Minding the gender gap: self-efficacy in heart failure

This invited commentary refers to ‘Sex-related differences in self-efficacy of patients with heart failure: a pooled cross-sectional study of the German Competence Network Heart Failure’, by F. Kerwagen et al., https://doi.org/10.1093/eurjcn/zvae112. Management of heart failure (HF) requires individuals to engage in HF self-care—the ongoing, iterative process of decision-making regarding health-promoting practices as well as the behaviours required to identify and manage signs and symptoms of HF.1 Better HF self-care is associated with improved quality of life2 as well as reduced risk of HF hospitalization and mortality.3,4 Self-efficacy, or the confidence in one’s ability to adopt or maintain a behaviour to impact change, has been identified as an essential component of HF self-care1,5 and is associated with greater morbidity and mortality in HF.6,7 Some studies, however, have shown that there are gender-specific differences in determinants of HF self-care, including that women may be less confident in self-care.8,9 A 2017 literature review found that lower self-efficacy in women at risk for and with cardiovascular disease is associated with decreased likelihood of engaging in health-promoting behaviours such as physical activity,10 an important part of self-care in HF. In another study of older adults with heart disease, self-esteem and stress were stronger predictors of self-care maintenance in women when compared with men.11 However, in HF, gender differences in self-efficacy have been largely uncharacterized. Understanding potential gender differences in self-efficacy would allow for better clinical identification of patients for intervention and may inspire future research focused on mechanisms driving associations of self-efficacy in HF with patient reported and clinical outcomes. Such studies will be an important step towards developing interventions to target gender disparities with the goal of improving outcomes. In this issue of the European Journal of Cardiovascular Nursing, Kerwagen et al.’s study titled Sex-related differences in self-efficacy of patients with heart failure: a pooled cross-sectional study of the German Competence Network Heart Failure sought to evaluate differences in self-efficacy by gender in individuals with HF.12 Their study is particularly timely considering the critical need for research to advance equitable cardiovascular care for women.13,14 The key finding of their study was that women had significantly higher odds of having low self-efficacy for HF self-care compared with men, independent of other significant risk factors. These findings are consistent with the existing evidence suggesting that women with HF have lower confidence in HF self-care.8 However, the reasons why women have lower self-efficacy than men in HF, and whether this translates directly into disparities in self-care and outcomes, are still unclear. There are likely gender and sex-related factors that may contribute to lower self-efficacy in women with HF. Globally, pervasive gender bias in and outside of healthcare means that living as a woman in the world is associated with poorer health outcomes and less control of decisional factors that contribute to health.15 Within healthcare, known gendered stereotypes can lead to women’s symptoms and concerns being dismissed,16 which has inspired calls to action to direct research and practice towards gender health equity in cardiovascular disease care.13,14 Additionally, there are known sex differences in HF presentation as well as equitable availability of and responses to evidence-based HF treatment.17,18 Particularly, women are more likely to develop HF with preserved ejection fraction (HFpEF).18 Although there have been recent advancements in evidence-based medical therapies for HFpEF, differences in response to these treatments persist in women compared with men.19 Women often benefit from many HF therapies at higher left ventricular ejection fractions and at lower doses than men.18 If these sex-specific differences are not considered, then women may not receive certain therapies, or may be intolerant to recommended doses. Perhaps if women do not experience the ‘expected’ response to a certain therapy, this may affect their confidence in treatment and their ability to ‘make sense’ of their symptom/functional experiences or impair their ability to engage in meaningful self-care due to symptom burden or medication side effects. Kerwagen et al. also found that individuals with higher depressive symptoms had significantly lower self-efficacy in HF self-care. Depression is known to be associated with all cardiovascular diseases, particularly HF, and women with HF are more likely to experience depression than men.20 In HF, the relationship between depression, self-efficacy, and HF self-care is not fully understood and presents an important area for future research. In summary, we commend Kerwagen et al. for this important contribution to our understanding of gender disparities in self-efficacy in HF. As noted by the authors, there are some limitations related to generalizability in their study that will be important to address in future studies (e.g. low percentage of female participants and majority ischaemic HF aetiology). Additionally, self-efficacy was operationalized using the two-item self-efficacy subscale of the 23-item Kansas City Cardiomyopathy Questionnaire (KCCQ-23), which was available in the German Competence Network Heart Failure. While the KCCQ overall summary score is a robust predictor of outcomes in HF,21 the two-item self-efficacy scale—which is not included in the KCCQ overall summary score—has suboptimal reliability (Cronbach’s alpha = 0.63).22 Future investigators may consider additional scales such as the PROMIS Self-Efficacy for Managing Chronic Conditions scale which is multidimensional and has more robust reliability (Cronbach’s alpha = 0.85–0.95).23 Nevertheless, Kerwagen et al.’s important study significantly adds to the growing body of evidence highlighting the critical gender disparity in self-efficacy in HF self-care. Ultimately, if women have lower self-efficacy, tailoring interventions to improve their self-care confidence to impact individual HF outcomes is essential. The insights from this study reinforce the critical need for a deeper understanding of mechanisms driving the gender gap in self-efficacy in HF self-care such that we can improve HF patient education, care, and outcomes. Noelle V. Pavlovic, Ph.D. (Conceptualization equal, Writing—review Quin E. Denfeld, Ph.D. R.N. (Writing—review and Mary Roberts Davis, PhD RN (Conceptualization lead, Writing—original draft lead) R.D. is funded by the Office of Research on Women's Health and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (K12AR084221). Q.E.D. is funded by the National Institute of Nursing Research of the National Institutes of Health (R01NR019054). N.V.P. is funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health (5T32HL007024-49). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.