Effectiveness of Motivational Interviewing on contribution to self-care, self-efficacy, and preparedness in caregivers of patients with heart failure: a secondary outcome analysis of the MOTIVATE-HF randomized controlled trial

Psychometric Testing of the Cross-Culturally Adapted Thai Version of the Caregiver Self-Efficacy in Contributing to Patient Self-Care Scale in Caregivers of Patients With Chronic Illnesses

AIM

To evaluate the psychometric properties of the Caregiver Self-Efficacy in Contributing to Patient Self-Care Scale (CSE-CSC).

BACKGROUND

The CSE-CSC scale was developed congruently with the Caregiver Contribution to Self-Care of Patient with Chronic Illness Inventory (CC-SC-CII) to assess caregiver self-efficacy (CSE), the motivation factor of caregiving. Its applicability in Asian populations, including Thailand, was limited.

METHODS

Psychometric tests were guided by COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) principles. This included translating the English version into Thai, following the principles of good practice for the translation and cultural adaptation process for patient-reported outcome (PRO) measures. Nine nursing experts evaluated the content validity. The analysis included caregivers of patients with chronic conditions from 16 primary care centres in Thailand. We tested the structural validity using exploratory factor analysis (EFA), confirmatory factor analysis (CFA) and concurrent validity for CC-SC-CII-v2. We tested the scale's reliability with methods for multidimensional and unidimensional constructs, the intraclass correlation coefficients (ICCs) and measurement error variance.

RESULTS

Kappa coefficient (k = 1.00) indicated the scale's excellent content validity. The final analysis included a total of 407 samples. The EFA with the first split-half subsample (n = 194) extracted a two-dimensional structure. One reflected CSE in Maintenance and Monitoring behaviour and another captured CSE in Management behaviour. CFA with the second split-half subsample (n = 213) and the overall sample (n = 407) supported the scale's bidimensional model with high factor loadings. Each dimension and the overall CSE-CSC scale positively correlated with each scale and the overall CC-SC-CII-v2. McDonald's ω and Cronbach's α (both ranged from 0.91-0.94) indicated excellent internal reliability. Test-retest reliability showed ICCs between 0.95 and 0.96. Measurement error yielded satisfactory results.

CONCLUSION

Testing of the Thai CSE-CSC scale supported validity and reliability, indicating that the scale can apply to Thai caregivers. This scale can be used in clinical practice and research to evaluate CSE in contribution to patient self-care.

Effects of dyadic care interventions for heart failure on patients' and caregivers' outcomes: A systematic review, meta-analysis and meta-regression

BACKGROUND

The contemporary model for managing heart failure has been extended to a patient-family caregiver dyadic context. However, the key characteristics of the model that can optimise health outcomes for both patients and caregivers remain to be investigated.

OBJECTIVES

This study aimed to identify the effects of dyadic care interventions on the behavioural, health, and health-service utilisation outcomes of patients with heart failure and their family caregivers and to explore how the intervention design characteristics influence these outcomes.

DESIGN

This study involved systematic review, meta-analysis, and meta-regression techniques.

METHODS

We performed a systematic review and meta-analysis, using 12 databases to identify randomised controlled trials or quasi-experimental studies published in English or Chinese between database inception and 31 December 2022. The considered interventions included those targeting patients with heart failure and their family caregivers to enhance disease management. Data synthesis was performed on various patient- and caregiver-related outcomes. The identified interventions were categorised according to their design characteristics for subgroup analysis. Meta-regression was performed to explore the relationship between care delivery methods and their effectiveness.

