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研究生：	曼瓦妮 Maithreepala, Sujeewa Dilhani
論文名稱：	以結構方程式探究憂鬱、自我效能對斯里蘭卡低收縮分率心衰竭患者自我照顧行為之影響 Depression, Self-Efficacy, and Self-Care Behavior among Patients with Heart Failure with Reduced Ejection Fraction in Sri Lanka: A Structural Equation Modeling Approach
指導教授：	徐畢卿 Shu , Bih-Ching
學位類別：	博士 Doctor
系所名稱：	醫學院 - 護理學系 Department of Nursing
論文出版年：	2025
畢業學年度：	114
語文別：	英文
論文頁數：	187
中文關鍵詞：	憂鬱、低收縮分率心衰竭、結構方程式、自我照顧行為、自我效能
外文關鍵詞：	Depression, Heart failure , Structural equation modeling, Self-care behavior, Self-efficacy
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背景：心衰竭（Heart Failure, HF）為全球高流行率的心血管疾病之一，低收縮分率心衰竭（Heart Failure with Reduced Ejection Fraction, HFrEF）屬臨床上較嚴重的心衰竭類型，再住院率高但治癒率低。HFrEF患者常因自我效能低合併對疾病和預後所產生的憂鬱，致不佳的自我照護行為。然而，即使自我照護行為、憂鬱和自我效能的相關性已於過去研究所證實，然而，斯里蘭卡HFrEF患者的自我照護行為是否亦與憂鬱及自我效能相關仍尚無定論。

目的：本研究旨以結構方程模式（Structural Equation Modeling, SEM）驗證憂鬱、自我效能對自我照護行為的影響。

研究方法：本研究採橫斷式設計，於斯里蘭卡康提醫院心衰竭門診進行收案。由於「自我照護自我效能量表」及「簡化版歐洲心衰竭自我照護行為量表(9-item European Heart Failure Self‐care Behaviour scale, EHFScB‐9)」未有僧伽羅語版本，故先進行此二問卷的跨文化轉譯和信效度檢驗。SEM則用於驗證憂鬱及自我效能對斯里蘭卡HFrEF患者自我照護行為的影響。

研究結果：本研究共召募271位2024年7月至11月間於斯里蘭卡康提醫院心衰竭門診就診的HFrEF患者(平均年齡65.9±9.7歲、76%為男性、74.5% 教育程度至小學）。本研究僧伽羅語化的「自我照護自我效能量表」及「簡化版歐洲心衰竭自我照護行為量表」具良好信效度，驗證性因素分析亦顯示兩量表皆具良好的效度（自我照護自我效能量表：χ²/df=1.86，RMSEA=0.056，CFI=0.995、簡化版歐洲心衰竭自我照護行為量表：χ²/df=2.75，RMSEA=0.080，CFI=0.950）；此兩量表已公開於線上資源供臨床及研究使用。SEM顯示本研究所假設憂鬱及自我效能將影響斯里蘭卡HFrEF患者自我照護行為的整體模型適配極佳（χ²/df=1.24，RMSEA=0.030，CFI=0.994），證實自我效能在憂鬱與自我照護行為具中介作用。憂鬱對自我效能具顯著負向影響（β = -0.559, p<.001）；自我效能則顯著預測「遵從處置」（β=0.641, p=.022）與「諮詢行為」（β=0.186, p=.010）；憂鬱對「諮詢行為」雖帶來負向的影響（β=-0.233, p=.044），但對「遵從處置」則無顯著影響（β=0.113, p=.485）。自我效能對於憂鬱和自我照護行為皆可達成顯著的直接與間接影響：與「遵從處置」間為完全中介（p<.05），「諮詢行為」間則為部分中介（p<.05）。

結論與建議：本研究結果顯示，自我效能可緩衝憂鬱對斯里蘭卡HFrEF患者自我照護行為不佳的影響，尤其能針對「遵從處置」和「諮詢行為」造成直接或間接的矯正效果。建議將患者的憂鬱篩檢納入HFrEF的常規照護，並發展以理論為基礎、護理師主導的介入措施以增強斯里蘭卡HFrEF患者的自我效能。未來可進一步透過縱貫性或隨機對照研究驗證其因果關係，以為此稀少研究情境的臨床實務提供策略指引。

