In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
T anscul u al Adap a ion and Theo e ical Models o Valida ion
o he Spanish Ve sion o he Sel -Ca e o Hea Failu e Index
Ve sion 6.2 (SCHFI .6.2)
Raúl Juá ez-Vela 1,2 , Angela Du an e 3, Rosa An onio-O iola 4,*, Vicen e Gea-Caballe o 5,6,* , Michał Czapla 7,
I án San olalla-A nedo 1,2 , Regina Ruiz de Viñasp e-He nández 1,2, Amaya Bu gos-Es eban 1,2,
JoséVicen e Bena e -Ce e a 8, Jo ge Rubio-G acia 9,10 and E cole Vellone 3


Ci a ion: Juá ez-Vela, R.; Du an e,
A.; An onio-O iola, R.; Gea-Caballe o,
V.; Czapla, M.; San olalla-A nedo, I.;
Ruiz de Viñasp e-He nández, R.;
Bu gos-Es eban, A.; Bena e -Ce e a,
J.V.; Rubio-G acia, J.; e al.
T anscul u al Adap a ion and
Theo e ical Models o Valida ion o
he Spanish Ve sion o he Sel -Ca e
o Hea Failu e Index Ve sion 6.2
(SCHFI .6.2). In . J. En i on. Res.
Public Heal h 2021,18, 569.
h ps://doi.o g/10.3390/
ije ph18020569
Recei ed: 7 Decembe 2020
Accep ed: 8 Janua y 2021
Published: 12 Janua y 2021
Publishe ’s No e: MDPI s ays neu-
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Copy igh : © 2021 by he au ho s. Li-
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4.0/).
1Depa men o Nu sing, Uni e si y o La Rioja, 26006 Log oño, La Rioja, Spain;
[email p o ec ed] (R.J.-V.); [email p o ec ed] (I.S.-A.); [email p o ec ed] (R.R.d.V.-H.);
[email p o ec ed] (A.B.-E.)
2G oup o Resea ch in Sus ainabili y o he Heal h Sys em, Cen e o Biomedial Resea ch o La Rioja—CIBIR,
26006 Log oño, Spain
3Depa men o Biomedicine and P e en ion, Uni e si y o Rome To Ve ga a, 00133 Rome, I aly;
[email p o ec ed] (A.D.); e [email p o ec ed] (E.V.)
4Hospi al Lluís Alcanys, Xa i a, 46800 Valencia, Spain
5Nu sing School La Fe, Adsc ip Cen e Uni e sidad de Valencia, 46026 Valencia, Spain
6Resea ch G oup GREIACC, Heal h Resea ch Ins i u e La Fe, 46026 Valencia, Spain
7Facul y o Heal h Sciences, W oclaw Medical Uni e si y, 50416 W oclaw, Poland;
[email p o ec ed]
8Depa men o Heal h Sciences, VIU Valencia In e na ional Uni e si y, 46003 Valencia, Spain;
[email p o ec ed]
9In e nal Medicine Se ice, Hospi al Clinico Lozano Blesa, 50009 Za agoza, Spain;
jo ge [email p o ec ed]
10 Hea Failu e G oup, Resea ch Ins i u e o A agon IIS A agon; 50009 Za agoza, Spain
*Co espondence: [email p o ec ed] (R.A.-O.); [email p o ec ed] (V.G.-C.)
Abs ac :
Backg ound: Hea ailu e (HF) is a majo and g owing public heal h p oblem wo ldwide.
Ac oss he wo ld, hea ailu e is associa ed wi h high mo ali y, high hospi aliza ion a es, and
poo quali y o li e. Sel -ca e is de ined as a na u alis ic decision-making p ocess in ol ing he
choice o beha io s ha main ain physiologic s abili y, he esponse o symp oms when hey occu ,
and he abili y o ollow he ea men egimen and con ol symp oms. One ins umen used o
measu e sel -ca e is he Sel Ca e o Hea Failu e Index. Aim: The pu pose o his s udy was
o es he psychome ic p ope ies o he Spanish e sion o he Sel Ca e o Hea Failu e Index
.6.2 (SCHFI .6.2). Me hodology: Be o e es ing i s psychome ic p ope ies, he SCHFI .6.2 was
ansla ed and adap ed om i s o iginal English e sion in o Spanish. Subsequen ly, we es ed he
ins umen ’s psychome ic p ope ies on a sample o 203 pa icipan s wi h HF. Desc ip i e s a is ics
we e used o analyze he sociodemog aphic and clinical a iables, and o desc ibe i em esponses.
