728609 research-article2017
CNU0010.1177/1474515117728609European Journal of Cardiovascular Nursing 0(0)Chen et al.
Original Article
A positive perspective of knowledge, attitude, and practices for health-promoting behaviors of adolescents with congenital heart disease
European Journal of Cardiovascular Nursing 1–9 © The European Society of Cardiology 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav https://doi.org/10.1177/1474515117728609 DOI: 10.1177/1474515117728609 journals.sagepub.com/home/cnu
Hui-Ru Huang1, Chi-Wen Chen2, Chin-Mi Chen3, Hsiao-Ling Yang4, Wen-Jen Su5, Jou-Kou Wang6 and Pei-Kwei Tsai7
Abstract Background: Health-promoting behaviors could serve as a major strategy to optimize long-term outcomes for adolescents with congenital heart disease. The associations assessed from a positive perspective of knowledge, attitudes, and practice model would potentially cultivate health-promoting behaviors during adolescence. Aim: The purpose of this study was to examine the relationships between disease knowledge, resilience, family functioning, and health-promoting behaviors in adolescents with congenital heart disease. Methods: A total of 320 adolescents with congenital heart disease who were aged 12–18 years were recruited from pediatric cardiology outpatient departments, and participated in a cross-sectional survey. The participants completed the Leuven Knowledge Questionnaire for Congenital Heart Disease; Haase Adolescent Resilience in Illness Scale; Family Adaptability, Partnership, Growth, Affection, and Resolve; and Adolescent Health Promotion scales. The collected data were analyzed using descriptive statistics and three multiple regression models. Results: Greater knowledge of prevention of complications and higher resilience had a more powerful effect in enhancing health-promoting behaviors. Having symptoms and moderate or severe family dysfunction were significantly more negatively predictive of health-promoting behaviors than not having symptoms and positive family function. The third model explained 40% of the variance in engaging in health-promoting behaviors among adolescents with congenital heart disease. Conclusion: The findings of this study provide new insights into the role of disease knowledge, resilience, and family functioning in the health-promoting behavior of adolescents with congenital heart disease. Continued efforts are required to plan family care programs that promote the acquisition of sufficient disease knowledge and the development of resilience for adolescents with congenital heart disease. Keywords Congenital heart disease, adolescent, disease knowledge, resilience, family functioning, health-promoting behaviors Date received: 15 May 2017; accepted: 3 August 2017
1Department
of Nursing, Fu Jen Catholic University Hospital, Taiwan of Nursing, National Yang-Ming University, Taiwan 3Department of Nursing, Fu Jen Catholic University, Taiwan 4School of Nursing, National Taiwan University, Taiwan 5Department of Pediatrics, Chang Gung Children’s Hospital, Taiwan 6Department of Pediatrics, National Taiwan University Hospital, Taiwan 2School
7Department
of Public Health and Center of Biostatistics, Chang Gung University, Taiwan
Corresponding author: Chi-Wen Chen, School of Nursing, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei, 11221, Taiwan. Email: [email protected]
2
Introduction Adolescence is the critical period for developing selfidentity and healthcare autonomy. Fostering autonomy could be beneficial in facilitating adolescents’ self-care by supporting them to maintain a healthy lifestyle. Engaging in health-promoting behaviors can prevent cardiac complications, including the development of arrhythmias, endocarditis, and heart failure and further optimize longterm outcomes for adolescents with congenital heart disease (CHD).1 Although adolescents with CHD may have experienced medical treatment or even surgical correction early in childhood, they may have positive perceptions of themselves, such as self-concept2 and sense of coherence.3–5 Adolescents with CHD also have considerable potential to practice health-promoting behavior similar to that of their counterparts without CHD.6 A survey of their knowledge, attitude, and practices is easy to conduct. These parameters are measurable and easily interpretable; thus, they have been widely adopted to investigate the health behavior of an individual and to assess healthcare delivery.7 However, the relationship between the positive mechanisms, particularly the attitude that enables positive psychosocial