SelfCare for the Prevention and Management of Cardiovascular Disease and Stroke

Self-care is defined as a naturalistic decision-making process addressing both the prevention and management of chronic illness, with core elements of self-care maintenance, self-care monitoring, and self-care management. In this scientific statement, we describe the importance of self-care in the American Heart Association mission and vision of building healthier lives, free of cardiovascular diseases and stroke. The evidence supporting specific self-care behaviors such as diet and exercise, barriers to self-care, and the effectiveness of self-care in improving outcomes is reviewed, as is the evidence supporting various individual, family-based, and community-based approaches to improving self-care. Although there are many nuances to the relationships between self-care and outcomes, there is strong evidence that self-care is effective in achieving the goals of the treatment plan and cannot be ignored. As such, greater emphasis should be placed on self-care in evidence-based guidelines. ( J Am Heart Assoc.
knowledge required to achieve these goals, discuss barriers to engagement in good self-care, and present optimal strategies whereby healthcare providers and systems can support individuals and families as they engage in self-care. Although our focus is on adults, we set the stage by describing the need for self-care at all life stages.

## Self-care defined
Self-care is fundamental to maintenance of health, and prevention and management of chronic illnesses. [bib_ref] Council on Nutrition, Physical Activity, and Metabolism, and Interdisciplinary Council on Quality..., Riegel [/bib_ref] The World Health Organization definition of self-careand other recent definitions focus primarily on healthy people. [bib_ref] Self-care in health: we can define it, but should we also measure..., Webber [/bib_ref] In this article, we use a definition of self-care from the Theory of Selfcare of Chronic Illness that addresses both the prevention and management of chronic illness, with core elements of selfcare maintenance, self-care monitoring, and self-care management. [bib_ref] A middle-range theory of self-care of chronic illness, Riegel [/bib_ref] In this definition, self-care is a process whereby individuals and their families maintain health through healthpromoting practices and managing illness. People who engage in self-care maintenance adhere to those behaviors needed to maintain physical and emotional stability. Self-care monitoring involves a process of observing oneself for changes in signs and symptoms-body listening. Self-care management is used by people as they respond to signs and symptoms when they occur.
Similar self-care activities are important whether one is concentrating on the prevention or management of CVD or stroke. With the onset of CVD or stroke, there are several additional elements of self-care that need to be incorporated into the health regimen. Categorically, these self-care behaviors can be mapped with key elements of the Theory of Selfcare of Chronic Illness. [bib_ref] A middle-range theory of self-care of chronic illness, Riegel [/bib_ref] Based on current evidence-based guidelines and complementary reviews, self-care maintenance, monitoring, and management of the common CVDs of hypertension, [bib_ref] 2014 evidence-based guideline for the management of high blood pressure in adults:..., James [/bib_ref] [bib_ref] AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of..., Eckel [/bib_ref] [bib_ref] Psychometric testing of the self-care of hypertension inventory, Dickson [/bib_ref] heart failure (HF), 6,14-16 stroke, [bib_ref] Council on Clinical Cardiology, and Council on Quality of Care and Outcomes..., Winstein [/bib_ref] [bib_ref] Self-efficacy and self-management after stroke: a systematic review, Jones [/bib_ref] atrial fibrillation (AF), [bib_ref] Self-management of atrial fibrillation: a new frontier for nursing research, Mccabe [/bib_ref] [bib_ref] Knowledge and selfmanagement behaviors of patients with recently detected atrial fibrillation, Mccabe [/bib_ref] coronary artery disease, [bib_ref] Developing self-management education in coronary artery disease, Peterson [/bib_ref] [bib_ref] Psychometric testing of the Self-Care of Coronary Heart Disease Inventory (SC-CHDI), Vaughan Dickson [/bib_ref] and peripheral artery disease [bib_ref] ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial..., Hirsch [/bib_ref] are presented in [fig_ref] Table 1: Self-Care of Common Cardiovascular Disorders Using the Middle-Range Theory of Self-Care Nomenclature [/fig_ref].
Of 8760 hours in a year, patients spend only around 10 hours or 0.001% of their time with healthcare providers, meaning all other health maintenance, monitoring, and management activities are done by individuals or patients and their families as self-care activities outside of the clinical or hospital setting. The basic self-care activities important in CVD and stroke prevention and management are captured in the American Heart Association (AHA) "Life's Simple 7" (ie, smoking cessation, maintenance of body mass index , physical activity, healthy diet, maintaining low cholesterol, maintaining normal blood pressure , and maintaining normal fasting plasma glucose). [bib_ref] Self-care in health: we can define it, but should we also measure..., Webber [/bib_ref] These behaviors have been shown to reduce incident stroke, [bib_ref] Life's Simple 7 and risk of incident stroke: the reasons for geographic..., Kulshreshtha [/bib_ref] HF, [bib_ref] American Heart Association's Life's Simple 7: avoiding heart failure and preserving cardiac..., Folsom [/bib_ref] venous thromboembolism, [bib_ref] American Heart Association's Life's Simple 7 and risk of venous thromboembolism: the..., Olson [/bib_ref] and chronic kidney disease, [bib_ref] Relationship of the American Heart Association's Impact Goals (Life's Simple 7) with..., Rebholz [/bib_ref] and even incident cognitive impairment [bib_ref] The American Heart Association Life's Simple 7 and incident cognitive impairment: the..., Thacker [/bib_ref] and non-CVD. [bib_ref] Association between Life's Simple 7 and noncardiovascular disease: the Multi-Ethnic Study of..., Ogunmoroti [/bib_ref] Self-Care as a Decision-Making Process Self-care is most commonly understood as a naturalistic decision-making process in which persons engage for the purpose of maintaining health and managing acute and chronic illness. 9,32-35 Self-care decision making is a complicated process. Better understanding of the nature of self-care decision making will help clinicians understand how to better teach self-care to their patients and to understand how selfcare fails and how to improve it. Naturalistic decision making has been used to explain the process of self-care in individuals with CVD, most commonly HF, as well as other chronic illnesses. [bib_ref] The situation-specific theory of heart failure self-care: revised and updated, Riegel [/bib_ref] [bib_ref] Qualitative analysis of naturalistic decision making in adults with chronic heart failure, Riegel [/bib_ref] [bib_ref] Self-care in patients with chronic heart failure, Davidson [/bib_ref] [bib_ref] Conceptualizing self-care in heart failure: a life course model of patient characteristics, Moser [/bib_ref] The naturalistic decision-making framework explains that, in real-world settings, people make decisions that are meaningful and familiar to them. [bib_ref] Taking stock of naturalistic decision making, Lipshitz [/bib_ref] These real-world decisions are complex; they involve uncertainty, ambiguity, dynamically evolving conditions, missing information, time stress, and high stakes. These decisions may also have ill-defined, shifting, or competing goals and involve multiple individuals. The naturalistic decision-making process explains how individuals make decisions given this complexity and how they develop the skills necessary to succeed when faced with similar situations. [bib_ref] The reinvention of decision making, Orasanu [/bib_ref] Naturalistic decision making emphasizes how individuals use their experience and personal values in decision making. [bib_ref] Taking stock of naturalistic decision making, Lipshitz [/bib_ref] Experience emerges from situational awareness,or perception of the situation, as well as comprehension of the significance of a specific situation. One's experience with the situation, each option, and past response create a set of patterns that include relevant actions and expected outcomes associated with each possible response. [bib_ref] Qualitative analysis of naturalistic decision making in adults with chronic heart failure, Riegel [/bib_ref] In this way, past experience and personal values lead to the actions taken in specific situations. [bib_ref] Naturalistic decision making, Klein [/bib_ref] Section Summary - Self-care is defined as a naturalistic decision-making process addressing both the prevention and management of chronic illness, with core elements of self-care maintenance, self-care monitoring, and self-care management. from 1950 to 2000 and is expected to increase by another 10 years by 2050.By 2050, the population aged 60 years will double; 25% of the population will be >60 years of age; 20% >65 years of age; and close to 5% will be >85 years of age.By most projections, an increase in morbidity affected years will accompany the increase in life expectancy. Aging is a major risk factor for noncommunicable chronic conditions, particularly CVD and stroke, so this "silver tsunami" [bib_ref] Preparing for an aging world: engaging biogerontologists, geriatricians, and the society, Nikolich-Zugich [/bib_ref] will result in huge numbers of elderly individuals with multiple chronic conditions. [bib_ref] Association rules analysis of comorbidity and multimorbidity: the Concord Health and Aging..., Held [/bib_ref] By 2050, the number of people with chronic conditions will escalate by 40%, and the number of older people with disabilities from chronic conditions will double. [bib_ref] Preparing for an aging world: engaging biogerontologists, geriatricians, and the society, Nikolich-Zugich [/bib_ref] Currently, at least 66% of all deaths worldwide are attributable to noncommunicable diseases, the most common of which is CVD, and this percentage is projected to increase in coming years. CVD is the primary cause of death in men and women in the United States and worldwide.Multiple lines of research convincingly demonstrate that preventing CVD is economically, socially, and humanly superior to even the best medical treatment of manifest CVD. [bib_ref] The comparative effectiveness of heart disease prevention and treatment strategies, Kottke [/bib_ref] [bib_ref] Substantial health and economic returns from delayed aging may warrant a new..., Goldman [/bib_ref] [bib_ref] Competing risks: investing in sickness rather than health, Goldman [/bib_ref] Using sophisticated modeling, 1 group compared CVD prevention versus treatment for a population aged 30 to 84 years with risk-factor levels, event rates, current behavior patterns, levels of treatment, and mortality rates resembling those of the US population. In the target population, 44% of all deaths were attributable to heart disease. Management of CVD risk factors before an event would have prevented or postponed 33% of these deaths. This compared with prevention of only 8% of deaths if "perfect care" was used during an acute event. These data provide strong support for the importance of selfcare in preventing CVD and further events. [bib_ref] The comparative effectiveness of heart disease prevention and treatment strategies, Kottke [/bib_ref] 

## Section summary
- A globally aging population will result in huge numbers of elderly individuals with multiple chronic conditions, including CVD and stroke, by 2050.

