The successful management of CHF often necessitates the compliance of patients and their families with life status changes. The life status adjustments include the adjustment of dietary factors and activities, and complying with complex drug regimens and symptom management (Happ et al., 1997; Brass-Mynderse 1996; Sullivan & Hawthorne, 1996; Dracup et al., 1994). Available data indicate that between one third and one half of heart failure readmissions, particularly those occurring within 90 days are preventable. Patients should comply with new restrictions and rules and should conform to them. Inadequacy in fulfilling any one of these necessities or restrictions could decrease the quality of life of the patient, resulting in unnecessary hospitalisation and potential early death (Happ et al., 1997). Thus, the targets in the management of CHF patients include pharmacological therapy in addition to the basic management principles, self-care strategies and patient education (Sullivan & Hawthorne, 1996; Davies & Bayliss 1994; McMuarray & Dargie 1996).
The quality of life and self-care of the patients are important dimensions in the management of CHF patients, and are related. Enhancement of quality of life could affect the self-care management positively and also application of suitable self-care management behaviours could enhance the quality of life.
Providing information only does not increase patient compliance. Previous researchers (Happ et al., 1997, Fleury, 1991) have observed that educational interventions have only increased the management knowledge of patients with chronic debilitating diseases, but healthy behavioural changes have not accompanied this. Thus, before starting a behavioural change, the judgment standards, beliefs, aims and comprehensive skills of the patient should be evaluated. Evaluating the personal knowledge and behaviour of the patient will help to form a base from which to develop some strategies and aims for behavioural changes (Happ et al., 1997, Fleury, 1991) . In summary, the content of education should be based on the educational level of the patient, his previous experiences in the health system and his age.
To strengthen the adaptation of patients to their condition, an emphatic approach by healthcare professionals and the use of individual attitude change models are helpful (Kasper et al., 2002; Venner & Selbinder, 1996; Enc, 1999a; 1999b). Individual models concentrate on what should be done for personal self-being. These models focus personal behaviours, beliefs and other personal characteristics which could be changed. To be able to provide suitable patient education, first self-care behaviours of the patients that are needed or lacking should be defined. Development of positive behaviours would increase the compliance of the patients for their disease management and would increase their levels of self-satisfaction of life. In order to provide this, a health promotion model was used in this study. The model define caring for the health and the avoidance of unhealthy behaviour. The aim is to promote health and prevent disease.
METHODOLOGY
The aim of the study was to investigate the effects of educational therapy modalities on self-care behaviours and the quality of life of the patient.
The study utilised an experimental design in which the patient group was used as its own control. Evaluations were made at three different times: baseline, and three and eight months after the education event. Consent to undertake the study was given by the research institute and a verbal consent was obtained from patients who participated in this study.
Sample
The sample consisted of 44 patients with congestive cardiac failure who were admitted to the Cardiology Department Istanbul University Cardiology Institute as outpatients or were hospitalised in the cardiology department.
Inclusion criteria
* All in- and out-patients admitted from September 2004 to December 2005 with documented CHF diagnosed at least one year ago, and aged between 40 to 75 years
* Literate
* Voluntary consent.
* No history of chronic renal failure
* Diagnosed with ischaemic cardiac disease, rheumatic cardiac disease, and dilate cardiomyopathies as aetiological factors and who are in classes II, III and IV according to the New York Heart Associations' CHF classification (depending on to the physical activities)
Assessment tools
In order to obtain baseline data several tools were used: The Multidimensional Health Locus of Control (which measures how the person perceives their health behaviours and their control of them) (Wallston et al., 1976), the Health Life Status Behavior Scale (which measures the health promotion behaviours associated with the healthy life status of the patient), Nottingham Health Profile Scale, Evaluation Form for Self-Care Behavior of CHF. Following the education intervention, the Nottingham Health Profile Scale and the Evaluation Form for Self-Care Behavior of CHF were administered in the third and eighth months.
The Nottingham Health Profile Scale was used to define the health quality of the patients with cardiovascular diseases. The first part of the scale is composed of physical activity, sleep, pain, energy, emotional reactions and social isolation; and these subgroups were used in the study. When using the scale, lower values equate to reduced quality of life.
The Evaluation Form for Self-care Behaviors of CHF patients is composed of 39 items. It is also divided into four self-care behaviour subgroups: dietary, weight and fluid gain, drug consumption, and activity, and rest. When using the scale, lower values indicate that self-care behaviours are not being followed.