We es ed he ac o ial alidi y o he SCHFI .6.2 using con i ma o y and explo a o y ac o analysis.
Resul s: Con i ma o y ac o analysis (CFA) was pe o med using he ou p e-exis ing models which
esul ed wi h poo i indices. Thus, we pe o med explo a o y ac o analysis (EFA) on each o he
SCHFI .6.2 scales. Conclusion: The Spanish e sion o he SCHFI .6.2. has good cha ac e is ics o
ac o ial alidi y and can be used in clinical p ac ice and esea ch o measu e sel -ca e in pa ien s
wi h HF.
Keywo ds: sel -ca e; hea ailu e; psychome ics
1. In oduc ion
Hea ailu e (HF) is a majo and g owing public heal h p oblem wo ldwide. In de-
eloped coun ies such as he Uni ed S a es, HF a ec s app oxima ely 2% o he adul
In . J. En i on. Res. Public Heal h 2021,18, 569. h ps://doi.o g/10.3390/ije ph18020569 h ps://www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2021,18, 569 2 o 10
popula ion [
1
], ising o abou 10% in people age 70 o olde . I is es ima ed ha app oxi-
ma ely 15 million Eu opeans su e om HF, wi h a p e alence ha anges om 0.4% o
2.3% in Eu opean popula ions [
2
]. In Spain, he p e alence o HF is 1.3% in people be ween
45 and 54 yea s bu ises o 16.1% in people o e he age o 75 [
3
]. Ac oss he wo ld, HF is
associa ed wi h high mo ali y, high hospi aliza ion a es, and poo quali y o li e [
4
]. In
Spain, HF is he i s cause o hospi aliza ion in adul s o e age 65 and ep esen s 2% o he
o al heal hca e budge [2].
Sel -ca e has been shown o imp o e quali y o li e and educe hospi aliza ion a es in
pa ien s wi h HF [
5
,
6
]. De ined as a na u alis ic decision-making p ocess, sel -ca e in ol es
he choice o beha io s ha main ain physiological s abili y (sel -ca e main enance) and
he esponse o symp oms when hey occu (sel -ca e managemen ) [
7
]. Bo h sel -ca e
main enance and sel -ca e managemen a e in luenced by sel -ca e con idence which is
he sel -e icacy in pe o ming sel -ca e [
7
,
8
]. Na u alis ic decision making desc ibes how
people make decisions in eal-wo ld se ings [9].
One ins umen used o measu e sel -ca e is he Sel Ca e o Hea Failu e Index
(SCHFI). This ins umen , de eloped in he USA, was ini ially comp ised o 15 i ems
di ided in o h ee scales. This e sion o he SCHFI was es ed in a U.S. sample o 760 HF
pa ien s [
10
], and was upda ed o e sion 6.2, in 2009. Ve sion 6.2 has 22 i ems di ided
in o he ollowing h ee scales: sel -ca e main enance, sel -ca e managemen , and sel -ca e
con idence. The o al sco e o each sepa a e scale is s anda dized om ze o o 100 [
11
].
Since hen, he ins umen has been ansla ed in o se e al o he languages [12–15].
Spanish is he second mos common spoken language in he wo ld [
16
], bu he psycho-
me ic p ope ies o he Spanish e sion o he SCHFI ha e, un il now, no been desc ibed.
Sel -ca e beha io s a e in luenced by language and cul u e [
17
]. Fo his eason, i
is impo an o ansla e, cul u ally adap , and assess he psychome ic p ope ies o he
SCHFI ac oss o he coun ies and languages. Adap ing an ins umen om one language
o ano he is a common p ac ice, bu a e doing so, in es iga o s mus e es psychome ic
cha ac e is ics o assu e equi alence [
18
]. The e o e, he pu pose o his s udy was o es
he psychome ic p ope ies o he Spanish e sion o he SCHFI .6.2.