adjustment to adversity and the cultivation of health-promoting behaviors, has not been investigated among adolescents with CHD. A healthy lifestyle has been identified as strongly associated with a good understanding of disease knowledge. Previous studies have shown that a higher level of diseaserelated knowledge was associated with lower levels of overall health-risk behaviors8 and, specifically, less saturated fat intake in adolescents with CHD.9 However, adolescents were found to possess poor levels of knowledge about CHD diagnosis, cardiovascular risk factors, symptoms of deterioration, endocarditis, and reproductive issues.8 Recent evidence suggests that the disease knowledge of adolescents with CHD may be an important outcome indicator of an educational program or exercise training intervention.10 Thus, identifying the levels of disease knowledge among adolescents with CHD may facilitate the understanding of health-promoting behaviors in this population. In addition to disease knowledge, resilience is closely related to health and well-being, and signifies a combination of abilities and characteristics that interact dynamically, allowing adolescents to have flexibility and self-esteem, and promoting their health behaviors.11,12 Lee et al.13 reported that the resilience of Korean adolescents with CHD was significantly related to economic status, task-oriented coping, and avoidance-oriented coping. Similarly, a Delphi study of Taiwanese adolescents with CHD found that of all healthcare needs, “cultivating a positive attitude toward the illness” was classified as very important with a high level of agreement by all patients, parents, and healthcare providers (p.128).14 Therefore,
European Journal of Cardiovascular Nursing 00(0) possessing a positive ability and attitude of resilience is crucial for adolescents with CHD, who must cope with long-term illness from childhood. Familial impact for adolescents with CHD is diverse and multi-faceted. Of the impacts, family functioning includes the mechanisms through which family members fulfill necessary roles, perform practical tasks that facilitate the family’s life together, and move ahead through time.15 Previous studies have shown that parental support and parenting style may predict the psychosocial functioning, quality of life, and health-risk behavior such as substance use of adolescents with CHD.16–18 Accordingly, more empirical research is needed to evaluate family functioning as a whole to examine the relationship between these adolescents’ satisfaction with family relationships and health-promoting behaviors. In summary, research has shown that disease knowledge, resilience, and family functioning are important factors associated with health-promoting behaviors in adolescents with CHD. Empirical evidence supporting the hypothesis that a positive perspective of knowledge, attitude and practice model is related to improve healthpromoting behaviors in this population is currently lacking. The aims of this study were to compare the levels of disease knowledge, resilience, family functioning, and health-promoting behaviors among adolescents with CHD of various cardiac functions, and examine the relationships between disease knowledge, resilience, family functioning, and health-promoting behaviors among adolescents with CHD.
Methods Design This study had a cross-sectional design, in which adolescents with CHD completed a one-time survey to explore the relationship between health-promoting behaviors and other factors.
Setting and participants All patients with CHD who were treated at the pediatric cardiology outpatient departments of two medical centers in Northern Taiwan and who met the inclusion criteria were approached for participation in this study. The inclusion criteria were 12–18 years of age and a diagnosis of CHD. The exclusion criteria were chromosomal disorders, extracardiac malformations, or other major chronic illness such as diabetes mellitus or chronic kidney disease. To achieve 80% power, the minimum sample size was determined to be 307 by using G-power analysis for multiple regression, with an α value of 0.05 and an effect size of 0.05.19 The present study was approved by the institutional review boards of the two hospitals, and written informed consent was obtained from the adolescents and their guardians. The
Huang et al. participants were recruited from April–August 2014. After the purposes and procedures of the study had been explained, eligible adolescents were asked to complete the demographic form and questionnaires.
Measurements General characteristics. A questionnaire was used to collect demographic information (e.g. age, sex, family economic status, religion, educational level, and marital status of parents) and a complete clinical history (e.g. diagnosis, surgeries, and cardiac function) provided by the patients and reviewed by the clinical chart as well. Cardiac function was categorized into normal, mildly, moderately, and severely impaired based on limitations on physical activity according to the New York Heart Association (NYHA) classification.20 Health-promoting behaviors. Health-promoting behavior was measured using the 40-item Adolescent Health Promotion (AHP) scale. Chen et al. originally developed the AHP scale in Chinese based on the literature and guided by the theoretical framework of Pender’s health promotion model and Orem’s self-care deficit theory.21 The AHP scale comprises six dimensions: nutrition, social support, health responsibility, life appreciation, exercise behavior, and stress management. Responses are rated on a fivepoint Likert scale, with a response of one indicating “never” and five indicating “always”. The total score ranges from 40–200, with higher scores indicating better health-promoting behaviors.21 The subscale scores and total scores were both calculated. The Cronbach’s alpha of the dimensions ranged from 0.76–0.91 in a previous study of adolescents with CHD.6 In the present study, Cronbach’s alpha ranged from 0.77 for the subscale of nutrition to 0.91 for the subscale of life appreciation, and the value was 0.95 for the entire scale. Disease knowledge. The level of disease knowledge was measured using the Chinese version of the Leuven Knowledge Questionnaire for Congenital Heart Disease (LKQCHD),22 which was originally developed by Moons et al.23 The self-report LKQCHD contains five domains: (a) knowledge of the heart defect and treatment; (b) knowledge regarding the prevention of complications; (c) knowledge of physical activities; (d) knowledge of sexuality and heredity; and (e) knowledge of contraception and pregnancy planning for female participants only. Overall, the questionnaire consists of 27 items comprising 34 questions for females. Male patients complete 31 questions for 25 items. The response options include “correct”, “does not know”, “incorrect”, and “incomplete.” In this study, the score of disease knowledge was calculated using the following formula: (correct questions/total questions)×100. A higher score indicated that
3 the participants possessed a higher level of disease knowledge.24 The scores of disease knowledge were evaluated according to the criteria defined by Moons et al.22,23 Furthermore, disease knowledge was categorized into poor knowledge (80% correctness). The excellent content and concurrent validity of the Chinese version of the LKQ-CHD have been demonstrated for adolescents with CHD.22 Resilience. Resilience refers to the ability of an individual to successfully manage his or her life, and to successfully adapt to change and stressful events in healthy and constructive ways.25 In this study, resilience was measured using the Chinese version of the Haase Adolescent Resilience in Illness Scale (HARIS) developed by Chen et al.26 The HARIS is a 13-item, self-report questionnaire comprising three dimensions: self-esteem, sense of mastery, and positive expectation. Responses are scored on a sixpoint Likert scale with a score of one indicating “strongly disagree” and six indicating “strongly agree”. The total score represents the sum of item scores after reverse scoring the fourth item. The total score ranges from 13–78, with higher scores indicating greater resilience.27 The internal reliability coefficient of the HARIS was 0.87 in the original study of adolescents with cancer,27 0.89 in a study of adolescents with brain tumors,26 and 0.87 in the present study of adolescents with CHD. Family functioning. Family functioning was measured using the five-item, self-report measure adapted from the Family Adaptability, Partnership, Growth, Affection, and Resolve (APGAR) instrument developed by Smilkstein.28 A family member’s perception of family functioning can be assessed by examining his or her satisfaction with family relationships. The measure evaluates five parameters of family functioning: adaptability, partnership, growth, affection, and resolve. Adaptability is the family’s resources available for coping with problems. Partnership is the sharing of problems among family members and decision making by the family. Growth is the support provided for and the acceptance of change in individual family members. Affection is the response of family members to the expression of feelings. Resolve is the satisfaction with the quality of time that family members spend together. The response options describe the frequency of feeling satisfied with each parameter on a three-point scale, with zero indicating hardly ever and two indicating almost always. Higher scores indicate more satisfaction with family functioning. A score of 0–3 indicates severe family dysfunction, 4–7 indicates moderate family dysfunction, and 8–10 indicates positive family function. The Family APGAR instrument has been widely used to evaluate family functioning in both research and clinical practice.29 The Cronbach’s alpha was 0.70 in a study of children with epilepsy or asthma,29