## A life course approach to cvd
By the time CVD is manifest, it usually has been a silent condition for years. [bib_ref] Projecting chronic disease prevalence, Manton [/bib_ref] Thus, it is essential that self-care of CVD risk factors is addressed as early as possible, not waiting for the emergence of overt CVD. Many advocate taking a "life course" approach to the prevention of chronic illnesses beginning with primordial prevention, because it is clear that the seeds of most noncommunicable diseases are planted very early in the life course. [bib_ref] Preparing for an aging world: engaging biogerontologists, geriatricians, and the society, Nikolich-Zugich [/bib_ref] [bib_ref] Life-course approach to chronic disease: the active and healthy aging perspective, Scuteri [/bib_ref] [bib_ref] A life course approach to cardiovascular aging, Hardy [/bib_ref] Epidemiological data suggest that events in the perinatal period, and possibly even in the periconception period, are associated with an increased risk of chronic diseases in later life. [bib_ref] Influence of maternal obesity on the long-term health of offspring, Godfrey [/bib_ref] This "fetal programming," also known as "developmental origins of health and disease," describes the process whereby a nutritional or endocrine event during a critical period of development results in an increased later risk of chronic disease. [bib_ref] Living with the past: evolution, development, and patterns of disease, Gluckman [/bib_ref] [bib_ref] Role of nutritional programming in determining adult morbidity, Lucas [/bib_ref] Low-birth-weight (LBW) infants have a higher risk for coronary heart disease, cerebrovascular disease, metabolic syndrome, type 2 diabetes mellitus, and hypertension as adults than normal-birth-weight infants 56-58 that is not explained by lifestyle factors such as smoking, diet, employment, alcohol, or exercise. 57,59 LBW may be caused by fetal, placental, or maternal factors, but, in many cases, the cause is not identified.
A number of potentially modifiable maternal risk factors have been associated with LBW, including young or old age (<17 years or >35 years), low BMI (<20 kg/m 2 ), alcohol or drug use, smoking, and poor nutrition. Preeclampsia is associated with LBW and a higher risk of stroke, hypertension, and obesity as well as evidence of widespread vascular dysfunction in the offspring. [bib_ref] Cardiovascular risk factors in children and young adults born to preeclamptic pregnancies:..., Davis [/bib_ref] [bib_ref] Pulmonary and systemic vascular dysfunction in young offspring of mothers with preeclampsia, Jayet [/bib_ref] [bib_ref] Pre-eclampsia is associated with increased risk of stroke in the adult offspring..., Kajantie [/bib_ref] [bib_ref] Cardiovascular biomarkers and vascular function during childhood in the offspring of mothers..., Lawlor [/bib_ref] Maternal obesity also predicts childhood obesity in the offspring. [bib_ref] Influence of maternal obesity on the long-term health of offspring, Godfrey [/bib_ref] Even maternal exercise during gestation may influence cardiometabolic status in the fetus and infant. [bib_ref] Exercise in pregnancy: weighing up the long-term impact on the next generation, Hopkins [/bib_ref] An intriguing study from the Helsinki Birth Cohort 1934-1944 reported that offspring of women who were preeclamptic compared with those of women with normotensive pregnancies have an increased risk for adulthood abnormalities in adaptive functioning, mental well-being, and later depressive symptoms, all of which might affect self-care in adulthood. [bib_ref] R aikk onen K. Maternal hypertensive disorders during pregnancy: adaptive functioning and..., Tuovinen [/bib_ref] [bib_ref] Depressive symptoms in adulthood and intrauterine exposure to pre-eclampsia: the Helsinki Birth..., Tuovinen [/bib_ref] Other periods during the life course are receiving increased attention for the appearance of risk factors that must be addressed early. For example, pregnancy is considered a "natural stress test" that uncovers risk for future CVD among mothers. [bib_ref] Cardiovascular care for women: the 10-Q Report and beyond, Wenger [/bib_ref] Women with hypertension or preeclampsia during pregnancy have more than double the risk for a future CVD or cerebrovascular disease death or diagnosis than women who do not have these conditions during pregnancy. [bib_ref] Cardiovascular disease risk in women with pre-eclampsia: systematic review and metaanalysis, Brown [/bib_ref] LBW among offspring or delivery of a preterm baby place the mother at increased risk for CVD. [bib_ref] A life course approach to cardiovascular aging, Hardy [/bib_ref] Early self-care during this window of opportunity could stave off the development of CVD.
Maternal risk factors place infants and adolescents at higher than normal risk for early development of CVD risk factors and higher risk of early disease. [bib_ref] Prediction of coronary artery calcium in young adults using the Pathobiological Determinants..., Gidding [/bib_ref] Thus, self-care must address maternal risk factors for LBW, primordial prevention (eg, not starting smoking, avoiding overweight, being active, eating a heart healthy and low-sodium diet), and the early appearance of cardiometabolic risk factors in LBW offspring. For example, childhood obesity is rising as are other risk factors, such as sedentary lifestyle, and early self-care intervention to prevent or manage these risk factors is needed. Primordial prevention of CVD risk factors is best addressed with multifaceted, population-based strategies involving increased education beginning in elementary schools or earlier, improvements in environmental infrastructure (eg, more sidewalks, parks, recreation centers, and easier access to healthful food choices), and regulatory initiatives (eg, tighter control of tobacco products, reduction in use of simple sugars and trans fats in foods). Such strategies are particularly important because, as this review highlights, it may be that only through primordial prevention will we achieve a marked reduction in the incidence and prevalence of CVD.

## Failure of routine care to promote self-care
Teaching and supporting self-care should be a major activity in our healthcare system. Yet, complexities in its conceptualization and practice result in underappreciation of selfcare by clinicians and healthcare systems. As a consequence, clinicians have not emphasized self-care, and the vast majority of people do not perform self-care behaviors well. [bib_ref] Role of selfcare in the patient with heart failure, Moser [/bib_ref] [bib_ref] Gender differences in heart failure self-care: a multinational cross-sectional study, Lee [/bib_ref] [bib_ref] A story of maladies, misconceptions and mishaps: effective management of heart failure, Horowitz [/bib_ref] Self-care research and clinical efforts have been hindered by the perceptions of both patients and providers that pharmacological interventions are more effective than lifestyle change. [bib_ref] Diabetes self-care among a multiethnic sample of older adults, Schoenberg [/bib_ref] [bib_ref] Barriers to non-insulin dependent diabetes mellitus (NIDDM) self-care practices among older women, Schoenberg [/bib_ref] Widespread failure of clinicians to follow, or give more than token attention to, CVD prevention guidelines has resulted in little change or worsening in CVD risk factors over time in many countries and points to a compelling need for a greater emphasis on self-care.Further evidence of this failure is evident in practice-based approaches to CVD risk reduction. [bib_ref] Kentucky Ambulatory Network. Cardiovascular risk education and social support (CaRESS): report of..., Pearce [/bib_ref] [bib_ref] The content of diet and physical activity consultations with older adults in..., Bardach [/bib_ref] Some reasons for the lack of effectiveness of clinical efforts to influence CVD risk include the limited training of providers about patient education and use of effective behavior change strategies, lack of time for patient encounters, lack of support in the clinic environment for a self-care-based approach, growth of healthcare systems focusing on care of acute events with little appreciation of the chronicity of most conditions, and better reimbursement for treatment than for prevention. [bib_ref] on behalf of the American Heart Association Physical Activity Committee of the..., Hivert [/bib_ref] Our clinical and societal focus on an illness-or diseasedriven model of episodic care has resulted in what Goldman et al call "investing in sickness rather than health." [bib_ref] Competing risks: investing in sickness rather than health, Goldman [/bib_ref] This investment and our changing demography have resulted in people living longer with multiple chronic conditions that are not well controlled because self-care is at the heart of control of chronic illnesses.

## Section summary
- The seeds of most noncommunicable diseases such as CVD are planted very early in the life course, requiring a massive shift in the focus on treatment of acute events to an early emphasis on self-care.

## Self-care behaviors
In this section, we address self-care behaviors at the individual, family, and community levels. The roots of health lie in behavior, genetics, social circumstances, health care, and environmental exposures.Inadequate or unavailable medical therapy is thought to contribute little (around 10%) to illness and disease, whereas the predominant force is behavior, contributing %40% to overall health.Other determinants of health include genetics and stress. Social circumstances and environment contribute another %20% to health.Thus, it is clear that improving self-care at the individual, family, and community levels could produce a major impact in health.

## Individual-level self-care behaviors
Autonomy, understanding self-care, and self-responsibility
Our healthcare system is built on the assumption that individuals seeking care will comply with healthcare providers' recommendations. Accountability is fostered in the context of keeping appointments and taking prescribed medications while following provider advice. The complex tasks of preventing chronic illnesses such as CVD and stroke commonly are addressed with provision of advice to "lose weight, get more activity, stop smoking" without provision of the knowledge, skills, and long-term support needed for people to be successful with these self-care behaviors. Training in self-care is not common in the current healthcare system (for either providers or patients), and there is little time for development of strong and respectful patient-provider partnerships.
Given the lack of emphasis on self-care in the healthcare system today, most patients expect that healthcare providers hold the responsibility for patients' health. [bib_ref] Can health care organizations improve health behavior and treatment adherence?, Bender [/bib_ref] Thus, both healthcare providers and patients will need a major change in expectations about their respective roles in the prevention and management of CVD and stroke. Recently, the National Academy of Medicine (formerly the Institute of Medicine) wrote a white paper, "Vital Directions for Health and Health Care," which addresses the major problems with healthcare systems today and changes that need to be made. One of their major focuses was "Empower People-Democratize Action for Health."With this focus comes the charge to develop a healthcare system in which patients and families are informed, empowered, and engaged in their own health care and that they are promoted as partners in making healthcare decisions and in ensuring that these decisions are commensurate with their goals for health and life.understand their current health status and their risk for future conditions in order to engage in adequate self-care. Such knowledge requires development of a partnership with all healthcare providers who are willing to promote self-care by keeping patients informed about their health status, thoroughly explaining all risk factors, and providing patients with access to appropriate sources of further information (eg, reputable web sources, books, and media outlets).
The "Know Your Numbers" campaign was designed to encourage people to determine their risk for CVD.Five risk factors are targeted: BP, total cholesterol, high-density lipoprotein cholesterol, blood glucose, and BMI. The goal is for people to determine whether any of these factors are abnormal, allowing them to take appropriate action to reduce their risk for CVD. A similar campaign is used for people with pre-diabetes mellitus or type 2 diabetes mellitus.There have been no studies to determine the effectiveness of these specific campaigns; however, the "Know Your Numbers" program in Australia to increase BP awareness resulted in a majority of people with hypertension seeking medical follow-up. 82

## Diet
Self-care related to diet differs from some other preventative lifestyle behaviors in that a new behavior is not required, such as exercise, but rather existing behaviors are modified. This can make dietary self-care challenging because it involves changing habitual behaviors that are embedded in culture and may have social consequences. Equally challenging are what can appear to be frequent changes to dietary recommendations, which may be frustrating to those attempting to follow guidelines. This may be particularly true in respect to changes in long-standing recommendations. One example is the change in current guidelines that no longer specify a maximum daily intake of dietary cholesterol, which people have spent the past 45 years struggling to limit. [bib_ref] Diets to prevent coronary heart disease 1957-2013: what have we learned?, Dalen [/bib_ref] Thus, it is important that people have confidence that the recommendations they are given are worth the effort to follow. The recent switch in focus away from restriction of specific nutrients to promoting heart-healthy dietary patterns 84 may increase stability in recommendations and reduce future frustration. It is important to note, however, that the recommended dietary patterns are still intended to restrict intake of specific nutrients, namely added sugars, trans fats, saturated fats, and sodium, indicating that these nutrients continue to be implicated in development of CVD.
Key components of current dietary recommendations 84 center around eating a varied, nutrient-dense diet that includes all vegetable subgroups: dark green, red and orange, legumes, and starchy. Also recommended are fruits, especially whole fruits, grains, particularly whole grains, fat-free or low-fat dairy, and protein from seafood, poultry, lean meats, eggs, nuts, seeds, and soy products. Unsaturated fat oils, such as soybean, corn, olive, canola, and safflower, are recommended. [bib_ref] Kris-Etherton P; on behalf of the American Heart Association Nutrition Committee of..., Van Horn [/bib_ref] The 2 most commonly recommended diets that achieve these recommendations are the Dietary Approaches to Stop Hypertension (DASH) and Mediterranean-style diets. [bib_ref] Kris-Etherton P; on behalf of the American Heart Association Nutrition Committee of..., Van Horn [/bib_ref] The recommendations can also easily be achieved with vegan or vegetarian diets as long as attention is paid to obtaining all essential amino acids and minerals. [bib_ref] Kris-Etherton P; on behalf of the American Heart Association Nutrition Committee of..., Van Horn [/bib_ref] Although adherence to dietary recommendations has improved over the past 10 years, it still remains low at 60% of the population.Although considerable research has been conducted testing the effect of various diets on cardiovascular health, studies to promote dietary adherence are limited. In a recent review of dietary advice interventions for healthy adults to improve CVD risk factors, most interventions focused on nutrient reductions, such as fats or sodium, or nutrient increases, such as fruits, vegetables, or fiber. [bib_ref] Dietary advice for reducing cardiovascular risk, Rees [/bib_ref] None focused on the currently recommended "whole diet" approach. Higher-intensity interventions with more personal contact were more effective than low-intensity interventions. Dietary advice appeared to be more effective for people with known or perceived risk for CVD who are more likely to be receptive to advice. Effectiveness of specific strategies was not identified in the review. In another recent review, strategies to change dietary behavior for prevention and management of chronic illness identified feedback, telephone follow-up after education sessions, provision of nutritional tools such as menus, and contracting as the most promising interventions. [bib_ref] Interventions to enhance adherence to dietary advice for preventing and managing chronic..., Desroches [/bib_ref] However, none of the interventions was clearly superior, primarily because of the low quality of the studies.
Published examples of how to apply current dietary guidelines are based on Western foods. [bib_ref] Kris-Etherton P; on behalf of the American Heart Association Nutrition Committee of..., Van Horn [/bib_ref] Cultural considerations are important when planning self-care strategies for everyone given the multiplicity of cultures and the effect of culture on diet. [bib_ref] The association between acculturation and dietary patterns of South Asian immigrants, Lesser [/bib_ref] For example, in many cases, the diets of first-generation immigrants are more heart-healthy than the typical Western diet on arrival in the United States, but gradually change to a more Western-style diet over time. [bib_ref] Dietary habits of Asian Indians in relation to length of residence in..., Raj [/bib_ref] In this case, strategies are needed to promote adoption of healthy components of the Western diet, rather than the large portion sizes or commercially prepared and convenience foods. For immigrants who maintain a diet from their home culture, the underlying principles of the guidelines can be applied by focusing on the selection of comparable foods.