RESULTS

We identified 48 studies representing 9171 patient-caregiver dyads. Meta-analyses suggested the positive effects of dyadic care interventions on patients' health outcomes [Hedges' g (95 % confidence interval {CI}): heart failure knowledge = 1.0 (0.26, 1.75), p = 0.008; self-care confidence = 0.45 (0.08, 0.83), p = 0.02; self-care maintenance = 1.12 (0.55, 1.70), p < 0.001; self-care management = 1.01 (0.54, 1.49), p < 0.001; anxiety = -0.18 (-0.34, -0.02), p = 0.03; health-related quality of life = 0.30 (0.08, 0.51), p < 0.001; hospital admission (risk ratio {95 % CI}: hospital admission = 0.79 (0.65, 0.97), p = 0.007; and mortality = 0.58 (0.36, 0.93), p = 0.02)]. Dyadic care interventions also improved the caregivers' outcomes [Hedges' g (95 % CI): social support = 0.67 (0.01, 1.32), p = 0.05; perceived burden = -1.43 (-2.27, -0.59), p < 0.001]. Although the design of the identified care interventions was heterogeneous, the core care components included enabling and motivational strategies to improve self-care, measures to promote collaborative coping within the care dyads, and nurse-caregiver collaborative practice. Incorporating the first two core components appeared to enhance the behavioural and health outcomes of the patients, and the addition of the last component reduced readmission. Interventions that engaged both patients and caregivers in care provision, offered access to nurses, and optimised continuity of care led to better patient outcomes.

CONCLUSIONS

These findings demonstrate that dyadic care interventions can effectively improve disease management in a family context, resulting in better health outcomes for both patients and caregivers. Additionally, this study provides important insights into the more-effective design characteristics of these interventions.

REGISTRATION NUMBER

The review protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (CRD42022322492).

The Influence of Caregiver Contribution to Self-care on Symptom Burden in Patients With Heart Failure and the Mediating Role of Patient Self-care: A Longitudinal Mediation Analysis

BACKGROUND

Patients with heart failure experience high symptom burden, which can be mitigated with adequate self-care. Caregiver contribution to self-care has been theorized to improve patient symptom burden. The mediating role of patient self-care in this relationship has not been tested yet.

OBJECTIVES

The aim of this study was to test whether ( a ) caregiver contribution to self-care influences patient self-care, ( b ) patient self-care influences symptom burden, and ( c ) patient self-care mediates the relationship between caregiver contribution to self-care and symptom burden.

METHODS

In this study, the authors conducted a secondary analysis of the baseline and 3-month data from the MOTIVATE-HF trial, which enrolled 510 dyads (patient with heart failure and caregiver) in Italy. Multigroup confirmatory factor analysis was used to test measurement invariance. Autoregressive longitudinal path analysis with contemporaneous mediation was used to test our hypotheses.

RESULTS

On average, caregivers were 54 years old and mainly female, whereas patients were 72.4 years old and mainly male. Better caregiver contribution to self-care maintenance was associated with better patient self-care maintenance (β = 0.280, P < .001), which, in turn, was associated with lower symptom burden (β = -0.280, P < .001). Patient self-care maintenance mediated the effect of caregiver contribution to self-care maintenance on symptom burden (β = -0.079; 95% bias-corrected bootstrapped confidence interval, -0.130 to -0.043). Better caregiver contribution to self-care management was associated with better patient self-care management (β = 0.238, P = .006). The model significantly accounted for 37% of the total variance in symptom burden scores ( P < .001).

CONCLUSIONS

This study expands the situation-specific theory of caregiver contribution to heart failure self-care and provides new evidence on the role of caregiver contribution to self-care and patient self-care on symptom burden in heart failure.

Mediators of the Association Between Cognitive Function and Self-care Behaviors in Patients Hospitalized With an Exacerbation of Heart Failure

BACKGROUND

Patients with heart failure (HF) must engage in self-care, yet their self-care is often poor. Cognitive function commonly is impaired in HF and is associated with poor self-care. Heart failure knowledge and self-care confidence also are needed to preform self-care. Few investigators have examined mediators of the association of cognitive function with self-care.

OBJECTIVES

The aim of this study was to determine whether HF knowledge and self-care confidence mediated the association of cognitive function with self-care maintenance and management among patients with HF.

METHODS

This was a cross-sectional observational study of 164 patients with HF. Cognitive function was assessed using the Montreal Cognitive Assessment. Self-care maintenance and self-care management behaviors and self-care confidence were measured using the Self-care of Heart Failure Index. Heart failure knowledge was measured using the Dutch Heart Failure Knowledge Scale. We conducted 2 parallel mediation analyses using the PROCESS macro in SPSS, one for self-care maintenance and one for self-care management.

RESULTS

Cognitive function was indirectly associated with self-care maintenance through HF knowledge (indirect effect, 0.54; 95% confidence interval, 0.10-1.02) and self-care confidence (indirect effect, 0.26; 95% confidence interval, 0.04-0.54). Those with better cognitive function had more HF knowledge and self-care confidence. Better cognitive function was not directly associated with self-care management but indirectly associated with better self-care management through higher self-care confidence (indirect effect, 0.50; 95% confidence interval, 0.04-1.05).

CONCLUSIONS

Both HF knowledge and self-care confidence mediated the association of cognitive function with self-care maintenance, and only self-care confidence mediated the association between cognitive function and self-care management. Interventions targeting HF knowledge and self-care confidence may improve self-care even for those with lower cognitive function and need to be developed and tested.

Postdischarge Caregiver Burden Among Family Caregivers of Older Trauma Patients

Importance

Caregiver burden, characterized by psychological distress and physical morbidity, affects more than 50 million family caregivers of older adults in the United States. Risk factors for caregiver burden among caregivers of older trauma patients have not been well characterized.

Objective

To characterize postdischarge caregiver burden among caregivers of older trauma patients and identify targets that can inform interventions to improve their experience.

Design, Setting, and Participants

This study used a repeated cross-sectional design. Participants were family caregivers for adults 65 years or older with traumatic injury who were discharged from 1 of 2 level I trauma centers. Telephone interviews were conducted at 1 month and 3 months postdischarge with family caregivers (identified by the patient as family or friends who provided unpaid care). Admissions occurred between December 2019 and May 2021, and data were analyzed from June 2021 to May 2022.

Exposure

Hospital admission for geriatric trauma.

Main Outcome and Measures

High caregiver burden was defined by a score of 17 or higher on the 12-item Zarit Burden Interview. Caregiver self-efficacy and preparedness for caregiving were assessed via the Revised Scale for Caregiving Self-Efficacy and Preparedness for Caregiving Scale, respectively. Associations between caregiver self-efficacy, preparedness for caregiving, and caregiver burden were tested via mixed-effect logistic regression.

Results

There were 154 family caregivers enrolled in the study. Their mean (SD) age was 60.6 (13.0) years (range, 18-92 years), 108 of 154 were female (70.6%). The proportion of caregivers experiencing high burden (Zarit Burden Interview score ≥17) was unchanged over time (1 month, 38 caregivers [30.9%]; 3 months, 37 caregivers [31.4%]). Participants with lower caregiver self-efficacy and preparedness for caregiving were more likely to experience greater caregiver burden (odds ratio [OR], 7.79; 95% CI, 2.54-23.82; P < .001; and OR, 5.76; 95% CI, 1.86-17.88; P = .003, respectively).

Conclusion and Relevance

This study found that nearly a third of family caregivers of older trauma patients experience high caregiver burden up to 3 months after the patients' discharge. Targeted interventions to increase caregiver self-efficacy and preparedness may reduce caregiver burden in geriatric trauma.

Social network interventions to support cardiac rehabilitation and secondary prevention in the management of people with heart disease

BACKGROUND

Globally, cardiovascular diseases (CVD, that is, coronary heart (CHD) and circulatory diseases combined) contribute to 31% of all deaths, more than any other cause. In line with guidance in the UK and globally, cardiac rehabilitation programmes are widely offered to people with heart disease, and include psychosocial, educational, health behaviour change, and risk management components. Social support and social network interventions have potential to improve outcomes of these programmes, but whether and how these interventions work is poorly understood.  OBJECTIVES: To assess the effectiveness of social network and social support interventions to support cardiac rehabilitation and secondary prevention in the management of people with heart disease. The comparator was usual care with no element of social support (i.e. secondary prevention alone or with cardiac rehabilitation).  SEARCH METHODS: We undertook a systematic search of the following databases on 9 August 2022: CENTRAL, MEDLINE, Embase, and the Web of Science. We also searched ClinicalTrials.gov and the WHO ICTRP. We reviewed the reference lists of relevant systematic reviews and included primary studies, and we contacted experts to identify additional studies.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) of social network or social support interventions for people with heart disease. We included studies regardless of their duration of follow-up, and included those reported as full text, published as abstract only, and unpublished data.