4
European Journal of Cardiovascular Nursing 00(0)
Table 1. General characteristics of adolescents with congenital heart disease, shown by cardiac function. Variables
Overall (n=320)
Without symptoms (n=197; 61.6%)
With symptomsa (n=123; 38.4%)
z-Value/χ2
Age (years)
Mean±SD 15.54±1.71 n (%) 169 (52.8) 151 (47.2)
Mean±SD 15.57±1.72 n (%) 109 (55.3) 88 (44.7)
Mean±SD 15.48±1.69 n (%) 60 (48.8) 63 (51.2)
–0.515
193 (60.3) 127 (39.7)
123 (62.4) 74 (37.6)
70 (56.9) 53 (43.1)
249 (77.8) 71 (22.2)
156 (79.2) 41 (20.8)
93 (75.6) 30 (24.4)
274 (85.6) 46 (14.4)
173 (87.8) 24 (12.2)
101 (82.1) 22 (17.9)
205 (64.1) 115 (35.9)
122 (61.9) 75 (38.1)
83 (67.5) 40 (32.5)
221 (69.1) 99 (30.9)
133 (67.5) 64 (32.5)
88 (71.5) 35 (28.5)
68 (21.3) 184 (57.5) 68 (21.3)
44 (22.3) 118 (59.9) 35 (17.8)
24 (19.5) 66 (53.7) 33 (26.8)
Sex Male Female Religion No Yes Perceived economic status Ordinary or higher Low Marital status of parents Married Divorced or bereaved Father’s educational level High school or below College or beyond Mother’s educational level High school or below College or beyond Number of heart operations None 1 2–7
1.303 0.966 0.562 2.001 1.013 0.576 3.723
SD: standard deviation. aIncludes: mild symptoms (n=105; 32.8%), moderate symptoms (n=10; 3.1%) and severe symptoms (n=8; 2.5%).
0.80 in a study of adolescents with asthma,30 and 0.91 in the present study of adolescents with CHD.
and was added to analyze the predictive effect. A twotailed p
CNU0010.1177/1474515117728609European Journal of Cardiovascular Nursing 0(0)Chen et al.
Original Article
A positive perspective of knowledge, attitude, and practices for health-promoting behaviors of adolescents with congenital heart disease
European Journal of Cardiovascular Nursing 1–9 © The European Society of Cardiology 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav https://doi.org/10.1177/1474515117728609 DOI: 10.1177/1474515117728609 journals.sagepub.com/home/cnu
Hui-Ru Huang1, Chi-Wen Chen2, Chin-Mi Chen3, Hsiao-Ling Yang4, Wen-Jen Su5, Jou-Kou Wang6 and Pei-Kwei Tsai7
Abstract Background: Health-promoting behaviors could serve as a major strategy to optimize long-term outcomes for adolescents with congenital heart disease. The associations assessed from a positive perspective of knowledge, attitudes, and practice model would potentially cultivate health-promoting behaviors during adolescence. Aim: The purpose of this study was to examine the relationships between disease knowledge, resilience, family functioning, and health-promoting behaviors in adolescents with congenital heart disease. Methods: A total of 320 adolescents with congenital heart disease who were aged 12–18 years were recruited from pediatric cardiology outpatient departments, and participated in a cross-sectional survey. The participants completed the Leuven Knowledge Questionnaire for Congenital Heart Disease; Haase Adolescent Resilience in Illness Scale; Family Adaptability, Partnership, Growth, Affection, and Resolve; and Adolescent Health Promotion scales. The collected data were analyzed using descriptive statistics and three multiple regression models. Results: Greater knowledge of prevention of complications and higher resilience had a more powerful effect in enhancing health-promoting behaviors. Having symptoms and moderate or severe family dysfunction were significantly more negatively predictive of health-promoting behaviors than not having symptoms and positive family function. The third model explained 40% of the variance in engaging in health-promoting behaviors among adolescents with congenital heart disease. Conclusion: The findings of this study provide new insights into the role of disease knowledge, resilience, and family functioning in the health-promoting behavior of adolescents with congenital heart disease. Continued efforts are required to plan family care programs that promote the acquisition of sufficient disease knowledge and the development of resilience for adolescents with congenital heart disease. Keywords Congenital heart disease, adolescent, disease knowledge, resilience, family functioning, health-promoting behaviors Date received: 15 May 2017; accepted: 3 August 2017
1Department
of Nursing, Fu Jen Catholic University Hospital, Taiwan of Nursing, National Yang-Ming University, Taiwan 3Department of Nursing, Fu Jen Catholic University, Taiwan 4School of Nursing, National Taiwan University, Taiwan 5Department of Pediatrics, Chang Gung Children’s Hospital, Taiwan 6Department of Pediatrics, National Taiwan University Hospital, Taiwan 2School
