Japan Journal of Nursing Science (2011) 8, 140–152

doi:10.1111/j.1742-7924.2010.00166.x

ORIGINAL ARTICLE

Effectiveness of an educational self-management program for
outpatients with chronic heart failure
jjns_166

140..152

Haruka OTSU1 and Michiko MORIYAMA2
1

Graduate School of Health Sciences, Hirosaki University, Hirosaki; and 2Graduate School of Health Sciences, Hiroshima
University, Hiroshima, Japan

Abstract
Aim: The occurrence rate of chronic heart failure (CHF) in Japan is estimated to be 50 000 per one million
persons. It is important for the Japanese medical financial system to institute a program of disease
management in order to prevent the deterioration of persons with CHF. However, there are still few studies
on the disease management of CHF in Japan. Therefore, the purpose of this study was to provide an
educational self-management program to Japanese outpatients with CHF in order to improve their clinicaloutcomes.
Methods: A randomized, controlled trial with 102 outpatients with CHF was conducted. There were 50
participants in the intervention group and 52 participants in the control group. The control group received
medical treatment and standard care. In addition to this, the intervention group also received an educational
program for 6 months. The program consisted of six nurse-directed sessions that were provided to each
outpatient once per month in a clinical setting for a total of 6 months. A follow-up session was conductedeach month for 6 months. The data collection was carried out at the start of the program and at 3, 6, 9, and12 months.
Results: Significant differences could be observed in the primary and secondary outcomes and in the process
indicators between the two groups after the program began. In other words, all the indicators improved forthe intervention group, compared to the control group. Therefore, this program was considered to beeffective.
Conclusion: Further long-term care is necessary for outpatients with CHF in order to prevent theirdeterioration and to maintain their health status, even though this 6 month program did provide them withproper knowledge regarding self-care for CHF and affected their therapy results.
Key words: chronic heart failure, disease management, educational program, self-management.

INTRODUCTION
With advancements in medicine and an increasing proportion of lifestyle diseases, the percentage of patientswith chronic diseases who must personally manage
themselves has increased and, at the same time, the onset

Correspondence: Haruka Otsu, Graduate School of Health
Sciences, Hirosaki University, 66-1 Honcho, Hirosaki,
Aomori 036-8564, Japan. Email: h_otsu@cc.hirosaki-u.ac.jp
Received 17 December 2009; accepted 14 June 2010.

and deterioration of many chronic diseases greatly alterpatients’ personal lifestyle and daily living (Matsuda &Sakamaki, 2004). Therefore, it is very important forpatients to manage their daily life, including their lifestyle. Although health professionals widely recognize
the importance of self-management and patient education in order to promote self-management, a support
system to promote such patient education and disease
management has yet to be developed in Japan, as compared with other advanced countries, because of restrictions in the Japanese health system and insurance
support system (Matsuda & Sakamaki, 2004).

© 2010 The Authors
Japan Journal of Nursing Science © 2010 Japan Academy of Nursing ScienceJapan Journal of Nursing Science (2011) 8, 140–152

The causes of chronic heart failure (CHF) vary, so
treatment is pathognomonic. Although the treatment isdetermined by the underlying etiology, evidence-based
clinical guidelines give a uniform procedure, regardlessof the causative factor. This consists of improving thepatients’ risk factors, such as reducing heart strain,drugs to strengthen heart function, control of fluid andsodium intake, exercise, smoking, and weight control.
Respiratory management and ventricular assistance areapplicable in relation to severe patients (Association
Study Group, 2005).
Heart failure is a major cause of hospital admission
for patients who are ⱖ65 years old in the USA andEurope and the rate of rehospitalization is high. As aresult, many intervention studies regarding disease management programs have been carried out and considerable achievement has been made in preventing
readmission (Cline, Israelsson, Willenheimer, Broms, &Erhardt, 1998; Ekman et al., 1998; Jaarsma et al., 1999;
Naylor et al., 1999; Rich et al., 1993; 1995; Schneider,
Hornberger, Booker, Davis, & Kralicek, 1993; Serxner,
Miyjaji, & Jeffords, 1998; Stewart, Marley, & Horowitz, 1999; Stewart, Pearson, & Horowitz, 1998; Stewart,
Vandenbroek, Pearson, & Horowitz, 1999; Strömberg
et al., 2003). In contrast, there are hardly any studies
regarding disease management programs in Japan,
except for those on the rehabilitation of patients withCHF (Goto et al., 2005; Izawa, Morio, Watanabe,Osada, & Omiya, 2006; Maruko & Ikeda, 2006). Thesestudies, however, did not focus on a global approach ordisease management. Furthermore, medical education
regarding health care is lacking in Japan and only
medical therapy is carried out by doctors (Moriyama
et al., 2006; Otsu & Moriyama, 2008).
Therefore, we developed a CHF disease management
program, based on effective programs from previous
studies that have been carried out in other countries, aJapanese evidence-based clinical guideline, and a surveyof the actual self-management conditions of patientswith CHF (Otsu & Moriyama, 2008). The results of thesurvey showed, in particular, that the patients with CHF
had inadequate knowledge of, and poor adherence to, alow-sodium diet. The patients who lacked such knowledge regarding a correct low-sodium diet developed more
serious conditions. Consequently, we developed a CHF
disease management program by which outpatients with
CHF could acquire self-management skills. This program
can contribute to the reduction of healthcare costs andthe development of medical treatment by reducing thedeterioration of patients with CHF and their readmission
and by improving their quality of life (QOL).

Self-management of chronic heart failure

METHOD
Development of the educational program
Consideration of a disease management program
An educational program and clinical indicators weredeveloped by using the evidence-based clinical guidelines of the Heart Failure Society of America (HFSA,
2006), a Japanese evidence-based clinical guideline on
CHF (revised version) (Association Study Group, 2005),
and the results of a baseline examination by Otsu &Moriyama (2008).
The relationship between the framework and theclinical indicators in this program is shown in Figure 1.
The left-side boxes with white downward arrows indicate the educational program and its process of skills
acquirement by the intervention group participants. The
right-side boxes with slightly slanting black arrows
mean the type of assistance by the support people in thisprogram: one nurse, one doctor, and/or the family. Furthermore, the thick, black downward arrows reflect
improvements in the outcomes as a result of the implementation of this framework.

Build a partnership between the patients and the health professional
Learn about social support (by family members, etc.)

Understand one’s ownclinical condition

Analyze and understand lifestyle problems

Understand the goal of, and reason for, proper treatment activity
Learn about beneficial changes in daily life
Discuss with a nurse
Apply to life situation
Self-monitoring of clinical indicators
Repetition learning

Beneficial change in daily life activities

Beneficial change in clinical indicators

Beneficial change in quality of life

Figure 1 Framework of the educational program and indicative outcomes of the study.

© 2010 The Authors
Japan Journal of Nursing Science © 2010 Japan Academy of Nursing Science141

H. Otsu and M. Moriyama

Japan Journal of Nursing Science (2011) 8, 140–152

Therefore, it is hypothesized that, after receiving
appropriate education, as shown in Figure 1, outpatients with CHF will choose and carry out appropriate
self-management activities and, as a result, will improvetheir clinical indicators and QOL.

Program description
The implementation period was set at 6 months, as theminimum time that is required to acquire self-care skills
is >6 months (Prochaska, Norcross, & DiClemente,1994). The program was carried out with a licensed
nurse as the researcher, who followed the research protocol that we developed, and the same researcher also
conducted the interviews. A 30 min session with an
outpatient after a clinical examination was carried out
each month. The six sessions consisted of the following:
an introduction on “How to adjust to CHF” and “Howto quit smoking” (if applicable), “A letter to the family”,“A reduced sodium and fluid diet and how to stop
drinking (alcohol)”, “Self-management”, “Medicine
administration-monitoring”, “Activities and exercises”,
and “How to control one’s emotions”. In particular, theoutpatients with CHF who did not practise a restrictedsodium diet were more likely to suffer from brain natriuretic peptide (BNP), a deteriorative indicator of CHF(Otsu & Moriyama, 2008), so this program aimed toprovide them with appropriate knowledge about thelow-sodium diet. The participants initially were required
to record the contents of their meals over 4 days andthen a researcher provided individual feedback regarding a correct low-sodium diet, based on a textbook
by Makino (1998). In the first session, the researcher
prepared a letter, describing ways to assist patientsand skills such as self-care, self-monitoring, and selfmanagement. This was given to the families. The
researcher provided individual education to the intervention group members by using the textbook by
Makino in the first half of the program and then discussing how to apply the knowledge in the second halfof the program. In the first session, the correct amounts
of sodium and fluid intake and activities or exercises,
based on a doctor’s directions for each patient, were
provided. These amounts were set as the target values.
At each session, the participants’ level of complianceand performance at home was verified.
Regarding self-monitoring, a calendar was used tocheck the daily medicine and weight-monitoring of eachpatient in order to verify correct medicine administration, to monitor for signs of advancing deterioration in
CHF symptoms, and to promote self-management. Furthermore, the heart function level of the participants in142

this study was slight-to-moderate, as determined by adoctor. Strict fluid intake restriction was not required at
this time and was excluded from goal-setting, eventhough knowledge on this subject was provided. The
researcher and each participant confirmed and reviewed
the inspection data and compliance together at each visit
and feedback for the participant and the primary doctor
was provided.
This educational program was based on the adultlearning method of learning through one’s own experience and was based on the theory of cognitive behavior (Hori, 1996; Lindeman, 1989). Therefore, theresearcher used the motivation interview method, which
provides operant reinforcement through praise.

Qualification of the project team member andquality control of the program
The team consisted of a cardiovascular specialist, anurse with >10 years of cardiovascular nursing experience in a cardiovascular unit, and a researcher with anursing license. The doctor listed all of the outpatientswith CHF that he had diagnosed and he was in charge ofproviding general care and reviewing the treatment
results for all the participants. The nurse handled thedata collection and general care and the researcher
carried out the educational program and data assessment. Information was actively shared and the plan wasclosely followed. The researcher learned behaviormodification techniques and how to carry out a motivating interview and all the team members reviewed theimplementation method and procedures, using theguidebook that was developed by the researcher.

Design and timeframe of the study
A randomized controlled trial was used and the enrollment of the participants occurred from August 20 to
September 30 2007. The research was carried out from
August 20 2007 to October 31 2008.