DATA COLLECTION AND ANALYSIS

Using Covidence, two review authors independently screened all identified titles. We retrieved full-text study reports and publications marked 'included', and two review authors independently screened these, and conducted data extraction. Two authors independently assessed risk of bias, and assessed the certainty of the evidence using GRADE. Primary outcomes were all-cause mortality, cardiovascular-related mortality, all-cause hospital admission, cardiovascular-related hospital admission, and health-related quality of life (HRQoL) measured at > 12 months follow-up.  MAIN RESULTS: We included 54 RCTs (126 publications) reporting data for a total of 11,445 people with heart disease. The median follow-up was seven months and median sample size was 96 participants. Of included study participants, 6414 (56%) were male, and the mean age ranged from 48.6 to 76.3 years. Studies included heart failure (41%), mixed cardiac disease (31%), post-myocardial infarction (13%), post-revascularisation (7%), CHD (7%), and cardiac X syndrome (1%) patients. The median intervention duration was 12 weeks. We identified notable diversity in social network and social support interventions, across what was delivered, how, and by whom.  We assessed risk of bias (RoB) in primary outcomes at > 12 months follow-up as either 'low' (2/15 studies), 'some concerns' (11/15), or 'high' (2/15). 'Some concerns' or 'high' RoB resulted from insufficient detail on blinding of outcome assessors, data missingness, and absence of pre-agreed statistical analysis plans. In particular, HRQoL outcomes were at high RoB. Using the GRADE method, we assessed the certainty of evidence as low or very low across outcomes. Social network or social support interventions had no clear effect on all-cause mortality (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.49 to 1.13, I2 = 40%) or cardiovascular-related mortality (RR 0.85, 95% CI 0.66 to 1.10, I2 = 0%) at > 12 months follow-up. The evidence suggests that social network or social support interventions for heart disease may result in little to no difference in all-cause hospital admission (RR 1.03, 95% CI 0.86 to 1.22, I2 = 0%), or cardiovascular-related hospital admission (RR 0.92, 95% CI 0.77 to 1.10, I2 = 16%), with a low level of certainty. The evidence was very uncertain regarding the impact of social network interventions on HRQoL at > 12 months follow-up (SF-36 physical component score: mean difference (MD) 31.53, 95% CI -28.65 to 91.71, I2 = 100%, 2 trials/comparisons, 166 participants; mental component score MD 30.62, 95% CI -33.88 to 95.13, I2 = 100%, 2 trials/comparisons, 166 participants).  Regarding secondary outcomes, there may be a decrease in both systolic and diastolic blood pressure with social network or social support interventions. There was no evidence of impact found on psychological well-being, smoking, cholesterol, myocardial infarction, revascularisation, return to work/education, social isolation or connectedness, patient satisfaction, or adverse events.  Results of meta-regression did not suggest that the intervention effect was related to risk of bias, intervention type, duration, setting, and delivery mode, population type, study location, participant age, or percentage of male participants.  AUTHORS' CONCLUSIONS: We found no strong evidence for the effectiveness of such interventions, although modest effects were identified in relation to blood pressure. While the data presented in this review are indicative of potential for positive effects, the review also highlights the lack of sufficient evidence to conclusively support such interventions for people with heart disease. Further high-quality, well-reported RCTs are required to fully explore the potential of social support interventions in this context. Future reporting of social network and social support interventions for people with heart disease needs to be significantly clearer, and more effectively theorised, in order to ascertain causal pathways and effect on outcomes.

