Screen Time and Cardiovascular Risks Among Middle-Aged Women Background Screen time is a marker of sedentary behavior that threatens the health of women. Extended screen time is associated with depression, insomnia, cardiovascular disease, and decreased quality of life. Objective In this study, we examined the factors associated with screen time and whether screen time is associated with the physiological and psychosocial health of middle-aged women. We applied a psycho-socioeconomic biobehavioral model of health and studied the outcomes of cardiometabolic biomarkers, insomnia, and quality of life. Methods Secondary data analysis was performed using data from a cross-sectional study conducted with 423 women between 40 and 65 years of age. Socioeconomic, physiological, psychosocial, and behavioral characteristics were measured. Self-reported screen time during the past week was measured using an ordinal scale. The data were analyzed using multivariate analysis of covariance, analysis of covariance, and logistic regression analysis. Results Twenty-four percent of subjects had at least 3 hours per day of screen time on weekdays, whereas 30.7% had at least 3 hours per day on weekends. Older women, unemployed women, and those who do not perform regular exercise were more likely to have at least 3 hours per day of screen time (P < .05). Screen time was associated with total cholesterol and low-density lipoprotein cholesterol levels, insomnia, and menopause-specific quality of life (P < .05). Conclusions Based on a psycho-socioeconomic biobehavioral framework, we found that screen time is associated with the physiological and psychosocial health of women independent of socioeconomic and biobehavioral variables. Efforts to reduce the amount of screen time targeting middle-aged women will help improve cardiometabolic biomarkers and quality of life. This study was supported by an Inha University research grant. The authors have no conflicts of interest to disclose. Correspondence Ok Kyung Ham, RN, MPH, PhD, Department of Nursing, Inha University, 100 Inha-ro, Nam-gu, Incheon 22212, Korea (okkyung@inha.ac.kr). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Distinct Factors Associated With Better Self-care in Heart Failure Patients With and Without Mild Cognitive Impairment Background A decline in cognition may limit patients' ability to effectively engage in self-care in those with heart failure (HF). However, several studies have shown no difference in self-care between HF patients with and without cognitive impairment. This may indicate that there are more salient factors associated with self-care in HF patients with cognitive impairment compared with those without cognitive impairment. Objective The aim of this study was to explore which factors are related to self-care based on the presence and absence of mild cognitive impairment (MCI) among patients with HF. Methods Patients with HF were recruited from outpatient settings. The Montreal Cognitive Assessment was used to screen for MCI. Self-care was measured with the Self-care of HF Index v.6.2. Two separate stepwise linear regressions were performed to identify which factors (HF knowledge, perceived control, functional status, multimorbidity, executive function, and social support) predicted self-care in HF patients with and without MCI. Results Of the 132 patients in this study, 36 (27.3%) had MCI. Self-care maintenance and management were associated with social support (β = 0.489) and executive function (β = 0.484), respectively, in patients with MCI. Perceived control was associated with both self-care maintenance and management in patients without MCI (βs = 0.404 and 0.262, respectively). Conclusion We found that social support and executive function were associated with self-care in HF patients with MCI, whereas perceived control was associated with self-care in HF patients with intact cognition. Clinicians should develop tailored interventions to enhance self-care by considering the distinct factors associated with self-care based on the presence or absence of MCI. This study was supported by the National Research Foundation of Korea grant funded by the Korean government (MEST) (2016R1A2B4008495). The authors have no conflicts of interest to disclose. Correspondence: Jin-Oh Choi, MD, PhD, Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Irwon-ro 81, Gangnamgu, Seoul, South Korea, 06351 (choijean5@gmail.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Active Physical Activity Patterns Are Associated With Improved Quality of Life and Depression Status in Taiwanese Women With Metabolic Syndrome Background: Metabolic syndrome (MetS), health-related quality of life (HRQL), and depression status are independently associated with cardiac health. Therefore, understanding the associations between MetS, HRQL, and depression status and determining factors related to improved HRQL and depression status in people with MetS may help in cardiovascular disease prevention. Objective: The aim of this study was to examine whether there are differences in HRQL and depression status between Taiwanese women with and without MetS and whether physical activity patterns are associated with HRQL and depression status in this population. Methods: A cross-sectional study of 326 Taiwanese middle-aged and older women (≥40 years) was conducted. Metabolic syndrome was determined based on the National Cholesterol Education Program Adult Treatment Panel III definition. Health-related quality of life and depression status were collected using the Short Form 36 Health Survey and Beck Depression Inventory. Univariate and multivariate linear regression analyses were conducted. Results: Women with MetS had lower HRQL (P < .001) and higher depression status (P = .002) than those without MetS. Participants with active physical activity patterns had higher HRQL (P < .001) and lower depression status (P = .046) than those with sedentary patterns. Among women with MetS, those with active physical activity patterns had higher HRQL (P = .001) and lower depression status (P = .007) than those with sedentary patterns. Conclusions: Metabolic syndrome is related to lower HRQL and higher depression status in women 40 years and older. Active physical activity patterns are associated with better HRQL and reduced depression status in middle-aged and older women (≥40 years) with MetS. This study was funded by the Tri-Service General Hospital (TSGH-100-05-193 and MOST107-2314-B016-068), Taipei, Taiwan. The authors have no conflicts of interest to disclose. Shang-Lin Chiang, MD, PhD, has equal contribution to the first author. Correspondence Chia-Huei Lin, PhD, RN, National Defense Medical Center. No. 161 Sec 6 Mingchuan E Rd, Neihu 114 District, 10114 Taipei, Taiwan, ROC (andyy520@mail.ndmctsgh.edu.tw). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Self-management Among Elderly Patients with Hypertension and Its Association With Individual and Social Environmental Factors in China Background: The hypertension control rate in China is much lower than that in developed countries. Self-management among elderly patients with hypertension can improve blood pressure control; thus, it is necessary to explore its association with individual and social environmental factors. Objective: Our objective was to investigate self-management among elderly patients with hypertension in China and its association with individual and social environmental factors based on the social ecological model. Methods: A total of 301 elderly patients with hypertension were recruited to do a questionnaire survey based on the social ecological model, which included the General Demographic Information Questionnaire, Hypertension Patients Self-Management Behavior Rating Scale, World Health Organization Well-Being Index, Family APGAR Index, and Social Support Rating Scale. Results: The lowest level of self-management behaviors was in exercise management, and the highest was in medication management. The results of multiple linear regression analysis showed that well-being, family function, sex, education level, and age were pivotal individual and social environmental factors influencing self-management behaviors among elderly patients with hypertension. Conclusions: There is a need to develop and test interventions that improve self-management in elderly patients with hypertension. Specifically, individualized interventions to promote exercise among elderly persons with hypertension who are single and living alone are needed. Male patients with a lower education level, poor well-being, poor family function, and the lowest self-management levels are a key population to target. X.-N.Z. and C.Q. contributed equally to this study. The research was supported by the National Natural Science Foundation of China (71673199) and the Science & Technology Development Fund of Tianjin Education Commission for Higher Education (2017SK097). The authors have no conflicts of interest to disclose. Correspondence Xiao-Ying Zang, PhD, School of Nursing, Tianjin Medical University, No. 22 Qixiangtai Rd, Heping District, Tianjin 300070, China (xiaoyingzang@163.com); Yue Zhao, PhD, School of Nursing, Tianjin Medical University, No. 22 Qixiangtai Rd, Heping District, Tianjin 300070, China (yuezhao35@hotmail.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Adherence to Treatment of Female Patients With Coronary Heart Disease After a Percutaneous Coronary Intervention Background: Adherence to treatment is essential to prevent the progression of coronary heart disease (CHD), which is the most common cause of death among women. Coronary heart disease in women has special characteristics: the conventional risk factors are more harmful to women than men, accumulation of risk factors is common, and women have nontraditional risk factors such as gestational diabetes and preeclampsia. In addition, worse outcomes, higher incidence of death, and complications after percutaneous coronary intervention have been reported more often among females than among male patients. Objective: The aim of this study was to test a model of adherence to treatment among female patients with CHD after a percutaneous coronary intervention. Methods: A cross-sectional, descriptive, and explanatory survey was conducted in 2013 with 416 patients with CHD, of which the 102 female patients were included in this substudy. Self-reported instruments were used to assess female patient adherence to treatment. Data were analyzed using descriptive statistics and a structural equation model. Results: Motivation was the strongest predictor for female patients' perceived adherence to treatment. Informational support, physician support, perceived health, and physical activity were indirectly, but significantly, associated with perceived adherence to treatment via motivation. Furthermore, physical activity was positively associated with perceived health, whereas anxiety and depression were negatively associated with it. Conclusions: Secondary prevention programs and patient education have to take into account individual or unique differences. It is important to pay attention to issues that are known to contribute to motivation rather than to reply on education alone to improve adherence. Statistical supervision: Pertti Töttö, professor, Department of Social Science, University of Eastern Finland (pertti.totto@uef.fi). Ethical approval was provided by the ethical review board of University Hospital of Kuopio (ref. 74/2012). The authors have no funding or conflicts of interest to disclose. Correspondence Kähkönen Outi, PhD, RN, Department of Nursing Science, University of Oulu, Aapistie 5, 90220 Oulu, Finland (outi.kahkonen@uef.fi). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Comparing the Barriers and Facilitators of Heart Failure Management as Perceived by Patients, Caregivers, and Clinical Providers Background: Heart failure (HF) management requires the participation of patients, their significant others, and clinical providers. Each group may face barriers to HF management that may be unique or may overlap. Objective: The aim of this study was to compare the barriers and facilitators of HF management as perceived by patients, significant others, and clinical providers. Methods: Participants were recruited from a Veterans Health Administration facility. Eligible patients had a diagnosis of HF (ICD9 code 428.XX), 1 or more HF-related visit in the previous year, and a significant other who was their primary caregiver. Significant others were adults with no history of cognitive impairments caring for patients with HF. Providers were eligible if they cared for patients with HF. All participants completed semistructured interviews designed to elicit barriers to managing HF and strategies that they used to overcome these barriers. Interviews were transcribed and analyzed using latent thematic analysis, and recruitment continued until thematic saturation was attained. Results: A total of 17 couples and 12 providers were recruited. All 3 groups identified poor communication as a key barrier to HF management, including communication between patients and their significant other, between couples and providers, and providers with each other. Significant others noted that the lack of direct communication with clinical providers hindered their efforts to care for the patient. All 3 groups emphasized the importance of family members in optimizing adherence to HF self-management recommendations. Conclusions: Providers, patients, and significant others all play important and distinct roles in the management of HF. Tools to enhance communication and collaboration for all 3 and supporting the needs of significant others are missing components of current HF care. This study was supported by funding from the VA Chronic Heart Failure QUERI. Drs Trivedi and Rosland were supported by VA HSR&D Career Development Awards. Drs Piette and Timko were supported by VA HSR&D Senior Research Career Scientist Awards. All views expressed herein are those of the authors and do not necessarily reflect those of the Department of Veterans Affairs. The authors do not have conflicts of interest to disclose. Correspondence Ranak B. Trivedi, PhD, 795 Willow Rd (MPD-152), Center for Innovation to Implementation, Bldg 324, B-134, Menlo Park, CA 94025 (ranakt@stanford.edu). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Factors Influencing Cardiovascular Risk Factors and Health Perception Among Kentuckians Living in Appalachia Background: Cardiovascular disease (CVD) and risk factors for CVD are prevalent among Appalachians from Kentucky. Appalachian men and women have high rates of engagement in unhealthy behaviors and poor physical health measures that increase their risk for CVD. Objective: In this study, the relationship among gender, CVD risk factors, and health perception in Appalachians from Kentucky was explored. Methods: This cross-sectional secondary analysis is from a randomized controlled trial on CVD health in rural Kentucky. To assess gender differences in smoking history, χ2 was used. Independent t tests compared the mean between participants 50 years or younger and those older than 50 years with differences in body mass index (BMI), waist circumference, systolic and diastolic blood pressure, hemoglobin A1C, total cholesterol, and physical activity. A multivariate linear regression analysis assessed variables predicting the outcome of health perception. Results: Most participants had a mean BMI of 33 kg/m2 and 94.3% of men used smokeless tobacco compared to 5.7% of the women. Differences existed between gender and current, ever, or never smoked (P < .001). Women had higher total cholesterol levels but men had higher waist circumference. Participants older than 50 years had higher engagement in physical activity than did those 50 years or younger. Higher BMI and hemoglobin A1C level were significant predictors of worse health perception (P ≤ .05). For every unit increase in the physical activity scale, there was a 0.2-unit improvement in health perception (P ≤ .001). Conclusion: Appalachians from Kentucky have many CVD risk factors. Minimal engagement in preventative measures against CVD can worsen patient outcomes. The authors have no funding or conflicts of interest to disclose. Correspondence Cilgy M. Abraham, BS, RN, 560 West 168th Street-Mail Code 6, New York, NY 10032 (cma2212@cumc.columbia.edu). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Daytime and Nighttime Sleep Characteristics and Pain Among Adults With Stable Heart Failure Background: Pain and sleep disturbance are common among patients with heart failure (HF) and are associated with symptom burden, disability, and poor quality of life. Little is known about the associations between specific sleep characteristics and pain in people with HF. Objective: The aim of this study was to describe the relationships between nocturnal sleep characteristics, use of sleep medication, and daytime sleep characteristics and pain among people with HF. Methods: We conducted a cross-sectional study of stable participants with HF. We administered the SF36 Bodily Pain Scale, Pittsburgh Sleep Quality Index, and Sleep Habits Questionnaire and obtained 3 days of wrist actigraphy and 1 night of home unattended polysomnography. We conducted bivariate analyses and generalized linear models. Results: The sample included 173 participants (mean [SD] age, 60 [16.1] years; 65.3% [n = 113] male). Insomnia symptoms (P = .0010), sleep duration (P = .0010), poor sleep quality (P = .0153), use of sleep medications (P = .0170), napping (P = .0029), and daytime sleepiness (P = .0094) were associated with increased pain. Patients with the longest sleep duration, who also had insomnia, had more pain (P = .0004), fatigue (P = .0028), daytime sleepiness (P = .0136), and poorer sleep quality (P < .0001) and took more sleep medications (P = .0029) than did those without insomnia. Conclusions: Pain is associated with self-reported poor sleep quality, napping, daytime sleepiness, and use of sleep medication. The relationship between pain and sleep characteristics differs based on the presence of insomnia and sleep duration. Studies are needed to evaluate the causal relationships between sleep and pain and test interventions for these cooccurring symptoms. Funding: R21NR011387, R01NR008022, and T32NR008346 (primary investigator, Margaret Grey). Shelli Feder was funded by the National Clinician Scholars Program and the Department of Veterans Affairs. The authors have no conflicts of interest to disclose. Correspondence Samantha Conley, PhD, RN, FNP-BC, 400 West Campus Dr, Orange, CT 06477 (samantha.conley@yale.edu). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Theory Testing of Patient Perspectives Using a Mobile Health Technology System in Heart Failure Self-care Background: There is an increasing interest in mobile health (mHealth), the use of mobile devices for supporting self-care in persons with heart failure. However, an established theoretical framework to explain, predict, and understand the phenomena of mHealth to support self-care is lacking. Objective: The aim of this study was to deductively test if the situation-specific theory of heart failure self-care could be applied in the context of persons with heart failure using an mHealth system with a tablet computer connected to a weighing scale to support their self-care. We wanted to test whether the 3 phases of the self-care process (ie, self-care maintenance, symptom perception, and self-care management) could be validated in the experiences of persons with heart failure using an mHealth tool. Methods: A qualitative study design was used with semistructured interviews. Data were analyzed deductively using content analysis and coded according to a structured matrix into 1 of the 3 predefined categories: self-care maintenance, symptom perception, or self-care management Results: Seventeen persons with heart failure, with mean age of 75 years, participated. The mHealth system was found to be feasible, influencing adherence and providing support for maintaining self-care as well as influencing both physical and psychological symptom perception. In persons with heart failure, the mHealth tool experience influenced the development and use of skills and fostered independence in self-care management. An interaction with healthcare professionals was sometimes needed in combination with the mHealth tool. Conclusions: The findings confirmed that “the situation-specific theory of heart failure self-care” could be applied in this context. Disclosure: All authors confirm the ICMJE criteria for authorship credit concerning best practice and ethical standards in the conduct and reporting of research (http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html) as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, and (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be published. The authors have no funding or conflicts of interest to disclose. Correspondence Ewa Hägglund, RN, PhD, Heart and Vascular Outpatient Clinic C289, Karolinska University Hospital, Huddinge, 14186 Stockholm, Sweden (eva.hagglund@sll.se). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

The Association Between Mutuality, Anxiety, and Depression in Heart Failure Patient-Caregiver Dyads: An Actor-Partner Interdependence Model Analysis Background Heart failure (HF) patient-caregiver dyads experience severe psychological problems, such as anxiety and depression. A variable that has been found to be associated with anxiety and depression in patients and caregivers in severe chronic conditions is mutuality. However, this association has not been explored in HF patient-caregiver dyads to date. Objective The aim of this study was to evaluate the associations among mutuality, anxiety, and depression in HF patient-caregiver dyads. Methods This was a cross-sectional study. Mutuality, anxiety, and depression in HF patient-caregiver dyads were assessed using the Mutuality Scale (MS) total and 4 dimension scores and the Hospital Anxiety and Depression Scale, respectively. Data were analyzed using the actor-partner interdependence model to examine how mutuality of patients and caregivers was associated with both the patients' own (actor effect) and their partners' anxiety and depression (partner effect). Results A sample of 366 dyads of patients with HF (mean age, 72 years; 56% male) and caregivers (mean age, 54 years; 73.3% female) was enrolled. Regarding patient anxiety, we observed only an actor effect between the MS dimension scores of “love and affection” and “reciprocity” and anxiety in patients (B = −1.108, P = .004 and B = −0.826, P = .029, respectively). No actor and partner effects were observed concerning caregiver anxiety. Regarding depression, we observed that only the MS dimension of “love and affection” in patients had both an actor (patient: B = −0.717, P = .032) and a partner (caregiver: B = 0.710, P = .040) effect on depression. Conclusions The assessment of MS in HF patient-caregiver dyads is important to formulate interventions aimed at improving anxiety and depression in patients and caregivers. The authors have no conflicts of interest to disclose. This study was funded by the Center of Excellence for Nursing Scholarship, Rome, Italy. The authors thank the Italian Association of Heart Failure Patients (Associazione Italiana Scompensati Cardiaci) for supporting this study. Correspondence Federica Dellafiore, RN, PhD, Department of Biomedicine and Prevention, University of Rome Tor Vergata; Health Professions Research and Development Unit, IRCCS Policlinico San Donato, Milan, Italy (federica.dellafiore@grupposandonato.it). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved