Dyadic incongruence in chronic heart failure: Implications for patient and carer psychological health and self-care

Effects of the family customised online FOCUS programme on patients with heart failure and their informal caregivers: a multicentre, single-blind, randomised clinical trial

Background

Living with heart failure can severely affect the physical and mental health of patients with heart failure and their caregivers. Available dyadic self-care interventions for heart failure are scarce, especially in China. We aimed to develop and test the family FOCUS programme.

Methods

This single-blind, randomised, controlled study was conducted at four hospitals in Tianjin, China. Patients with heart failure (aged at least 18 years) and their caregiver (dyads) were randomly assigned to either the intervention (n = 71) or control (n = 71) group in a 1:1 ratio. The primary outcomes of this study were patient self-care, with three specific dimensions (self-care maintenance, symptom perception, and self-care management), and caregiver contribution to self-care, mirroring these three dimensions. The outcomes were assessed at baseline (T0) and 4 (T1), 12 (T2), and 24 (T3) weeks post-discharge, respectively. This work is registered on ChiCTR, ChiCTR2100053168.

Findings

Between May 20, 2022, and September 30, 2022, 142 dyads with heart failure were enrolled. The intervention group exhibited dropout rates of 6%, 8.5%, and 18.3% at 4, 12, and 24 weeks after discharge, while the control group showed 9.9%, 12.3%, and 25.4%. Compared with the control group, patients in the intervention group reported improved self-care maintenance (β: 8.5, 95% CI: 0.7, 16.4) and management (β: 7.2, 95% CI: 0.1, 14.3) at T1, as well as improved symptom perception at both T1 (β: 9.7, 95% CI: 1.5, 17.9) and T2 (β: 9.6, 95% CI: 0.6, 18.6). Furthermore, caregiver contributions to self-care maintenance, self-care management, and symptom perception (excluding T3) exhibited significant improvements at all timepoints.

Interpretation

Although the significant improvements in patients' self-care were not long-lasting, this study suggested that the family FOCUS programme consistently enhanced caregivers' contributions to self-care. Future work could explore the effect of the family FOCUS programme on families with multiple chronic conditions.

Funding

The National Natural Science Foundation of China.

Better together: Relationship quality and mental health among cardiac patients and spouses

Reductions in marital relationship quality are pervasive post-cardiac event. It is not yet understood how relationship quality is linked to mental health outcomes in couples where one member has established cardiovascular disease (CVD) and the interdependence within dyads is seldom measured. This research is required as psychological distress has been independently linked to CVD incidence, morbidity, and mortality. This study assessed associations of relationship quality with depression and anxiety among patients with CVD and their spouses. Participants completed questionnaires measuring four dimensions of relationship quality and mental health. Data were analyzed using an Actor-Partner Interdependence Model with hierarchical moderation analyses. 181 dyads (N = 362 participants) comprised the study sample. Most patients had coronary artery disease (66.3%) and 25.9% were female. Patients reported higher relationship satisfaction and fewer anxiety symptoms than did spouses. Patients and spouses with high dyadic consensus and affectional expression reported fewer mental health symptoms, but only when the other partner also perceived high levels of consensus and affectional expression in the relationship. Patients and spouses with low dyadic cohesion reported worse mental health symptoms (actor effects), but those effects were no longer significant when both the patient and the spouse appraised the relationship as having high levels of dyadic cohesion. Taken together, relationship quality is linked to mental health symptoms in patients with CVD and their spouses. Longitudinal and experimental studies are now warranted to further substantiate the cross-sectional findings of this study.

Person with Heart Failure and Care Partner Dyads: Current Knowledge, Challenges, and Future Directions: State-of-the-Art Review

Over the past decade, there has been substantial growth in heart failure (HF) research that focuses on persons with HF and their care partners (family members or other close friends that provide unpaid support) as an interdependent team, or care dyad. In this state-of-the-art review, we use a dyadic lens to identify and summarize current research on HF care dyads, from qualitative studies, to nonexperimental quantitative studies, to randomized controlled trials. Although much work has been done, this literature is younger and less well-developed than care dyad literatures from other conditions (eg, cancer, Alzheimer's disease). We discuss the substantial challenges and limitations in this body of work, with an eye toward addressing common issues that impact rigor. We also look toward future directions, and discuss the promise dyadic research holds for improving patient, care partner, and relationship health.