## Weight control
Maintaining a healthy body weight is an important self-care behavior and current dietary guidelines emphasize the importance of weight control.This is achieved by consuming appropriate serving sizes of recommended foods to meet estimated caloric demand. Estimating and tracking caloric intake is difficult over the course of a typical day and therefore not a successful strategy for weight control. Fortunately, serving sizes for specific food categories are provided in the guidelines for each level of caloric intake. Estimating serving sizes can be quickly mastered after a brief period of measuring out portion sizes. Individual caloric need is based on activity level, indicating that self-care strategies for increasing activity carry equal importance with diet in body weight maintenance.
Weight loss for people who are obese has been a longstanding recommendation for cardiovascular health.It should be noted that with the exception of bariatric surgery, no interventions have been associated with substantial weight loss sustained over time. So, setting initial weight loss targets of 5% to 10% can have a clinically significant impact on CVD risk.Self-care for weight loss is rarely achieved alone. Most successful lifestyle interventions for weight loss require participation in a program, either individually or in a group, for 6 months.Long-term weight maintenance may require an ongoing support system. Computer-based interventions are an attractive alternative to in-person programs for convenience and cost. However, the evidence suggests that, whereas these programs are better than passive interventions such as pamphlets or a manual, they are not equal in effectiveness to in-person programs. [bib_ref] Interactive computer-based interventions for weight loss or weight maintenance in overweight or..., Wieland [/bib_ref] However, the majority of these studies were not highly interactive, so it is possible that interventions that provide greater interaction may be equally effective to in-person programs.

## Physical activity and exercise
Aerobic exercise is a self-care behavior with incontrovertible health benefit, including systemic improvement in oxygen consumption, endothelial function, inflammation, BP, and insulin resistance as well as improvement in functional status, sleep quality, and quality of life. [bib_ref] Cardiovascular benefits of exercise, Agarwal [/bib_ref] The importance of physical activity on mortality risk was highlighted in the Oslo II study. [bib_ref] Increases in physical activity is as important as smoking cessation for reduction..., Holme [/bib_ref] Elderly men who engaged in 30 minutes of physical activity 6 d/w had a 40% mortality risk reduction at 12-year follow-up -a benefit comparable to that observed with smoking cessation.
There is increasing evidence that inactivity or sedentary behavior is independently associated with negative outcomes independent of overall exercise or physical activity levels. In patients with symptomatic chronic HF, physical inactivity and high levels of daily television screen time are associated with greater risk of all-cause and cardiac mortality whereas modest exercise is associated with reduced all-cause and cardiac mortality. [bib_ref] Impact of physical inactivity on mortality in patients with heart failure, Doukky [/bib_ref] In patients with diabetes mellitus, every 60 min/d increase in objectively measured sedentary behavior resulted in a 13% increase in mortality, independent of physical activity. [bib_ref] The effects of objectively measured sedentary behavior on all-cause mortality in a..., Loprinzi [/bib_ref] However, in adults without past CVD, higher physical activity levels and not sedentary behavior were related to lower CVD mortality. [bib_ref] Associations of accelerometry-assessed and self-reported physical activity and sedentary behavior with all-cause..., Evenson [/bib_ref] Cardiac rehabilitation teaches and encourages self-care and is recommended in clinical practice guidelines for patients with acute myocardial infarction or coronary revascularization, [bib_ref] ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic..., Fihn [/bib_ref] other cardiac surgical procedures, chronic HF, [bib_ref] ACCF/AHA guideline for the management of heart failure: a report of the..., Yancy [/bib_ref] stroke, [bib_ref] Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Guidelines for..., Kernan [/bib_ref] and peripheral artery disease. [bib_ref] AHA/ACC guideline on the management of patients with lower extremity peripheral artery..., Gerhard-Herman [/bib_ref] Traditional models of cardiac rehabilitation and structured exercise therapy have required a supervised setting in a healthcare environment to achieve the greatest benefit. However, there is increasing evidence that structured programs that take place in a home-or community-based environment may be as effective and more accessible to patients with CVD, who are often older and more debilitated. [bib_ref] Step-monitored home exercise improves ambulation, vascular function, and inflammation in symptomatic patients..., Gardner [/bib_ref] [bib_ref] Home-based walking exercise in peripheral artery disease: 12-month followup of the GOALS..., Mcdermott [/bib_ref] [bib_ref] Home-based walking exercise intervention in peripheral artery disease: a randomized clinical trial, Mcdermott [/bib_ref] The efficacy of these programs is augmented by incorporation of strategies such as health coaching and activity tracking. Despite the demonstrated benefits of cardiac rehabilitation, only 20% to 30% of eligible patients participate and referral is significantly lower in women than men. [bib_ref] Sex bias in referral of women to outpatient cardiac rehabilitation? A metaanalysis, Colella [/bib_ref] Ades et al 105 estimate that if participation in cardiac rehabilitation increased to 70% of eligible patients, 12 000 lives and 87 000 hospitalizations could be saved in the first year alone.

## Smoking cessation
Never smoking and smoking cessation are essential self-care behaviors with significant benefit to smokers and those exposed to tobacco smoke. Smokers who quit after a CVD event have better outcomes than those who continue to smoke, with health benefits that begin almost immediately. In those who quit, the risk of a recurrent event is the same as a nonsmoker within 3 years, and the risk of death from CVD is decreased by two thirds in former smokers versus those who continue to smoke. [bib_ref] Smoking cessation and the cardiovascular patient, Prochaska [/bib_ref] [bib_ref] Smoking cessation for the secondary prevention of coronary heart disease, Critchley [/bib_ref] Smoking reduction rather than cessation has little effect on clinical or biological markers, confirming that even minor exposure to tobacco smoke is harmful and illustrating the importance of complete cessation. [bib_ref] Does smoking reduction in midlife reduce mortality risk? Results of 2 long-term..., Hart [/bib_ref] [bib_ref] Smoking reduction fails to improve clinical and biological markers of cardiac disease:..., Joseph [/bib_ref] Smoking cessation is an extremely challenging self-care behavior because of the addiction to tobacco, but medication can facilitate quitting, 111 even in those who are not yet ready to quit. In one trial, patients who were not willing to quit in the next month, but were willing to reduce the number of cigarettes smoked, were randomized to varenicline or placebo and instructed to reduce the number of cigarettes smoked by 50%, 75%, and 100% over 12 weeks. At weeks 21 to 24, those randomized to the varenicline group had a 38% abstinence rate compared with 13% in the placebo group. [bib_ref] Effect of varenicline on smoking cessation through smoking reduction: a randomized clinical..., Ebbert [/bib_ref] Psychosocial interventions, behavioral interventions, telephone counseling, and self-help materials are also effective in promoting smoking cessation, with the best results achieved with more intense interventions. [bib_ref] Psychosocial interventions for smoking cessation in patients with coronary heart disease, Barth [/bib_ref] Group therapy is as effective as individual therapy, especially when augmented by physician advice or nicotine replacement therapy. [bib_ref] Group behaviour therapy programmes for smoking cessation, Stead [/bib_ref] Healthcare providers who give brief advice to quit at every interaction with a smoker increase the odds of quitting by 34%, [bib_ref] Physician advice for smoking cessation, Stead [/bib_ref] which is further enhanced with brief counselling. [bib_ref] Managing tobacco use: the neglected cardiovascular disease risk factor, Rigotti [/bib_ref] A combined approach to smoking cessation significantly increases the likelihood that a smoker will be able to quit.Patients who quit after an acute CVD event may be more successful at maintaining this self-care behavior over time than patients with a slowly progressing chronic disease. [bib_ref] Smoking cessation after an acute coronary syndrome: immediate quitters are successful quitters, Snaterse [/bib_ref] [bib_ref] Smoking cessation counseling in vascular surgical practice using the results of interviews..., Newhall [/bib_ref] More research is needed to understand how best to help smokers quit.

## Alcohol use
The data on alcohol use are confusing and the public is unsure what constitutes good self-care. Alcohol contributes to the development of hypertension and is associated with cardiomyopathy. Light-to-moderate alcohol consumption is protective in patients with stable ischemic heart disease. Current guidelines state that 1 or 2 drinks/d is reasonable for patients with stable ischemic heart disease. [bib_ref] ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic..., Fihn [/bib_ref] Similarly, current stroke guidelines suggest that stroke patients who drink heavily should reduce their alcohol consumption, but it may be reasonable for them to consume light-to-moderate amounts of alcohol. [bib_ref] Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Guidelines for..., Kernan [/bib_ref] An inverse relationship was found between alcohol intake and acute coronary syndrome. [bib_ref] Alcohol intake and risk of acute coronary syndrome and mortality in men..., Hansen [/bib_ref] Moderate drinking was associated with a lower mortality rate than abstaining or heavy drinking. [bib_ref] Alcohol intake and risk of acute coronary syndrome and mortality in men..., Hansen [/bib_ref] Similar confusing results were found in diabetes mellitus, 120,121 incident HF, [bib_ref] Alcohol consumption and risk of heart failure: the Atherosclerosis Risk in Communities..., Gonc alves [/bib_ref] and ischemic and hemorrhagic stroke. [bib_ref] Alcohol consumption and risk of stroke in women, Jimenez [/bib_ref] [bib_ref] Midlife alcohol consumption and the risk of stroke in the Atherosclerosis Risk..., Jones [/bib_ref] Given the potential negative health and societal consequences of alcohol dependence or abuse, people who do not currently drink alcohol should not be encouraged to begin drinking. Those who do consume alcohol should be informed of the potential risks and encouraged to consume alcohol in moderation.

