Original Article

Psychometric evaluation of the nine-item heart failure self-care behavior scale (9-EHFScBS)


Background & Aim: Self-care in patients with heart failure can improve multiple outcomes and reduce mortality. Measuring self-care requires valid and reliable tools. This study aimed to determine the psychometric properties of the 9-items European Heart Failure Self-Care Behavior Scale.
Methods & Materials: The present study is a psychometric evaluation. The original version of the tool was translated from English to Persian using the standard Backward-Forward method. The questionnaire's validity was assessed using face, content, criterion (the Self-Care of Heart Failure Index v.6 as a criterion), and construct validity.  An exploratory factor analysis approach was used to construct validity with a sample of 216 patients with chronic heart failure referred to Dr. Shariati and Imam Khomeini Hospital's heart clinics in Tehran; and Ayatollah Mousavi Hospital in Zanjan. The reliability of the questionnaire was evaluated by internal consistency and stability methods.
Results: After the validation process (validity and reliability), all 9 items of the questionnaire were approved and remained. The content validity index of the total content of the questionnaire was calculated to be 0.96. Based on factor analysis, only one factor was confirmed for the questionnaire. The correlation between the present questionnaire and the Self-Care of Heart Failure Index v.6 was positive and significant (p<0.001, r=0.753). Internal consistency (α=0.728) and stability (0.897) of the questionnaire were also confirmed.
Conclusion: The European Heart Failure Self-Care Behavior Scale is valid and reliable for measuring Iranian patients' self-care behaviors with heart failure.