Eligibility criteria
The purpose of this program was to strengthen self-care
activity, prevent disease deterioration, and improve
QOL. The participants consisted of outpatients with
CHF, regardless of age, sex, primary disease or complication, description of treatment, resident status, orfamily composition, whose heart function level was at
Grades I–III, according to the New York Heart Association’s (NYHA’s) heart function levels (Criteria Committee, New York Heart Association, 1964), and who had
the physical, mental, and cognitive competence to fully
participate in this program. Hence, the exclusion criteria© 2010 The Authors
Japan Journal of Nursing Science © 2010 Japan Academy of Nursing ScienceJapan Journal of Nursing Science (2011) 8, 140–152

in this program were: (i) dementia; (ii) mental illness;(iii) critical illness and end-stage disease; and (iv) those
who were under long-term care (i.e. levels 4–5 by
Japanese certification; Ministry of Health, Labor andWelfare, 2009). The sample size was estimated to be 100
participants because the a, b, and standard effect sizes
for the two-way ANOVA were 0.05, 0.20, and 0.70,
respectively.

Study procedures
After receiving written and oral consent from the participants, they were randomly divided into an intervention group and a control group by using a computer
program. For the intervention group, a mental andsocial assessment interview was carried out. Subsequently, an interview and data collection were carriedout each month for 6 months. The interview was conducted in a private room. The control group received
standard treatment and care at a medical facility. Bothgroups were given follow-up reviews at 6 months andadditional data was collected for 6 months after theintervention period.
The evaluation was carried out at the time ofenrollment (baseline) and at 3, 6 (completion of theintervention), 9, and 12 months (6 months after theintervention). At the last session, the degree of satisfaction of the intervention group also was determined.

Evaluation index
Program completion rate and evaluation of the
program by the participants
The probability of program completion and an evaluation of the program were carried out. The latter evaluation was based on a one-to-five point scale: 1
represented “Very bad” and 5 represented “Very good”.

Self-management of chronic heart failure

Secondary outcomes
The secondary outcomes were identified by using the
MacNew Heart Disease Health-related Quality of Life
(QOL) Instrument, as developed by Höfer, Lim, Guyatt,and Oldridge (2004), in order to measure the QOL ofpatients with heart disease, including patients with coronary artery and/or heart failure. This original scale consists of 27 items and we developed a Japanese version
that consists of 19 items. The reliability, validity, andvalue were confirmed by Otsu, Moriyama, and Nakaya(2010). The subscale includes emotional, physical, andsocial conditions with a seven-grade scale. The scores
were calculated from each condition or as a cumulativescore, with a higher score representing a better condition. The researcher interviewed the participants, using
the MacNew Heart Disease Health-related QOL Instrument, and assessed their condition from the results.

Process indicators
The process indicators were identified as compliancewith a sodium-restricted diet, compliance with medicine
administration, compliance with activities or exercise,quitting smoking and drinking, and the self-monitoringof weight and a deterioration in the symptoms of CHF.
The self-monitoring of the deterioration in the symptoms of CHF included the monitoring of paroxysmal
dyspnea, ankle edema, coughing at night, and shortnessof breath. The level of compliance with sodium restriction, medicine, activities or exercise, and weight were
described on a four-point scale (0–3), with a higher score
representing greater compliance. Other indicators were
evaluated as “Good” or “Poor”. The researcher assessed
compliance on the basis of the participants’ self-reports.
Regarding the data-collection period of effect measurements, the process indicators were taken every
month; the clinical and secondary outcomes were taken
every 3 months.

Primary outcomes
The primary outcomes were identified as: death due to
CHF, hospital admission due to CHF, BNP data, the
NYHA’s heart function level, blood pressure (including
systolic blood pressure, diastolic blood pressure, andpulse pressure), weight, and a deterioration in the symptoms related to CHF, such as arrhythmia, paroxysmal
dyspnea, distention of the jugular vein, moist rale, ankle
edema, coughing at night, and shortness of breath. The
doctor measured the clinical indicators and recorded theresults during the examinations and the intervention
group members monitored any symptoms of deterioration related to CHF by themselves at home.

Data analysis
Chi-squared tests and t-tests or Mann–Whitney U-tests
were carried out after verifying normality at the time ofenrollment (baseline) in order to analyze the basic
attributes and physiological data. Regarding the compliance data in the process indicators, a four-level scorewas given for each compliance performance: 3.0 was
given to the participants who were always in compliance, 2.0 was given to the participants who were partially in compliance, 1.0 was given to those who wereslightly in compliance, and 0 was given to the patients
who were not in compliance at all. After that, the© 2010 The Authors
Japan Journal of Nursing Science © 2010 Japan Academy of Nursing Science143

H. Otsu and M. Moriyama

Japan Journal of Nursing Science (2011) 8, 140–152

average compliance performance score was calculated
for each group. A repeated comparative two-way
ANOVA was carried out on the physiological data, suchas the blood pressure, weight, BNP, NYHA’s heart function level, process indicators (such as sodium restriction,
medicine, activities, and weight-monitoring), and QOL
score at 3, 6, 9, and 12 months between the intervention
and control groups. Additionally, multiple comparisonswere carried out if interaction effects were not confirmed
but the main effect was confirmed within groups. The
degree of satisfaction of the program was determined ona percentage basis. SPSS ver.15.0 (SPSS, New York,
USA) was used for the analysis and a rate of <5% wasconsidered to be significant.
Regarding the symptoms related to CHF and selfmonitoring, the participants were divided into an “existence” group if they had any symptoms and into a “nonexistence” group if they did not have any symptoms at
all, according to the self-reported data. Regarding compliance with quitting smoking and/or drinking and theself-monitoring of a deterioration in symptoms, the participants also were divided into “existence” and “nonexistence” groups. The former had very or mostly goodcompliance behavior and the latter had fairly or quite
bad compliance behavior, according to the self-reported
data. On this basis, the c2-test was carried out.