2. Me hods
2.1. T ansla ion, Adap a ion, and Modeling
Be o e es ing i s psychome ic p ope ies, he SCHFI .6.2 was ansla ed and adap ed
om i s o iginal English e sion in o Spanish. We ollowed he guidelines published
by Bea on e al. [
19
], which di ided he p ocess in o he ollowing six s eps, namely:
(1) ansla ion, (2) syn hesis, (3) back ansla ion, (4) syn hesis o back ansla ion, (5) expe
commi ee e iew o he ansla ed e sion, and (6) p e es ing.
Acco ding o his me hodology, he o iginal SCHFI .6.2 was ansla ed in o Spanish
by a esea che who was amilia wi h he ins umen and i s cha ac e is ics. This Spanish
ansla ion was blindly back ansla ed in o English by a bilingual esea che who had no
seen he o iginal English e sion. Bo h esea che s we e ins uc ed o use simple sen ences,
and a oid me apho s, colloquial e minology, passi e sen ences, and hypo he ical s a e-
men s. The back- ansla ed e sion o he SCHFI was e iewed by he o iginal au ho o he
ins umen o check he accu acy o he ansla ion. Mino ansla ion issues we e esol ed
by e-mail and a inal Spanish e sion o he SCHFI .6.2 was es ablished. Subsequen ly, an
expe commi ee compa ed and con as ed bo h he o iginal and back- ansla ed e sions
o he SCHFI and ag eed, by consensus, on a inal Spanish e sion o he SCHFI .6.2. The
objec i e o he expe commi ee was he adap a ion as p ecisely as possible o he o iginal
language o he Spanish e sion o he SCHFI. I was made up o na i e eache s in bo h
languages wi h clinical expe ience. As a inal s age, cogni i e in e iews we e comple ed
on a sample o 32 pa ien s. In his phase, mino changes we e made o he ansla ion
in o de o imp o e he eadabili y o he i ems. Fo example, o cla i y he di e ences
be ween he i ems measu ing “exe cise” and “physical ac i i y”, we added some examples
o physical ac i i y (i.e., ga dening and housekeeping).
In . J. En i on. Res. Public Heal h 2021,18, 569 3 o 10
2.2. P ocedu es and S a is ical Analysis
This s udy was conduc ed in he no heas egion o A agon (Spain) using a c oss-
sec ional design.
We en olled a sample o n= 203 pa icipan s admi ed o he Hospi al Clínico Lozano
Blesa in Za agoza (Spain), who me he ollowing inclusion c i e ia: (1) being diagnosed
wi h HF acco ding o he Eu opean Socie y o Ca diology (ESC) c i e ia [
2
], and (2) being
18 yea s o olde . We excluded pa ien s wi h a signi ican cogni i e impai men es ablished
by sco ing less han 4 poin s on he six-i em sc eene [
20
]. All da a we e collec ed by
quali ied nu ses, who had been speci ically ained o his pu pose, du ing he pa ien s’
admission. Once he pa ien s had g an ed hei in o med consen o pa icipa ion in he
s udy, hey we e in e iewed. The s udy was conduc ed du ing 2018.
All pa icipan s comple ed he Spanish e sion o he SCHFI .6.2, comp ising i s
h ee scales, i.e., he sel -ca e main enance scale (10 i ems), he sel -ca e managemen scale
(six i ems), and he sel -ca e con idence scale (six i ems). Each i em uses a i e-poin Like
scale o esponses. We also adminis e ed a sociodemog aphic ques ionnai e o collec
cha ac e is ics and ac o s ela ed o HF such as age, smoking habi , numbe o p e ious
hospi aliza ions, ma i al s a us, and le el o educa ion.
Sociodemog aphic and clinical a iables we e summa ized using desc ip i e s a is ics
such as mean and s anda d de ia ion in he case o quan i a i e a iables, and equencies
in he case o ca ego ical a iables. In addi ion, desc ip i e s a is ics we e used o desc ibe
i em esponses and o summa ize scale sco es.
We es ed he ac o ial alidi y o he SCHFI using ac o analysis. Ini ially, we
es ed he p e iously published SCHFI models [
21
,
22
] using con i ma o y ac o analysis
(CFA). Howe e , he i o hese models was poo o he Spanish e sion o he SCHFI.