## Medication adherence
Self-care includes taking medicines as prescribed and responsible selection and use of nonprescription medicines. Medication adherence is most likely when patients are well informed about medications, including potential side effects, the potential for drug interactions, and when to contact their clinician to discuss discontinuing or changing medications. Responsible use also includes understanding the pros and cons of using nonprescription or over-the-counter medicines, following the label recommendations, and an ongoing evaluation of the benefits and effectiveness of the drug. Responsible use also involves informing healthcare providers of the use of both prescription and nonprescription drugs.
Poor adherence to the medication regimen is a major factor in the inadequate achievement of CVD treatment goals. [bib_ref] Medication adherence in cardiovascular disease, Baroletti [/bib_ref] [bib_ref] Medication adherence: its importance in cardiovascular outcomes, Ho [/bib_ref] [bib_ref] Non-adherence to cardiovascular medications, Kolandaivelu [/bib_ref] Nonadherence to cardiovascular medicine is associated with greater risk of adverse effects and inappropriate therapeutic drug escalations. [bib_ref] Medication adherence: its importance in cardiovascular outcomes, Ho [/bib_ref] [bib_ref] Non-adherence to cardiovascular medications, Kolandaivelu [/bib_ref] [bib_ref] Electronically monitored medication adherence predicts hospitalization in heart failure patients, Riegel [/bib_ref] Unfortunately, no clearly effective method of promoting medication adherence has been identified. Two recent systematic reviews found significant improvement in medication adherence through the use of text messages. [bib_ref] Does mHealth increase adherence to medication? Results of a systematic review, Anglada-Martinez [/bib_ref] [bib_ref] Mobile phone interventions for the secondary prevention of cardiovascular disease, Park [/bib_ref] [bib_ref] Mobilizing your medications: an automated medication reminder application for mobile phones and..., Patel [/bib_ref] Patel et al [bib_ref] Mobilizing your medications: an automated medication reminder application for mobile phones and..., Patel [/bib_ref] found that a mobile phone-based automated medication reminder system showed promise in improving medication adherence and BP control in individuals at high risk for CVD.

## Family-level self-care
Informal caregivers, typically family members, exert a significant influence on self-care, [bib_ref] Family caregivers of patients with heart failure: a longitudinal study, Pressler [/bib_ref] [bib_ref] Exploring the relationship of patient and informal caregiver characteristics with heart failure..., Buck [/bib_ref] with lack of support identified as an important barrier to self-care . [bib_ref] Pacific Islanders' perspectives on heart failure management, Kaholokula [/bib_ref] [bib_ref] Whose job is it? Gender differences in perceived role in heart failure..., Dickson [/bib_ref] [bib_ref] Gender-specific barriers and facilitators to heart failure self-care: a mixed methods study, Riegel [/bib_ref] The most supportive contributions from caregivers are positive responses to a perceived need in a specific situation. [bib_ref] Determinants of effective heart failure self-care: a systematic review of patients' and..., Clark [/bib_ref] Family caregivers positively influence self-care by facilitating adherence to medications and diet as well as vigilance in monitoring. [bib_ref] Context matters in HF self-care: a qualitative systematic review, Strachan [/bib_ref] [bib_ref] Caregivers' contributions to heart failure self-care: a systematic review, Buck [/bib_ref] In HF, significant family-level factors associated with patient self-care include sex, quality of life, relationship type and quality, social support, and factors associated with aging or disease progression such as number of chronic conditions, impaired activities of daily living, cognition, number of hospitalizations, and duration of experience with the illness. [bib_ref] Determinants of heart failure self-care maintenance and management in patients and caregivers:..., Bidwell [/bib_ref] However, even when caregivers are invested and involved in promoting self-care, they are limited by their own lack of knowledge or skill. [bib_ref] Context matters in HF self-care: a qualitative systematic review, Strachan [/bib_ref] Recent studies have focused on couples or dyadic influences on self-efficacy, [bib_ref] Exploring the relationship of patient and informal caregiver characteristics with heart failure..., Buck [/bib_ref] [bib_ref] Effect of structured homebased exercise on walking ability in patients with peripheral..., Li [/bib_ref] self-care, [bib_ref] Determinants of heart failure self-care maintenance and management in patients and caregivers:..., Bidwell [/bib_ref] and dyadic patterns in collaborating on self-care. [bib_ref] Patterns and predictors of patient and caregiver engagement in heart failure care:..., Lee [/bib_ref] In HF, dyadic patterns of self-care have been identified as novice and complementary, inconsistent and compensatory, or expert and collaborative. [bib_ref] Patterns and predictors of patient and caregiver engagement in heart failure care:..., Lee [/bib_ref] Self-care self-efficacy, or task-specific confidence, is generally higher in informal caregivers than in patients. [bib_ref] Effect of structured homebased exercise on walking ability in patients with peripheral..., Li [/bib_ref] Caregivers who rate the quality of the relationship higher are more likely to score the best in self-care self-efficacy. [bib_ref] Exploring the relationship of patient and informal caregiver characteristics with heart failure..., Buck [/bib_ref] Other investigators have found that when dyads disagree on self-care, this disagreement causes distress and dysfunction in the couple. [bib_ref] Patient and caregiver incongruence in advanced heart failure, Kitko [/bib_ref] [bib_ref] Patient and caregiver congruence: the importance of dyads in heart failure care, Retrum [/bib_ref] [bib_ref] Patient-identified factors related to heart failure readmissions, Retrum [/bib_ref] However, significant heterogeneity exists across dyads. [bib_ref] Effect of structured homebased exercise on walking ability in patients with peripheral..., Li [/bib_ref] In a recent joint scientific statement from the AHA, American College of Cardiology, and American Geriatrics Society, models of care that integrate caregivers into decision making was identified as a significant practice gap across guidelines. [bib_ref] Tirschwell DL; on behalf of the American Heart Association Older Populations Committee..., Rich [/bib_ref] Community-Level Self-Care
The range of environmental factors that impact health and the ability of people to perform self-care is remarkably broad. The World Health Organization European Healthy Cities program identified 12 key health determinants, including access to services, healthy food, open spaces, safe environments, healthy air, physical activity, and social cohesion. [bib_ref] Healthy urban planning in European cities, Barton [/bib_ref] A number of studies have attempted to correlate walkability in the built environment with body weight, generally using BMI calculations. A 2008 review found that neighborhoods with barriers to physical activity were associated with higher BMI. [bib_ref] Neighborhoods and obesity, Black [/bib_ref] However, a more-recent systematic review failed to find that the multicomponent, community-wide interventions studied effectively increased physical activity for the population, although some studies with environmental components observed more people walking. [bib_ref] Community wide interventions for increasing physical activity, Baker [/bib_ref] Community-level dietary self-care strategies should include considerations for the food environment (shops, supermarkets, cafes, takeaways, restaurants, and vending machines). [bib_ref] The local food environment and diet: a systematic review, Caspi [/bib_ref] Food deserts, defined as areas with limited availability of nearby food markets, are present in both urban and rural areas. [bib_ref] Disparities and access to healthy food in the United States: a review..., Walker [/bib_ref] These food deserts are believed to limit access to heart healthy foods and be associated with higher food costs. Recent evidence, however, does not support the hypothesis that food deserts in urban neighborhoods significantly affect eating or shopping habits of people living in those neighborhoods. [bib_ref] A food desert in Detroit: associations with food shopping and eating behaviours,..., Budzynska [/bib_ref] [bib_ref] Neighborhood food environment, diet, and obesity among Los Angeles County adults, Mejia [/bib_ref] People in rural areas may be more affected; transportation may be a greater barrier in rural areas than transportation to stores nearby in urban neighborhoods. [bib_ref] Disparities and access to healthy food in the United States: a review..., Walker [/bib_ref] [bib_ref] Neighborhood food environment, diet, and obesity among Los Angeles County adults, Mejia [/bib_ref] Food-cost disparities exist in rural areas, with the cost of healthier foods higher in areas with greater poverty and less population density than in morewealthy, high-density counties. [bib_ref] Food cost disparities in rural communities, Hardin-Fanning [/bib_ref] Similarly, counties with the poorest population health ratings had the highest-cost foods compared with counties with the best population health ratings. Regardless of urban or rural location, individual food affordability and accessibility need to be considered. In these cases, careful assessment of access barriers and identification of community resources may be needed for individual success. The food environment in different countries can be vastly different. In England, the availability of fast-food outlets around schools is thought to be an obstacle to establishing healthy eating habits. [bib_ref] Does the local food environment around schools affect diet? Longitudinal associations in..., Smith [/bib_ref] A link has been demonstrated between fast-food availability and obesity in older children. [bib_ref] Understanding the relationship between food environments, deprivation and childhood overweight and obesity:..., Cetateanu [/bib_ref] 

## Section summary
- The evidence supporting individual-(eg, exercise), family-(eg, social support), and community-level (eg, accessibility of healthy food) self-care approaches is described.

## Cvd outcomes of self-care
In this section, we summarize the data supporting self-care for hypertension, coronary heart disease, peripheral artery disease, stroke, AF, and HF. There are so many studies focused on individual self-care behaviors that we summarize only meta-analyses. A brief summary of mechanisms of effectiveness concludes this important section.

## Hypertension
Self-measurement and monitoring of BP is a major emphasis in the self-care of hypertension. In a recent meta-analysis, there was evidence that self-measurement of BP was superior to usual care (24 trials) in reducing systolic (A3.1 mm Hg) and diastolic (A2.0 mm Hg) BP at 6 months.In the metaanalysis, additional support beyond self-measurement (24 trials) resulted in even greater reductions in systolic (A3.4 to A8.9 mm Hg) and diastolic (A1.9 to A4.4 mm Hg) BP compared with usual care up to 12 months.Another meta-analysis of 11 trials of self-measurement of BP interventions versus usual care demonstrated a significant reduction in diastolic (weighted mean difference, A2.02; 95% confidence interval [CI], A2.93 to A1.11), but not systolic, BP. [bib_ref] The effect of selfmonitoring of blood pressure on medication adherence and lifestyle..., Fletcher [/bib_ref] The researchers also provided evidence that selfmeasurement of BP interventions compared with usual care [bib_ref] Lifestyle modification programmes for patients with coronary heart disease: a systematic review..., Janssen [/bib_ref] In summary, there is evidence across multiple trials to support self-care interventions that are focused on lifestyle modifications as a means to improve clinical outcomes in coronary heart disease. In contrast, interventions focused solely on improving adherence to cardiac rehabilitation only seem to influence uptake, but not adherence behavior or quality of life.

## Peripheral artery disease
Li et al [bib_ref] Effect of structured homebased exercise on walking ability in patients with peripheral..., Li [/bib_ref] 

## Stroke
A recent systematic meta-review of 13 systematic reviews representing 101 individual trials of self-care support interventions with stroke survivors provide high-quality evidence to support self-care. [bib_ref] Self-management support interventions for stroke survivors: a systematic meta-review, Parke [/bib_ref] The researchers concluded that support for self-care in the context of therapy rehabilitation delivered soon after a stroke resulted in short-term (<1 year) improvement in activities of daily living and reductions in the risk of dependence and death poststroke. [bib_ref] Self-management support interventions for stroke survivors: a systematic meta-review, Parke [/bib_ref] 

## Atrial fibrillation
Heneghan et al [bib_ref] Selfmonitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data, Heneghan [/bib_ref] [bib_ref] Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation, Clarkesmith [/bib_ref] The researchers suggested that they may not have found benefit because 4 of the trials included mixed indication cohorts and 10 further trials were excluded because they did not provide AF-specific data. They also suggest some patient-specific factors that could have impacted intervention effectiveness (eg, older age and inaccurate beliefs). Although there is evidence across multiple trials that self-testing and self-care of oral anticoagulation reduces the risk of thromboembolic events at large, more research is needed into mechanisms other than time in therapeutic range by which self-care interventions are successful in AF.