Ethical considerations
Approval from the ethics committee of the university of
the researcher was obtained and all the necessary procedures for this research were carried out at the target
facilities. The purpose and description of the study,
method and type of data collection, method of publication of the research results, voluntary participation,refusal to participate (which did not result in any disadvantage), and protection of privacy were all explained.
The participants’ consent was obtained in writing. The
data was managed by using serial numbers without personal names. Additionally, we explained that the control
group members could participate in this program after
the study period was over if they so desired.

RESULTS
Probability of program completion andevaluation of the program
One-hundred-and-four outpatients with CHF wereenrolled in this study and were divided into two groupsof 52 each. Immediately after this, two patients from theintervention group no longer could participate due to144

hospital admission. Thus, at the start there were 50
patients in the intervention group and 52 patients in thecontrol group. The flow of participants in this study isshown in Figure 2. Moreover, one patient in the intervention group asked to withdraw after 1 month. Therefore, 49 patients in the intervention group completed theprogram, with a program completion probability of
98.0%. In contrast, the probability rate of the control
group was 90.3%. The number of participants fromthe control group at the conclusion of the study was 47
due to one hospital admission for a deterioration in
CHF symptoms after 2 months, one withdrawal
after 3 months, one fatality due to gastric cancer after
4 months, one hospital admission due to pneumonia
after 4 months, and one fatality due to an unknown
cause after 5 months.
The educational self-management program was rated
as either “good” or “very good” by 78.4% of the intervention group. In contrast, a small 6.1% of the groupfelt that the tasks were “a little difficult”.

Baseline comparison between the groups
The variables of the participants are shown in Table 1.
There was no significant difference between the twogroups at baseline.

Examination of the effects of the program
Primary outcomes
There was no fatality due to CHF in either group. No
one was hospitalized due to a deterioration in CHF
symptoms during the program. However, there was one
hospital admission for 30 days from the intervention
group due to a deterioration in CHF symptoms after
6 months (after the end of the program) and one for
90 days from the control group after 3 months.
The interaction effects were not shown between thetwo groups regarding BNP as a result of the repeated
two-way ANOVA, but the main effect was confirmed
within the intervention group. Therefore, in addition,
multiple comparisons were carried out and, as a result,
there were significant differences regarding BNP in
the intervention group at 3 months (P = 0.032) and at
6 months (P = 0.002) (Table 2).
There was no significant difference in the NYHA’s
heart function levels, but there was a 13.6% improvement in the intervention group after 12 months(Table 3). Regarding the systolic blood pressure, theinteraction effects were not shown between the twogroups as a result of the repeated two-way ANOVA,
but the main effect was confirmed within the interven-© 2010 The Authors
Japan Journal of Nursing Science © 2010 Japan Academy of Nursing ScienceJapan Journal of Nursing Science (2011) 8, 140–152

Self-management of chronic heart failure

No. who were approached: 132
No. who refused: 28

No. who were randomized: 104

No. of control participants: 52

No. of study program participants: 52

No. who participated in

No. who participated in the program : 49

the p rogram : 47

No. who stopp ed participating in the program : 5

No. who stopp ed participat ing in the program : 3

N o . w h o w e r e l o s t t o fo l l o w-u p : 0

N o . w h o w e r e l o s t t o fo l l o w-u p : 2

N o. w h o w e r e i n c l u d e d i n t h e an a l y s i s : 47

N o . w h o w e r e i n c l u d e d i n t h e an a l y s i s : 4 9

No . who were e x c l u d e d f r o m t h e an a l y s i s : 5

N o . w h o w e r e e x c l u d e d f r o m t h e an a l y s i s : 3

Figure 2 Participant flow in the study.

tion group. Therefore, in addition, multiple comparisons were carried out and, as a result, the systolicblood pressure in the intervention group improved
significantly between 3 and 12 months (P = 0.040), 6
and 12 months (P = 0.045), and 9 and 12 months(P = 0.025). In contrast, there was no significant
difference between the two groups regarding the diastolic blood pressure and pulse pressure (Table 2).
Regarding the participants’ weight, the intervention
group significantly improved from the time of enrollment (baseline) and at 3, 9, and 12 months, at a rateof 5% (Table 2).
The related deterioration in the symptoms of CHF isshown in Table 4. The participants were divided into an“existence” group if they had any deterioration of symptoms and a “non-existence” group if they did not haveany such symptoms at all, according to the self-reported
data. On this basis, the c2-test was carried out. The
control group showed significantly higher levels of
shortness of breath at 3 months (P = 0.038), 9 months(P = 0.011), and 12 months (P = 0.041). There was no
significant difference between the two groups regarding
the other symptoms, such as arrhythmia, paroxysmal
dyspnea, moist rale, ankle edema, and coughing atnight.