Subsequen ly, we pe o med explo a o y ac o analysis (EFA) in o de o de e mine he
numbe o la en cons uc s and he unde lying ac o s uc u e o each SCHFI .6.2 scale.
Fo he CFA, we used he ollowing i indices: (1)
χ2
es , non-signi ican alues a e
in e p e ed as suppo ing model i ; (2) compa a i e i index (CFI), alues
≥
0.90 o > 0.95
suppo good i ; (3) no med i index (NFI), alues
≥
0.90 suppo good i ; and (4) oo
mean squa e e o o app oxima ion (RMSEA), alues < 0.06 indica e good app oxima ion
o i . Fo he EFA, we used p incipal axis ac o ing and P oMax oblique o a ion. Da a
analysis was pe o med using SPSS and IBM SPP-AMOS V24 (IBM Co po a ion, New
O cha d Road A monk, New Yo k, NY, USA).
2.3. E hical Conside a ions
This s udy adhe ed o Eu opean and Spanish da a p o ec ion egula ions (O ganic
Law 3/2018 and Gene al Da a P o ec ion Regula ion (EU) 2016/679). The s udy p o ocol
was e iewed and app o ed by a local esea ch e hics commi ee ( e e ence no. P15/0216).
A local e hics commi ee app o ed he s udy be o e da a collec ion began. All pa icipan s
we e ully in o med abou he aims o he s udy and signed he in o med consen o m p io
o comple ing he esea ch ins umen s. Pa icipa ion was olun a y, and con iden iali y
and anonymi y we e sa egua ded a all imes.
3. Resul s
Table 1illus a es he main sociodemog aphic cha ac e is ics o he sample. The e we e
sligh ly mo e men han women (50.2%) and he mean age o he sample was 81.10 yea s.
Mos o he subjec s we e widowe s (46.8%) and hey we e mos ly educa ed up o a p ima y
school le el (87.2%).
In . J. En i on. Res. Public Heal h 2021,18, 569 4 o 10
Table 1. Main sociodemog aphic cha ac e is ics o he sample (n= 203).
Va iables n%
Female 101 49.8
Male 102 50.2
Single 15 7.4
Ma ied 92 45.3
Di o ce 1 0.5
Windo e 95 46.8
Educa ion Le el
P ima y school 177 8.2
Seconda y school 13 6.4
Voca ional educa ion and aining 1 0.5
Gene al ce i ica e o educa ion 6 3
Uni e si y 6 3
Wo k
Employed wo ke 3 1.5
Sel -employed 5 2.5
Pensione 193 95.1
Unemploymen 2 1
Do You Smoke Cu en ly?
Yes 13 6.4
No 188 92.6
Do You D ink Alcoholic D inks?
Yes 12 5.9
No 189 93.1
AGE HEIGHT WEIGHT
How many DAYS
ha e you been
hospi alized
du ing las 12
mon hs due o
hea ailu e (HF)?
(yea s) (cm) (kg)
25 h Pe cen ile 76.00 150.00 67.00 7.00
50 h Pe cen ile 83.00 160.00 76.00 10.00
75 h Pe cen ile 87.00 169.00 87.30 14.75
The mean, s anda d de ia ion (SD), skewness, and ku osis alues o he Spanish
e sion o he SCHFI a e epo ed in Table 2. Rega ding he sel -ca e main enance scale, he
i em wi h he highes sco e was “keep doc o o nu se appoin men s”, whe eas he i em
wi h he lowes sco e was “exe cise o 30 min”. In he sel -ca e managemen scale, he
i em “call he physician o nu se” in he case o symp oms had he highes sco e, whe eas
i em Numbe 16, i.e., e alua ing symp om ea men , had he lowes sco e. Finally, in
he sel -ca e con idence scale, he i em wi h he highes sco e was Numbe 18, e alua ing
con idence in ollowing he ea men ad ice, and he i em wi h he lowes sco e was
Numbe 21, e alua ing how well a emedy wo ks.
In . J. En i on. Res. Public Heal h 2021,18, 569 5 o 10
Table 2. Desc ip i e s a is ics o he Sel Ca e o Hea Failu e Index (SCHFI) i ems.