Associations of perceived and common dyadic coping with self-care in older couples with cardiovascular disease: A dyadic analysis

BACKGROUND

Dyadic engagement of patients and caregivers in self-care is essential for management of heart disease. However, little is known how dyadic coping at individual and partner levels is associated with self-care in couples living with cardiovascular disease.

OBJECTIVE

This study examined whether dyadic coping at self, partner, and common levels was associated with patients' engagement in self-care and spouses' contribution to self-care in older couples living with cardiovascular disease.

METHODS

In this cross-sectional study, 288 older patients and spouses were recruited from outpatient heart clinics in Qazvin, north of Iran. Data were collected using the Dyadic Coping Inventory, the Self-care of Coronary Heart Disease Inventory, and the Caregiver's Contribution to Self-care of Coronary Heart Disease. Dyadic data were analyzed using the actor-partner interdependence model.

RESULTS

The results showed that patients' engagement in self-care maintenance was associated with partner dyadic coping in patients, self and common dyadic coping in spouses. Patients' engagement in self-care monitoring was only associated with self dyadic coping in spouses. Dyadic analysis also showed that self-care confidence in patients was only associated with by partner dyadic coping in spouses.

CONCLUSIONS

This study revealed that self-care was associated with dyadic coping employed by each member of the dyad at self, partner and common levels. Findings of this study suggest that perceived and provided levels of dyadic coping can be employed for maintaining or restoring self-management in older couples living with cardiovascular disease.

How Does Spiritual Well-Being Change Over Time Among US Patients with Heart Failure and What Predicts Change?

Few studies have examined how spiritual well-being changes over time in patients with heart failure. We conducted a secondary analysis of data from the Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) trial (N = 314). Spiritual well-being was measured using the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp) at baseline and 12-month follow-up. Of the 165 patients with spiritual well-being data at follow-up, 65 (39%) experienced probable clinically meaningful changes (> 0.5 SD) in spiritual well-being (35 improved, 30 declined). Increased pain (p = 0.04), decreased dyspnea (p < 0.01), and increased life completion (p = 0.02) were associated with improvement in overall spiritual well-being. Exploratory analyses found different predictors for FACIT-Sp subscales.

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.

Exploring Culturally Responsive Religious and Spirituality Health Care Communications among African Americans with Advanced Heart Failure, Their Family Caregivers, and Clinicians

Background: Religion and spirituality (R/S) impact how African Americans (AAs) cope with serious illness, yet are infrequently addressed in patient-clinician communication. Objectives: To explore AAs with advanced heart failure and their family caregivers' (FCGs) preferences about R/S in patient-clinician communication. Methods: An embedded qualitative interview within a parent randomized trial about the role of R/S in the illness experience and in clinician interactions with patients and FCGs in a Southern U.S. state. Transcribed interviews were analyzed using constant comparative analysis to identify emergent themes. Results: AA participants (n = 15) were a mean age of 62 years, were female (40%), and had >high school diploma/GED (87%). AA FCGs (n = 14) were a mean age of 58; were female (93%); had >high school diploma/General Education Development (GED) (93%); and were unemployed (86%). Most (63%) were patients' spouses/partners. All patients and FCGs were Protestant. Participants reported the critical role of R/S in living with illness; however, patients' and FCGs' perspectives related to inclusion of R/S in health care communications differed. Patients' perspectives were as follows: (1) R/S is not discussed in clinical encounters and (2) R/S should be discussed only if patient initiated. FCGs' perspectives about ideal inclusion of R/S represented three main diverging themes: (1) clinicians' R/S communication is not a priority, (2) clinicians should openly acknowledge patients' R/S beliefs, and (3) clinicians should engage in R/S conversations with patients. Conclusion: Key thematic differences about the role of R/S in illness and preferences for incorporating R/S in health care communications reveal important considerations about the need to assess and individualize this aspect of palliative care research and practice.