## Heart failure
For more than a decade, there has been evidence from metaanalyses of randomized, controlled trials that interventions focused on enhancing self-care in HF are efficacious versus usual care in improving outcomes. McAlister et al [bib_ref] Multidisciplinary strategies for the management of heart failure patients at high risk..., Mcalister [/bib_ref] first provided evidence across 4 trials that interventions focused on enhancing HF self-care reduced all-cause hospitalizations and HF hospitalizations. A subsequent meta-analysis of trials focused on HF self-care provided evidence that interventions focused on improving self-care (5 trials) reduced all-cause readmission and HF readmissions (3 trials). [bib_ref] Effects of self-management intervention on health outcomes of patients with heart failure:..., Jovicic [/bib_ref] reviewed trials focused on self-care interventions and quality of life in HF. Nine of the 17 trials included in her review showed an improvement in quality of life compared to usual care; but, methodological heterogeneity across the trials reviewed interfered considerably with the ability to draw any strong conclusions. [bib_ref] Self-care and quality of life outcomes in heart failure patients, Grady [/bib_ref] Ditewig et al 171 completed a systematic review without a meta-analysis on effectiveness of self-management programs in HF and concluded that self-care interventions generally had a positive effect on all-cause readmission, mortality, and quality of life. These researchers also highlighted significant methodological heterogeneity across studies that interfered with any strong summative conclusions. Another meta-analysis focused on structured telephone support interventions to improve HF self-care. [bib_ref] Structured telephone support or non-invasive telemonitoring for patients with heart failure, Inglis [/bib_ref] In this meta-analysis, selfcare focused structured telephone support interventions reduced all-cause mortality [bib_ref] Do self-management interventions work in patients with heart failure? An individual patient..., Jonkman [/bib_ref] In subsequent analyses, it was concluded that no specific intervention characteristics other than longer intervention duration were associated with better self-management intervention efficacy. [bib_ref] What are effective program characteristics of selfmanagement interventions in patients with heart..., Jonkman [/bib_ref] In summary, there is sufficient information across many trials that interventions targeting HF self-care are associated with better clinical outcomes and improvements in quality of life, suggesting readiness for implementation studies.

## Mechanisms of effectiveness
Healthy self-care behaviors lower the risk of incident disease, and the mechanisms underlying these effects can be broadly summarized as cardioprotection. [bib_ref] The influence of heart failure self-care on health outcomes: hypothetical cardioprotective mechanisms, Lee [/bib_ref] This is particularly true of the self-care maintenance behaviors of smoking cessation, maintaining normal BMI, routine physical activity, reducing dietary sodium intake, decreasing alcohol use, and maintaining a healthy diet, a low cholesterol, a normal BP, and a normal fasting plasma glucose. Other selfcare maintenance behaviors help reduce inflammation attributed to infection in CVD such as routine preventive dental care and annual influenza vaccination. [bib_ref] Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in..., Lockhart [/bib_ref] [bib_ref] Influenza vaccination and reduction in hospitalizations for cardiac disease and stroke among..., Nichol [/bib_ref] Medication adherence is perhaps the most obvious cardioprotective self-care behavior. For example, it has been proposed that HF patients who are adherent to prescribed therapies may avoid the escalation of loop diuretics, 178-180 avoid the need for inotropic therapy, [bib_ref] Heart failure etiology and response to milrinone in decompensated heart failure: results..., Felker [/bib_ref] [bib_ref] Continuous intravenous dobutamine is associated with an increased risk of death in..., O&apos;connor [/bib_ref] and potentially avoid having efficacious therapies discontinued during hospitalization, [bib_ref] Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated..., Metra [/bib_ref] all of which are associated with worse outcomes. When the emphasis of self-care changes from preventing to managing CVD and secondary prevention, these health behaviors become no less important because they address common cardiovascular pathophysiological mechanisms such as inflammation. [bib_ref] Markers of inflammation and cardiovascular disease: application to clinical and public health..., Pearson [/bib_ref] Section Summary
- In hypertension, there is evidence across multiple trials demonstrating that self-care monitoring of BP is an efficacious means of reducing BP and improving medication adherence. - In coronary heart disease, self-care interventions that focus on lifestyle modifications improve clinical outcomes. - In peripheral artery disease, there is evidence across multiple trials that home-based exercise programs improve walking ability. - In stroke, there is evidence across multiple systematic reviews and multiple trials to support self-care as a means of improving activities of daily living, quality of life, and self-efficacy, as well as reducing dependency and premature death. - In AF, self-care monitoring of oral anticoagulation reduces the risk of thromboembolic events, but more research is needed into mechanisms of self-care for AF other than time in therapeutic range. - In HF, there is sufficient information across many trials that interventions targeting HF self-care are associated with better clinical outcomes and improved quality of life, suggesting the need for implementation studies. - Further research is needed to fully understand the mechanisms by which self-care exerts benefit.

## Factors influencing self-care
To effectively perform the self-care behaviors needed to prevent or manage CVD requires self-care knowledge, skills, confidence, and motivation to engage in these activities routinely, while contending with multiple individual barriers. [bib_ref] Testing a model of patient characteristics, psychologic status, and cognitive function as..., Cameron [/bib_ref] [bib_ref] Knowledge is insufficient for self-care among heart failure patients with psychological distress, Hwang [/bib_ref] [bib_ref] Social networks, work and network-based resources for the management of long-term conditions:..., Rogers [/bib_ref] These individual barriers can be compounded by family and community influences. Some of these major barriers are described below.

## Individual factors influencing self-care
Depression Depression and depressive symptoms are substantially more common in people with CVD that in the general population. The highest rates are observed in patients with HF (20%-30% depending on assessment used), [bib_ref] Depression in heart failure a meta-analytic review of prevalence, intervention effects, and..., Rutledge [/bib_ref] but rates with other cardiac conditions do not lag far behind. [bib_ref] Comparison of prevalence of symptoms of depression, anxiety, and hostility in elderly..., Moser [/bib_ref] Depression and depressive symptoms are independently and strongly associated with death, recurrent major cardiac events, and cardiac and allcause hospitalizations in the short and long term. [bib_ref] Depression in heart failure a meta-analytic review of prevalence, intervention effects, and..., Rutledge [/bib_ref] [bib_ref] Major depression and long-term survival of patients with heart failure, Freedland [/bib_ref] [bib_ref] Association of depressive symptoms and micronutrient deficiency with cardiac event-free survival in..., Song [/bib_ref] [bib_ref] Depression and multiple rehospitalizations in patients with heart failure, Freedland [/bib_ref] Depression and depressive symptoms are associated with poor self-care in those with CVD or risk factors for CVD. [bib_ref] Difficulty taking medications, depression, and health status in heart failure patients, Morgan [/bib_ref] [bib_ref] Major depression and medication adherence in elderly patients with coronary artery disease, Carney [/bib_ref] [bib_ref] Depression, adherence behavior, and coronary disease outcomes, Ziegelstein [/bib_ref] [bib_ref] Patients with depression are less likely to follow recommendations to reduce cardiac..., Ziegelstein [/bib_ref] [bib_ref] Depression is a risk factor for noncompliance with medical treatment: meta-analysis of..., Dimatteo [/bib_ref] Self-care areas negatively affected include diet and medication adherence, exercise adherence, self-monitoring, and appropriate response to symptoms. [bib_ref] Relationship between psychosocial variables and compliance in patients with heart failure, Evangelista [/bib_ref] [bib_ref] How do depressive symptoms influence self-care among an ethnic minority population with..., Dickson [/bib_ref] [bib_ref] Cognitive behavior therapy for depression and self-care in heart failure patients: a..., Freedland [/bib_ref] [bib_ref] Living arrangements modify the relationship between depressive symptoms and self-care in patients..., Lee [/bib_ref] [bib_ref] Investigation of anxiety and depression symptom co-morbidity in a community sample with..., Smith [/bib_ref] [bib_ref] Prehospital delay, precipitants of admission, and length of stay in patients with..., Wu [/bib_ref] Poor self-efficacy Self-efficacy, or confidence in one's ability to perform a particular behavior, is a powerful and consistent influence on performance of self-care across patient populations, various self-care behaviors, and developmental levels. [bib_ref] Self-efficacy: toward a unifying theory of behavioral change, Bandura [/bib_ref] [bib_ref] Cognitive processes mediating behavioral change, Bandura [/bib_ref] [bib_ref] A situation-specific theory of heart failure self-care, Riegel [/bib_ref] The effect of self-efficacy on self-care behaviors has been demonstrated for both self-care maintenance and management behaviors in multiple chronic CVD populations.
A systematic review of evidence to identify intrapersonal, social, and physical environmental determinants of moderateto-vigorous intensity physical activity among working-age women found that enhanced self-efficacy was a consistent positive influence on activity. [bib_ref] Why are adult women physically active? A systematic review of prospective cohort..., Prince [/bib_ref] Among patients with coronary artery disease, self-efficacy is a significant predictor of physical activity, especially in the early phase of initiating physical activity behavior. [bib_ref] The roles of self-efficacy and motivation in the prediction of short-and long-term..., Slovinec [/bib_ref] Increased levels of self-efficacy promote greater antihypertensive and HF medication adherence [bib_ref] Factors influencing medication compliance among hypertensive older African American adults, Rimando [/bib_ref] [bib_ref] Psychological factors and treatment adherence behavior in patients with chronic heart failure, Schweitzer [/bib_ref] and dietary adherence. [bib_ref] Health literacy, self-efficacy, food label use, and diet in young adults, Cha [/bib_ref] Smoking cessation is clearly linked with confidence to quit and confidence to quit in the face of obstacles. [bib_ref] Task and barrier self-efficacy among treatment-seeking smokers with current, past or no..., Clyde [/bib_ref] When examining self-efficacy in persons with HF categorized on their level of self-care performance, higher selfcare confidence increased the odds of being an expert in selfcare. [bib_ref] A typology of heart failure self-care management in non-elders, Dickson [/bib_ref] [bib_ref] From novice to expert: confidence and activity status determine heart failure self-care..., Riegel [/bib_ref] Self-efficacy is a key influencer of enhanced self-care in populations with cardiac and comorbid conditions [bib_ref] Multiple comorbid conditions challenge heart failure self-care by decreasing self-efficacy, Dickson [/bib_ref] and specifically complex self-care in those with concomitant HF and diabetes melliitus. [bib_ref] Clinical and socio-demographic determinants of self-care behaviours in patients with heart failure..., Ausili [/bib_ref] In a secondary analysis of data from symptomatic older HF patients, level of comorbidity moderated the relationship between self-efficacy and self-care maintenance, but not self-care management. [bib_ref] Predictors of hospitalization and quality of life in heart failure: a model..., Buck [/bib_ref] Specifically, in patients with less comorbidity, the relationship between self-efficacy and self-care was significantly stronger than in patients with more comorbidity. It appears that the additional conditions make it difficult for patients to identify the self-care needed in specific situations, thereby decreasing self-efficacy. Self-care confidence appears to be an important factor influencing HF self-care even in patients with impaired cognition, and interventions addressing confidence were suggested as a way to improve self-care in this population. [bib_ref] Self-care confidence may be more important than cognition to influence self-care behaviors..., Vellone [/bib_ref] Self-efficacy is reinforced by the actual performance of the self-care behavior; with successful performance, selfefficacy is enhanced, whereas failure undermines selfefficacy.Self-efficacy enhancement empowerment early in a lifestyle intervention program improves self-efficacy and adherence to healthy lifestyle behaviors. [bib_ref] Early empowerment strategies boost self-efficacy to improve cardiovascular health behaviors, Kashani [/bib_ref] A study testing an intervention to improve HF symptom monitoring and response found greater improvements in self-care confidence in the intervention group compared with a control group. [bib_ref] Heart failure symptom monitoring and response training, Jurgens [/bib_ref] A study of behavioral factors influencing physical activity in patients with stable coronary artery disease found that perceived social support explained 12% of the variance in physical activity, with self-efficacy partially mediating the relationship between perceived social support and physical activity. [bib_ref] Perceived social support and physical activity among patients with coronary artery disease, Won [/bib_ref] Cognitive decline CVD is a major and increasingly recognized cause of dementia. The incidence of cognitive decline increases with increasing age because of pathological changes in the cardiovascular and cerebrovascular systems commonly observed in those who have not maintained cardioprotective lifestyle habits through the life course. [bib_ref] A life course approach to cardiovascular aging, Hardy [/bib_ref] CVD in many of its manifestations (eg, coronary artery disease, AF, hypertension, and myocardial infarction) and most CVD risk factors (eg, smoking, obesity, sedentary lifestyle) are independently associated with cognitive dysfunction along the continuum from mild cognitive impairment to dementia. [bib_ref] Heart disease as a risk factor for dementia, Ng [/bib_ref] For example, cognitive impairment is common among those with HF, [bib_ref] Cognition in heart failure: an overview of the concepts and their measures, Bauer [/bib_ref] [bib_ref] Cognitive impairment in heart failure, Dardiotis [/bib_ref] with a prevalence ranging from 25% to 50%. [bib_ref] Cognitive functioning and chronic heart failure, Pressler [/bib_ref] [bib_ref] Cognitive impairment in older adults with heart failure: prevalence, documenttion and impact..., Dodson [/bib_ref] [bib_ref] Prevalence of cognitive impairment in older adults with heart failure, Gure [/bib_ref] In the cardiac population, cognitive decline commonly includes deterioration in memory and learning, attention, executive function, psychomotor speed, and visuospatial recall. [bib_ref] Cognitive impairment in heart failure, Dardiotis [/bib_ref] [bib_ref] Prevalence of memory disorders in ambulatory patients aged 70 years with chronic..., Hanon [/bib_ref] [bib_ref] Cognitive deficits in chronic heart failure, Pressler [/bib_ref] [bib_ref] Cognitive impairment in heart failure: a systematic review of the literature, Vogels [/bib_ref] Such impairment can have a profoundly negative effect on an individual's ability to engage in effective self-care. [bib_ref] The association between mild cognitive impairment and self-care in adults with chronic..., Currie [/bib_ref] Interestingly, engagement in intensive CVD risk reduction self-care activities can improve cognitive impairment. For example, in older adults with HF, increased daily physical activity was associated with better cognition. [bib_ref] Daily physical activity is associated with subcortical brain volume and cognition in..., Alosco [/bib_ref] Optimal medical management, [bib_ref] ACCF/AHA guideline for the management of heart failure: executive summary: a report..., Yancy [/bib_ref] [bib_ref] Link between change in cognition and left ventricular function following cardiac resynchronization..., Hoth [/bib_ref] cardiac rehabilitation, [bib_ref] Cardiac rehabilitation is associated with lasting improvements in cognitive function in older..., Alosco [/bib_ref] and computer-based cognitive training programs [bib_ref] PROspective MEmory Training to improve HEart failUre Selfcare (PROMETHEUS): study protocol for..., Cameron [/bib_ref] [bib_ref] Healthcare resource use among heart failure patients in a randomized pilot study..., Pressler [/bib_ref] can improve cognitive function. Improvement in self-care behaviors was observed when patients used a computerized board game that stimulated daily activities. [bib_ref] PROspective MEmory Training to improve HEart failUre Selfcare (PROMETHEUS): study protocol for..., Cameron [/bib_ref] 

