Caregivers' Heart Failure Knowledge is Necessary but not Sufficient to Assure Engagement with Patients in Self-care Maintenance

Disease-related knowledge in people with chronic obstructive pulmonary disease and their informal caregivers: A multilevel modelling analysis

AIMS AND OBJECTIVES

To assess the level of chronic obstructive pulmonary disease (COPD)-related knowledge within patient and informal caregiver dyads, and to identify factors influencing the knowledge level considering the interdependence within the dyads.

BACKGROUND

Patients with COPD and their informal caregivers present poor disease knowledge and different characteristics are associated with their level of knowledge. Disease knowledge and related characteristics have been assessed separately in patients and informal caregivers, without considering possible influence within the dyads.

DESIGN

Cross-sectional study.

METHODS

A convenience sample of dyads was recruited in outpatient and inpatient settings in Central and South Italy. The Bristol COPD Knowledge Questionnaire was used to measure disease knowledge. Sociodemographic, clinical and caregiving characteristics, self-efficacy and depression were measured in patients and caregivers. Multilevel modelling was used to analyse COPD knowledge at the level of the dyad to control for interdependency between patients and informal caregivers. The STROBE guidelines for cross-sectional studies were followed for study reporting.

RESULTS

We recruited 133 dyads. The total level of correct knowledge shared by dyads was 32.89%. Dyads presented higher levels of correct knowledge about disease symptoms, smoking cessation and vaccination, and lower about COPD treatment. Younger patients with greater self-efficacy, who attended pulmonary rehabilitation and were cared for by a spouse/partner with low levels of depression, and informal caregivers who were patients' spouse/partner were more likely to have higher levels of disease-related knowledge.

CONCLUSIONS

Our study advances dyadic research in COPD. Future studies should investigate the effects of shared knowledge and incongruent knowledge (where one member knows more than the other) on patient self-care and caregiver contribution to patient self-care.

RELEVANCE TO CLINICAL PRACTICE

Our study shows what knowledge nurses should provide in educational programmes directed at patients and caregivers, and which dyads have greater knowledge deficits, to whom offer targeted educational interventions.

Heart Failure Care: Testing Dyadic Dynamics Using the Actor-Partner Interdependence Model (APIM)-A Scoping Review

Self-care behaviors are essential for the effective treatment of heart failure (HF), and poor self-care may lead to adverse clinical events in patients with HF. A growing body of literature addresses the need to analyze the characteristics of both patient and caregiver since they are in mutual, long-term interaction, and their reactions to events are dependent on each other. One of the most common approaches for analyzing data on HF self-care dyads is the Actor–Partner Interdependence Model (APIM). The purpose of this study was to conduct a scoping review to answer the following question: what did we learn from HF dyadic studies based on the APIM approach? Medline, Academic Search Ultimate, and CINAHL Complete databases were searched, using the terms “dyad,” “dyadic,” and “heart failure,” for studies published between 2009 and April 2021. Fifteen studies were reviewed from a pool of 106 papers. Studies using the APIM approach revealed interrelated patient and caregiver characteristics that influence self-care and explain many complex dyadic behaviors. Our analysis provided evidence that (1) APIM is a useful analytical approach; (2) a family-oriented approach can improve the functioning of a patient with HF; and (3) social support from caregivers significantly enhances patients’ adaptation to illness.

The influence of dyadic congruence and satisfaction with dyadic type on patient self-care in heart failure

BACKGROUND

Chronic illness management is increasingly carried out at home by individuals and their informal caregivers (dyads). Although synergistic in concept, the nuances of dyadic congruence in caring for patients with heart failure are largely unexamined.

AIMS

The purpose of this study was to examine the role of dyadic-type congruence on patient self-care (maintenance, symptom perception, and management) while controlling for actor and partner effects.

METHODS

This secondary data analysis of 277 dyads consisted of a series of multilevel models to examine the impact of dyadic congruence on a patient's self-care maintenance, symptom perception, and self-care management. Patient-level and caregiver-level data were input into each model simultaneously to account differential appraisals of factors related to the dyad.

RESULTS

Bivariate analyses yielded dyad congruence which was associated with better patient self-care maintenance, symptom perception and management. However, after multilevel models were constructed, dyad congruence was found to be a significant predictor of patient's symptom perception scores, but not self-care maintenance or management scores. Caregiver's satisfaction with the dyad was differentially and significantly associated with self-care - it was inversely associated with patient self-care maintenance and positively associated with patient self-care management.

CONCLUSION

This is the first study, to our knowledge, reporting that congruence in heart failure dyads is associated with better patient symptom perception and this advances our prior hypothesis that dyad typologies could be used to predict patient self-care performance. Since symptom perception is the key to preventing heart failure exacerbation, screening heart failure patient and caregiver dyads for congruence is important in clinical settings.