Background: Heart failure (HF) is a worldwide epidemic. Heart Failure with Reduced Ejection Fraction (HFrEF) is the most clinically severe form of HF, causing nearly half of HF rehospitalizations and associated with low survival rate. Patients with HFrEF exhibit poor self-care behaviors due to inadequate self-efficacy and prevalence of comorbid depression. No studies have evaluated the complex relationship among HF self-care behavior, self-care self-efficacy, and depression, in Sri Lanka.

Aim: The aim of this study was to evaluate a hypothesized conceptual model examining the direct and indirect effects of depression and self-care self-efficacy on self-care behavior among patients with HFrEF, using Structural Equation Modeling (SEM).

Methods: This study employed a two-phase, cross-sectional design among patients with HFrEF (n = 271) attending the HF clinic at the National Hospital Kandy-Sri Lanka from July 2024 to November 2024. In Phase I, the Self-Care Self-Efficacy Scale and the 9-item European Heart Failure Self-care Behavior Scale were translated, culturally adapted, and psychometrically validated to Sinhala Language. In Phase II, SEM was applied to test the hypothesized mediation model, examining the mediating role of self-care self-efficacy in the relationship between depression and self-care behaviors, with age and perceived social support included as covariates. Indirect effects were tested via 5,000-sample bootstrapping.

Results: A total of 271 patients with HFrEF were included (mean age = 65.9 ± 9.7 years). The majority were male (76%) and had a primary level of education (74.5%). During the Phase I, the Confirmatory factor analysis (CFA) supported the unidimensional structure of the Self-Care Self-Efficacy Scale - Sinhala version with excellent model fit (χ²/df = 1.86, RMSEA = 0.056, CFI = 0.995), and strong factor loadings (β = 0.689–0.883). The CFA of European Heart Failure Self-care Behavior Scale - Sinhala version, confirmed a two-factor structure comprising ‘adherence to regimen’ and ‘consulting behavior’, with good fit indices (χ²/df = 2.75, RMSEA = 0.080, CFI = 0.950). The adapted Sinhala versions of Self-Care Self-Efficacy Scale-Sinhala and European Heart Failure Self-care Behavior Scale are publicly available online, enhancing their use in clinical and research settings. In Phase II, the structural model demonstrated excellent fit (χ²/df = 1.24, RMSEA = 0.030, CFI = 0.994) demonstrating the mediating role of self-care self-efficacy between depression and the two self-care behavior domains, while controlling for age and social support. Depression had a significant negative effect on self-efficacy (β = –0.559, p < .001). Self-care self-efficacy significantly associated with both selfcare domains; ‘adherence to regimen’ (β = 0.641, p = .022) and ‘consulting behavior’ (β = 0.186, p = .010). Depression also had a direct negative effect on ‘consulting behavior’ (β = –0.233, p = .044), but not on ‘adherence to regimen’ (β = 0.113, p = .485). Self-care Self-efficacy fully mediated the effect of depression on ‘adherence to regimen’ (indirect effect: p < .05). For consulting behavior, partial mediation was observed (indirect effect: p < .05), with both direct and indirect effects remaining significant.

Conclusion and recommendations: Our findings demonstrated that self-care self-efficacy plays a significant mediating role, buffering the adverse effects of depression on heart failure self-care behavior across two key domains: adherence to regimen and consulting behavior. It fully mediated the pathway to adherence to regimen and partially mediated the effect on consulting behavior. Routine psychological screening and theory-based nurse-led interventions that strengthen self-efficacy are essential components of HF care. Future research should focus on longitudinal or randomized trials to confirm causal pathways and guide evidence-based practice in similar low-resource contexts.