Secondary outcomes
The results of the MacNew Heart Disease Healthrelated QOL Instrument are shown in Table 5. The
total, emotional, physical, and social scores in the intervention group were significantly better at 6, 9, and12 months, at a rate of 1%, as compared to the control
group.

Process indicators
The participants were divided into an “existence”
group and a “non-existence” group. The former hadvery or mostly good compliance behavior and thelatter had fairly or quite bad compliance behavior,according to the self-reported data. On this basis, thec2-test was carried out. The level of compliance withmedicine administration and activities or exercise wassignificantly high in the intervention group. However,there was no significant difference between the twogroups regarding compliance with quitting smoking
and drinking (Table 6). The implementation rate ofself-monitoring regarding a deterioration in the symptoms of CHF in the intervention group significantly
improved, as compared to the control group, at 6 and12 months.

© 2010 The Authors
Japan Journal of Nursing Science © 2010 Japan Academy of Nursing Science145

H. Otsu and M. Moriyama

Japan Journal of Nursing Science (2011) 8, 140–152

Table 1 Baseline comparison between the groups
Participant variable

Intervention group (n = 49)
N (%) or mean ⫾ SD

Control group (n = 47)
N (%) or mean ⫾ SD

P-value31 (63.3)/18 (36.7)
71.6 ⫾ 9.3
7 (14.3)
13 (26.5)

30 (63.8)/17 (36.2)
74.6 ⫾ 8.1
6 (12.8)
6 (12.8)

1.000
0.198
1.000
0.125

40 (81.6)
16 (32.7)
24 (49.0)
5 (10.2)

36 (76.6)
22 (46.8)
23 (48.9)
1 (2.1)

0.620
0.211
1.000
0.204

128.2 ⫾ 11.9
71.3 ⫾ 5.5
57.7 ⫾ 10.0
62.1. ⫾ 11.4

131.2 ⫾ 7.0
71.5 ⫾ 4.7
58.6 ⫾ 9.4
62.7 ⫾ 10.7

0.565
0.881
0.656
0.780

39 (79.6)
153.2 ⫾ 149.1
12 (24.5)
0 (0.0)0 (0.0)0 (0.0)3 (6.1)0 (0.0)5 (10.2)

38 (80.9)
163.6 ⫾ 198.5
11 (23.4)
0 (0.0)0 (0.0)0 (0.0)0 (0.0)0 (0.0)6 (12.8)

1.000
0.769
1.000
–
–
–
0.242
–
0.757

5 (10.2)
23 (46.9)
10 (20.4)
24 (49.0)
18 (36.7)
16 (32.7)

2 (4.3)17 (36.2)
13 (27.7)
22 (46.8)
10 (21.3)
20 (42.6)

0.436
0.308
0.477
0.841
0.118
0.400

Basic attributes
Sex (male/female)Age (years)
Living alone
WorkerUnderlying disease
Hypertension
Ischemic heart disease
Valvular disease
Cardiomyopathy
Blood pressure
Systolic blood pressure
Diastolic blood pressure
Pulse pressure
Body weight
Clinical condition
New York Heart Association’s heart function Grade II
Brain natriuretic peptide
Arrhythmia
Paroxysmal dyspnea
Distention of the jugular vein
Moist rale
Ankle edema
Coughing at night
Shortness of breath
Curative drug
Angiotensin-converting enzyme inhibitor
b-blocker
Digitalis productDiuretic
Aldosterone antagonist
Angiotensin-receptor antagonist

DISCUSSION
Effectiveness of the intervention program
According to the process indicators, the level of compliance with a sodium-restricted diet and activities or
exercise and the implementation of self-monitoring
regarding weight and a deterioration of symptoms significantly improved in the intervention group, as compared to the control group, at ⱖ6 months. Furthermore,
the data on BNP, an important clinical indicator of CHF
deterioration, significantly improved at 3 and 6 months
in the intervention group. Additionally, the MacNew
Heart Disease Health-related QOL Instrument scoresignificantly improved in the intervention group after
6 months. Therefore, based on this data, this program is146

considered to be effective as it could lead to disease
management and help prevent a deterioration in symptoms.
Another reason why the program is considered to beeffective is that it is based on an evidence-based guideline (Association Study Group, 2005; HFSA, 2006) andbasic research that provides group characteristics (Otsu& Moriyama, 2008); thus, the program could satisfy theneeds of the participants. From these results, it wasthought that knowledge of CHF and self-management
were easy to learn by the intervention group. Moreover,setting goals for each participant and the continuanceof self-monitoring encouraged proper self-management
behavior; therefore, the symptoms improved and, inturn, the QOL also improved. Hence, the evidence© 2010 The Authors
Japan Journal of Nursing Science © 2010 Japan Academy of Nursing Science58.0 ⫾ 6.8
62.1 ⫾ 11.7

56.7 ⫾ 9.3

62.1 ⫾ 11.4

Pulse pressure(mmHg)