Initially, physicians assessed the patients in terms of the inclusion criteria for entry into the study. Patients included in the sample were provided with general information about the study and then basic data about their demographic and disease status, their behaviours about improving their healthcare, and their quality of life and self-care behaviours about CHF were collected. The educational strategies are defined according to these data.
A face-to-face interview lasting 30-40 minutes was conducted with each patient. A group education session was provided to the patients and to their relatives by the researchers supported by a CHF handbook for the patient and CHF brochure for the patients' relatives (Enc et al., 2002). The relatives' brochure contained evidence-based information about the disease, probable life style changes, drug therapy, symptom control and management options. The primary physician of the patient and two specialised nurses provided the education. Group education was planned to include twenty people, of which ten were patients and ten were patients' relatives. The duration of the group education was planned as a total of one and a half hours, with forty minutes of education, ten minutes of free time and forty minutes of discussion about each patient's question. As soon as the education session was completed, a CHF patient handbook and CHF brochure for the patients' relatives was given to each patient and their relatives.
After the education session, the interview was repeated in the third and eighth month. Data were collected about adaptation of the CHF patients to the self-care behaviours and their quality of life. Each interview was about fifteen minutes' duration. If there were insufficient self-care behaviours of the CHF patients during the interview, individual education and consultation were continued.
Patient inquiry forms and patients' medical notes were used to collect data about demographical variables and disease characteristics. Data was collected about the patients' perceptions of health-care management and their control over their health-care using the Multidimensional Health Locus of Control Scale and data about their attitudes for improving their health with healthy living options using the Health Promotion Life-Style Profile Scale (Esin, 1997). Quality of life was assessed using the Nottingham Health Profile Scale and self-care behaviours were assessed using the Evaluation Form for Self-care Behaviors of CHF patients (Durademir, 1998).
Two of the 44 patients enrolled in the study died and seven decided not to participate after the first examination or later. Therefore, the study was completed with the remaining cohort of 35 patients.
Statistical analysis was performed with percentage calculations, median and standard deviation tests, and by paired student's t test which compared the quality of life and self-care behaviours of CHF patients before and after the education sessions at three and eight months.
RESULTS
35 patients formed the study group. The patients enrolled into the study were between 40-75 years of age (mean 59.86, SD 9.16 years). Thirteen of the cases (37.14%) were female and 22 (62.86%) were male. The demographic characteristics of the patients are shown in Table 1. According to the clinical status of the patients, percentages of the aetiological factors for the congestive cardiac failure were 47.7% for ischaemic cardiac disease, 31.4% for rheumatic valvular disorders, and 22.9% for dilated cardiomyopathy. 82.9% of the patients had been treated for CHF for three years and over. The clinical status and disease characteristics of the patients are shown in Table 1.
The points obtained from the scales included in the Health Promotion Model can be seen in Table 2. According to Table 2, the internal health controls and powerful external health controls of the patients were above the mean value, but chance factor was under the mean value. When their attitudes about improvement of their health-care were investigated, the median values (in points) for subgroups of fulfillment for their self-management and for support of their relatives were greater than the median value; nutrition and stress management were at the median level; and exercise subgroup was under the median value. Patient/family group education was planned according to these data.
Quality of life
The quality of life of the patients included in the study was evaluated by using the Nottingham Health Profile Scale. While total quality of life of the cases was significantly low at the first visit before the education, it was higher at the third and eighth months (respectively p = 0.003 and p = 0.001) (see Table 3). The augmentation in the quality of life continued at the assessment the eighth month (see Figure 1).
When the subscales of quality of life were evaluated, the subscale having the lowest scores for quality of life before the education were the dimensions of emotional reactions, sleep quality and energy, and then social isolation (see Table 3).
Self-care behaviours were evaluated using the CHF self-care behaviors evaluation form (see Table 3). The total score for the self-care behaviours of the CHF patients increased in a significant manner after the education session, when compared with the total scores before the education (p < 0.0001) (91.17, SdD 8.63; and 101.86, SD 7.32, respectively) (see Table 3). The augmentation in the CHF self-care behaviours also continued at the eighth month controls (see Figure 2).