ORAL DEFENSE CERTIFICATE	i
CHINESE ABSTRACT	ii
ENGLISH ABSTRACT	iv
ACKNOWLEDGEMENTS	vi
TABLE OF CONTENTS	vii
LIST OF TABLES 	xiv
LIST OF FIGURES 	xvi
CHAPTER ONE: INTRODUCTION	1
1.1	Background 	1
1.2	Heart failure in Sri Lanka	4
1.3	Gaps of knowledge 	6
1.4	Significance of the study 	9
1.5	Objectives of the Study	11
1.6	Research hypothesis	11
1.7	Hypothesized conceptual model and definition of terms	12
CHAPTER TWO: LITERATURE REVIEW	15
2.1	Heart failure	16
   2.1.1	Heart failure definition and classification	16
   2.1.2	Causes of heart failure and its burden among adults.	18
2.2	Depression 	19
   2.2.1	Depression as a comorbid condition in heart failure 	19
   2.2.2	Consequences of comorbid depression in heart failure patients 	19
2.3	Heart failure self-care behavior  	20
   2.3.1	Self-care behaviors 	20
   2.3.2	Heart failure with reduced ejection fraction and importance of Self-care behaviors	22
   2.3.3	Depression in heart failure and its effect on self-care behavior 	23
2.4	Self-efficacy in heart failure	24
  2.4.1	Self-efficacy 	24
  2.4.2	Self-efficacy and social support in self-care behavior	25
  2.4.3	Depression, Self-efficacy, and self-care behavior	26
2.5	Confounding factors in heart failure self-care and its role as control variables	27
2.6	Summary	28
CHAPTER THREE: METHODOLOGY	29
3.1	Study design 	29
3.2	Population and Subjects	31
   3.2.1	Criteria of the population	31
   3.2.2	Inclusion criteria	31
   3.2.3	Exclusion criteria	31
   3.2.4	Study setting	32
   3.2.5	Sampling technique	33
3.3	Measurements	33
   3.3.1	Demographic data and other variables	33
   3.3.2	Depression	33
   3.3.3	Self-efficacy	34
   3.3.4	Self-care behavior 	36
   3.3.5	Social support	37
3.4	Data collection procedure	38
3.5	Ethical approval	39
3.6	Data analysis 40
Descriptive Statistics
Correlational analysis
Outcome analysis of the structural model
CHAPTER FOUR: RESULTS	49
Demographic data and descriptive statistics	49
Phase I	
Cross-cultural adaptation of scales and psychometric validation.	51
4.1	Cross-cultural adaptation: Self-Care Self-Efficacy and European Heart Failure Self-care Behavior Scale	51
   4.1.1	Cross-cultural adaptation: Self-Care Self-Efficacy scale	51
   4.1.2	Permission and Public Availability of the Sinhala Version of the Self-Care Self-Efficacy Scale	52
   4.1.3	Cross-cultural adaptation: European Heart Failure Self-care Behavior Scale.	53
   4.1.4	Permission and public availability of the Sinhala Version of the Sinhala version of European Heart Failure Self-care Behavior Scale 	54
4.2 	Psychometric validation: Self-Care Self-Efficacy scale and European Heart Failure Self-care Behavior Scale 	55
   4.2.1.	Reliability and Construct Validity of the Self-Care Self-Efficacy Scale	55
   4.2.2.	Reliability and Construct Validity of the European Heart Failure Self-care Behavior Scale- 9	57
Phase II
Evaluation of the structural relationships among depression, self-care self-efficacy, and HF self-care behavior) using Structural Equation Modeling (SEM)	60
4.3 	Objective 1: Descriptive statistics for key variables.	60
4.4	Objective 2: Bivariate group comparisons: association between sociodemographic data and depression, self-efficacy, self-care behaviors and social support	61
4.5	Objective 3: Correlational analysis among primary constructs: association between depression, self-efficacy, social support, and self-care behaviors	64
4.6	Objective 4: Evaluation of model fit statistics to test the hypothesized mediation model, and evaluation of the direct and indirect (mediated) effects of depression on two domains of self-care behavior (adherence to regimen and consulting behavior) through self-care self-efficacy, employing Structural Equation Modeling (SEM).	65
   4.6.1	Model fit evaluation	65
   4.6.2	Structural path estimates	67
   4.6.3	Mediation analysis and total effects	67
   4.6.4	Influence of covariates: age and social support	68
   4.6.5	Residual variances and covariances	70
   4.6.6	Hypothesis Testing Results	70
CHAPTER FIVE: DISCUSSION	73
5.1	Phase I: Cross-cultural adaptation of scales and psychometric validation.	73
   5.1.1	Cross-cultural adaptation: Self-Care Self-Efficacy Scale	73
   5.1.2	Reliability and content validity: Self-Care Self-Efficacy Scale	73
   5.1.3	Psychometric validation Self-Care Self-Efficacy Scale	75
   5.1.4	Cross-cultural adaptation: European Heart Failure Self-care Behavior Scale	76
   5.1.5	Reliability and content validity: European Heart Failure Self-care Behavior Scale	77
  5.1.6	Psychometric validation of European Heart Failure Self-care Behavior Scale	78
5.2	Phase II: Evaluation of structural relationships among depression, self-care self-efficacy, and HF self-care behavior.	80
5.2.1	Discussion of participant characteristics and group differences	80
5.2.2	Structural equation modeling: hypothesis testing and model dynamics	83
5.3	Strengths	87
5.4	Limitations	89
5.5	Research and clinical implications and recommendations  	90
5.6	Conclusions	92
References	94
Appendix A: Ethical approval: Ethics Review Committee of the Faculty of Allied Health Sciences, University of Peradeniya	113
Appendix B-1: Participant information sheet and consent form (English)	114
Appendix B-2: Participant information sheet and consent form (Sinhala)	119
Appendix C-1: Patient health questionnaire (PHQ-9) (English Version)	123
Appendix C-2: Patient health questionnaire (PHQ-9) (Sinhala Version)	124
Appendix D-1: Self‐Care self‐efficacy scale (SCSE) (English version)	125
Appendix D-2: Self‐Care self‐efficacy (SCSE) scale (Sinhala Version)	126
Appendix E- 1 - European heart failure self-care behavior scale -9 (English Version)	127