Weight (kg)61.8 ⫾ 11.6

58.7 ⫾ 9.7

71.8 ⫾ 5.1

130.4 ⫾ 12.9

6 months© 2010 The Authors
Japan Journal of Nursing Science © 2010 Japan Academy of Nursing Science
12 months

Grade I
Grade II
Grade III
Grade IV
P-value

New York Heart
Association’s heart
function level

Controlgroup(n = 52)N (%)

0 (0.0)0 (0.0)40 (80.0)41 (78.8)
10 (20.0)
11 (21.2)
0 (0.0)0 (0.0)1.000

Intervention
group(n = 50)
N (%)

Baseline

Baseline–

61.2 ⫾ 11.7

58.0 ⫾ 8.8

71.2 ⫾ 4.7–

60.6 ⫾ 11.3

55.0 ⫾ 11.0

70.5 ⫾ 5.5

Controlgroup(n = 47)N (%)

0 (0.0)0 (0.0)40 (81.6)
37 (78.7)
9 (18.4)
10 (21.3)
0 (0.0)0 (0.0)0.247

Intervention
group(n = 49)N (%)

3 months

60.1 ⫾ 9.2
62.0 ⫾ 11.0

62.3 ⫾ 10.4

70.9 ⫾ 6.3

130.8 ⫾ 9.2

6 months

59.5 ⫾ 9.5

71.4 ⫾ 3.9

130.9 ⫾ 11.2

3 months

Controlgroup(n = 47)N (%)
0 (0.0)0 (0.0)43 (87.8)
35 (74.5)
6 (12.2)
12 (25.5)
0 (0.0)0 (0.0)
0.076

Intervention
group(n = 49)N (%)

6 months

12 months

Control} group(n = 47)
N (%)–

61.5 ⫾ 11.0

57.7 ⫾ 8.6

71.7 ⫾ 4.7

0 (0.0)0 (0.0)42 (85.7)
35 (74.5)
7 (14.3)
12 (25.5)
0 (0.0)0 (0.0)0.089

Intervention
group(n = 49)N (%)

9 months–

61.8 ⫾ 10.4

61.6 ⫾ 11.1

70.7 ⫾ 4.4

132.3 ⫾ 10.3 129.3 ⫾ 9.5

9 months

Control group (mean ⫾ SD)

163.6 ⫾ 198.5 165.3 ⫾ 190.0 197.9 ⫾ 188.2

62.7 ⫾ 10.1

60.1 ⫾ 8.3

71.5 ⫾ 4.7

129.6 ⫾ 11.3 125.9 ⫾ 10.9 131.2 ⫾ 7.0

9 months

Table 3 Changes in the New York Heart Association’s heart function levels*P < 0.05, **P < 0.01.

153.2 ⫾ 149.1 124.1 ⫾ 126.1 111.2 ⫾ 101.2

72.7 ⫾ 4.7

71.3 ⫾ 5.5

Diastolic bloodpressure(mmHg)

Brain
natriuretic
peptide(pg/mL)131.0 ⫾ 8.6

3 months

128.2 ⫾ 11.9

Baseline

Systolic bloodpressure(mmHg)

VariableIntervention group (mean ⫾ SD)

Table 2 Changes in the physiological data

0.517
0.710

2.851
0.027*

Withingroups

2.661
0.033*
10.8820.000**
4.234
0.022*

0 (0.0)0 (0.0)44 (93.6)
37 (78.7)
3 (6.4)10 (21.3)
0 (0.0)0 (0.0)0.089

Controlgroup(n = 47)N (%)

12 months

3.159
0.079
0.049
0.826
3.220
0.051

0.000
0.995

2.283
0.135

BetweengroupsIntervention
group(n = 47)
N (%)

0.401
0.806
0.696
0.513
2.423
0.128

1.015
0.397

1.047
0.38

Interaction

Two-way ANOVA(upper row: F-value; lower row:
P-value)

Japan Journal of Nursing Science (2011) 8, 140–152
Self-management of chronic heart failure147

H. Otsu and M. Moriyama

Japan Journal of Nursing Science (2011) 8, 140–152

Table 4 Presence of the symptoms of deterioration in chronic heart failure in the participants
Intervention group (n = 49)

Control group (n = 47)

PeriodExistenceN (%)

Non-existence
N (%)

ExistenceN (%)

Non-existence
N (%)

P-valueParoxysmal dyspnea

Baseline
3 months
6 months
9 months
12 months

0 (0.0)0 (0.0)0 (0.0)0 (0.0)0 (0.0)49 (100.0)
49 (100.0)
49 (100.0)
49 (100.0)
47 (100.0)

0 (0.0)0 (0.0)0 (0.0)0 (0.0)0 (0.0)47 (100.0)
47 (100.0)
47 (100.0)
47 (100.0)
47 (100.0)

–
–
–
–
–

Ankle edema

Baseline
3 months
6 months
9 months
12 months

3 (6.1)5 (10.2)2 (4.1)2 (4.1)1 (2.1)46 (93.9)
44 (89.8)
47 (95.9)
47 (95.9)
46 (97.9)

0 (0.0)0 (0.0)1 (2.1)2 (4.3)2 (4.3)47 (100.0)
47 (100.0)
46 (97.9)
45 (95.7)
45 (95.7)