Frequency of self-care behaviours of CHF patients
When the CHF self-care activity subscales before the education were evaluated, the self-care activities mostly fulfilled were drug usage, followed by compliance with dietary rules. The self-care activities that were least fulfilled were observing weight gain and fluid intake, followed by attitudes to work and rest (see Table 3).
When the effect of education on CHF self-care behaviours was evaluated at three and eight months, there were significant behaviour changes found with respect to compliance with dietary rules, observing weight gain and fluid intake, and working and resting, compared to the results before the education (p < 0.0001). However, there was no statistically significant difference in drug usage (see Table 3).
DISCUSSION
The findings of the study suggest that the education provided to the CHF patients, based on the health promotion model, improved their self-care behaviours and significantly increased their quality of life.
As the self-health (internal) control of individuals, as measured by the multidimensional health locus of controls, were above the median value in our study, it suggests that the self-health control of the individuals was high and they had the motivation to start and to continue the positive health attitudes. As the powerful external environmental effect is high, this shows that the effect level of the other individuals (family, doctor, nurse) on the health status of the patient is high. This result may be explained by the fact that the individuals diagnosed as CHF are at least 50 years of age and need other people to assist with the management of their symptoms.
When the attitudes of the patients about improving their health-care were investigated, as the sublevels of "support of other people" and "improving his-her self-confidence" are over the mean value (see Table 2), it supports the above results. The "exercise" sublevel is the least performed attitude, which is similar other findings in the literature. Bennet et al. (2000) reported that most of the patients have walked wanderingly without any plan instead of regular exercise, and Carlson et al. (2001) reported that participation in regular physical activities was low and most patients preferred walking. Ni et al. (1999) reported that 30% of patients ceased to exercise regularly (as they believed it to be harmful) after the diagnosis of the CHF.
An important conclusion of our study is that the attitude changes of the CHF patients by the third and eighth months after the education about their self-care behaviours for CHF and their life qualities (Figures 1,2) were improved and continued to stay at the same high level. Jaarsma et al. (1999) have reported that self-care behaviours of both the research and control groups have improved in a month (study which included an education plus observation by a nurse), but improvement in the research group were better, and self-care behaviours of both groups decreased by the eighth month, thus suggesting that education and support should be continued.
As at the third and eighth month in our study, there were improvements about the self-care behaviours for CHF and as the quality of life was high and continued to stay at this high level, it can be attributed to:
* Including the patient and her/his relatives to the group education at the beginning
* Providing the education by a primary physician and two specialised nurses
* Continuing education and supporting when there is need after the baseline education
* Positive cooperation and compliance of the primary physician, nurse and the patient
Knox and Mischeke (1999) who reported results similar to ours had applied a management program which included patient consultation, education, out-patient observation and household management and compliance observation to decrease the duration of hospitalisation and expenditures. These authors reported that compliance rates of the patients was approximately 89.5% 18 months later, and hospitalisation rates reported were 0.6/patient/year (national hospitalisation rate was 1.7/ patient/year). Again Kasper et al., (2002) have reported fewer re-hospitalisation, improved life-quality, and less weight gained at 6 months after the education.
The dimensions with the lowest quality of life scores before the education in our study, were emotional reactions, sleep quality and energy dimensions, then social isolation subgroup followed next (Table 2). Bennett et al. (2000), and Carlson et al. (2001) have reported that the symptoms mostly encountered by the patient were weakness, sleeplessness and depression. The CHF patients have symptoms associated with their therapy regimens. Diuretics are the drugs frequently used by the CHF patients and as they cause frequent urination at night, they defragment sleep, and also awaken the patient early. In our study most of the patients reported that they were taking diuretics after noon before the education and thus urinated frequently at night. As the sleep quality of the patients has increased after the education, it can be evaluated as an adaptation to the advice. In addition, Bennett et al., (2000) have also reported that, most of the patients were hindered from visiting places without toilets and also were hindered from climbing stairs because of low energy levels. This resulted in exhaustion and also hindered them from going out of home; all of these have resulted in social isolation.
The self-care behaviours for drug usage and visiting the doctor's office regularly are the attitudes frequently observed both before the education and after the education in our study, and this is in contrast with the literature reporting high non-compliance with drug usage. The most important reason for re-hospitalisation of the CHF patients in different studies is non-compliance to drug therapy (Happ et al., 1997; Ghali et al., 1988; Feenestra et al., 1998). The results of our study are similar to the results of Ni et al. (1999) who reported most of the patients (74%) were taking their drugs, and 25% were usually complying with their prescriptions. Artinian et al. (2003) and Evangelista et al. (2001) reported that most patients complied and were taking advised drugs and visiting the doctor's office regularly.
