Transcultural adaptation and theoretical models of validation of the spanish version of the self-care of heart failure index version 6.2 (schfi v.6.2)

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- al wi h ega d o ju isdic ional clai- ms in published maps and ins i u io- nal a ilia ions. Copy igh : © 2021 by he au ho s. Li- censee MDPI, Basel, Swi ze land. This a icle is an open access a icle dis ibu ed unde he e ms and con- di ions o he C ea i e Commons A - ibu ion (CC BY) license (h ps:// c ea i ecommons.o g/licenses/by/ 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 . Re e ences 1. Sa a ese, G.; Lund, L.H. Global Public Heal h Bu den o Hea Failu e. Ca d. Fail. 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