Use of Motivational Interviewing in Older Patients with Multiple Chronic Conditions and Their Informal Caregivers: A Scoping Review

The use of motivational interviewing is relatively new in multiple chronic conditions (MCCs). A scoping review was conducted according to JBI methodology to identify, map and synthesize existing evidence on the use of motivational interviewing to support self-care behavior changes in older patients with MCCs and to support their informal caregivers in promoting patient self-care changes. Seven databases were searched, from database inception to July 2022, for studies that used motivational interviewing in interventions for older patients with MCCs and their informal caregivers. We identified 12 studies, reported in 15 articles, using qualitative, quantitative, or mixed-method designs, conducted between 2012 and 2022, describing the use of motivational interviewing for patients with MCCs. We could not locate any study regarding its application for informal caregivers. The scoping review showed that the use of motivational interviewing is still limited in MCCs. It was used mainly to improve patient medication adherence. The studies provided scant information about how the method was applied. Future studies should provide more information about the application of motivational interviewing and should address self-care behavior changes relevant to patients and healthcare providers. Informal caregivers should also be targeted in motivational interviewing interventions, as they are essential for the care of older patients with MCCs.

The Impact of an Intervention to Improve Caregiver Contribution to Heart Failure Self-care on Caregiver Anxiety, Depression, Quality of Life, and Sleep

BACKGROUND

Better caregiver contribution to self-care in heart failure is associated with better patient outcomes. However, caregiver contribution to self-care is also associated with high anxiety and depression, poor quality of life, and poor sleep in caregivers. It is still unclear whether interventions that encourage caregivers to contribute more to patient self-care might increase caregivers' anxiety and depression and decrease their quality of life and sleep.

OBJECTIVE

The aim of this study was to assess the impact of a motivational interview intervention aimed at improving caregiver contribution to self-care in heart failure on caregivers' anxiety, depression, quality of life, and sleep.

METHODS

This is a secondary outcome analysis of the MOTIVATE-HF trial. Patients with heart failure and their caregivers were randomized into arm 1 (motivational interview to patients), arm 2 (motivational interview to patients and caregivers), and arm 3 (standard care). Data were collected between June 2014 and October 2018. The article has been prepared following the Consolidated Standards of Reporting Trials checklist.

RESULTS

A sample of 510 patient-caregiver dyads was enrolled. Over the year of the study, the levels of anxiety, depression, quality of life, and sleep in caregivers did not significantly change among the 3 arms.

CONCLUSIONS

Motivational interview aimed at improving caregiver contribution to self-care does not seem to increase caregiver anxiety and depression, nor decrease their quality of life and sleep. Thus, such an intervention might be safely delivered to caregivers of patients with heart failure, although further studies are needed to confirm our findings.

Remote motivational interviewing to improve patient self-care and caregiver contribution to self-care in heart failure (REMOTIVATE-HF): Rationale, design, and methodology for a multicentre randomized controlled trial

In patients with heart failure (HF), self-care, and caregiver contribution to self-care (i.e., the daily management of the disease by patients and caregivers) are essential for improving patient outcomes. However, patients and caregivers are often inadequate in their self-care and contribution to self-care, respectively, and struggle to perform related tasks. Face-to-face motivational interviewing (MI) effectively improves self-care and caregiver contribution to self-care, but the evidence on remote MI is scarce and inconclusive. The aims of this randomized controlled trial will be to evaluate whether remote MI performed via video call in patients with HF: (1) is effective at improving self-care maintenance in patients (primary outcome); (2) is effective for the following secondary outcomes: (a) for patients: self-care management, self-care monitoring, and self-efficacy; HF symptoms; generic and disease-specific quality of life; anxiety and depression; use of healthcare services; and mortality; and (b) for caregivers: contribution to self-care, self-efficacy, and preparedness. We will conduct a two-arm randomized controlled trial. We will enroll and randomize 432 dyads (patients and their informal caregivers) in Arm 1, in which patients and caregivers will receive MI or, in Arm 2, standard care. MI will be delivered seven times over 12 months. Outcomes will be assessed at baseline and 3 (primary outcome), 6, 9, and 12 months from enrollment. This trial will demonstrate whether an inexpensive and easily deliverable intervention can improve important HF outcomes. With the restrictions on in-person healthcare professional interventions imposed by the COVID-19 pandemic, it is essential to evaluate whether MI is also effective remotely.