The reasons for high compliance to the drug usage both before the education and after the education in our study were: high external and internal control, patients' health insurances; and because of new arrangements in the health system not necessitating frequent prescription and clear cooperation and participation of the patient, doctor and nurse.
Most patients in our study have reported complying to the diet advised before the education, but at the third and eighth months after the education, especially attitudes about "complying to the amounts of salt advised, not adding salt while eating, avoiding from consuming meals containing salt ingredients and using spices to give delicious taste to the meal" had changed positively. We concluded that the CHF patients did not have full knowledge about the ingredients of their meals before. Riegel and Carlson (2002) have reported that most of patients do not understand the importance of their symptoms and reach wrong decisions. They do not believe that the self-care attitudes are good for themselves, and do not have a clear thought about preventing CHF symptoms when dietary sodium intake is restricted. Bennett et al., (2000) have reported that most patients did not comply with the dietary rules, but used low sodium diet to prevent CHF symptoms. Evangelista et al., (2001) reported low compliance rates about dietary intake and exercises. Thus subgroups of the dietary compliance instead of general dietary compliance of the CHF patients should be investigated and education should be planned accordingly.
In our study, we have concluded that factors such as supporting basic education by use of educational material, showing clear cut relations between CHF and nutritional rules, involvement of patients' relatives in educational process and maintenance of individual education in accordance with patients' needs were effective in providing and maintenance of behavioural change. The least applied self-care behaviours of CHF patients before the education were observing their weight gains and fluid intake and this is similar to other studies. Artinian et al. (2003) reported that the least performed behaviour was symptom control and management; Ni et al. (1999) reported that 40% of the patients did not know the importance of weight control, 37.2% did not regard weight-gain as an important problem, and 36% prefer to consume a lot of fluid; and Carlson et al. (2001) reported that it is difficult for most patients to recognise changes in symptoms and signs of CHF.
With all of these results, when an individualised model is used for CHF management (Health Promotion Model), group education, participation of the patient and his/her relatives in the education and continuing individualised education over time to positive effects on patient compliance result.
CONCLUSIONS
In our study, group education was provided to the patients diagnosed with CHF and to their relatives by the primary physician and by two specialised nurses in accordance with the planned education of the Health Promotion Model. Individualised education and consultation services were continued at regular intervals. At the end of the study, the quality of life of the CHF patients increased and behaviour changes about CHF self-care behaviours (dietary habits, management of weight-fluid intake and activity-resting habits) had continued. To apply these changes to a larger scale of CHF patients, Health Management Policy should be developed. Also longer periods of study, with a larger number of cases are advised.
REFERENCES
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Brass-Mynderse NJ (1996). Disease management for chronic congestive heart failure. J Cardiovascular Nursing 11;54-62.
Carlson B, Riegel B, Moser DK (2001). Self-care abilities of patients with heart failure. Heart & Lung 30, 351-9.
Davies SW, Bayliss J (1994). The Handbook of Chronic Heart Failure for Clinician. Istanbul: Bristol-Mayers Sguibb.
Dracup K, Baker DW, Dunbar RA, Brooks NH, Johnson LC, Oken C, Massie B (1994). Managment of heart failure II. counselling, education and lifestyle modifications. JAMA. 272, 1442-463.
Durademir AB (1998). Life qualities of chronic heart failure patients and self-care behaviours. Istanbul University, Health Science Institute, Nursing Department, Doctorate Thesis, Istanbul.
Enar R., Ilerigelen B, Okay T (1999). (Eds. for Kayet Groups) Heart Failure. Heart Failure Group. Istanbul: Servier Medication and Investigation A.[section].
Enc N (1999a). The evaluation of self-care behaviour in patients with heart failure. 1st National Congress of Internal Disease, the Congress Book of Internal Disease Nursing Program. Antlaya; November 03-07.
Enc N (1999b). Self care behaviour strategies in patients with chronic heart failure and education: Effects of improving self-care behaviour in patients with heart failure. 1st National Congress of Internal Disease, the Congress Book of Internal Disease Nursing Program. Antalya; November 03-07.