## Multimorbidity
The rise in prevalence of multimorbidity is a function of the aging of the population.By 2030, 170 million people in the United States are expected to be performing self-care for 1 chronic condition. [bib_ref] The Agency for Healthcare Research and Quality Multiple Chronic Conditions Research Network:..., Leroy [/bib_ref] Self-care is crucial for complex patients with multimorbidity, yet the presence of more than 1 condition is a significant barrier to self-care and is associated with poor outcomes such as mortality and increased healthcare use. [bib_ref] Clinical practice guidelines and quality of care for older patients with multiple..., Boyd [/bib_ref] [bib_ref] The conceptualization and measurement of comorbidity: a review of the interprofessional discourse, Meghani [/bib_ref] Currently, the most commonly co-occurring conditions are arthritis, hypertension, and diabetes mellitus. [bib_ref] Prevalence of multiple chronic conditions among US adults: estimates from the National..., Ward [/bib_ref] When only CVD index populations are considered, the top 5 conditions are hypertension, hyperlipidemia, diabetes mellitus, arthritis, and anemia. [bib_ref] AHA/ACC/HHS strategies to enhance application of clinical practice guidelines in patients with..., Arnett [/bib_ref] Multimorbidity creates a web of co-occurring, interacting conditions, each of which require self-care. A recent review and analysis of multiple CVD data sets identified a complex network of 10 conditions (musculoskeletal disorders, thyroid disease, anemia, renal impairment, arrhythmias, cognitive impairment, depression/anxiety, respiratory disease, sleep disorders, and diabetes mellitus/metabolic disorders) that complicate self-care and increase mortality. [bib_ref] Addressing the conundrum of multimorbidity in heart failure: do we need a..., Stewart [/bib_ref] The higher the number of chronic illnesses, the lower the adequacy of self-care. [bib_ref] Multiple comorbid conditions challenge heart failure self-care by decreasing self-efficacy, Dickson [/bib_ref] The complexity of multimorbidity has a direct effect on individual self-care decisions, particularly in the higher-level decision-making tasks of symptom recognition and management. [bib_ref] Multiple comorbid conditions challenge heart failure self-care by decreasing self-efficacy, Dickson [/bib_ref] For example, someone with dyspnea must detect a change in the subjective perception of shortness of breath, interpret its meaning, label it correctly as associated with a particular condition, and then respond appropriately with the correct symptom management protocol. [bib_ref] The situation-specific theory of heart failure self-care: revised and updated, Riegel [/bib_ref] Complicating this task is the overlap in symptom patterns coupled with distinct and sometimes conflicting self-care requirements of each individual chronic condition. [bib_ref] Descriptions of barriers to self-care by persons with comorbid chronic diseases, Bayliss [/bib_ref] Symptom monitoring and differentiating the cause of a particular symptom are the most challenging skills when more than 1 chronic illness is present. [bib_ref] Multiple comorbid conditions challenge heart failure self-care by decreasing self-efficacy, Dickson [/bib_ref] Key barriers to patient self-care arises from the confusing or contradictory information provided by multiple healthcare providers. [bib_ref] Challenges of self-management when living with multiple chronic conditions systematic review of..., Liddy [/bib_ref] Management strategies must take into account the multiple and complex issues created by the web of multimorbidity in order to develop efficacious and efficient self-care support programs.
Multimorbidity is significantly higher in non-Hispanic white and black women than in any other demographic groups. [bib_ref] Prevalence of multiple chronic conditions among US adults: estimates from the National..., Ward [/bib_ref] Because these populations have been historically understudied, little is known about outcomes of patients who are older, female, or racially diverse. These issues have a direct impact on the development of clinical practice guidelines and guideline-directed care. [bib_ref] AHA/ACC/HHS strategies to enhance application of clinical practice guidelines in patients with..., Arnett [/bib_ref] Prevalence, poor outcomes, and understudied populations all point to a critical need for research to delineate the impact of multimorbidity on selfcare.

## Family-level factors influencing self-care
A growing body of research points to a significant impact of social relationships on all-cause and disease-specific morbidity and mortality. [bib_ref] Social relationships and health, House [/bib_ref] [bib_ref] Health promoting effects of friends and family on health outcomes in older..., Seeman [/bib_ref] [bib_ref] Social network type and long-term condition management support: a cross-sectional study in..., Vassilev [/bib_ref] Both the size and diversity of one's social network or capital (informal connections available for support, help, and information) are strongly and prospectively linked with CVD morbidity and mortality. In particular, epidemiological data suggest that people who have larger, more integrated social networks are at reduced risk for mortality and ischemic heart disease 253 and stroke [bib_ref] Social networks and incident stroke among women with suspected myocardial ischemia, Rutledge [/bib_ref] and have a better prognosis after myocardial infarction, [bib_ref] Living alone after myocardial infarction, Case [/bib_ref] compared with more socially isolated individuals.

## Community-level factors influencing self-care
Social networks simultaneously reflect both the individual's social capital and the community's social structures. People who are connected to a network or community rich in support, social trust, information, and healthy norms may have more access to resources that can help them achieve health goals. [bib_ref] Building a network theory of social capital, Lin [/bib_ref] [bib_ref] Investments in social capitalimplications of social interactions for the production of health, Bolin [/bib_ref] Studies of urban versus rural communities suggest that rural residents have a higher burden of risk factors and encounter more challenges with self-care than their urban counterparts because of inequalities related to socioeconomic resources and access to care. [bib_ref] Social determinants of cardiovascular disease risk factor presence among rural and urban..., Quarells [/bib_ref] [bib_ref] Cardiovascular risk factors differ between rural and urban Sweden: the 2009 Northern..., Lindroth [/bib_ref] [bib_ref] Cardiovascular medication utilization and adherence among heart failure patients in rural and..., Murphy [/bib_ref] [bib_ref] Self-care in rural residents with heart failure: what we are missing, Lee [/bib_ref] However, other studies in lower-and upper-middle-income countries report a greater prevalence of CVD risk factors attributed to urbanization, 262-265 so this issue remains unclear. It is not yet sufficiently clear what factors at the community level are proportionately more important to CVD risk management. Several study protocols have been designed to identify these critical elements, but results are not yet available. [bib_ref] Social networks, work and network-based resources for the management of long-term conditions:..., Rogers [/bib_ref] [bib_ref] Social networks of health care providers and patients in cardiovascular risk management:..., Heijmans [/bib_ref] [bib_ref] Strong Hearts, Healthy Communities: a rural community-based cardiovascular disease prevention program, Seguin [/bib_ref] Section Summary - Knowledge, skills, confidence, and motivation are required to effectively perform self-care. - Common individual barriers that impede self-care include depression, poor self-efficacy, cognitive decline, and multimorbidity. - Lack of social support is the most important family-level factor influencing self-care.
- Lack of social capital at the community-level limits access and affordability of care.