7Department
of Public Health and Center of Biostatistics, Chang Gung University, Taiwan
Corresponding author: Chi-Wen Chen, School of Nursing, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei, 11221, Taiwan. Email: [email protected]
2
Introduction Adolescence is the critical period for developing selfidentity and healthcare autonomy. Fostering autonomy could be beneficial in facilitating adolescents’ self-care by supporting them to maintain a healthy lifestyle. Engaging in health-promoting behaviors can prevent cardiac complications, including the development of arrhythmias, endocarditis, and heart failure and further optimize longterm outcomes for adolescents with congenital heart disease (CHD).1 Although adolescents with CHD may have experienced medical treatment or even surgical correction early in childhood, they may have positive perceptions of themselves, such as self-concept2 and sense of coherence.3–5 Adolescents with CHD also have considerable potential to practice health-promoting behavior similar to that of their counterparts without CHD.6 A survey of their knowledge, attitude, and practices is easy to conduct. These parameters are measurable and easily interpretable; thus, they have been widely adopted to investigate the health behavior of an individual and to assess healthcare delivery.7 However, the relationship between the positive mechanisms, particularly the attitude that enables positive psychosocial adjustment to adversity and the cultivation of health-promoting behaviors, has not been investigated among adolescents with CHD. A healthy lifestyle has been identified as strongly associated with a good understanding of disease knowledge. Previous studies have shown that a higher level of diseaserelated knowledge was associated with lower levels of overall health-risk behaviors8 and, specifically, less saturated fat intake in adolescents with CHD.9 However, adolescents were found to possess poor levels of knowledge about CHD diagnosis, cardiovascular risk factors, symptoms of deterioration, endocarditis, and reproductive issues.8 Recent evidence suggests that the disease knowledge of adolescents with CHD may be an important outcome indicator of an educational program or exercise training intervention.10 Thus, identifying the levels of disease knowledge among adolescents with CHD may facilitate the understanding of health-promoting behaviors in this population. In addition to disease knowledge, resilience is closely related to health and well-being, and signifies a combination of abilities and characteristics that interact dynamically, allowing adolescents to have flexibility and self-esteem, and promoting their health behaviors.11,12 Lee et al.13 reported that the resilience of Korean adolescents with CHD was significantly related to economic status, task-oriented coping, and avoidance-oriented coping. Similarly, a Delphi study of Taiwanese adolescents with CHD found that of all healthcare needs, “cultivating a positive attitude toward the illness” was classified as very important with a high level of agreement by all patients, parents, and healthcare providers (p.128).14 Therefore,
European Journal of Cardiovascular Nursing 00(0) possessing a positive ability and attitude of resilience is crucial for adolescents with CHD, who must cope with long-term illness from childhood. Familial impact for adolescents with CHD is diverse and multi-faceted. Of the impacts, family functioning includes the mechanisms through which family members fulfill necessary roles, perform practical tasks that facilitate the family’s life together, and move ahead through time.15 Previous studies have shown that parental support and parenting style may predict the psychosocial functioning, quality of life, and health-risk behavior such as substance use of adolescents with CHD.16–18 Accordingly, more empirical research is needed to evaluate family functioning as a whole to examine the relationship between these adolescents’ satisfaction with family relationships and health-promoting behaviors. In summary, research has shown that disease knowledge, resilience, and family functioning are important factors associated with health-promoting behaviors in adolescents with CHD. Empirical evidence supporting the hypothesis that a positive perspective of knowledge, attitude and practice model is related to improve healthpromoting behaviors in this population is currently lacking. The aims of this study were to compare the levels of disease knowledge, resilience, family functioning, and health-promoting behaviors among adolescents with CHD of various cardiac functions, and examine the relationships between disease knowledge, resilience, family functioning, and health-promoting behaviors among adolescents with CHD.