Enc N, Yigit Z, Altiok MG, Batukan O (2002). The Handbook of Heart Failure for Patients. First ed. Istanbul: Yelken Basim Yayin.
Esin MNO (1997). Evaluating and improving of health behaviours in the industry workers. Istanbul University, Health Science Institute, Nursing Department, Doctorate Thesis, Istanbul.
Evangelista LS, Berg J, Dracup K (2001). Relationship between psychosocial variables and compliance in patients with heart failure. Heart & Lung 30, 294-301.
Feenestra J, Grobbee DE, Jonkman FAM, Hoes AW, Stricker BHC (1998. Prevention of relapse in patients with congestive heart failure: the role of precipitating factors. Heart 80, 432-34.
Fleury JD (1991). Wellness motivation in cardiac rehabilitation. Heart & Lung 20, 3-8.
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Jaarsma T, Halfens R, Huijer AH, Dracup K, Gorgels T, Ree JV, Stappers J (1999). Efects of education and support on self-care and resource utilization in patients with heart failure. European Heart Journal 20, 673-682.
Kasper EK, Gerstenblith G, Hefter G, Anden EV, Brinker JA, Thiemann DR, Terrin M, Forman S, Gottlieb SH (2002). A randomised trial of the efficacy of multidisiplinary care in heart failure outpatients at high risk of hospital readmission. Journal of the American College of Cardiology 9, 471-480.
Knox D, Mischke L (1999). Implementing a congestive heart failure disease managment program to decrease lenght of stay and cost. (absct) Journal of Cardiovascular Nursing 14, 55-74.
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Professor Nuray Enc, PhD, Professor, Istanbul University Florence Nightingale High Nursery School, Department of Internal Diseases, Medical Nursing, Istanbul, Turkey.
Zerrin Yigit, MD, Associate Professor, Istanbul University, Cardiology Institute, Cardiology Department, Istanbul, Turkey.
Meral Gun Altiok, PhD, Mersin University School of Nursing and Midwifery, Mersin, Turkey.
E-mail: nurayenc@yahoo.com
Table 1: Demographic and clinical features of the chronic heart
failure patients
Demographics Features n Percentage (%)
Gender Female 13 37.14
Male 22 62.86
Age 40-49 5 14.29
50-59 12 34.29
60-69 13 37.14
70-75 5 14.29
Marital status Married 29 82.86
Not married 1 2.86
Widow 4 1.43
Divorced 1 2.86
Education Primary school 20 57.14
High school 10 28.57
University 5 14.29
Number of Alone 2 5.71
family 2-4 27 77.14
members 5-7 6 17.14
Health Have 34 97.14
insurance Don't have 1 2.86
Clinical Features n Percentage (%)
Diagnosed Ischaemic 16 45.71
disease heart disease
Rheumatic 11 31.43
heart disease
Dilate 8 22.86
cardiomyopathy
Duration of Last 1 year 3 8.57
disease Last 3 years 3 8.57
> last 3 year 29 82.86
Hypertension Positive/ 19/16 54.29/45.71
Negative)
Diabetes (Positive/ 8/27 22.86/77.14
mellitus Negative)
type 2
Hyperlipidemia (Positive/ 6/29 17.14/82.86
Negative)
Behavioural Habits n Percentage (%)
Nicotine (Positive/ 8/27 22.86/77.14
consumption Negative)
Alcohol (Positive/ 6/29 17.14/82.86
consumption Negative)
Table 2. Distribution of median points calculated by different
scales
Median
value of
Min and min and max
Scales max points points
Multi- internal 12-72 42
dimensional control
Health Locus
Control Dominant external 12-72 42
control
Chance effect 12-72 42
Healthy To 13-52 32.5
Life Status demonstrate
Behaviour his/her
Scale
Responsibility 10-40 25
about health
Exercise 5-20 12.5
Nutrition 6-24 15
Support of 7-28 17.5
others
Management 7-28 17.5
of stress
Nottingham Physical 0-100 50
Health activities
Profile
(quality Energy 0-100 50
of life)
Pain 0-100 50
Sleep 0-100 50
