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Perceived Stress Among Patients With Heart Failure Who Have Low Socioeconomic Status

A Mixed-Methods Study

Dickens, Carolyn, PhD, APRN; Dickson, Victoria Vaughan, PhD, RN, FAHA, FAAN; Piano, Mariann R., PhD, RN, FAHA, FAAN

Journal of Cardiovascular Nursing: May/June 2019 - Volume 34 - Issue 3 - p E1–E8
doi: 10.1097/JCN.0000000000000562
Feature Article/Online Only

Background: Patient populations with low socioeconomic status (SES) experience psychological stress because of social determinants of health. Social determinants of health contribute to self-care—especially among patients with heart failure (HF).

Objective: We sought to describe the influence of stress and social determinants of health on self-care in patients with HF who have low SES.

Methods: In this mixed-methods, concurrent embedded study, participants (N = 35) were recruited from 2 urban hospitals in Chicago if they had low SES and were readmitted within 120 days of an exacerbation of HF. We conducted semistructured interviews to collect qualitative data about stressors associated with patients' living circumstances, strategies patients used to foster self-care, family dynamics, and coping strategies patients used to decrease stress. We measured psychological stress (Perceived Stress Scale [PSS-10]), and self-care (Self-care of Heart Failure Index). Content analysis was used to analyze the qualitative data, and descriptive statistics were used to describe the sample. In the final analytic phase, the qualitative and quantitative data were integrated.

Results: Self-care was poor: 91.5% of participants had Self-care of Heart Failure Index subscale scores lower than 70. Perceived stress was high: 34% of participants had PSS-10 scores of 20 or higher. Several social determinants of health emerged as affecting self-care: financial stress, family personal health, past impactful deaths, and a recent stressful event (eg, child's death). Participants lived in areas with high crime and violence, and participants described many stressful events. However, among participants whose PSS-10 scores were lower than 20 (indicating lower stress), there was discordance among the description of factors impacting self-care and their PSS-10 score.

Conclusions: Social determinants of health negatively impact the ability of low-SES patients to manage their HF symptoms and adhere to a medication and dietary regimen. It is important that healthcare providers assess patients' stressors so appropriate referral to services can occur.

Carolyn Dickens, PhD, APRN Clinical Assistant Professor, Department of Medicine, College of Medicine, University of Illinois at Chicago.

Victoria Vaughan Dickson, PhD, RN FAHA, FAAN Associate Professor and Director, Pless Center for Research, Rory Meyers College of Nursing, New York, New York.

Mariann R. Piano, PhD, RN, FAHA, FAAN Nancy and Hilliard Travis Professor of Nursing Senior and Associate Dean for Research, Vanderbilt University School of Nursing, Nashville, Tennessee.

Funding sources: Heart Failure Society of America: Nursing Research Award University of Illinois College of Nursing: Seth Rosen Research Award.

The authors have no conflicts of interest to disclose.

Correspondence Carolyn Dickens, PhD, APRN, Department of Medicine, College of Medicine, University of Illinois at Chicago, 840 South Wood St, 10th Fl, Chicago IL 60612 (

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