Learning a new way of living together: a qualitative study exploring the relationship changes and intervention needs of patients with cardiovascular disease and their partners

OBJECTIVES

Cardiovascular disease (CVD) not only affects the patient, but has implications for the partner. Emerging evidence suggests that supportive couple relationships enhance CVD outcomes and reduce patient and partner distress. To date, however, little research has been done to address the couple relationship as a potentially important component of cardiac care. This article examines the impact of CVD on the couple relationship and assesses the perceived needs and desired intervention components of patients with CVD and their partners.

DESIGN

Qualitative study using directed and conventional content analysis.

SETTING

Single-centre, tertiary cardiac care hospital that serves a population of 1.4 million in the Champlain region of Ontario, Canada.

PARTICIPANTS

Patients with CVD and their partners (n=32, 16 couples) participated in focus groups. Patients were mainly male (75%), white (87.5%), aged 64.4 years (range 31-81 years), with varied cardiac diagnoses (50% coronary artery disease; 18.75% valve disease; 18.75% heart failure; 12.5% arrhythmia).

RESULTS

Five categories were generated from the data reflecting changes within the couple relationship as a result of CVD: (1) emotional and communication disconnection; (2) overprotection of the patient; (3) role changes; (4) adjustment to lifestyle changes; and (5) positive relationship changes. Three categories were constructed regarding intervention needs and desired resources: (1) practical resources; (2) sharing with peers; and (3) relationship enhancement.

CONCLUSIONS

Overall, the data suggest that there were profound changes in the couple relationship as a result of CVD, and that there is considerable need to better support the caregiving spouses and the couple as a unit. These results call for interventions designed to provide instrumental support, peer-sharing opportunities and relationship quality enhancement to help couples cope with CVD. Future studies should examine whether couples-based programming embedded into cardiac rehabilitation can be effective at improving relationship quality and reducing patient and partner stress in the aftermath of a cardiac event.

Can a complex adaptive systems perspective support the resiliency of the heart failure patient - informal caregiver dyad?

PURPOSE OF REVIEW

A holistic palliative approach for heart failure care emphasizes supporting nonprofessional informal caregivers. Informal caregivers play a vital role caring for heart failure patients. However, caregiving negatively affects informal caregivers' well being, and in turn heart failure patients' health outcomes. This opinion article proposes that complex adaptive systems (CAS) theory applied to heart failure models of care can support the resiliency of the heart failure patient - informal caregiver dyad.

RECENT FINDINGS

Heart failure care is enacted within a complex system composed of patients, their informal caregivers and a variety of health professionals. In a national study, we employed a CAS perspective to explore how all parts of the heart failure team function interdependently in emergent and adaptive ways. Salient in our data were the severe vulnerability of elderly heart failure patients and their long-term partners who suffered from a chronic illness. Novel approaches are needed that can quickly adapt and reorganize care when unpredictable disturbances occur in the couples' functional capacity.

SUMMARY

The linear protocol-driven care models that shape heart failure guidelines, training and care delivery initiatives do not adequately capture heart failure patients' social environment. CAS is a powerful theoretical tool that can render visible the most vulnerable members of the heart failure team, and incite robust specialized holistic palliative heart failure care models.

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.

Dyadic effects of perceived social support on family health and family functioning in patients with heart failure and their nearest relatives: Using the Actor-Partner Interdependence Mediation Model

Background

Social support, family functioning and family health are essential elements in the treatment of heart failure, yet most heart failure studies focus on the pharmacological interventions. This study aimed to examine whether perceived social support from nurses is associated with better family functioning of patients with heart failure and their nearest relatives and to examine whether family health mediates this relationship.

Methods and findings

A sample of 312 patients with heart failure and 312 of their nearest relatives were included in the study. The Family Functioning, Health and Social Support questionnaire was used to collect the data. Dyadic data were analysed by the Actor–Partner Interdependence Mediation Model with distinguishable dyads using structural equation modelling. Patients and nearest relatives who perceived more social support had a higher level of family health and functioned better within the family. One partner effect was found, indicating that the higher the level of family health of the nearest relative, the better the family functioning of the patient (p <0.001). Family health partially (in the patient) and completely (in the nearest relative) mediated the association between social support and family functioning.

Conclusion

This study indicated that patients with heart failure and their nearest relatives who perceived more social support from nurses were more likely to have high level of family health and function better within the family. The interdependent relationships found in our study highlight a dyadic and family-oriented approach to improve family functioning in patients with heart failure.