Background Prognosis is worse in unmarried patients compared to married patients with heart failure (HF). The reasons for differences in outcomes are unclear, but variations in medication adherence may play a role, as medication adherence is essential to achieving better outcomes. Objective To determine whether medication adherence mediated the relationship between marital status and cardiac event-free survival in patients with HF. Method Demographic, clinical and psychosocial data were collected by questionnaires and medical record review for 136 HF patients (61 ± 11, 70% male, 60% NYHA III/IV). Medication adherence was monitored objectively for 3 months using the Medication Event Monitoring System. Cardiac event-free survival data were obtained by patient/family interview, hospital data base and death certificate review. A series of regression and Cox-survival analyses were performed to determine whether medication adherence mediated the relationship between marital status and event-free survival. Results Cardiac event-free survival was worse in unmarried patients than married patients. Unmarried patients were more likely to be nonadherent and were 2 times more likely to experience an event than married patients (p = .017). Marital status was not a significant predictor of event-free survival after entering medication adherence in the model, demonstrating a mediation effect of adherence on the relationship of marital status to survival. Conclusion Medication adherence mediated the relationship between marital status and event-free survival. It is important to design interventions to increase medication adherence that take into account subgroups, such as unmarried patients, who are at higher risk for nonadherence.

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Background Patients hospitalized with heart failure are often readmitted. Health literacy may play a substantial role in the high rate of readmissions. The purpose of this study was to examine the association of health literacy with the composite end point of heart failure readmission rates and all-cause mortality in patients with heart failure living in rural areas. Methods and Results Rural adults (n = 575), hospitalized for heart failure within the last 6 months completed the Short Test of Functional Health Literacy in Adults (STOFHLA) to measure health literacy and were followed for at least two years. The percent of patients with the end point of heart failure readmission or all-cause death was different (p=0.001) among the three STOFHLA score levels. Unadjusted analysis revealed that patients with inadequate or marginal health literacy were 1.94 (95% confidence intervals [CI] 1.43, 2.63; p < 0.001) times, and 1.91 (95% CI 1.36, 2.67; p < 0.001) times, respectively, more likely to experience the outcome. After adjustment for covariates, health literacy remained a predictor of outcomes. Of the other covariates, worse functional class, higher comorbidity burden and higher depression score predicted worse outcomes. Conclusion Inadequate or marginal health literacy is a risk factor for heart failure rehospitalization or all-cause mortality among rural heart failure patients. Clinical Trials Registration: ClinicalTrials.gov; NCT00415545; http://clinicaltrials.gov/ct2/show/NCT00415545?term=dracup&rank=3

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Background Self-care management of a low-sodium diet is a critical component of comprehensive heart failure (HF) treatment. Aims The primary purpose of this study was to examine the effectiveness of an educational intervention on reducing the dietary sodium intake of patients with HF. Secondary purposes were to examine the effects of the intervention on attitudes, subjective norm, and perceived behavioural control towards following a low-sodium diet. Methods This was a randomized clinical trial of an educational intervention based on The Theory of Planned Behavior. Patients were randomized to either a usual care (n=25) or intervention group (n=27) with data collection at baseline, 6 weeks, and 6 months. The intervention group received low-sodium diet instructions and the usual care group received no dietary instructions. Nutrition Data Systems-Research software was used to identify the sodium content of foods on food diaries. Attitudes, subjective norm, and perceived behavioural control were measured using the Dietary Sodium Restriction Questionnaire. Results Analysis of covariance (between-subjects effects) revealed that dietary sodium intake did not differ between usual care and intervention groups at 6 weeks; however, dietary sodium intake was lower in the intervention group (F=7.3, df=1,29, p=0.01) at 6 months. Attitudes subscale scores were higher in the intervention group at 6 weeks (F=7.6, df=1, 38, p<0.01). Conclusion Carefully designed educational programmes have the potential to produce desired patient outcomes such as low-sodium diet adherence in patients with heart failure.