Mean SD Skewness Ku osis
Sel -ca e main enance scale
Lis ed below a e common ins uc ions gi en o pe sons wi h hea
ailu e. How ou inely do you do he ollowing?
1. Weigh you sel 2.14 1.389 0.759 −0.860
2. Check you ankles o swelling 3.2834 1.49547 −0.388 −1.335
3. T y a oid ge ing sick 3.3155 1.72643 −0.321 −1.654
4. Do some physical ac i i y 2.4225 1.33929 0.453 −0.954
5. Keep doc o o nu se appoin men s 4.3155 1.28345 −1.843 1.987
6. Ea a low-sal die 2.9198 1.58249 0.084 −1.572
7. Exe cise o 30 min 1.6952 1.26071 1.732 1.622
8. Fo ge o ake one o you medicines 1.8182 1.42900 1.453 0.469
9. Ask o low-sal i ems when ea ing ou o isi ing o he s 2.0267 1.37345 0.983 −0.447
10. Use a sys em (pill box . . . ) o help you emembe you medicines 3.6738 1.68022 −0.739 −1.183
Sel -ca e managemen scale
In he pas mon h ha e you had ouble b ea hing o ankle swelling? †
11. I you had ouble b ea hing o ankle swelling in he pas mon h,
how quickly did you ecognize i as symp oms o HF? 2.5357 1.95731 0.011 −1.599
Lis ed below a e emedies ha people wi h HF use. I you ha e ouble
b ea hing o ankle swelling, how likely a e you o y one o hese
emedies?
12. Reduce he sal in you die 2.6150 1.70432 0.381 −1.600
13. Reduce you luid in ake 1.6471 1.24587 1.843 2.010
14. Take an ex a wa e pill 1.5294 1.14203 2.138 3.295
15. Call he physician o nu se 4.1872 1.47095 −1.486 0.485
Think o a emedy you ied he las ime you had ouble b ea hing o
ankle swelling.
16. How su e we e you ha he emedy helped o did no help? 1.4064 1.47581 0.834 −0.330
Sel -ca e con idence scale
In gene al, how con iden a e you ha you can . . .
17. Keep you sel ee o hea ailu e symp oms 2.8021 1.33537 −0.002 −1.316
18. Follow he ea men ad ice you ha e been gi en 3.4332 1.41405 −0.595 −0.930
19. E alua e he impo ance o you symp oms 2.8503 1.26535 −0.165 −1.158
20. Recognize changes in you heal h i hey occu 2.8396 1.30998 −0.163 −1.255
21. Do some hing ha will elie e you symp oms 2.0535 1.23014 0.896 −0.354
22. E alua e how well a emedy wo ks 1.7647 1.17694 1.408 0.885
†
This ques ion is used o iden i y pa ien s who epo ed symp oms. The sel -ca e managemen scale can be comple ed only i pa ien s
epo ed symp oms du ing he las mon h.
The CFA was pe o med ini ially on he p e iously published SCHFI models [
12
,
21
,
22
]
model i was de e mined by combining in o ma ion om he ollowing exac i s a is ics:
Chi-squa e es (
χ2
), compa a i e ix index (CFI), no med ix index (NFI), and oo mean
squa e e o o app oxima ion (RMSEA). Howe e , he i indices o he abo e models we e
all poo (Table 3).

In . J. En i on. Res. Public Heal h 2021,18, 569 6 o 10
Table 3. CFA i indices o he es ed SCHFI .6.2 models.
Models χ2(pValue) DF CFI NFI RMSEA
Model 1 785.842 (<0.001) 206 0.627 0.560 0.123
Model 2
Sel -ca e main enance scale 189.160 (<0.001) 35 0.573 0.545 0.148
Sel -ca e managemen scale 52.949 (<0.001) 9 0.624 0.616 0.155
Sel -ca e con idence scale 137.585 (<0.001) 9 0.816 0.809 0.266
Model 3
Sel -ca e main enance scale 95.629 (<0.001) 32 0.828 0.770 0.103
Sel -ca e managemen scale
Sel -ca e con idence scale 137.425 (<0.001) 8 0.817 0.809 0.295
Model 4
Sel -ca e main enance scale 75.041 (<0.001) 21 0.853 0.814 0.118
Sel -ca e managemen scale
Sel -ca e con idence scale 137.527 (<0.001) 9 0.817 0.809 0.277
No e.
χ2
= chi squa e es ; DF = Deg ee o F eedom; CFI = Compa a i e Fi Index; NFI = no med i index; RMSEA = Roo Mean Squa e
E o o App oxima ion.
Model 1 was es ed wi h he h ee SCHFI .6.2 scales in a single model as in Riegel
e al.; Model 2 was es ed pe o ming sepa a e con i ma o y ac o analyses, one pe each
scale and in Vellone e al.; Model 3 was es ed wi h 2 ac o s pe each SCHFI .6.2 scale
acco ding o Vellone e al.; Model 4 was es ed wi h ou ac o s in sel -ca e main enance
scale, wo ac o s in sel -ca e managemen scale and one ac o in sel -ca e con idence scale
as in Ba ba anelli e al. Sel -ca e managemen model in Model 3 and 4 was no iden i ied.
Since none o he es ed models ob ained suppo i e i indices, we pe o med ex-
plo a o y ac o analysis (EFA) on each o he SCHFI .6.2 scales (see Tables 4–6). In
deciding he bes ac o solu ion o he EFA, we conside ed he ollowing c i e ia: (1) ac o
loading >0.30, (2) he numbe o i ems pe ac o , (3) he in e p e abili y o he solu ion,
(4) he sc ee plo o he eigen alue, and (5) he heo y unde pinning he SCHFI. Acco ding
o hese c i e ia, he bes solu ion was iden i ying wo ac o s o each o he SCHFI .6.2
scales. In he sel -ca e main enance scale, he i s ac o included I ems 1,2 3, 5, 6, and
10. This ac o was named “illness beha io s”. The second ac o included I ems 4, 7, and
9, and was named “heal h p omo ion beha io s”. In he sel -ca e managemen scale, we
iden i ied wo ac o s. The “p e en ion beha io s” ac o included I ems 11,12, and 15, and
he “illness beha io s” ac o included I ems 13, 14, and 16. Finally, wo ac o s we e also
iden i ied in he sel -ca e con idence scale, namely he ac o called “ a ge ed p e en ion
beha io s”, which included I ems 17, 18, 19, and 20, and he ac o called “au onomous
p e en ion beha io s”, which included I ems 21 and 22.
Table 4. Explo a o y ac o analysis o he sel -ca e main enance scale.
I ems
Fac o Loadings (S anda dized Be as)
Fac o 1 Fac o 2
10.353 0.213
20.532 0.162
30.511 −0.058
4 0.056 0.785
50.768 0.007
60.578 0.191
7−0.109 0.680
8 0.003 0.142
9 0.090 0.450
10 0.691 −0.291
Fac o 1, illness beha io s and Fac o 2, heal h p omo ion beha io s.
In . J. En i on. Res. Public Heal h 2021,18, 569 7 o 10
Table 5. Explo a o y ac o analysis o he sel -ca e managemen scale.
I ems
Fac o Loadings (S anda dized Be as)
Fac o 1 Fac o 2
11 0.522 −0.150
12 0.880 0.238
13 −0.001 0.659
14 −0.309 0.703
15 0.407 −0.124
16 0.117 0.263
Fac o 1, p e en ion beha io s and Fac o 2, illness beha io s.
Table 6. The explo a o y ac o analysis o he sel -ca e con idence.
I ems
Fac o Loadings (S anda dized Be as)
Fac o 1 Fac o 2
17 0.844 −0.066
18 0.743 −0.014
19 0.939 −0.018
20 0.817 −0.111
21 0.163 0.766
22 −0.123 0.951
Fac o 1, a ge ed p e en ion beha io s and Fac o 2, au onomous p e en ion beha io s.