1. Nadrian H, Shojafard J, Mahmoodi H, Rouhi Z, Rezaeipandari H. Cognitive determinants of self-care behaviors among patients with heart failure: A path analysis. Health Promotion Perspectives. 2018;8(4):275-82.
2. Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, Ghofrani A. 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension: the joint task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). European Heart Journal. 2016 Jan 1;37(1):67-119.
3. Kommuri NV, Johnson ML, Koelling TM. Relationship between improvements in heart failure patient disease specific knowledge and clinical events as part of a randomized controlled trial. Patient Education and Counseling. 2012 Feb 1;86(2):233-8.
4. Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN. Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation. 2019 Mar 5;139(10):e56-28.
5. Hjelm, C. M., Broström, A., Riegel, B., Årestedt, K., & Strömberg, A. (2015). The association between cognitive function and self-care in patients with chronic heart failure. Heart & Lung, 44(2), 113–119.
6. Echouffo-Tcheugui JB, Bishu KG, Fonarow GC, Egede LE. Trends in health care expenditure among US adults with heart failure: The Medical Expenditure Panel Survey 2002-2011. American Heart Journal. 2017 Apr 1;186: 63-72.
7. Jaarsma T, Strömberg A, Gal TB, Cameron J, Driscoll A, Duengen HD, Inkrot S, Huang TY, Huyen NN, Kato N, Köberich S. Comparison of self-care behaviors of heart failure patients in 15 countries worldwide. Patient Education and Counseling. 2013 Jul 1;92(1):114-20.
8. Moser DK, Dickson V, Jaarsma T, Lee C, Stromberg A, Riegel B. Role of self-care in the patient with heart failure. Current Cardiology Reports. 2012 Jun 1;14(3):265-75.
9. Aghajanloo A, Negarandeh R, Janani L, Tanha K, Hoseini-Esfidarjani S-S. Self-care status in patients with heart failure: Systematic review and meta- analysis. Nurs Open. 2021;8:2235–2248.
10. Vellone E, Jaarsma T, Strömberg A, Fida R, Årestedt K, Rocco G, Cocchieri A, Alvaro R. The European Heart Failure Self-care Behaviour Scale: new insights into factorial structure, reliability, precision and scoring procedure. Patient Education and Counseling. 2014 Jan 1;94(1):97-102.
11. Jaarsma T, Årestedt KF, Mårtensson J, Dracup K, Strömberg A. The European Heart Failure Self‐care Behaviour scale revised into a nine‐item scale (EHFScB‐9): a reliable and valid international instrument. European Journal of Heart Failure. 2009 Jan;11(1):99-105.
12. Cameron J, Worrall-Carter L, Driscoll A, Stewart S. Measuring self-care in chronic heart failure: A review of the psychometric properties of clinical instruments. Journal of Cardiovascular Nursing. 2009 Nov 1;24(6):E10-22.
13. González B, Lupón J, Parajón T, Urrutia A, Herreros J, Valle V. Aplicación de la escala europea de autocuidado en insuficiencia cardíaca (EHFScBS) en una unidad de insuficiencia cardíaca en España [Use of the European Heart Failure Self-care Behaviour Scale (EHFScBS) in a heart failure unit in Spain]. Rev Esp Cardiol. 2006 Feb;59(2):166-70. Spanish.
14. Köberich S, Glattacker M, Jaarsma T, Lohrmann C, Dassen T. Validity and reliability of the German version of the 9-item European Heart Failure Self-care Behaviour Scale. Eur J Cardiovasc Nurs. 2013 Apr;12(2):150-8.
15. Uchmanowicz I, Wleklik M. Polish adaptation and reliability testing of the nine-item European Heart Failure Self-care Behaviour Scale (9-EHFScBS). Kardiologia Polska (Polish Heart Journal). 2016;74(7):691-6.
16. Vellone E, Jaarsma T, Strömberg A, Fida R, Årestedt K, Rocco G, Cocchieri A, Alvaro R. The European Heart Failure Self-care Behaviour Scale: new insights into factorial structure, reliability, precision and scoring procedure. Patient Education and Counseling. 2014 Jan 1;94(1):97-102.
17. Yildiz E, Behice ER. The Turkish Version of Reliability and Validity of Nine Item-European Heart Failure Self-Care Behaviour Scale. Kafkas Journal of Medical Sciences. 2018;8(1):55-60.
18. Lee CS, Lyons KS, Gelow JM, Mudd JO, Hiatt SO, Nguyen T, Jaarsma T. Validity and reliability of the European Heart Failure Self-care Behavior Scale among adults from the United States with symptomatic heart failure. European Journal of Cardiovascular Nursing. 2013 Apr 1;12(2):214-8.
19. Siabani S, Leeder SR, Davidson PM, Najafi F, Hamzeh B, Solimani A, Siahbani S, Driscoll T. Translation and validation of the Self-care of Heart Failure Index into Persian. Journal of Cardiovascular Nursing. 2014 Nov 1;29(6):E1-5.
20. Shahbazzadeh Sh. Development and Psychometric Evaluation of the Instrument for Hookah Smoking Initiation among Women: A Sequential Exploratory Mixed Methods Design. PhD thesis. Tehran University of Medical Science. 2014.
21. Plitcha SB, Kelvin EA. Munro's Statistical Methods for Health Care Research. 6 ed. Philadelphia: Lippincot Williams and Wilkins; 2013.
22. Heravi-Karimooi M, Anoosheh M, Foroughan M, Sheykhi MT, Hajizadeh E. Designing and determining psychometric properties of the Domestic Elder Abuse Questionnaire. Iranian Journal of Ageing. 2010 Apr 10;5(1):7-21.
23. Bryant FB, Yarnold PR. Principal components analysis and exploratory and confirmatory factor analysis. In L. G. Grimm & R R. Yarnold (Eds.), Reading and understanding multivariale statistics. 1995. Washington, DC: American Psychological Association.
24. Meyers LS, Gamst GC, Guarino AJ. Applied Multivariate Research: Design and Interpretation. SAGE Publications, 2012.
25. Jafari H, Saeidi N, Kaabi AM, Noshadi E, Hallafi HR. Application of exploratory factor analysis method in the evaluating the competitiveness of port services. Journal of Marine Science and Technology. 2015;14(2):96-112.
26. Heidarali H. The provide and standardize the measures of job satisfaction Publications State Management Training Center. Tehran, 2002.
27. Souza AC, Alexandre NMC, Guirardello EB. Psychometric properties in instruments evaluation of reliability and validity. Epidemiol Serv Saude. 2017 Jul-Sep;26(3):649-659.
28. Flodén A, Lennerling A, Fridh I, Rizell M, Forsberg A. Development and psychometric evaluation of the instrument: attitudes towards organ donor advocacy scale (ATODAS). The Open Nursing Journal. 2011; 5:65-73.
29. Baumgartner TA, Chung H. Confidence limits for intraclass reliability coefficients. Measurement in Physical Education and Exercise Science. 2001 Sep 1;5(3):179-88.
30. Jaarsma T, Strömberg A, Mårtensson J, Dracup K. Development and testing of the European heart failure self‐care behaviour scale. European Journal of Heart Failure. 2003 Jun;5(3):363-70.
31. Mohammadbeigi A, Mohammadsalehi N, Aligol M. Validity and reliability of the instruments and types of measurments in health applied researches. Journal of Rafsanjan University of Medical Sciences. 2015 Mar 10;13(12):1153-70.
32. Polit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice. Wolters Kluwer Health/Lippincott, Williams & Wilkins, Philadelphia. 2008.
33. Lin CY, Pakpour AH, Broström A, Fridlund B, Årestedt K, Strömberg A, Jaarsma T, Mårtensson J. Psychometric properties of the 9-item European Heart Failure Self-Care Behavior Scale using confirmatory factor analysis and Rasch analysis among Iranian patients. Journal of Cardiovascular Nursing. 2018 May 1;33(3):281-8.
IssueVol 9 No 1 (2022): Winter QRcode
SectionOriginal Article(s)
DOI https://doi.org/10.18502/npt.v9i1.7330
heart failure; psychometrics; validation; reliability

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
Negarandeh R, Ghasemi E, Janani L. Psychometric evaluation of the nine-item heart failure self-care behavior scale (9-EHFScBS). NPT. 2021;9(1):46-53.