Methods Design This study had a cross-sectional design, in which adolescents with CHD completed a one-time survey to explore the relationship between health-promoting behaviors and other factors.
Setting and participants All patients with CHD who were treated at the pediatric cardiology outpatient departments of two medical centers in Northern Taiwan and who met the inclusion criteria were approached for participation in this study. The inclusion criteria were 12–18 years of age and a diagnosis of CHD. The exclusion criteria were chromosomal disorders, extracardiac malformations, or other major chronic illness such as diabetes mellitus or chronic kidney disease. To achieve 80% power, the minimum sample size was determined to be 307 by using G-power analysis for multiple regression, with an α value of 0.05 and an effect size of 0.05.19 The present study was approved by the institutional review boards of the two hospitals, and written informed consent was obtained from the adolescents and their guardians. The
Huang et al. participants were recruited from April–August 2014. After the purposes and procedures of the study had been explained, eligible adolescents were asked to complete the demographic form and questionnaires.
Measurements General characteristics. A questionnaire was used to collect demographic information (e.g. age, sex, family economic status, religion, educational level, and marital status of parents) and a complete clinical history (e.g. diagnosis, surgeries, and cardiac function) provided by the patients and reviewed by the clinical chart as well. Cardiac function was categorized into normal, mildly, moderately, and severely impaired based on limitations on physical activity according to the New York Heart Association (NYHA) classification.20 Health-promoting behaviors. Health-promoting behavior was measured using the 40-item Adolescent Health Promotion (AHP) scale. Chen et al. originally developed the AHP scale in Chinese based on the literature and guided by the theoretical framework of Pender’s health promotion model and Orem’s self-care deficit theory.21 The AHP scale comprises six dimensions: nutrition, social support, health responsibility, life appreciation, exercise behavior, and stress management. Responses are rated on a fivepoint Likert scale, with a response of one indicating “never” and five indicating “always”. The total score ranges from 40–200, with higher scores indicating better health-promoting behaviors.21 The subscale scores and total scores were both calculated. The Cronbach’s alpha of the dimensions ranged from 0.76–0.91 in a previous study of adolescents with CHD.6 In the present study, Cronbach’s alpha ranged from 0.77 for the subscale of nutrition to 0.91 for the subscale of life appreciation, and the value was 0.95 for the entire scale. Disease knowledge. The level of disease knowledge was measured using the Chinese version of the Leuven Knowledge Questionnaire for Congenital Heart Disease (LKQCHD),22 which was originally developed by Moons et al.23 The self-report LKQCHD contains five domains: (a) knowledge of the heart defect and treatment; (b) knowledge regarding the prevention of complications; (c) knowledge of physical activities; (d) knowledge of sexuality and heredity; and (e) knowledge of contraception and pregnancy planning for female participants only. Overall, the questionnaire consists of 27 items comprising 34 questions for females. Male patients complete 31 questions for 25 items. The response options include “correct”, “does not know”, “incorrect”, and “incomplete.” In this study, the score of disease knowledge was calculated using the following formula: (correct questions/total questions)×100. A higher score indicated that