4. Discussion
The objec i e o his s udy was o ca y ou he c oss-cul u al adap a ion and alida ion
in o Spanish o he SCHFI .6.2, and o imp o e ou unde s anding o he dimensions
measu ed by he SCHFI .6.2 (sel -ca e main enance, sel -ca e managemen , and sel -ca e
con idence), hus, ob aining a cul u ally equi alen ins umen o assess sel -ca e skills,
which implies he choice o beha io s ha main ain physiological s abili y, he esponse o
symp oms when hey occu , and he abili y o ollow he ea men egimen and con ol
symp oms o a oid HF decompensa ion. To ou knowledge, his is he i s s udy alida ing
he SCHFI .6.2 in Spanish language. To da e, simila alida ion s udies, ou side he U.S,
ha e been conduc ed only in I aly [12], B azil [13], I an [14], and China [15].
Du ing he c oss-cul u al adap a ion p ocess, some e ms and exp essions we e modi-
ied o ensu e cul u al equi alence o cla i y he di e ences be ween he i ems ha mea-
su ed “exe cise” and “physical ac i i y”. To imp o e unde s andabili y in ou en i onmen ,
hese adjus men s we e add essed by adding some examples. Once ansla ed and back
ansla ed, i ems we e e alua ed in a ep esen a i e sample o pa ien s esiding in he
no heas egion o A agon (Spain).
Rega ding he cha ac e is ics o he pa icipan s, in ou s udy, he e we e mo e men
han women, wi h a mean age o 81.10 yea s, a low educa ional le el, and, as expec ed, in a
si ua ion o wo k inac i i y. This ypology o pa ien s di e s g ea ly om ha o he sample
used by Riegel e al. in he o iginal cons uc ion and alida ion o he ques ionnai e ( hey
we e younge , and mos had seconda y educa ion). The sample was by a he oldes as
compa ed wi h he o he alida ions, including he o iginal, om 55.8 yea s in he Chinese
sample o 72.73 yea s in he I alian sample. Rega ding he dis ibu ion by sex, he sample
p esen ed simila cha ac e is ics o ha o he o iginal s udy. The g ea p edominance o
men o e women in he sample o B azil (78.9%) and China (71%) s ands ou .
In he Ame ican sample, he educa ional le el was highe ; he majo i y had seconda y
and highe educa ion, which ep esen ed a clea di e ence o he s udy. In he alida ions
ca ied ou in I aly and China, he e was a g ea p edominance o pa ien s wi h p ima y
school le el s udies (mo e han 74%). This di e ence can be explained, in pa icula , in he
Spanish sample by aking in o accoun he age di e ences.
In . J. En i on. Res. Public Heal h 2021,18, 569 8 o 10
The ini ial CFA es o he h ee SCHFI scales in a single model o es ac o alidi y
esul ed in a poo i o he Spanish e sion, as did he es s o he o he exis ing mod-
els. This was no comple ely unexpec ed because sel -ca e is in luence by se e al ac o s
including cul u e, pa ien educa ion, and he heal h ca e sys ems [7].
The sel -ca e main enance scale e ealed wo ac o s ha we called disease beha io s
and heal h-p omo ing beha io s. I ems ela ed o “exe cise and ac i i y” we e sepa a ed
om he o he i ems. I should be aken in o accoun ha , in Spain, exe cise is seen as a
bene i by he younge g oups bu i is no a li es yle o he elde ly, he e o e, he esul
may be due o he lack o a ailabili y o ca diac ehabili a ion p og ams, as in he Chinese
s udy, bu i may also be because he main symp om o ch onic HF is he limi ed abili y o
exe cise. An i em ha had an unexpec ed esul was “Ask o low-sal i ems when ea ing
ou o isi ing o he s”. This may be ela ed o he wo k si ua ion o he sample since mos
we e in a si ua ion o inac i i y, which implies amily meals and ew e en s.
The ac o analysis o he sel -ca e managemen scale e ealed wo ac o s ha we
called he “p e en ion beha io s” ac o and he “illness beha io s” ac o . I was unlikely
ha he pa ien s would educe hei “ luid in ake and/o inc ease he dose o diu e ics”,
as well as “e alua e he e ec i eness o he ea men ”. This could be due o he ac ha
sel -ca e managemen ecommenda ions a e no a common p ac ice in Spain and in I aly,
as desc ibed by Da Conceicao e al. [
23
] and Cocchie i e al. [
24
]. This was also e lec ed
in he Eu opean s udy and he B azilian s udy in ela ion o he i em “ ake an addi ional
diu e ic”, which e lec s di e ences in he ea men no ms ha may be ela ed o he
coun y’s heal h sys em.