## Interventions to enhance self-care
Literally hundreds of studies have been conducted testing approaches to promoting self-care in CVD populations.
Interventions based on self-care decision making 268,269 focus on the importance of building experiential skill in specific behaviors, sociocultural resources (ie, social support), and personal values. Innovative CVD self-care decision aids support complex decision making by assisting those with CVD and stroke to recognize decision situations (ie, those occasions with an opportunity to choose between courses of action) and by providing aids to facilitate effective responses based on evidence [bib_ref] Modelling elderly cardiac patients decision making using Cognitive Work Analysis: identifying requirements..., Dhukaram [/bib_ref] and promote adherence to effective prevention strategies. [bib_ref] A randomized trial of an intervention to improve use and adherence to..., Sheridan [/bib_ref] One particular complex decision that has captured the attention of investigators is the response to symptoms. Numerous studies have demonstrated that the time from initial symptom onset to seeking urgent treatment is prolonged in individuals with acute coronary syndrome and stroke. [bib_ref] Effect of a community intervention on patient delay and emergency medical service..., Luepker [/bib_ref] [bib_ref] Reducing delay in seeking treatment by patients with acute coronary syndrome and..., Moser [/bib_ref] Even in patients with extant CVD, the delay in onset of worsening symptoms to urgent healthcare utilization is often measured in days. [bib_ref] Length of delay in seeking medical care by patients with heart failure..., Gravely-Witte [/bib_ref] Individual-Level Self-Care Interventions A consistent theme among successful studies addressing symptom response and a variety of other self-care behaviors is the use of motivational approaches to promote self-care. For example, a systematic review and meta-analysis of interventions to improve medication adherence in adults with hypertension included 112 eligible treatment-versus-control group outcome comparisons of 34 272 subjects. [bib_ref] Interventions to improve medication adherence in hypertensive patients: systematic review and meta-analysis, Conn [/bib_ref] The most promising intervention components were those linking adherence behavior with habits, giving adherence feedback to patients, self-monitoring of BP, using pill boxes and other special packaging, and motivational interviewing. The most effective interventions used multiple components and were delivered over many days.

## Knowledge and skill
Interventions to improve self-care in persons with CVD have generally included an educational component intended to improve knowledge and understanding about CVD and associated self-care practices. [bib_ref] Tailoring consumer resources to enhance self-care in chronic heart failure, Driscoll [/bib_ref] [bib_ref] Knowing how, Jason [/bib_ref] Strategies to increase patient knowledge include didactic sessions, use of written materials and/or technology (eg, DVDs, iPADs), mHealth applications, and telemonitoring. [bib_ref] Cardiovascular disease self-care interventions, Dickson [/bib_ref] The effects of such strategies are mixed. Although some investigators report increased knowledge, results have been inconclusive as to the improvement in self-care behaviors. [bib_ref] Interventions to enhance adherence to medications in patients with heart failure: a..., Molloy [/bib_ref] [bib_ref] Pilot study to determine the impact of a multidisciplinary educational intervention in..., Gwadry-Sridhar [/bib_ref] [bib_ref] Heart Failure Adherence and Retention Trial Investigators. The Heart Failure Adherence and..., Powell [/bib_ref] [bib_ref] A multicenter disease management program for hospitalized patients with heart failure, Tsuyuki [/bib_ref] A recent systematic review of 33 HF interventions examined the main mechanism of program effectiveness on clinical outcomes and reported that when interventions focused on improving knowledge alone, the effects were diminished. [bib_ref] A systematic review of the main mechanisms of heart failure disease management..., Clark [/bib_ref] The general consensus is that knowledge is necessary for effective selfcare, but not sufficient to improve behavior or influence outcomes. [bib_ref] Knowledge is insufficient for self-care among heart failure patients with psychological distress, Hwang [/bib_ref] [bib_ref] Targeted intervention improves knowledge but not self-care or readmissions in heart failure..., Davis [/bib_ref] [bib_ref] How can we improve adherence to blood pressure-lowering medication in ambulatory care?..., Schroeder [/bib_ref] In addition to knowledge, adequate self-care requires skill in performing routine preventive behaviors and skill in making decisions about signs and symptoms of a worsening condition. [bib_ref] Are we teaching what patients need to know? Building skills in heart..., Dickson [/bib_ref] Skill refers to the ability to use information and apply it in a specific context, [bib_ref] Knowing how, Jason [/bib_ref] that is, carry out a task with a predetermined result. Much of what we know about how to improve skill in self-care comes from the HF self-care literature. [bib_ref] A typology of heart failure self-care management in non-elders, Dickson [/bib_ref] [bib_ref] Heart failure symptom monitoring and response training, Jurgens [/bib_ref] [bib_ref] Health status and self-care outcomes after an educationsupport intervention for people with..., Clark [/bib_ref] [bib_ref] Motivational interviewing to improve self-care for patients with chronic heart failure: MITI-HF..., Masterson Creber [/bib_ref] Patients report needing tactical selfcare skills ("how to"; eg, preparing meals, monitoring weight) as well as situational skill ("what to do when"). [bib_ref] Are we teaching what patients need to know? Building skills in heart..., Dickson [/bib_ref] [bib_ref] Socio-cultural influences on heart failure self-care among an ethnic minority black population, Dickson [/bib_ref] Skill development has been studied in numerous populations with HF and shown to be important in improving self-care in ethnically diverse samples 268 as well as persons with both HF and diabetes mellitus. [bib_ref] A pilot test of an integrated self-care intervention for persons with heart..., Dunbar [/bib_ref] There is a growing body of literature examining the effects of interventions to improve self-care in persons with other CVDs, including hypertension, 291,292 AF, 167 coronary heart disease, [bib_ref] Reduction in 2-year recurrent risk score and improved behavioral outcomes after participation..., Murphy [/bib_ref] [bib_ref] Patient education in the management of coronary heart disease, Brown [/bib_ref] and stroke, [bib_ref] Self management programmes for quality of life in people with stroke, Fryer [/bib_ref] with a shift in focus to skill development as essential to improving self-care and related outcomes. For example, the "Keep Moving toward Healthy Heart and Healthy Brain" trial compared the effects of an exercise intervention that incorporated skills training to promote physical activity on clinical outcomes of BP, heart attack, and stroke. [bib_ref] Efficacy of a community-based physical activity program KM2H2 for stroke and heart..., Gong [/bib_ref] Participants in the intervention group compared with those in the usual care group had reduced incidence of heart attack and stroke and a moderate reduction in BP (A3.72 mm Hg in systolic BP and A2.92 mm Hg in diastolic BP) 6 months after the intervention. The intervention group also demonstrated significant increases in physical activity at 3 and 6 months postintervention. Another example of the emerging emphasis across CVD self-care trials on skill development is the ACT (Achieving Blood Pressure Control Together) study, 292 a planned trial testing the effects of an intervention that includes skills training to enhance performance of hypertension self-care behaviors to improve BP in black adults with uncontrolled hypertension.
Technology to Support Self-Care Maintenance, Monitoring, and Management
Rapidly evolving personal technologies offer the promise of support for many aspects of self-care. The widespread availability of mobile phones has generated intense interest in mHealth (mobile health)-the use of mobile phones to receive information and coaching to support self-care. mHealth provides the prospect of increasing our reach to deliver efficient, affordable healthcare services to widespread populations in need of primary and secondary prevention for diverse goals such as smoking cessation, weight loss, and physical activity. [bib_ref] Mobile phone interventions to increase physical activity and reduce weight: a systematic..., Stephens [/bib_ref] [bib_ref] Measuring and influencing physical activity with smartphone technology: a systematic review, Bort-Roig [/bib_ref] [bib_ref] Cardiovascular disease self-management: pilot testing of an mHealth healthy eating program, Dale [/bib_ref] [bib_ref] mHealth in cardiovascular health care, Chow [/bib_ref] Mobile phone text messaging ("mHealth 1.0" 300 ) has been shown to be effective in promoting a wide variety of self-care behaviors such as physical activity [bib_ref] mHealth in cardiovascular health care, Chow [/bib_ref] [bib_ref] A mobile phone intervention increases physical activity in people with cardiovascular disease:..., Maddison [/bib_ref] [bib_ref] Design and rationale of the tobacco, exercise and diet messages (TEXT ME)..., Chow [/bib_ref] [bib_ref] Patterns, predictors and effects of texting intervention on physical activity in CHD-insights..., Thakkar [/bib_ref] [bib_ref] Increasing physical activity in stroke survivors using STARFISH, an interactive mobile phone..., Paul [/bib_ref] and adherence to multiple lifestyle behaviors, [bib_ref] Text message and internet support for coronary heart disease self-management: results from..., Dale [/bib_ref] including BP control, weight control, and smoking cessation. [bib_ref] Effect of lifestyle-focused text messaging on risk factor modification in patients with..., Chow [/bib_ref] The content of successful text messages has included advice, motivational reminders, and support to change lifestyle behaviors. Notably, although the results are promising, they are still limited to a small number of trials, inconsistent outcome measures, and ineffective reporting of intervention characteristics. [bib_ref] The effectiveness of mobile-health behaviour change interventions for cardiovascular disease self-management: a..., Dale [/bib_ref] The duration of effects remains to be determined.
A recent systematic review found that 79% of studies of text messaging, mobile applications, and telemonitoring by mobile phones were effective in improving CVD outcomes. [bib_ref] Mobile phone interventions for the secondary prevention of cardiovascular disease, Park [/bib_ref] Some key factors associated with improved outcomes included personalized messages with tailored advice, greater engagement (2-way text messaging, higher frequency of messages), and use of multiple modalities. Not every mHealth intervention has been effective, however; the recent BEAT-HF (Better Effectiveness After Transition-Heart Failure) trial failed to reduce readmissions at 6 months in HF patients receiving telemonitoring and health coaching by telephone. [bib_ref] Better Effectiveness After Transition-Heart Failure (BEAT-HF) Research Group. Effectiveness of remote patient..., Ong [/bib_ref] Large-scale, longitudinal studies are warranted to gain a clear understanding of the effects of mHealth on behavior change, CVD risk factors, and clinical outcomes and better identify who will benefit most from these interventions."mHealth 2.0" 300 involves more-complex approaches than messaging, such as smartphone software applications (apps) and the use of sensors or monitors for self-care monitoring. Thousands of apps have been created since they first appeared in 2008, with health a particular focus. Systematic reviews on the effectiveness of mobile phone and tablet apps in self-care of long-term conditions support their potential for improving management and health outcomes through self-care. They also note, however, that health apps are largely unregulated and few are evidence based. [bib_ref] A content analysis of smartphonebased applications for hypertension management, Kumar [/bib_ref] [bib_ref] The mobile revolution-using smartphone apps to prevent cardiovascular disease, Neubeck [/bib_ref] [bib_ref] The effectiveness of self-management mobile phone and tablet apps in long-term condition..., Whitehead [/bib_ref] Wearable devices such as pedometers measure exercise parameters, heart rate, and sleep. Self-care monitoring helps people become more aware of how their bodies work and what is normal, and enables them to track their progress in real time and stay motivated while making lifestyle changes. Wearable monitoring devices may alert a patient earlier to a change in health that needs medical attention. Even "lowtech" home-based equipment such as weight scales and BP monitors remain useful. Monitoring of BP, [bib_ref] Self-monitoring of blood pressure promotes achievement of blood pressure target in primary..., Halme [/bib_ref] glucose, [bib_ref] Dietitian-coached management in combination with annual endocrinologist follow up improves global metabolic..., Battista [/bib_ref] perceived exertion, [bib_ref] The Borg scale as an important tool of self-monitoring and self-regulation of..., Carvalho [/bib_ref] body weight, [bib_ref] Effect of the self-monitoring approach on exercise maintenance during cardiac rehabilitation: a..., Izawa [/bib_ref] [bib_ref] A simplified education program improves knowledge, self-care behavior, and disease severity in..., Caldwell [/bib_ref] international normalized ratio values, [bib_ref] Comparing self-management of oral anticoagulant therapy with clinic management: a randomized trial, Men Endez-J Andula [/bib_ref] [bib_ref] A randomized trial of patient self-managed versus physicianmanaged oral anticoagulation, Sunderji [/bib_ref] [bib_ref] Selfmanagement of oral anticoagulation in nonvalvular atrial fibrillation (SMAAF study), Voller [/bib_ref] calorie intake and energy expenditure, 322,323 postprandial glycemia, [bib_ref] Postprandial glucose monitoring further improved glycemia, lipids, and weight in persons with..., Zhang [/bib_ref] and HF symptoms [bib_ref] Heart failure symptom monitoring and response training, Jurgens [/bib_ref] [bib_ref] The association between regular symptom monitoring and self-care management in patients with..., Lee [/bib_ref] [bib_ref] A comprehensive symptom diary intervention to improve outcomes in patients with HF:..., Lee [/bib_ref] [bib_ref] A randomized controlled trial of self-management programme improves health-related outcomes of older..., Shao [/bib_ref] has been shown to be comparable to provider management to improve outcomes.
In the future, "mHealth 3.0" may involve smartphone machine-learning algorithms and body sensors that make accurate patient-specific assessments and recommendations. [bib_ref] Rising above the rhetoric: mobile applications and the delivery of cost-effective cardiovascular..., Kazi [/bib_ref] An example would be an app that recognizes that BP is elevated or detects an alarming arrhythmia through electrocardiograph signal analysis. [bib_ref] An intelligent telecardiology system using a wearable and wireless ECG to detect..., Lin [/bib_ref] [bib_ref] A comprehensive survey of wearable and wireless ECG monitoring systems for older..., Baig [/bib_ref] New self-care behaviors will emerge such as adherence to wearing these sensors and making decisions in response to such alerts.
There is potential for people with mobile devices to use apps with sensors and machine-learning algorithms to selfdiagnose and treat. Use of these apps may shift the focus of patients away from CVD prevention to CVD treatment. Of equal concern is that they will also allow people to bypass healthcare providers. Consequently, it is essential that providers play an active role in the development of mHealth technology that supports active patient and healthcare provider engagement in self-care. In the AHA scientific statement on the use of mHealth-based strategies for CVD prevention, the authors called for testing of mHealth approaches that provide interaction between patients and healthcare providers using real-time data for joint decision making. [bib_ref] Behavior Change Committee of the Council on Cardiometabolic Health, Council on Cardiovascular..., Burke [/bib_ref] This use of mHealth technology has the potential to revolutionize self-care by allowing patients, family members, and providers to engage in active, real-time partnerships regarding self-care.

