeghi MR, Sirfi MR. The relationship between socioeconomic status and self-care in patients with heart failure: The role of illness-related worries mediator. Nurs Patient Welf J Mashhad Univ Med Sci. 2018;5(17):5\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLauder W, Roxburgh M. Self-neglect consultation rates and comorbidities in primary care. Int J Nurs Pract. 2012;18(5):454\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZawisza K, Galas A, Tobiasz-Adamczyk B, Grodzicki T. 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BMC Geriatr. 2023;23(1):818. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12877-023-04538-1\u003c/span\u003e\u003cspan address=\"10.1186/s12877-023-04538-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Psychometric Properties, Instrument Development, Self-Care, Neglect, Heart Failure","lastPublishedDoi":"10.21203/rs.3.rs-7549181/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7549181/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePatients with heart failure often neglect self-care, including diet, medication, daily activities, exercise, and stress management. The purpose of this study was to develop a valid and reliable measure for the neglect of self-care in patients with heart failure.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThe study was methodological research. A three-stage mixed methods study was conducted: (a) in-depth interviews with patients with heart failure were analyzed to extract key themes; (b) these themes, combined with a literature review, informed the development of a 55-item preliminary instrument; and (c) the instrument's content, face, and construct validity were assessed using content validity ratio, content validity index, and exploratory factor analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eSubscales in the final instrument Drug negligence\", \"Nutritional negligence\", \"Sexual negligence\", \"Environmental negligence\", \"Physical activity negligence\", \"Informational-communicational negligence\u0026rdquo; and \u0026ldquo;Negligence in prioritizing self-care\u0026rdquo;. Reliability of the instrument was .92.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe final 35-item \u0026ldquo;neglect of self-care in patients with heart failure \u0026ldquo;demonstrated strong psychometric properties.\u003c/p\u003e\u003ch2\u003eClinical trial number:\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e","manuscriptTitle":"Neglect of self-care in patients with heart failure: Instrument Development and Psychometric Properties","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-05 12:50:42","doi":"10.21203/rs.3.rs-7549181/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-10-27T09:47:47+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-01T06:50:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-22T05:46:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-22T05:46:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2025-09-06T07:33:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a95d24c3-5222-4f3f-9657-c293dd8f09fc","owner":[],"postedDate":"November 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-05T12:50:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-05 12:50:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7549181","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7549181","identity":"rs-7549181","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}