The ac o analysis o he sel -ca e con idence scale e ealed wo ac o s ha we called
“ a ge ed p e en ion beha io s” and “au onomous p e en ion beha io s”, which again did
no di e om he esul s o he I alian s udy, sepa a ing wo i ems ha equi e aining,
i.e., “do some hing o elie e you symp oms” and “e alua e how well a emedy wo ks”,
om he es o he i ems ha did no equi e making decisions.
Con i ma o y ac o analysis in he B azilian, Pe sian, and Chinese e sions e ealed
ha he SCHFI .6.2 models hey es ed was qui e simila o he o iginal es ing, bu his
was no he esul o ou s udy, since he p e iously published SCHFI models [
21
,
22
] did
no achie e he expec ed esul s wi h suppo i e i indices. When he EFA was pe o med
on each o he SCHFI .6.2 scales, a di e en ac o ial s uc u e eme ged which was di e en
o m he published models.
5. Limi a ions
The s udy has some limi a ions ha a e impo an o highligh . The sample size,
al hough su icien o assess he main objec i es o he s udy, could be imp o ed by he
addi ion o mo e pa icipan s. Howe e , in he li e a u e, only I aly has a bigge sample
size. The s udies o B azil, China, and I an had smalle samples.
We encoun e ed some di icul ies in applying he ins umen s. The low educa ional
le el o mos o he esponden s o ced us o ha e a p oac i e a i ude, i.e., o e ing help,
bu ha ing an objec i e a i ude in hei adminis a ion. Th ough his, we we e able o
induce ce ain answe s, al hough we ied o main ain an objec i e a i ude a all imes and
only in e ened when he esponden eques ed i and in o de o cla i y he meaning o
any o he ques ions, a he han o induce o a o ce ain answe s. I would be bene icial
o ca y ou mo e s udies in di e en egions.
6. Conclusions
As compa ed wi h he es o he alida ions, he esul s o anscul u al alida ion
we e be e han he Pe sian, Chinese, and B azilian e sions and we e simila o he I alian
e sion. Ou s udy has shown ha he Spanish e sion o he SCHFI .6.2. has a ac o ial
alidi y and could be used in clinical p ac ice and esea ch o measu e sel -ca e in pa ien s
wi h HF.
In . J. En i on. Res. Public Heal h 2021,18, 569 9 o 10
Au ho Con ibu ions:
Concep ualiza ion, R.J.-V. and A.D.; me hodology, V.G.-C.; so wa e, R.A.-O.;
alida ion, A.D.; o mal analysis, E.V.; in es iga ion, A.D.; esou ces, R.R.d.V.-H.; da a cu a ion, A.B.-
E.; w i ing—o iginal d a p epa a ion, J.V.B.-C.; w i ing— e iew and edi ing, J.R.-G.; isualiza ion,
I.S.-A.; supe ision, M.C.; p ojec adminis a ion, R.J.-V. All au ho s ha e ead and ag eed o he
published e sion o he manusc ip .
Funding: This esea ch ecei ed no ex e nal unding.
Ins i u ional Re iew Boa d S a emen :
The s udy was conduc ed acco ding o he guidelines o he
Decla a ion o Helsinki, and app o ed by he Ins i u ional Re iew Boa d o Comi éde In es igación
de la Comunidad Au ónoma de A agón-CEICA (P15/0216).
In o med Consen S a emen :
All pa icipan s we e ully in o med abou he aims o he s udy and
signed he in o med consen o m p io o comple ing he esea ch ins umen s. Pa icipa ion was
olun a y, and con iden iali y and anonymi y we e sa egua ded a all imes.
Da a A ailabili y S a emen :
The anonymous da a p esen ed in his s udy is a ailable upon eques
om he i s au ho . The da a is no publicly a ailable due o he legisla ion on pe sonal da a
p o ec ion and cu en legisla ion.
Acknowledgmen s:
The au ho s wan o acknowledge Ba ba a Riegel om Uni e si y o Pennsyl a-
nia o he suppo and help.
Con lic s o In e es : The au ho s decla e no con lic o in e es .
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