## Family-level self-care interventions
Recognition of the positive influence of family engagement on self-care has supported the design and testing of familyfocused self-care interventions for CVD patients and their family members. Although some clinical trials testing familyor dyad-level interventions for CVD self-care hold promise, they are limited in number, tend to have small sample sizes with short evaluation time frames, are based on varying theoretical frameworks, and have yielded conflicting results. The majority of studies have been with HF patients. Promising approaches focus on communication, decision making, reciprocity, 330 caregiver self-care, coping and communication, problem solving, and dealing with stress and negative emotions. [bib_ref] A couples' based selfmanagement program for heart failure: results of a feasibility..., Trivedi [/bib_ref] Factors that may interfere with a family-focused approach include high levels of anxiety and lack of perceived control among the family members, 332,333 disease severity, and caregiver burden. [bib_ref] A couples' based selfmanagement program for heart failure: results of a feasibility..., Trivedi [/bib_ref] Multiple intervening and complex factors affect familylevel self-care. The timing in the trajectory of care, preexisting and evolving comorbidities, psychosocial status at baseline, family context and relational variables, as well as health literacy and dyadic interdependence converge to influence self-care. Family-focused self-care approaches needs to incorporate these factors when designing interventions for dyads or families. Furthermore, given that the physical and mental health of caregivers may be affected by the demands of caregiving, family-focused interventions need to offer support without increasing burden to the family caregiver.

## Community-level self-care interventions
Community settings such as social or community centers provide an additional option to the local medical facility or the home in helping to build self-care skills. [bib_ref] COACH trial: a randomized controlled trial of nurse practitioner/community health worker cardiovascular..., Allen [/bib_ref] Participants in community-based self-care training initiatives showed significant improvement in self-care maintenance and self-care management [bib_ref] Building skill in heart failure self-care among community dwelling older adults: results..., Dickson [/bib_ref] [bib_ref] Benefits of a nurse-managed wellness program. A senior center model. Using community-based..., Campbell [/bib_ref] [bib_ref] Implementing a community-based self care training initiative: a process evaluation, South [/bib_ref] and in CVD risk reduction. [bib_ref] Community Outreach and Cardiovascular Health (COACH) Trial: a randomized, controlled trial of..., Allen [/bib_ref] There is, however, a paucity of studies on the direct links between community activities and CVD. One exception is a new and encouraging report from the World Health Organization, which found that 6 in 10 people globally are currently protected by at least 1 tobacco control measure-4 times more than in 2007. These community-level approaches reflect policies, warnings, advertising bans, and taxes for example.Theoretically, community neighborhoods may encourage self-care through activities and events that raise awareness and knowledge about healthy lifestyles, encourage collective activity and engagement, and alleviate social isolation. Examples include organized walks and runs, health fairs, farmers' markets, and support groups in the local community. Some evidence from the United States suggests that adults with access to a community garden consume more fruit and vegetables, [bib_ref] Fruit and vegetable intake among urban community gardeners, Alaimo [/bib_ref] and community gardens have been used to improve the diet of poor communities, particularly in the developing world. Farmers' markets and community gardens may promote active lifestyles and mental well-being, [bib_ref] Review of the nutritional implications of farmers' markets and community gardens: a..., Mccormack [/bib_ref] but few well-designed studies have been completed to confirm this assumption. Support in the community may come from lay community health workers such as health trainers or coaches. [bib_ref] Social networks, work and network-based resources for the management of long-term conditions:..., Rogers [/bib_ref] Dye et al 341 reported a successful initiative designed to improve hypertension self-care among older rural residents through education and support offered by trained volunteers. Participants received baseline and follow-up health risk appraisals with blood work, educational materials, and items such as BP monitors and pedometers. These participants demonstrated significant increases in hypertension-related knowledge that persisted at 16 weeks, as well as significant improvements in stage of readiness to change behaviors and in actual behaviors. Furthermore, clinically significant decreases in all outcome measures were observed, with statistically significant changes in systolic BP, weight, and glucose.

## Section summary
- Educational strategies focused on increasing knowledge have been inconclusive as to the improvement in self-care behaviors. Skill development approaches to improve selfcare are more promising than purely educational approaches. - Technology is promising as an approach to improving selfcare behaviors in an efficient and affordable manner. The duration of effect needs further study. Future devices may use sensors and machine-learning algorithms that allow self-diagnosis and treatment. It is essential that healthcare providers play an active role in the development of mHealth technology that supports active patient and healthcare provider engagement in self-care. - Promising family-focused intervention approaches have focused on communication, decision making, reciprocity, caregiver self-care, coping and communication, problem solving, and dealing with stress and negative emotions. Factors that interfere with family-focused approaches include high levels of anxiety and lack of perceived control among the family members, disease severity, and caregiver burden. - Community-based interventions encourage self-care through activities and events that raise awareness and knowledge about healthy lifestyles (eg, AHA Heart Walk), encourage collective activity and engagement, and alleviate social isolation. There are few studies on the direct links between community activities and self-care outcomes.

# Conclusions and implications
In this scientific statement, we have argued the importance of self-care in the AHA mission and vision of building healthier lives, free of CVD and stroke. The evidence supporting specific self-care behaviors, the effectiveness of self-care in improving outcomes, and barriers to self-care were discussed. Although there are many nuances to relationships between self-care and outcomes, there are numerous instances of Level A (multiple populations evaluated, data derived from multiple trials or metaanalyses) and Class I to IIa evidence (benefit  risk with sufficient evidence from multiple trials or meta-analyses) regarding interventions that promote cardiovascular selfcare. As such, greater emphasis should be placed on selfcare in evidence-based guidelines. Many self-care behaviors are consistent across cardiovascular conditions, and most CVD risk reduction self-care activities prevent other diseases as well. Ultimately, promoting wide uptake of the self-care behaviors outlined in this document is essential to reducing the incidence and prevalence of chronic CVD and other noncommunicable diseases.
To be maximally effective, self-care to optimize healthy lifestyle and prevent chronic CVD must become part of the culture of society. [bib_ref] American Heart Association Strategic Planning Task Force and Statistics Committee. Defining and..., Hong [/bib_ref] A theme in the research summarized in this scientific statement is that interventions are more effective for people with known CVD than those without perceived risk. We can build on this knowledge with the design of interventions that focus the attention of individuals with CVD or perceived risk of CVD on self-care [fig_ref] Table 2: A World View of CVD Risk Area Issues and Comorbid Conditions That... [/fig_ref]. However, to truly control CVD, self-care must be practiced by all individuals at all ages and should not be relegated to only those who already have CVD. Further research is required to understand the factors that enable and motivate people to make healthy self-care choices.

## Disclosures writing group disclosures
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be "significant" if (a) the person receives $10 000 or more during any 12month period, or 5% or more of the person's gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under the preceding definition.
*Modest. 

## Significant.

# Reviewer disclosures
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be "significant" if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person's gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under the preceding definition.
*Modest.
[fig] Figure.: Self-care is often thought of as solely an individual-level behavior, but, in reality, self-care occurs at the individual, family, and community level. [/fig]
[table] Table 1: Self-Care of Common Cardiovascular Disorders Using the Middle-Range Theory of Self-Care Nomenclature [/table]
[table] Table 2: A World View of CVD Risk Area Issues and Comorbid Conditions That Increase CVD Risk Worldwide Worldwide, 15.5% of all births (20 million) are LBW. LBW infants are more than twice as common in developing countries (16.5%) as in developed countries (7%) 343Changing demographics with increase in diabetes mellitus, obesity, hypertension Age-adjusted death rates higher for males and strikingly higher for blacks compared with whites 344 Risk factors more prevalent in minorities with resultant increase in CVD 344 Racial disparity345,346 LBW infant rate of blacks twice that of whites347 CVD death rates highest in the most rural counties348 Alcohol and tobacco highest in the world46,349 Large imbalance between nations related to economics and race/ ethnicity46,349 Yes Yes Asia, >40 countries and >3 billion people Increase in obesity and cholesterol on top of high tobacco and hypertension Increasing conversion of cerebral vascular disease to CVD as primary cause of death350,351 Large disparity in CVD, disproportionate risk factors in indigenous population 352 Racial disparity353,354 In Australia, compared with non-indigenous people, Aboriginal and Torres Strait Islander peoples were 3 times more likely to have a heart attack and nearly twice as likely to die of heart disease 354 The indigenous Maori of New Zealand have higher rates of CVD mortality and morbidity than that for non-Maori non-Pacific New Zealanders 353Poorer diets, increased smoking, increased obesity (high end of obesity figures for Organization for Economic Cooperation and Development countries), less exercise, limited access to effective health care and medications357,358 Yes Yes CVD indicates cardiovascular disease; LBW, low birthweight; NA, not applicable; WHO, World Health Organization. [/table]