Social 0-100 50
isolation
Emotional 0-100 50
reactions
Self-care Dietary habits 12-36 24
behaviours
of chronic Drug usage 13-39 26
heart
failure Management 6-18 12
patients of weight-fluid
intake
Activity- 8-24 16
resting habits
Baseline
median
Baseline value of
min and max min and max
Scales points points
Multi- internal 37-70 55
dimensional control
Health Locus
Control Dominant external 29-72 59
control
Chance effect 18-61 41
Healthy To 24-49 40
Life Status demonstrate
Behaviour his/her
Scale
Responsibility 13-38 25
about health
Exercise 5-17 8
Nutrition 12-24 17
Support of 13-28 21
others
Management 10-26 17
of stress
Nottingham Physical 0-55,44 13
Health activities
Profile
(quality Energy 0-100 26
of life)
Pain 0-70.27 9
Sleep 0-87.43 25
Social 0-80.64 18
isolation
Emotional 0-92.92 25
reactions
Self-care Dietary habits 21-34 29
behaviours
of chronic Drug usage 13-39 32
heart
failure Management 6-16 11
patients of weight-fluid
intake
Activity- 13-22 18
resting habits
Table 3. Comparison of life quality and self-care behaviours of
CHF patients pre-education and post-education at three and eight
months
Scales Pre Post
educ'n educ'n
month 3
Nottingham Physical 13.05 [+ or -] 6.90 [+ or -]
Health activities 12.59 12.10
Profile
Scale Energy 25.55 [+ or -] 14.79 [+ or -]
(quality 34.67 32.97
of life)
Pain 8.92 [+ or -] 1.53 [+ or -]
14.02 5.59
Sleep 25.07 [+ or -] 15.50 [+ or -]
28.02 25.40
Social 18.02 [+ or -] 4.58 [+ or -]
isolation 28.30 14.34
Emotional 25.07 [+ or -] 10.12 [+ or -]
reactions 25.82 18.85
Total 115,66 53.41 [+ or -]
[+ or -] 86.40
106.01
Self-care Dietary 29.09 [+ or -] 32.71 [+ or -]
behaviours habits 3.16 2.71
of CHF
patients Drug 32.29 [+ or -] 34.00 [+ or -]
usage 5.03 5.08
Weight/ 11.09 [+ or -] 13.06 [+ or -]
fluid 2.74 1.92
intake
Activity- 17.71 [+ or -] 21.54 [+ or -]
resting 2.96 2.37
habits
Total 91.17 [+ or -] 101.86
8.63 [+ or -] 7.32
Scales p Post p
(1-2 educ'n (1-3
control) month 3 control)
Nottingham Physical 0.018 7.36 [+ or -] 0.05
Health activities 10.97
Profile
Scale Energy NS 7.04 [+ or -] 0.015
(quality 24.53
of life)
Pain 0.001 1.10 [+ or -] 0.005
3.72
Sleep NS 11.88 [+ or -] 0.022
18.51
Social 0.006 3.65 [+ or -] 0.001
isolation 10.64
Emotional NS 7.20 [+ or -] >0.0001
reactions 10.70
Total 0.003 38.23 [+ or -] 0.001
51.27
Self-care Dietary <0.0001 31.69 [+ or -] 0.039
behaviours habits 0.25
of CHF
patients Drug 0.025 34.15 [+ or -] ns
usage 2.97
Weight/ 0.001 13.09 [+ or -] 0.002
fluid 2.09
intake
Activity- <0.0001 21.68 [+ or -] <0.0001
resting 2.16
habits
Total <0.0001 101.53 <0.0001
[+ or -] 7.67
Figure 1. Nottingham Health Profile of HF patients
Before education 115.66
3 months after education 53.41
8 months after education 38.23
Note: Table made from bar graph.
Figure 2. Evaluation of the self-care behaviours of the
heart failure patients
Before education 91.17
3 months after education 101.86
8 months after education 101.53
Note: Table made from bar graph.Source Citation
Enc, Nuray, Zerrin Yigit, and Meral Gun Altiok. "Effects of education on self-care behaviour and quality of life in patients with chronic heart failure/Efectos de la educacion en el comportamiento de autocuidado y la calidad de vida en pacientes con insuficiencia cardiaca cronica." Connect: The World of Critical Care Nursing 7.2 (2010): 115+. Academic OneFile. Web. 10 June 2010.
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Disclaimer:This information is not a tool for self-diagnosis or a substitute for professional care.
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