0.242
0.056
1.000
1.000
1.000

Coughing at night

Baseline
3 months
6 months
9 months
12 months

0 (0.0)0 (0.0)0 (0.0)1 (2.0)0 (0.0)49 (100.0)
49 (100.0)
49 (100.0)
48 (98.0)
47 (100.0)

0 (0.0)2 (4.3)1 (2.1)0 (0.0)0 (0.0)47 (100.0)
45 (95.7)
46 (97.9)
47 (100.0)
47 (100.0)

–
0.237
0.490
1.000
–

Shortness of breath

Baseline
3 months
6 months
9 months
12 months

5 (10.2)
3 (6.1)5 (10.2)
3 (6.1)3 (6.4)44 (89.8)
46 (93.9)
44 (89.8)
46 (93.9)
44 (93.6)

7 (12.8)
10 (21.3)
11 (23.4)
12 (25.5)
11 (23.4)

41 (87.2)
37 (78.7)
36 (76.6)
35 (74.5)
36 (76.6)

0.757
0.038*
0.104
0.011*
0.041*

Symptom*P < 0.05.

supporting the hypothesis in Figure 1 could be validated
and the framework was considered to be effective.
A follow-up review 6 months after the implementation of the program was conducted and, as a result,
physiological data, such as blood pressure and weight,
and compliance behaviors, except for quitting smoking
and drinking, improved and could be maintained. The
QOL scores in the intervention group were significantly
better, as compared to the control group, although thescores in the intervention group decreased after
the program. For these reasons, the effectiveness of the
program, which aimed to continuously reinforce theparticipants’ knowledge of CHF and to teach behavior
modification, could be maintained.
From the above, it can be shown that this program
was very effective for disease management overall, as
the intervention group was self-motivated to carry out
primary health care and the clinical and secondary outcomes improved.

Operation of the program
The completion probability rate was 98.0%, which is avery high rate. A relationship of trust between the healthprofessionals (including the researcher) and the partici-

148

pants could be established and the teamwork between
the local physician and the researcher is considered to be
the main reason for this very high completion probability rate.
In addition, the intervention group participants were
given the task of self-monitoring and received feedbackon the results of the task and examination data eachmonth. They were praised for their efforts. This process
gradually led to repeated self-examination, habitual
self-monitoring, confidence, and an interest in selfmanagement, as well as the very high completion probability.
Although many of the participants in the study were
elderly, they did not feel burdened by the tasks, such as
self-monitoring each month, and personally wished tocontinue the tasks after the intervention. Even after thecompletion of this study, the participants considered thisprogram to be suitable and planned to continue theprogram’s routine.
Moreover, the satisfaction level of the program was
78.4% and there was no reply of dissatisfaction, so thedegree of participant satisfaction is considered to be veryhigh. Only one participant felt that he could not participate sufficiently, as a result of his work commitments.

© 2010 The Authors
Japan Journal of Nursing Science © 2010 Japan Academy of Nursing Science6.69 ⫾ 0.69
6.79 ⫾ 0.61

6.27 ⫾ 0.69

6.40 ⫾ 0.64

PhysicalSocial© 2010 The Authors
Japan Journal of Nursing Science © 2010 Japan Academy of Nursing Science
2.85 ⫾ 0.36
2.49 ⫾ 0.72
2.49 ⫾ 0.69

2.57 ⫾ 0.62

0.11 ⫾ 0.31

0.66 ⫾ 0.76

Medicine

Activities/exercises

Weight-monitoring†–

2.53 ⫾ 0.65

2.94 ⫾ 0.25

2.53 ⫾ 0.65

6.64 ⫾ 0.63

6.49 ⫾ 0.66

6.35 ⫾ 0.59

6.41 ⫾ 0.61

9 months

2.53 ⫾ 0.62

2.36 ⫾ 0.67

2.83 ⫾ 0.43

2.47 ⫾ 0.69

6.45 ⫾ 0.67

6.29 ⫾ 0.64

6.08 ⫾ 0.64

6.20 ⫾ 0.60

12 months

1.07 ⫾ 0.88

0.18 ⫾ 0.65

2.53 ⫾ 0.69

1.71 ⫾ 0.97

6.45 ⫾ 0.61

6.23 ⫾ 0.68

6.09 ⫾ 0.66

6.17 ⫾ 0.59

Baseline

1.46 ⫾ 1.00

1.31 ⫾ 1.08

2.71 ⫾ 0.55

1.80 ⫾ 0.97

6.54 ⫾ 0.48

6.34 ⫾ 0.53

6.24 ⫾ 0.57

6.29 ⫾ 0.48

6 months–

0.56 ⫾ 0.66

2.71 ⫾ 0.55

1.64 ⫾ 0.88

6.15 ⫾ 0.73

5.92 ⫾ 0.74

5.82 ⫾ 0.59

5.87 ⫾ 0.65

9 months

Control group (mean ⫾ SD)**P < 0.01. †Analysis of the weight-monitoring at 9 months was excluded due to a large number of missing values.

2.72 ⫾ 0.62

1.72 ⫾ 1.04

Compliance
Sodium restriction

6.59 ⫾ 0.55

6.07 ⫾ 0.55

Emotional

6 months

6.65 ⫾ 0.61

Baseline

6.16 ⫾ 0.58

MacNew Heart Disease
Health-related Quality ofLife Instrument
Total

VariableIntervention group (mean ⫾ SD)

1.22 ⫾ 1.07

0.73 ⫾ 0.86

2.69 ⫾ 0.51

1.73 ⫾ 0.96

5.78 ⫾ 0.99

5.68 ⫾ 0.09

5.53 ⫾ 0.89

5.65 ⫾ 0.85

12 months

10.6540.000**
0.904
0.425
39.7390.000**
68.8010.000**

10.3140.000**
8.173
0.000**
7.559
0.000**
10.1600.000**

Interaction

21.1500.000**
2.794
0.098
179.2940.000**
18.2480.000**

10.0970.002**
10.6160.002**
9.906
0.002**
8.345
0.005**

Between groups

12.4670.000**
9.218
0.000**
12.5240.000**
122.184
0.000**

26.1570.000**
30.0800.000**
20.1610.000**
21.3850.000**

Within groups

Two-way ANOVA(upper row: F-value; lower row: P-value)

Table 5 Changes in the quality of life and level of compliance with the chronic heart failure self-management program of the participants

Japan Journal of Nursing Science (2011) 8, 140–152
Self-management of chronic heart failure149

H. Otsu and M. Moriyama

Japan Journal of Nursing Science (2011) 8, 140–152

Table 6 Compliance with the self-management program for chronic heart failure
Intervention group

Control group

Period

Good
N (%)

Poor
N (%)

Good
N (%)

Poor
N (%)

P-value

Quit smoking

Baseline
6 months
9 months
12 months

42 (85.7)
46 (93.9)
44 (89.8)
42 (89.4)

7 (14.3)
3 (6.1)5 (10.2)
5 (10.6)

46 (97.9)
45 (95.7)
46 (97.9)
46 (97.9)

1 (2.1)2 (4.3)1 (2.1)1 (2.1)

0.059
1.000
0.204
0.203

Quit drinking

Baseline
6 months
9 months
12 months

32 (65.3)
28 (57.1)
29 (59.2)
27 (57.4)

17 (34.7)
21 (42.9)
20 (40.8)
20 (42.6)

38 (80.9)
32 (68.1)
30 (63.8)
28 (59.6)

9 (19.1)
15 (31.9)
17 (36.2)
19 (40.4)

0.110
0.298
0.679
1.000

Symptom deterioration

Baseline
6 months
12 months

14 (28.6)
31 (63.3)
31 (66.0)

35 (71.4)
18 (36.7)
16 (34.0)

11 (23.4)
14 (29.8)
18 (38.3)

36 (76.6)
33 (70.2)
29 (61.7)

0.645
0.001**
0.013*

Compliance behavior*P < 0.05, **P < 0.01.

Thus, a telephone or email consultation service andeducational material are also needed for working
people. The development of a program that matches thelifestyle of those who are working is needed in the
future.

Limitations of the study and future tasks
As the participants in this study were retired elderly
persons, no problem was observed in relation to completing the program. However, other methods of consultation, such as telephone or mail, in addition tointerviews, are considered necessary for future participants who are younger, still working, and/or raisingchildren.
This program provided knowledge on CHF and waseasy to implement, so it could be provided by a nurse
who is not a cardiovascular specialist and, from thisstandpoint, it has great utilization potential. For its
future adoption in nursing practise, it is assumed that anurse can provide the program to 60–100 outpatients
per month because it was possible for three-to-five outpatients to participate per day. However, implementation is thought to be difficult for hospitals with >200
beds without charging a medical treatment fee and forfacilities with an insufficient number of nursing staff
members. The introduction of this program requires thecooperation of the nursing staff and the business
manager.
It is essential for the validation of this program thatfurther large-scale trials are carried out in order to generalize this study, even though it was successful for 49
outpatients in the intervention group.

150

Some further development is necessary for futurestudies. For example, in regard to compliance, the data
was self-reported and was left to the judgment of theindividual. However, the basis for measuring compliance was ambiguous to some extent. Thus, in addition
to subjective data, objective data should be developed.

CONCLUSIONS
There was no significant difference between the intervention and control groups in regard to smoking anddrinking. It meant that these aspects of compliancebehavior did not improve during the 6 month program.
As they related to lifestyle habits, enhanced motivational
programs in the long term are needed to improve suchlifestyles.
Further continued long-term care is necessary for outpatients with CHF in order to prevent their deterioration and to maintain their health status, although this
6 month program did provide the participants withappropriate knowledge regarding self-care for CHF and,moreover, the program positively affected the patients’
therapy results. No previous study has been reported oncontinued long-term care after an educational programof several months, so further research requires carefulattention.

ACKNOWLEDGMENTS
We are extremely grateful to all the participants and forthe collaboration of Dr Yuzo Mori and Chief Nurse
Shuko Uchiumi of the Mori Heart Clinic, Aomori,© 2010 The Authors
Japan Journal of Nursing Science © 2010 Japan Academy of Nursing ScienceJapan Journal of Nursing Science (2011) 8, 140–152

Japan. This study is based on a special health science
research grant-in-aid from Aomori University of Healthand Welfare, Aomori, Japan, and was carried out at that
university between 2007 and 2008 (basic research 22B).

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© 2010 The Authors
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