Cross-cultural adaptation of the caregiver contribution to heart failure self-Care into Brazilian Portuguese and content validation

BACKGROUND

The Caregiver Contribution to Heart Failure Self-Care (CACHS) is a Canadian instrument that assesses caregivers' (CGs) contributions to heart failure (HF) patients' self-care, but a Brazilian version was lacking.

AIMS

To adapt CACHS into Brazilian Portuguese and to estimate the content validity of the adapted version.

METHODS

A psychometric study of cross-cultural adaptation and content validation was conducted. Linguistic equivalence was assessed by eight professional experts. Content validity was assessed by an expert professional panel (n=8; for clarity, theoretical relevance and practical relevance) and a CG panel (n=46; for cognitive debriefing of the adapted instrument). In the cultural adaptation, the items were considered equivalent if experts reached an agreement ≥80%. In the content validation, the items were considered acceptable if content validity coefficients (CVC) were ≥0.70.

RESULTS

The translated version was considered consistent with the original CACHS by the authors. In the second round of linguistic equivalence assessment, all items achieved 100% agreement, except for one item, which presented 75% agreement in conceptual equivalence. The CVC in the first and second rounds of content validity assessment by experts was 0.80 to 0.90. During cognitive testing, the CGs requested explanations on three items, which were reformulated. All CGs then understood the Brazilian version of CACHS, named CACHS - Versão Brasileira (CACHS-Br).

CONCLUSIONS

CACHS-Br is equivalent to the original version and provided satisfactory evidence of content validity. Further psychometric testing of this version should allow for the measurement of the CG contributions to HF self-care in Brazil.

Pilot Implementation of a Low-Literacy Zone Tool for Heart Failure Self-management

Heart failure affects 6.5 million Americans, with 1 million hospitalizations annually, a 22% readmission rate, and $31 billion in health care costs. Palliative care decreases symptom burden, readmissions, and costs. Many elderly patients have difficulty recognizing and reporting heart failure symptoms to their providers in a timely manner. Self-management tools with color-coded zones (green = "all clear," yellow = "caution," red = "take action") help patients recognize and respond to heart failure symptoms and reduce readmissions. The purpose of this quality improvement project was to develop, implement, and evaluate a low-literacy zone tool for heart failure self-management with home-based palliative care patients. An interdisciplinary palliative care team developed this zone tool. Health literacy was prescreened with the Newest Vital Sign instrument. Nurses provided the zone tool to patients and caregivers and instructed them in use of this tool for daily self-monitoring. In postimplementation surveys, participants rated the zone tool as easy to understand and helpful in recognizing and reporting symptoms. This project demonstrated feasibility of a new zone tool for heart failure self-management, resulting in a practice change for this home-based palliative care program. The interdisciplinary team eventually developed similar zone tools for cancer, cirrhosis, chronic obstructive pulmonary disease, dementia, and frailty self-management.

A Situation-Specific Theory of Caregiver Contributions to Heart Failure Self-care

BACKGROUND

The literature on caregiver contributions to heart failure (HF) patient self-care has grown rapidly during the last few years, but theory guiding this growth is lacking.

OBJECTIVE

The purpose of this article is to describe a Situation-Specific Theory of Caregiver Contributions to HF Self-care.

RESULTS

We describe theoretical assumptions, the process by which caregivers contribute to HF self-care, factors influencing caregiver contributions to HF self-care, known predictors (caregiver, patient, and dyadic related) and outcomes of caregiver contributions to HF. These outcomes may be caregiver and patient related and positive and/or negative. Caregiver contributions to HF self-care include interacting processes of self-care maintenance, symptom monitoring and perception, and self-care management. Caregiver confidence and cultural values are discussed as important influences on caregiver contributions to HF self-care. Recursive pathways are hypothesized between processes and outcomes. Ten theoretical propositions are proposed.

CONCLUSIONS

The Situation-Specific Theory of Caregiver Contributions to HF Self-care is still in its infancy, and more research is needed to strengthen the evidence supporting the theory. But at this point, the theory may help to guide future studies addressing caregiver contributions to HF self-care and clinical practice aimed at improving caregiver and patient outcomes.

Heart Failure Care Dyadic Typology: Initial Conceptualization, Advances in Thinking, and Future Directions of a Clinically Relevant Classification System

BACKGROUND

Heart failure (HF) dyadic self-care science is advancing rapidly, as evidenced by recent theoretical work, literature reviews, and multiple empiric studies. Typologies, once considered archaic, are now viewed as person-oriented classification systems that allow a whole-system view of information patterns. This whole-system view is particularly needed to understand complex tasks like dyadic HF self-care.

PURPOSE

The purpose of this article is to review the initial conceptualization of an HF care dyadic typology and the present advances in our thinking and suggest future directions for this clinically relevant classification system.