3 the participants possessed a higher level of disease knowledge.24 The scores of disease knowledge were evaluated according to the criteria defined by Moons et al.22,23 Furthermore, disease knowledge was categorized into poor knowledge (80% correctness). The excellent content and concurrent validity of the Chinese version of the LKQ-CHD have been demonstrated for adolescents with CHD.22 Resilience. Resilience refers to the ability of an individual to successfully manage his or her life, and to successfully adapt to change and stressful events in healthy and constructive ways.25 In this study, resilience was measured using the Chinese version of the Haase Adolescent Resilience in Illness Scale (HARIS) developed by Chen et al.26 The HARIS is a 13-item, self-report questionnaire comprising three dimensions: self-esteem, sense of mastery, and positive expectation. Responses are scored on a sixpoint Likert scale with a score of one indicating “strongly disagree” and six indicating “strongly agree”. The total score represents the sum of item scores after reverse scoring the fourth item. The total score ranges from 13–78, with higher scores indicating greater resilience.27 The internal reliability coefficient of the HARIS was 0.87 in the original study of adolescents with cancer,27 0.89 in a study of adolescents with brain tumors,26 and 0.87 in the present study of adolescents with CHD. Family functioning. Family functioning was measured using the five-item, self-report measure adapted from the Family Adaptability, Partnership, Growth, Affection, and Resolve (APGAR) instrument developed by Smilkstein.28 A family member’s perception of family functioning can be assessed by examining his or her satisfaction with family relationships. The measure evaluates five parameters of family functioning: adaptability, partnership, growth, affection, and resolve. Adaptability is the family’s resources available for coping with problems. Partnership is the sharing of problems among family members and decision making by the family. Growth is the support provided for and the acceptance of change in individual family members. Affection is the response of family members to the expression of feelings. Resolve is the satisfaction with the quality of time that family members spend together. The response options describe the frequency of feeling satisfied with each parameter on a three-point scale, with zero indicating hardly ever and two indicating almost always. Higher scores indicate more satisfaction with family functioning. A score of 0–3 indicates severe family dysfunction, 4–7 indicates moderate family dysfunction, and 8–10 indicates positive family function. The Family APGAR instrument has been widely used to evaluate family functioning in both research and clinical practice.29 The Cronbach’s alpha was 0.70 in a study of children with epilepsy or asthma,29
4
European Journal of Cardiovascular Nursing 00(0)
Table 1. General characteristics of adolescents with congenital heart disease, shown by cardiac function. Variables
Overall (n=320)
Without symptoms (n=197; 61.6%)
With symptomsa (n=123; 38.4%)
z-Value/χ2
Age (years)
Mean±SD 15.54±1.71 n (%) 169 (52.8) 151 (47.2)
Mean±SD 15.57±1.72 n (%) 109 (55.3) 88 (44.7)
Mean±SD 15.48±1.69 n (%) 60 (48.8) 63 (51.2)
–0.515
193 (60.3) 127 (39.7)
123 (62.4) 74 (37.6)
70 (56.9) 53 (43.1)
249 (77.8) 71 (22.2)
156 (79.2) 41 (20.8)
93 (75.6) 30 (24.4)
274 (85.6) 46 (14.4)
173 (87.8) 24 (12.2)
101 (82.1) 22 (17.9)
205 (64.1) 115 (35.9)
122 (61.9) 75 (38.1)
83 (67.5) 40 (32.5)
221 (69.1) 99 (30.9)
133 (67.5) 64 (32.5)
88 (71.5) 35 (28.5)
68 (21.3) 184 (57.5) 68 (21.3)
44 (22.3) 118 (59.9) 35 (17.8)
24 (19.5) 66 (53.7) 33 (26.8)
Sex Male Female Religion No Yes Perceived economic status Ordinary or higher Low Marital status of parents Married Divorced or bereaved Father’s educational level High school or below College or beyond Mother’s educational level High school or below College or beyond Number of heart operations None 1 2–7
1.303 0.966 0.562 2.001 1.013 0.576 3.723
SD: standard deviation. aIncludes: mild symptoms (n=105; 32.8%), moderate symptoms (n=10; 3.1%) and severe symptoms (n=8; 2.5%).
0.80 in a study of adolescents with asthma,30 and 0.91 in the present study of adolescents with CHD.
and was added to analyze the predictive effect. A twotailed p