Appendix E- 2 - European heart failure self-care behavior scale-9 (Sinhala Version)	128
Appendix F- 1:  Multidimensional perceived social support scale (MSPSS)- (English Version)	129
Appendix F- 2:  Multidimensional perceived social support scale (MSPSS) - (Sinhala Version)	130
Appendix G: Evidence email confirming permission granted to use Sinhala version of the patient health Questionnaire (PHQ-9)	131
Appendix H: Evidence email confirming permission granted to translate the English version of the self-care self-efficacy scale (SCSE) into Sinhala	132
Appendix I: Evidence email confirming permission granted to translate the English version of the European heart failure self-care behavior scale into Sinhala	133
Appendix J: Evidence email confirming permission granted to use Sinhala version of multidimensional perceived social support scale (MSPSS) 	135
Appendix K: Evidence of Permission Granted to Use Sinhala Version of the European Heart Failure Self-Care Behavior Scale 	137
Appendix L: Evidence of Permission Granted to Use Sinhala Version of the self-care self-efficacy scale (SCSE) 	139
Appendix M-1: Web Page of the Sinhala Version of the Self-Care Self-Efficacy Scale (SCSE)	142
Appendix M-2: Web Page of the Sinhala Version of the European Heart Failure Self-care Behavior Scale-9 (EHFScBS-9)	143
Appendix M-3: Copyright Approval for the Sinhala Version of the European Heart Failure Self-care Behavior Scale-9 (EHFScBS-9)	144
Appendix N: Administrative Approvals from the Director of the National Hospital, Kandy, and the Consultant Cardiologist and Head Nurse (Sister-in-Charge) of the Cardiology Clinic, prior to data collection	145
Appendix O: Standardized Factor Loadings for Observed Indicators in the Measurement Model of the Final Structural Equation Model	147
Appendix P: Residual Variances and Covariances for Observed and Latent Variables in the Final SEM	150
Appendix Q. Intercepts for Observed and Latent Variables in the Final Structural Equation Model	153
                                    

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