CONCLUSIONS

Development and testing of the typology across 5 studies resulted in a well-characterized, pragmatic and parsimonious, person-oriented classification system for understanding how patients and informal caregivers conduct patients' HF self-care at home. The 4 types are characterized as 2 individually oriented types-type I, patient oriented; type II, caregiver oriented; and 2 relationally oriented types-type III, collaboratively oriented; and type IV, incongruently oriented. We have devised a single-item measure of typology group that can be assessed in the clinical setting. Once this information is ascertained, the clinician can personalize the plan of care to the realities of the dyad.

IMPLICATIONS

Dyads that disagree on who is responsible for self-care may forego or delay action, resulting in self-care failures with subsequent HF advancement, hospitalization, and mortality. As the HF dyadic self-care science has advanced, we have come to appreciate the complexity that arises when 2 individuals work together on 1 complex task-HF self-care.

Heart Failure Self-care Within the Context of Patient and Informal Caregiver Dyadic Engagement: A Mixed Methods Study

BACKGROUND

Recent heart failure (HF) patient and informal caregiver (eg, dyadic) studies have either examined self-care from a qualitative or quantitative perspective. To date, the 2 types of data have not been integrated.

OBJECTIVE

The aim of this study was to understand HF self-care within the context of dyadic engagement.

METHODS

This was a cross-sectional, mixed methods (quantitative/qualitative) study. Heart failure self-care was measured with the Self-care of Heart Failure Index (v.6) dichotomized to adequate (≥70) or inadequate (<69). Dyadic symptom management type was assessed with the Dyadic Symptom Management Type scale. Interviews regarding self-care were conducted with both dyad members present. Content analytic techniques were used. Data were integrated using an information matrix and triangulated using Creswell and Plano Clark's methods.

RESULTS

Of the 27 dyads, HF participants were 56% men, with a mean age of 77 years. Caregivers were 74% women, with a mean age of 66 years, representing spouses (n = 14) and adult children (n = 7). Quantitatively, few dyads scored as adequate (≥70) in self-care; the qualitative data described the impact of adequacy on the dyads' behavior. Dyads who scored higher, individually or both, on self-care self-efficacy and self-care management were less likely to change from their life course pattern. Either the patient or dyad continued to handle all self-care as they always had, rather than trying new strategies or reaching out for help as the patient's condition deteriorated.

CONCLUSIONS

Our data suggest links that should be explored between dyadic adequacy and response to patients' symptoms. Future studies should assess dyadic adequacy longitudinally and examine its relationship to event-free survival and health services cost.

Shared heart failure knowledge and self-care outcomes in patient-caregiver dyads

BACKGROUND

Patient's knowledge about heart failure (HF) contributes to successful HF self-care, but less is known about shared patient-caregiver knowledge.

OBJECTIVES

The purpose of this analysis was to: 1) identify configurations of shared HF knowledge in patient-caregiver dyads; 2) characterize dyads within each configuration by comparing sociodemographic factors, HF characteristics, and psychosocial factors; and 3) quantify the relationship between configurations and patient self-care adherence to managing dietary sodium and HF medications.

METHODS

This was a secondary analysis of cross-sectional data (N = 114 dyads, 53% spousal). Patient and caregiver HF knowledge was measured with the Atlanta Heart Failure Knowledge Test. Patient dietary sodium intake was measured by 3-day food record and 24 h urine sodium. Medication adherence was measured by Medication Events Monitoring System caps. Patient HF-related quality of life was measured by the Minnesota Heart Failure Questionnaire; caregiver health-related quality of life was measured by the Short Form-12 Physical Component Summary. Patient and caregiver depression were measured with the Beck Depression Inventory-II. Patient and caregiver perceptions of caregiver-provided autonomy support to succeed in heart failure self-care were measured by the Family Care Climate Questionnaire. Multilevel and latent class modeling were used to identify dyadic knowledge configurations. T-tests and chi-square tests were used to characterize differences in sociodemographic, clinical, and psychosocial characteristics by configuration. Logistic/linear regression were used to quantify relationships between configurations and patient dietary sodium and medication adherence.

RESULTS

Two dyadic knowledge configurations were identified: "Knowledgeable Together" (higher dyad knowledge, less incongruence; N = 85, 75%) and "Knowledge Gap" (lower dyad knowledge, greater incongruence; N = 29, 25%). Dyads were more likely to be in the "Knowledgeable Together" group if they were White and more highly educated, if the patient had a higher ejection fraction, fewer depressive symptoms, and better autonomy support, and if the caregiver had better quality of life. In unadjusted comparisons, patients in the "Knowledge Gap" group were less likely to adhere to HF medication and diet. In adjusted models, significance was retained for dietary sodium only.

CONCLUSIONS

Dyads with higher shared HF knowledge are likely more successful with select self-care adherence behaviors.